Indications For Carotid Endarterectomy Research Articles

Feasibility and Accuracy of Measuring Carotid Plaque Volume (Burden) With Contrast-Enhanced Tomographic 3D Ultrasound and Ultrasound Image Fusion

Stenosis severity has been the indication for carotid endarterectomy (CEA) for four decades, but the annual stroke risk in asymptomatic carotid stenosis >70% is under 2%. Atherosclerotic volume has emerged as a risk factor for future stroke, but needs to be measured non-invasively. Tomographic ultrasound (tUS) is a novel technology that assembles 3D images in seconds. We evaluated accuracy of measuring Carotid Plaque Volume (CPV) with tUS in patients undergoing CEA. Consecutive patients were imaged immediately before CEA by tUS and contrast-enhanced tUS (CEtUS). CPV was measured using tUS, CEtUS and a fused images incorporating both tUS and CEtUS by trained vascular scientists. Precise volume of the endarterectomy specimen was measured using Archimedes technique. Mean±sd(range) CPV in 129 endarterectomy specimens was 0.75±0.43cm3(0.10-2.47cm3). Mean±sd CPV measured by tUS (n=114) was 0.87±0.51cm3, CEtUS (n=104) was 0.75±0.45cm3 and with fusion (n=95) was 0.83±0.49cm3. Differences between specimen volume and CPV measured by tUS (0.13±0.24cm3), CEtUS (-0.01±0.21cm3) or fusion (-0.08±0.20) were clinically insignificant. Intra-/inter-observer differences were minimal. TUS accurately measures CPV with excellent intra-/inter-observer agreement. CEtUS improves accuracy if precise CPV measurement is needed for research but tUS alone would be sufficient for population screening.

Coronary revascularization of patients with silent coronary ischemia may reduce the risk of myocardial infarction and cardiovascular death after carotid endarterectomy

BackgroundMajor adverse cardiac events (MACEs) are the primary cause of death after carotid endarterectomy (CEA). We sought to determine whether selective coronary revascularization of CEA patients with asymptomatic coronary ischemia can reduce the risk of MACEs, myocardial infarction (MI), and cardiac death after endarterectomy compared with CEA patients receiving standard cardiac evaluation and care. MethodsTwo groups of patients with no cardiac history or symptoms undergoing elective CEA were compared. Group I: patients enrolled in a prospective study of noninvasive preoperative cardiac evaluation using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) to detect asymptomatic (silent) coronary ischemia with selective postoperative coronary revascularization. Group II: matched Control patients with standard preoperative cardiac evaluation and no postoperative coronary revascularization. Lesion-specific coronary ischemia in group I was defined as FFRCT ≤ 0.80 distal to coronary stenosis with severe ischemia defined as FFRCT ≤ 0.75. End points included MACEs, cardiac death, MI, cardiovascular (CV) death, stroke, and all-cause death through 3-year follow-up. ResultsGroup I (n = 100) and group II (n = 100) patients were similar in age (68 vs 67 years), gender (65% vs 62% male), comorbidities, and indications for CEA (53% vs 48% symptomatic carotid stenosis). In group I, FFRCT analysis revealed lesion-specific coronary ischemia in 57% of patients, severe coronary ischemia in 44%, left main ischemia in 7%, and multivessel ischemia in 28%. The status of coronary ischemia in group II was unknown. CEA was performed without complications in both groups, and all patients received optimal postoperative medical therapy. In group I, elective coronary revascularization was performed in 33 patients (27 percutaneous coronary intervention; 6 coronary artery bypass grafting) 1 to 3 months after CEA. Group II patients had no elective coronary revascularization. During 3-year follow-up, compared with group II, group I patients had fewer MACEs (4% vs 17%, hazard ratio [HR]: 0.21 [95% confidence interval (CI): 0.07-0.63], P = .004), fewer cardiac deaths (2% vs 9%, HR: 0.20 [95% CI: 0.04-0.95], P = .030), fewer MIs (3% vs 17%, HR: 0.16 [95% CI: 0.05-0.54], P = .001), and fewer CV deaths (2% vs 12%, HR: 0.16 [95% CI: 0.004-0.07], P = .009). There were no significant differences in the rates of stroke or all-cause death. ConclusionsPreoperative diagnosis of silent coronary ischemia with selective coronary revascularization after CEA may reduce the risk of MACEs, cardiac death, MI, and CV death during 3-year follow-up compared with CEA patients receiving standard cardiac evaluation and care.

Comparative Results of Emergency Carotid Endarterectomy and Emergency Carotid Angioplasty With Stenting in the Acute Period of Ischemic Stroke. Multicenter Study Results

AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA). MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism protection systems were used. Carot-id endarterectomy was performed according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combined end-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms. RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the diagnosis and prognosis of LV UR after 12 months. RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%); group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2: n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001; OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p<0.0001; OR=0.29; 95% CI 0.17–0.48). Thus, in the CEE group, every 5th patient had a complication. CONCLUSION Carotid angioplasty with stenting is the safest method of revascularization for patients in the acute period of ACVA. This is largely due to the reduction in the risk of reperfusion syndrome and the prevention of embolism due to the use of modern protection systems. Carotid endarterectomy can be performed with comparable efficiency only when a tempo-rary shunt is placed in the internal carotid arteries in the absence of unstable atheroscle-rotic plaque.

Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review.

Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.

Can Carotid Plaque Volume be Measured by 3d Tomographic Ultrasound?

Introduction - Carotid Plaque Volume (CPV) correlates more closely than severity of stenosis with symptoms of cerebral ischemia in patients with carotid disease [1]. If we could measure CPV by a minimally-invasive technique, it may replace severity of stenosis as the principle indication for carotid endarterectomy (CEA) and may even be used for population screening in the future. Methods - Standard Duplex and 3D tomographic ultrasound (tUS) imaging of the carotid bifurcations were undertaken on the day of CEA in 50 patients. CPV of the endarterectomy specimen was measured using a validated modified Archimedes suspension technique. CPV by tUS was calculated by dedicated software using the intima-plaque and plaque-blood boundaries in 1mm slices through the tUS image, corrected for the plaque length. Results - The mean endarterectomy specimen CPV was 0.92±0.51cm3 and the tUS CPV was 1.08±0.61cm3 with the mean difference between the endarterectomy specimen and tUS CPV’s being only -0.16±0.24cm3 (95% LOA -0.63-0.32). There was an excellent correlation (Figure) between CPV measured by tUS and the endarterectomy specimen with r = 0.92 (95%CI 0.87 – 0.96 cm3) p<0.0001. There was no correlation between CPV and the severity of stenosis measured by peak systolic velocity; (r = 0.0052, p=0.97). Conclusion - tUS measurement of CPV strongly correlated with CPV of the endarterectomy specimen and is an accurate technique for calculating atherosclerotic burden or CPV. This technique may lead to a new indication for CEA and possibly even to population screening for carotid disease associated with enhanced stroke risk.

Carotid endarterectomy in patients with high plaque

BackgroundDifficult cephalad exposure during carotid endarterectomy in patients with high plaque (HP) may lead to increased incidence of complications after carotid endarterectomy. We report on our experience of carotid endarterectomy in patients with HP. MethodsThis is a retrospective review of 1,233 consecutive patients who underwent carotid endarterectomy by a single surgeon at 2 teaching hospitals between January 1989 to December 2018. Group A consisted of patients with HP (n = 100) diagnosed by computed tomography angiography of the neck in 90, catheter-based arteriography in 8, and an unexpected finding during carotid endarterectomy in 2 patients. Group B consisted of 1,133 consecutive carotid endarterectomies with plaque ending in Zone 1 non-high plaque (nHP). ResultsBoth groups were similar in age (70.9 ± 8.7 vs 70.3 ± 9.1, P = .53). There was a preponderance of male patients in the HP group (78.0% vs 66.1%, P = .02). Associated risk factors, including coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease, and hyperlipidemia, were similar in both groups. Indications for carotid endarterectomy in HP patients include recent stroke (<8 weeks) in 15 patients (15.0%), transient ischemic attack in 23 patients (23.0%), and asymptomatic in 62 patients (62.0%). Three patients (3.0%) with HP required shunt placement compared with 10.9% in the nHP group (P = .009). Completion carotid arteriogram was performed in 6 patients. Perioperative stroke and mortality were similar in both groups. The incidence of cranial nerve injury was higher in the HP group. ConclusionMost patients with HP can be diagnosed with computed tomography angiography of the neck or catheter-based arteriography. Shunt requirement in patients with HP is significantly lower than in the nHP group. Perioperative stroke and mortality in patients with HP undergoing carotid endarterectomy is similar to the nHP group; however, there is a higher incidence of permanent cranial nerve injury. Carotid artery stenting should be considered in cases in which carotid endarterectomy may be challenging, such as in patients with HP. Overall, our results demonstrate that carotid endarterectomy can be safely performed in patients with HP, however, at an increased risk of permanent cranial nerve injury.

Cost-effectiveness of novel imaging tests to select patients for carotid endarterectomy

ObjectiveWe estimated the cost-effectiveness of novel imaging tests to select patients for carotid endarterectomy (CEA) in patients with significant carotid stenosis using a computer model and explored the minimum prognostic performance that a new confirmatory test must have in order to be cost-effective versus the guideline-based strategy. MethodsThe guidelines recommend initial duplex ultrasonography (DUS) followed by a confirmatory test if DUS shows 30–69% stenosis; a positive CT-angiography (CTA) is an indication for CEA. In an alternative strategy, we replaced CTA with CE-DUS, and in another strategy we replaced it by a hypothetical imaging test and estimated the minimum prognostic performance that the test must have in order to be cost-effective versus the guideline-based strategy. We assessed the potential cost-effectiveness in four age- and sex-specific subpopulations. ResultsFor 60-year-old men, a perfect confirmatory test (100% sensitivity and specificity) improves health (0.066 quality-adjusted life years) and reduces costs (€110/$146) versus the guideline-based strategy. Potential health gain is smaller for 80-year-old men, while no health gain is expected for women. Assuming 100% sensitivity, a test must have a specificity of at least 66% for 60-year-old men and 87% for 80-year-old men to be cost-effective. Similarly, assuming 100% specificity, a test must have a sensitivity of at least 58% for 60-year-old men and 66% for 80-year-old men. ConclusionsInformation from new imaging technologies may improve stroke risk prediction and thereby improve decisions about which patients should undergo CEA. However, their cost-effectiveness strongly depends on the current test strategy and choice of patient subpopulation.

Electric brain activity in patients with simultaneous coronary artery bypass grafting and carotid endarterectomy

To analyze the postoperative electroencephalography (EEG) power changes in patients after simultaneous coronary artery bypass grafting (CABG) and a left- or right-sided carotid endarterectomy (CEE). Forty-four patients with indications for surgical myocardial revascularization, including 24 patients with indications for CEE, were studied. Patients after simultaneous coronary and carotid surgery were divided into groups depending on the side of CEE: the left+CEE CABG group included 14 patients, the right CEE+CABG group included 10 patients. The group of isolated CABG consisted of 20 patients. The resting-state EEG with closed eyes was recorded before and at the 7-10th day after surgery. The changes of the spectral power (μV2/Hz), theta1 (4-6 Hz), theta2 (6-8 Hz), alpha1 (8-10 Hz), alpha2 (10-13 Hz) rhythms were analyzed, the hemispheric asymmetry (HA) coefficient of the rhythms was calculated. In the early postoperative period, the power of theta1 and theta2 rhythms increased compared to the preoperative level regardless of the type of cardiosurgical intervention. A local character of postoperative theta activity changes was revealed in the left+CEE CABG group, whereas the most pronounced decrease of the alpha-rhythm HA coefficient was observed in the right CEE+CABG group at the 7-10th day after surgery in comparison to the preoperative level. The results of the study suggest that the simultaneous coronary and carotid surgery does not significantly exacerbate the severity of brain damage compared to isolated CABG.

Хирургическое лечение атеротромботической и гемодинамической форм ишемического инсульта

Цель. Проанализировать результаты хирургического лечения пациентов с поражением сонных артерий в остром и раннем восстановительном периоде ишемического инсульта.&#x0D; Материалы и методы. Проанализированы результаты хирургического лечения 47 пациентов с гемодинамически значимым стенозом сонных артерий (СА) и/или наличием эмбологенной бляшки в остром и раннем восстановительном периоде ишемического инсульта в ИОНХ имени В. Т. Зайцева НАМН Украины с 2014 по 2017 г. Среди пациентов 41 (87,2%) мужчина и 6 (12,8%) женщин. Средний возраст оперированных больных - (60 ± 15) лет. Всем пациентам, обследуемым по поводу предполагаемого ишемического инсульта, сначала выполняют компьютерную томографию (КТ) как более быстрое исследование, позволяющее исключить кровоизлияние в мозг. Показаниями к каротидной эндартерэктомии были стеноз СА более 60%, окклюзия СА или наличие эмбологенной бляшки. Всем пациентам выполняли оперативное вмешательство под проводниковой анестезией, что позволяло контролировать сознание в период пережатия СА. Наличие неврологического дефицита было показанием к выполнению эндартерэктомии из внутренней сонной артерии (ВСА) с использованием временного шунта и вшиванием синтетической заплаты в 17% наблюдений. Эверсионная эндартерэктомия была выполнена 39 больным.&#x0D; Результаты. Непосредственные результаты операции оценивали комплексно на основании степени изменения клинического статуса и наличия послеоперационных осложнений. У 32 больных в послеоперационном периоде осложнений не было. Регресс неврологического дефицита отмечали с 7-х сут после операции, в зависимости от степени проявления - до 3 - 4 мес. Больным проведен контроль проходимости СА и состояния зоны ишемии на 14-е сутки. Констатировали отсутствие стеноза СА и уменьшение очага ишемии в 2 раза. Особое опасение в послеоперационном периоде вызывал реперфузионный синдром, который проявлялся у 35% больных головной болью и головокружением. Данный синдром начинался с 3-х сут, требовал контроля и коррекции артериального давления (АД) и исчезал самостоятельно на 7 – 10-е сут.&#x0D; Выводы. Пациентам с поражением СА в остром и раннем восстановительном периоде ишемического инсульта необходимо выполнять магнитно-резонансную томографию (МРТ) или КТ с контрастированием в первые 6 ч для определения тактики лечения.&#x0D; При гемодинамически значимом стенозе и нестабильности бляшки больным с ишемическим инсультом необходимо выполнять каротидную эндартерэктомию в первые 14 сут.&#x0D; Каротидная эндартерэктомия уменьшает риск повторного ишемического инсульта и зону ишемии головного мозга в 98% наблюдений.

Retinal ganglion cell complex and peripapillary retinal nerve fiber layer thicknesses following carotid endarterectomy.

To examine changes in retinal ganglion cell complex (GCC) and peripapillary retinal nerve fiber layer (RNFL) thicknesses by optical coherence tomography (OCT) in contralateral and ipsilatateral eyes of carotid artery stenosis (CAS) patients before and after carotid endarterectomy (CEA). Forty-two consecutive patients diagnosed with CAS (70-99% stenosis rate) who underwent CEA were included in this prospective cross-sectional study. The indication for CEA was based on the Asymptomatic Carotid Atherosclerosis Study. Doppler ultrasonography and computed tomography angiography were performed to calculate CAS. All the subjects underwent an ophthalmological examination, including best corrected visual acuity (BCVA), intraocular pressure (IOP) measurements, biomicroscopy, fundoscopy, and OCT before and after the surgery. The mean preoperative intraocular pressure was 15.2 ± 2.1mmHg in the ipsilateral eye and 15.8 ± 2.7 in the contralateral eye. The mean postoperative intraocular pressure in the ipsilateral and contralateral eye was 18.6 ± 3.0 and 19.3 ± 3.8, respectively. The intraocular pressure was significantly higher in postoperative eyes (p = 0.0001). There was a statistically significant decrease in peripapillary RNFL thickness in superior quadrants postoperatively in ipsilateral eyes. The retinal GCC layer thickness was not significantly different before and after CEA in ipsilateral and contralateral eyes. Carotid endarterectomy results in thinning of the superior peripapillary RNFL thickness. To the best of our knowledge, this is the first study to examine peripapillary RNFL and GCC thicknesses before and after CEA.

CREST-2: Identifying the Best Method of Stroke Prevention for Carotid Artery Stenosis: National Institute of Neurological Disorders and Stroke Organizational Update.

One of the great achievements of modern medicine is the successful prevention of stroke and other cardiovascular diseases. Although the incidence of stroke has substantially declined over the last 30 years, ≈200 000 preventable stroke deaths still occur annually in the United States. According to a recent study based on the Greater Cincinnati/Northern Kentucky Stroke Study, annually ≈41 000 strokes in the United States are attributed to extracranial internal carotid artery stenosis. Early revascularization for symptomatic carotid stenosis—that is, in patients with recent ipsilateral stroke or TIA—is well established as effective at preventing ipsilateral stroke. Carotid stenosis in the absence of symptoms is extremely common, but the best treatment is unclear. While 2 randomized trials showed a benefit of carotid endarterectomy (CEA) over antiplatelet therapy with aspirin, the number needed to treat approaches 200. Does aggressive risk factor control change that balance? Population screening for carotid stenosis followed by revascularization is considered to cause net harm. Are complication rates from endarterectomy and stenting now low enough to justify expanding their indications in asymptomatic patients? The National Institute of Neurological Disorders and Stroke (NINDS)–funded CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) is an ambitious attempt to further refine the treatment of asymptomatic carotid stenosis. As one of the largest randomized stroke prevention trials, the first CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) was designed to compare the safety and efficacy of 2 stroke prevention procedures for carotid artery narrowing—CEA and carotid artery stenting (CAS)—in symptomatic and asymptomatic individuals. Starting in December 2000, this NINDS-funded trial enrolled >2500 patients at 117 sites in the United States and Canada. Because of slow enrollment, the trial took 9 years to complete. In 2010, the results of CREST indicated that the 2 revascularization procedures were equivalent for …

Abstract WP126: Transcranial Doppler and Microemboli Detection. Relationships to Symptomatic Status and Histopathology Findings

Introduction: Microemboli, as detected by transcranial Doppler (TCD), are hypothesized to be associated with carotid plaque instability and symptomatic subject status associated with motor, sensory, visual and speech deficits of stroke and transient ischemic attack (TIA). However, the current clinical exam does not assess sequeli of small emboli and probable differences between symptomatic and asymptomatic plaques. The purpose of this study was to determine the relationship between symptomatic status, microemboli presence and histopathology findings. Methods: TCD examination was performed on 60 study subjects for an hour to assess the presence of microemboli, prior to undergoing clinically indicated carotid endarterectomy. Macroscopic scoring for cholesterol, thrombus, calcium and ulceration were performed with a dissecting microscope. Histopathological examination, with high power magnification on fixed plaque was scored for hemorrhage, hemosiderin, inflammation, percent cholesterol and calcium. Pearson’s chi-squared test was used to assess the frequency of microemboli between symptomatic and asymptomatic subjects. Logistic regression was used to analyze the relationship between operative and histopathology plaque findings and presence of microemboli. Results: The frequency of microemboli signals, as detected with TCD, was not significantly different between symptomatic and asymptomatic subject groups (p=0.88) nor was there any difference observed in the macroscopic or histopathology scoring of these plaques (p-values all &gt; 0.05). The presence of microemboli was associated with an ulceration score (regardless of symptomatic or asymptomatic status, p=0.034), with a one level increase in ulceration rating associated with an odds ratio of 5.86 (95% [CI] 1.55, 4.34). Conclusion: These findings suggest that both symptomatic and asymptomatic subjects (with clinical indications for carotid endarterectomy) may have plaque with similar features of instability and ability to create emboli. Thus, identifying new ways to measure plaque instability may provide important information for optimizing treatment to prevent future stroke. It also suggests that present clinical exam does not detect the sequeli of small emboli.

Surgical Treatment of Carotid Artery Stenosis.

The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) have not been established. CEA is more appropriate than CAS if soft atherosclerotic plaques are included in the stenotic lesion, since such soft plaques are associated with a high incidence of ischemic complications during CAS. This report presents our surgical methods and the clinical results of CEA and CAS, and suggests an appropriate treatment strategy using plaque diagnosis, especially for high-risk patients. From January 2001 until December 2013 we surgically treated carotid stenosis in 241 lesions by CEA, and 309 lesions by CAS. The average age of the patients was 70.5 in CEA and 71.4 in CAS. The symptomatic stenosis rate was 67 % and the average stenotic rate was 82 % in CEA; these were 61 % and 66 %, respectively, in CAS. Stenosis of carotid arteries was relieved in all cases after CEA or CAS. Peri-operative mortality with CEA and CAS was 0.4 % (1/241) and 0.3 % (1/309), respectively. Morbidity by ischemic stroke with CEA and CAS was 2.9 % (7/241) and 1.6 % (5/309), respectively. Surgical morbidity was not high in patients with medical risk factors. Carotid stenotic lesions can be treated with comparably low morbidity and mortality rates using CEA and/or CAS even with high risks when appropriate surgical methods are selected, considering each characteristic of carotid stenosis using plaque diagnosis.

The Significance of Cerebral Hemodynamics Imaging in Carotid Endarterectomy: A Brief Review

The indication of carotid endarterectomy (CEA) is principally determined by the presence or absence of symptoms and the degree of stenosis. However, the results of recent studies have implicated the usefulness of cerebral hemodynamics imaging for perioperative assessments. Many studies using single-photon emission computed tomography (SPECT) have demonstrated that cerebral hemodynamics imaging assessments are useful in the prediction and assessment of post-CEA hyperperfusion. In studies using transcranial Doppler ultrasonography, SPECT, or positron-emission tomography (PET), cerebral hemodynamic impairment is highly likely to increase the risk of cerebral infarction in patients with asymptomatic carotid artery stenosis. In other studies using the same modalities, cerebral hemodynamic impairment might be related to cognitive impairment in carotid artery stenosis, and this cognitive impairment might be improved with CEA. Nuclear medicine techniques involve the injection of radioactive tracers. Arterial spin labeling (ASL) is an emerging technique of perfusion magnetic resonance imaging (MRI) for the noninvasive measurement of cerebral perfusion. ASL could detect pathologic states such as hypoperfusion, impaired vasoreactivity, and postoperative hyperperfusion activities that are equivalent to SPECT. In addition, regional perfusion imaging visualizes cerebral perfusion territories by selective ASL. In conclusion, cerebral hemodynamic imaging would be useful for the perioperative assessment of CEA. However, there is a lack of sufficient scientific evidence to confirm the benefits, necessitating further study.

Residual high-grade stenosis after recanalization of extracranial carotid occlusion in acute ischemic stroke.

Residual stenosis after recanalization of an acute symptomatic extracranial occlusion of the internal carotid artery (ICA) might be an indication for carotid endarterectomy. We evaluated the proportion of residual high-grade stenosis (≥70%, near occlusions not included) on follow-up imaging in a consecutive series of patients with an acute symptomatic occlusion of the extracranial ICA. We included patients participating in the Dutch Acute Stroke Study (DUST), who had an acute symptomatic occlusion of the extracranial ICA that was diagnosed on computed tomographic angiography within 9 hours after onset of neurological symptoms. Follow-up imaging of the carotid artery had to be available within 7 days after admission. Of the 1021 patients participating in DUST between May 2009 and May 2013, an acute symptomatic occlusion of the extracranial ICA was found in 126 (12.3%) patients. Follow-up imaging was available in 86 (68.3%) of these patients. At follow-up, a residual stenosis of <30% was found in 15 (17.4%; 95% confidence interval, 10.8-26.9) patients, a 30% to 49% stenosis in 3 (3.5%; 95% confidence interval, 0.8-10.2) patients, a 50% to 69% stenosis in 2 (2.3%; 95% confidence interval, 0.1-8.6) patients, and a ≥70% stenosis in 14 (16.3%; 95% confidence interval, 9.8-25.6) patients. A near or persistent occlusion was present in the remaining 52 (60.5%) patients. A residual high-grade stenosis of the extracranial ICA occurs in 1 of 6 patients with a symptomatic occlusion in the acute stage of cerebral ischemia. Because this may have implications for secondary prevention, we recommend follow-up imaging in these patients within a week after the event. http://www.clinicaltrials.gov. Unique identifier: NCT00880113.

Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Predictors and consequences of unplanned hospital readmission within 30 days of carotid endarterectomy

In the United States, vascular surgeons frequently perform carotid endarterectomy (CEA). Given the resource burden of unplanned readmission (URA), we sought to identify the predictors and consequences of URA after this common vascular surgery procedure to identify potential points of intervention. Using a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA (2001-2011). Demographic and perioperative factors were prospectively collected. The primary end point was 30-day postdischarge URA after CEA. The secondary end point was 1-year survival. We performed a univariable analysis for URA followed by a multivariable Cox model. A Kaplan-Meier analysis was performed for 1-year survival. During the study period, 840 patients underwent 897 CEAs. The 30-day postdischarge overall readmission rate and URA rate were 8.6% and 6.5%, respectively. Most URA patients (n= 42; 73.4%) were readmitted for a CEA-related reason (headache, cardiac, hypertension, surgical site infection, bleeding/hematoma, stroke/transient ischemic attack, dysphagia, or hyperperfusion syndrome). Seventeen patients (29.3%) had more than one reason for URA. Median time to URA was 4days (interquartile range, 1-9days). Postoperative length of stay, indication for CEA, and discharge destination were not associated with URA. In multivariable analysis, in-hospital occurrence of congestive heart failure (hazard ratio [HR], 15.1; 95% confidence interval [CI], 4.7-48.8; P< .001), stroke (HR, 5.0; 95% CI, 1.8-14.0; P< .001), bleeding/hematoma (HR, 3.1; 95% CI, 1.4-6.9; P= .003), and prior coronary artery bypass grafting (HR, 2.0; 95% CI, 1.2-3.5; P= .01) were significantly associated with URA. Patients in the URA group also had decreased survival during 1year (91% vs 96%; P= .01, log-rank). The 30-day URA rate after CEA is low (6.5%). Prior coronary artery bypass grafting and in-hospital postoperative occurrence of stroke, bleeding/hematoma, and congestive heart failure identify those at increased risk of URA, and URA signals increased long-term risk of postoperative mortality.

頚動脈狭窄症に対する外科治療

Although the 2009 guidelines for the treatment of cerebrovascular disease indicate carotid endarterectomy (CEA) as a first-line treatment for patients with carotid stenosis, carotid stenting (CAS) has been performed about twice as often as CEA. Reasons for this finding may include: 1) a lack of surgeons familiar with CEA; 2) scarcity of teaching systems for CEA; and 3) medical or social tendencies toward performing less invasive surgery. However, the number of CEA surgeries has not decreased over the last decade. Indications for CEA or CAS should be determined according to the condition of the patient and the technical skills of the surgeon. Favorable factors for CEA include: 1) unstable plaque; 2) plaque with ulcer; 3) plaque with floating thrombus; 4) plaque with severe calcification; 5) excessively tortuous access route; 6) patients who are considered at excessive risk of needing to stop antiplatelet therapy in the future. To keep CEA as an effective surgical option, surgeons should perform CEA with a complication rate ＜3% and a low restenosis rate, and should create teaching systems for CEA surgeons.

Discharge on the First Postoperative Day after Elective Carotid Endarterectomy

Medical complications may prolong the hospital stay after elective carotid endarterectomy (CEA). We prospectively assessed the social and medical feasibility and safety of patient discharge on the first postoperative day after elective CEA and unplanned readmissions. Between June 2011 and January 2012, 57 consecutive patients scheduled for elective CEA were enrolled with the aim of discharge on the first postoperative day if there were no medical contraindications and on the condition that the patient should not be left alone during the first day and night at home. CEA was carried out under local or general anesthesia. After discharge, the patients were contacted to ascertain the occurrence of arterial hypertension, cerebral hyperperfusion, focal cerebral ischemia, or hospital readmission. Sixty-two CEA were carried out in 57 patients (33 men and 24 women ranging in age from 51-89 years). The indications for CEA were: asymptomatic high grade stenosis in 27, hemispheric transient ischemic attack in 12, amaurosis fugax in 6, recovered stroke in 16, and nonlateralizing signs in 1. There were no cases of perioperative stroke or death. Discharge on the first postoperative day was achieved in 45 cases (73%). In 15 cases (24%), discharge was on the second postoperative day because of the absence of a relative (12 cases) or for medical reasons (3 cases). Discharge was on day 3 in 1 case, and on day 10 in another, both for medical reasons. No cases of severe arterial hypertension, stroke, mortality, or readmission for reasons related to the CEA procedure were recorded up to postoperative day 30. In this study, the majority of patients undergoing elective CEA were discharged safely on the first postoperative day. Social reasons, rather than medical reasons, underlied most cases of later discharge. There were no unplanned readmissions for complications of CEA.

Predictors and Consequences of Unplanned Hospital Readmission Within 30 Days of Carotid Endarterectomy

Carotid endarterectomy (CEA) is the operation vascular surgeons perform most frequently in the US. Given the resource burden of unplanned readmissions (URA), we sought to identify the predictors/consequences of URA within 30 days (d) of CEA for potential points of intervention. Retrospective analysis of consecutive CEAs (2001-2011) at a single institution. Primary endpoint was URA within 30d. Factors crudely associated with URA at P < .05 were included in the stepwise multivariable analysis. Death through 1 year was compared with the log rank test for the Kaplan-Meier estimator. 840 patients underwent 896 CEAs. Median postop LOS was 1 day (interquartile range [IQR], 1-2). Overall 30d readmission rate was 8.6% and URA rate was 6.5%. The most frequent reasons for URA were cardiac, other medical complications and headache. Nearly half of the URA patients (27, 46.5%) were readmitted for a CEA-related reason (headache, cardiac, hypertension, wound infection, bleeding/hematoma, stroke/TIA, dysphagia, hyperperfusion syndrome). 16 (27.5%) patients had more than one reason for URA. Median time to URA was 4d (IQR 1-9). Unadjusted risk factors for URA were history of CAD, CABG, or CHF and postop in-hospital occurrence of stroke, bleeding/hematoma, myocardial infarction or CHF. Hospital LOS, indication for CEA and discharge destination were not associated with URA. In multivariable analysis, prior CABG (adjusted odds ratio [OR], 2.2, 95% CI, 1.2-3.9; P = .009) and postop in-hospital stroke(OR, 7.1, 95% CI, 2.0-25.1; P = .003), bleeding/hematoma (OR, 3.3; 95% CI, 1.4-8.2; P = .009) and CHF (OR, 55.2, 95% CI, 5.5-52.5; P = .006) were significantly associated with URA. URA was associated with increased mortality over 1 year (log rank test, P = .02). The 30-day URA rate after CEA is low (6.5%). Prior CABG and in-hospital postop occurrence of stroke, bleeding/hematoma and CHF identify those at increased risk of URA. URA may signal increased long-term risk of postoperative mortality.