Patients Undergoing Carotid Endarterectomy Research Articles

Diagnostic accuracy of preoperative quantitative susceptibility mapping for detecting histologic intraplaque hemorrhage in cervical ICA stenosis in patients undergoing carotid endarterectomy.

Quantitative susceptibility mapping (QSM) has been proposed to assess intraplaque hemorrhage (IPH) in the carotid artery. The purpose of this study was to compare the diagnostic accuracy of preoperative QSM with that of the conventional T1-weighed (T1W) three-dimensional (3D)-FSE sequence for detecting IPH in cervical ICA stenosis in patients undergoing carotid endarterectomy (CEA) using histology as the reference standard. Carotid T1W 3D-FSE and QSM images were obtained from 16 patients with cervical ICA stenosis before CEA. Relative signal intensity (RSI) and susceptibility of the ICA were measured on three axial images including the location of most severe stenosis on T1W 3D-FSE and QSM images, respectively. Three transverse sections of carotid plaques excised by CEA, which corresponded with images on MRI, were stained with H&E, antibody against glycophorin A and Prussian blue, and the relative area (RA) of histologic IPH was calculated. The correlation coefficient was significantly greater between susceptibility and RA-histologic IPH (ρ = 0.691) than between RSI and RA-histologic IPH (ρ = 0.413; P = .0259). The areas under the receiver operating characteristic curves for detecting histologic sections consisting primarily of IPH (RA-histologic IPH > 40.7%) tended to be greater for susceptibility (0.964) than for T1WI FSE-RSI (0.811). Marginal homogeneity was observed between susceptibility and histologic sections consisting primarily of IPH (P = .0412) but not between T1W FSE-RSI and histologic sections consisting primarily of IPH (P = .1824). Pre-CEA QSM detects histologic IPH in cervical ICA stenosis more accurately than preoperative T1W 3D-FSE imaging. QSM = quantitative susceptibility mapping; IPH = intraplaque hemorrhage; T1W = T1-weighed; 3D = three-dimensional; CEA = carotid endarterectomy; RSI = relative signal intensity; RA = relative area.

Predictors of Prolonged Length of Stay after Elective Carotid Revascularization

Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of > 1 day, after elective carotid revascularization. Patients undergoing carotid endarterectomy (CEA), Transcarotid artery revascularization (TCAR) and Transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of > 1 day, after each procedure. A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the 3 procedures. Age, female sex, nonwhite race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday and postoperative hypo- or hypertension were significantly associated with pLOS across all 3 procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (< 11 cases/year) and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all 3 procedures; CEA (HR,1.64; 95%CI, 1.49-1.82), TCAR (HR,1.56; 95%CI, 1.35-1.80), and TFCAS (HR,1.33; 95%CI,1.08-1.64) (all P<0.05). A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients are risk for pLOS highlight quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Optimization of cerebral oxygenation based on regional cerebral oxygen saturation monitoring during carotid endarterectomy: A Phase III multicenter, double-blind randomized controlled trial

BackgroundWhether the optimization of cerebral oxygenation based on regional cerebral oxygen saturation (rSO2) monitoring reduces the occurrence of cerebral ischemic lesions is unknown. MethodsThis multicenter, randomized, controlled trial recruited adults admitted for scheduled carotid endarterectomy. Patients were randomized between the standard of care or optimization of cerebral oxygenation based on rSO2 monitoring using near-infrared spectroscopy. In the intervention group, in case of a decrease in rSO2 in the intervention, the following treatments were sequentially recommended: (1) increasing oxygenotherapy, (2) reducing the tidal volume, (3) legs up-raising, (4) performing a fluid challenge and (5) initiating vasopressor support. The primary endpoint was the number of new cerebral ischemic lesions detected using magnetic resonance imaging pre- and postoperatively. Secondary endpoints included new neurological deficits and mortality on day 120 after surgery. ResultsAmong the 879 patients who were randomized, 665 (75.7%) were men. There was no statistically significant difference between groups for the mean number of new cerebral ischemic lesions per patient up to 3 days after surgery: 0.35 (±1.05) in the standard group vs. 0.58 (±2.83), in the NIRS group; mean difference, 0.23 [95% CI, -0.06 to 0.52]; estimate, 0.22 [95% CI, -0.06 to 0.50]. New neurological deficits up to day 120 after hospital discharge were not different between the groups: 15 (3,39%) in the standard group vs. 42 (5,49%) in the NIRS group; absolute difference, 2,10 [95% CI, -0,62 to 4,82]. There was no significant difference between groups for the median [IQR] hospital length of stay: 4.0 [4.0 to 6.0] in the standard group vs 5.0 [4.0-6.0] in the NIRS group; mean difference, -0.11 [95% CI, -0.65 to 0.44]. The mortality rate on day 120 was not different between the standard group (0.68%) vs. the NIRS group (0.92%); absolute difference = 0.24% [95% CI, -0.94 to 1.41]. ConclusionsAmong patients undergoing carotid endarterectomy, optimization of cerebral oxygenation based on rSO2 did not reduce the occurrence of cerebral ischemic lesions postoperatively compared with controlled hypertensive therapy. Trial registrationClinicalTrials.gov identifier: NCT01415648.

The MMP-9 promoter genetic variant rs3918242, mRNA and protein expression in advanced carotid plaque tissue.

The MMP-9 is a known player in atherosclerosis, yet associations of the MMP-9 -1562C/T variant (rs3918242) with various atherosclerotic phenotypes and tissue mRNA expression are still contradictory. This study aimed to investigate the MMP-9 -1562C/T variant, its mRNA and protein expression in carotid plaque (CP) tissue, as a risk factor for CP presence and as a marker of different plaque phenotypes (hyperechoic and hypoechoic) in patients undergoing carotid endarterectomy. The MnSOD as an MMP-9 negative regulator was also studied in relation to CP phenotypes. Genotyping of 770 participants (285 controls/485 patients) was done by tetra-primer ARMS PCR. The MMP-9 mRNA expression in 88 human CP tissues was detected by TaqMan® technology. The protein levels of MMP-9 and MnSOD were assessed by Western blot analysis. The MMP-9 -1562C/T variant was not recognized as a risk factor for plaque presence or in predisposing MMP-9 mRNA and protein levels in plaque tissue. Patients with hypoechoic plaques had significantly lower MMP-9 mRNA and protein levels than those with hyperechoic plaque (p = 0.008, p = 0.003, respectively). MnSOD protein level was significantly higher in hypoechoic plaque compared to hyperechoic (p = 0.039). MMP-9 protein expression in CP tissue was significantly affected by sex and plaque type interaction (p = 0.009). Considering the differences of MMP-9 mRNA and protein expression in CP tissue regarding different plaque phenotypes and the observed sex-specific effect, the role of MMP-9 in human atherosclerotic plaques should be further elucidated.

O250: Blood Pressure Homeostasis and Hyper-perfusion Syndrome Following Carotid Surgeries

Abstract Objectives We aim to compare blood pressure homeostasis in patients undergoing bilateral versus unilateral carotid surgeries. Our primary endpoints are the incidence of postoperative hypertension and hyperperfusion syndrome (HPS). Secondary endpoints are major adverse cardiovascular events and all-cause mortality. Methods All patients undergoing carotid endarterectomy (CEA) from 2003 to 2022 were reviewed. We performed 1230 carotid interventions, of which 690 procedures had ten years of follow-up. Results Both the unilateral (512) and bilateral (91) carotid interventions caused a significant acute elevation in blood pressure (p&amp;lt;0.001). In unilateral carotid interventions, the mean SBP was 137 ± 19.90 mmHg preoperatively and 152 ± 25.80 postoperatively (p&amp;lt;0.001). Smoking (p=0.007), hyperfibrinogenemia (p=0.004), emergency admission (p=0.005), ipsilateral carotid stenosis &amp;gt;90% (p=0.022), and previous ipsilateral carotid intervention (p=0.003) were significantly associated with the development of postoperative hypertension. No incidence of HPS occurred in the unilateral group. In bilateral carotid interventions, the mean SBP was 138 ± 20.50 mmHg preoperatively and 159 ± 24.60 mmHg postoperatively (p&amp;lt;0.001). Emergency admission (p=0.012) and plaque morphology (p=0.035) were significantly associated with postoperative hypertension. Three patients with bilateral carotid interventions had HPS (3.3%) and developed hemorrhagic stroke within 30 days. Multivariate analysis found postoperative stage II hypertension following bilateral carotid procedures to be an independent predictor of stroke (p=0.004). However, postoperative hypertension was not an independent predictor of myocardial infarction (p=0.475) and mortality (p=0.608). Conclusion Significant acute elevation in blood pressure occurred following carotid surgeries. We observed HPS post bilateral carotid interventions, with postoperative hypertension being an independent predictor of peri-operative stroke.

Nonpreferential but Detrimental Accumulation of Macrophages With Clonal Hematopoiesis-Driver Mutations in Cardiovascular Tissues-Brief Report.

Clonal hematopoiesis of indeterminate potential (CHIP) is an acquired genetic risk factor for both leukemia and cardiovascular disease. It results in proinflammatory myeloid cells in the bone marrow and blood; however, how these cells behave in the cardiovascular tissue remains unclear. Our study aimed at investigating whether CHIP-mutated macrophages accumulate preferentially in cardiovascular tissues and examining the transcriptome of tissue macrophages from DNMT3A (DNA methyltransferase 3 alpha) or TET2 (Tet methylcytosine dioxygenase 2) mutation carriers. We recruited patients undergoing carotid endarterectomy or heart surgeries to screen for CHIP mutation carriers using targeted genomic sequencing. Myeloid and lymphoid cells were isolated from blood and cardiovascular tissue collected during surgeries using flow cytometry. DNA and RNA extracted from these sorted cells were subjected to variant allele frequency measurement using droplet digital polymerase chain reaction and transcriptomic profiling using bulk RNA sequencing, respectively. Using droplet digital polymerase chain reaction, we detected similar variant allele frequency of CHIP in monocytes from blood and macrophages from atheromas and heart tissues, even among heart macrophages with and without CCR2 (C-C motif chemokine receptor 2) expression. Bulk RNA sequencing revealed a proinflammatory gene profile of myeloid cells from DNMT3A or TET2 mutation carriers compared with those from noncarriers. Quantitatively, CHIP-mutated myeloid cells did not preferentially accumulate in cardiovascular tissues, but qualitatively, they expressed a more disease-prone phenotype.

Modern approaches to perioperative management of patients undergoing carotid endarterectomy in acute period of ischemic stroke

This article presents the Moscow Botkin Hospital experience of using combination of general and superficial cervical plexus regional anesthesia during carotid endarterectomy performed in patients in the acute period of atherothrombotic genesis ischemic stroke. The result of reliable antinociceptive protection of the body from the activation of the sympatho-adrenal system against the background of surgical manipulations was the prevention of episodes of critical hypertension and ensuring normalization of systemic hemodynamics. By reducing the need for opioids, patients’ awakening is accelerated, and their time in the operating room is minimized. In addition, the time of necessary observation in the intensive care unit and the need for anesthesia at the immediate postoperative period, is also reduced. The above factors, as well as a multidisciplinary approach to the patient, allowed not only to provide reliable prevention of recurrent vascular incidents in the acute period of ischemic stroke, but also to improve the neurological outcomes.

Cartoid Near Occlusion: Time to Re-think Endarectomy?

Carotid near occlusion (CNO) treatment is still controversial. In the discussion of surgical revascularization of these patients, periprocedural complications and technical failure should be considered in addition to the long-term results. We examined the efficacy and safety of surgical treatment in CNO and non-CNO patients undergoing carotid endarterectomy (CEA). Data from 152 patients (118 male and 34 female) who underwent isolated CEA between January 2018 and June 2020 without critical contralateral lesions were retrospectively analyzed. Patients were divided into 2 groups: CNO (n = 52) and non-CNO (n = 100). The groups were compared regarding postoperative transient ischemic attack (TIA), ipsilateral ischemic stroke, and mortality. The success rate of the procedure was 100% in the CNO group and 99% in the Non-CNO group. In the Non-CNO group, 1 patient had ipsilateral ischemic stroke on postoperative day 0, and this patient was treated with carotid artery stenting. While the number of patients who died in the non-CNO group was 3 (3%) overall, the exitus rate was 1 (1.9%) in the CNO group (P >.05). In the CNO group, retinal TIA was observed in 1 patient (1.9%), ischemic stroke in 2 patients (3.8%), and TIA in 1 patient (1.9%). In the non-CNO group; Retinal TIA was observed in 1 patient (1.0%), ischemic stroke in 2 patients (2.0%), and TIA in 2 patients (2.0%). There was no statistically significant difference between the groups in terms of postoperative neurologic complications and primary endpoints at 12-month follow-up (P >.05). Carotid endarterectomy is a safe, feasible, and advantageous procedure in selected CNO patients, as in non-CNO carotid artery patients. Therefore, we recommend a surgical approach to prevent neurological events in CNO patients.

Our experiences with carotid artery endarterectomy operations

Aims: In this retrospective study, we aimed to presentour experiences with patients undergoing carotid endarterectomy (CEA) operations. Methods: Between January 2011 and January 2021, a total of 88 patients (27 female, 61 male, mean age; 68.9 ± 8.7 and 41-88 years old) who underwent CEA were included in the study.Patients' files were reviewed.Bilateral CEA was performed in 2 of the patients. The complaints and demographic characteristics of the patients are shown in Table 1 and Table 2, respectively. Coronary artery bypass grafting (CABG) was also performed in 10 (8 of them simultaneously and 2 of them 1 month later)of the patients. In one of these simultaneously operated patients, aortic valve replacement was performed in addition to CEA and CABG. On the other hand, the operation was terminated due to the development of intraoperative sudden cardiac arrest in 2 patients. Results: Polytetrafluoroethylene patch, biological patch, Dacron patch, and great saphenous vein patch were used in 1, 1, 3,and 40 patients, respectively, while the CEA site was primarily closed in 43 patients.Characteristic features ofthe CEA operations are shown in Table 3. Also, complications of CEA surgery are shown in Table 4.In-hospital mortality was detected in 3 patients. Conclusion: The early results of our CEA operations are in line with the literature.

Intraplaque Neovascularization, CD68+ and iNOS2+ Macrophage Infiltrate Intensity Are Associated with Atherothrombosis and Intraplaque Hemorrhage in Severe Carotid Atherosclerosis.

Atherosclerosis is a progressive disease that results from endothelial dysfunction, inflammatory arterial wall disorder and the formation of the atheromatous plaque. This results in carotid artery stenosis and is responsible for atherothrombotic stroke and ischemic injury. Low-grade plaque inflammation determines biological stability and lesion progression. Sixty-seven cases with active perilesional inflammatory cell infiltrate were selected from a larger cohort of patients undergoing carotid endarterectomy. CD68+, iNOS2+ and Arg1+ macrophages and CD31+ endothelial cells were quantified around the atheroma lipid core using digital morphometry, and expression levels were correlated with determinants of instability: ulceration, thrombosis, plaque hemorrhage, calcification patterns and neovessel formation. Patients with intraplaque hemorrhage had greater CD68+ macrophage infiltration (p = 0.003). In 12 cases where iNOS2 predominated over Arg1 positivity, the occurrence of atherothrombotic events was significantly more frequent (p = 0.046). CD31 expression, representing neovessel formation, correlated positively with atherothrombosis (p = 0.020). Intraplaque hemorrhage is often described against the background of an intense inflammatory cell infiltrate. Atherothrombosis is associated with the presence of neovessels and pro-inflammatory macrophages expressing iNOS2. Modulating macrophage polarization may be a successful therapeutic approach to prevent plaque destabilization.

Prevalence and prognostic effects of comorbid coronary artery disease detected in patients undergoing carotid endarterectomy

Abstract Introduction Coronary artery disease (CAD) shares common risk factors with carotid artery stenosis and is a known perioperative risk factor for carotid endarterectomy (CEA). It is feasible to perform CEA with continuation of antiplatelet drugs, including dual antiplatelet therapy. Differing opinions exist with respect to detection of CAD prior to CEA. To support the discussions, we aimed to assess recent prevalence and prognostic effects of comorbid CAD in patients undergoing CEA without known CAD. Methods This single-center prospective cohort study included patients scheduled for elective CEA between 2013 and 2021. Of these, 108 patients without a medical history of CAD (mean age 76.6±7.3 years, 73.1% men) underwent coronary computed tomography angiography (CCTA). Coronary angiography (CAG) and subsequent fractional flow reserve (FFR) estimation were performed where necessary. CAD was defined as total or subtotal occlusion observed on CCTA, ≥75% stenosis on CAG, or lesions with FFR ≤ 0.80 in the major coronary arteries. Optimal medical therapy and/or coronary revascularization was added according to the presence, severity, and extent of CAD. The primary endpoint was MACE (the composite of all-cause mortality, myocardial infarction, or stroke) after CEA. Results The prevalence of comorbid CAD was 19.4% (21 of 108 patients). During a mean follow-up of 4.0 years, the incidence of MACE and stroke was significantly higher in patients with CAD (adjusted HR: 3.10, 95% CI: 1.43–6.71, p=0.0042 and HR: 2.76, 95% CI 1.08–7.31, p=0.041, respectively). Other than patient age, only CAD was a significant predictor of MACE. Conclusions CAD is commonly detected in patients undergoing CEA, and it predicts future MACE and stroke event.

Non-preferential, but detrimental accumulation of macrophages with clonal hematopoiesis-driver mutations in cardiovascular tissues

Abstract Background Clonal hematopoiesis of indeterminate potential (CHIP) is an acquired genetic risk factor of cardiovascular (CV) disease transmitted by myeloid cells. Harboring CHIP is associated with higher risk of coronary artery disease and worse prognosis of congestive heart failure. Studies show that circulating monocytes of CHIP carriers are more pro-inflammatory than those of non-carriers, but to what extend mutant monocytes and their progenies accumulate in the tissue of CV lesions remains unknown. First, we aimed to identify the frequencies of mutant macrophages in human carotid plaque and heart tissues relative to those of mutant monocytes in the patients’ blood. Second, we compared the gene expression profiles of circulating and tissue myeloid cells of CHIP carriers with those from non-carriers. Methods We recruited patients undergoing carotid endarterectomy and aortic valve replacement. Blood and CV tissue (carotid plaque or right atrium appendix) of patients who provided study consents were retrieved during the surgeries and immediately processed for the isolation of lymphocytes and myeloid cells. Whole blood DNA was subjected to CHIP mutation screening. DNA and RNA of eight DNMT3A or TET2 mutation carriers and eight matched non-carriers were isolated from sorted cells. We measured the frequencies of CHIP mutations in each sorted cell type using a droplet-digital PCR method. RNA of the sorted myeloid cells from the carriers and matched non-carriers were subjected to RNA sequencing. Results Our data showed that CHIP-mutant monocytes in the blood is similar to that of CHIP-mutant macrophages in both the plaque (ratio versus monocytes =1.2, p=0.44) and the heart (ratio versus monocytes=0.89, p=0.47), suggesting a comparable ability of mutant and non-mutant monocytes to accumulate in the cardiovascular lesions. Near absence of CHIP clones in lymphocytes (ratio versus monocytes=0.06, p&amp;lt;0.0001) confirmed the myeloid skewing driven by DNMT3A or TET2 mutations. Unexpectedly, we detected similar size of CHIP clones in CCR2-positive and CCR2-negative cardiac macrophages (ratio=0.95, p=0.77), challenging the current paradigm that CCR2-negative cardiac macrophages represent a resident population with minimal monocyte contribution. Transcriptomic profiles of blood and tissue monocytes/macrophages from these carriers were distinct from those of eight matched non-carriers, featuring differentially up-regulated cytokines (eg. IL1B, S100A9) and chemokines (eg. CXCL1, CCL3) in cells from the carriers. Myeloid cells from the carriers up-regulated genes enriching pathways related to immune activation and inflammation. Conclusion Our study manifested the presence of pro-inflammatory CHIP-mutant myeloid cells in human plaque and heart tissues. The equivalent size of CHIP clones in the circulation and tissue suggests a comparable ability of mutant and non-mutant monocytes to accumulate in CV lesions, but inflammation may mediate CHIP-associated CV diseases.

Abstract 17231: Importance of Intra Plaque Hemorrhage During Carotid Artery Revascularization

Introduction: The American Heart Association currently estimates that every 3 minutes a person dies from a stroke. Carotid artery stenosis, a major risk factor for new and recurrent strokes, can be treated with carotid artery revascularization. Vascular emboli released during this procedure are non-invasively detected by transcranial doppler (TCD) ultrasound as micro embolic signals (MES). In this study we aim to show the relationship between carotid plaque characteristics and MES rates that were detected by TCD-monitoring throughout the stages of the carotid artery revascularization procedures. Methods: Before elective carotid revascularization 30 patients (mean age 72±8 years; 16 males, 14 females) underwent 3-T MRI. After localization of the carotid bifurcation using phase contrast imaging, Time-of-Flight, 3D T1 weighting, transverse T1 and T2 weightings and proton density sequences were acquired. The different plaque components: lipid core, intraplaque hemorrhage, calcification and the characterization of the fibrous cap were assessed. While 20 patients underwent carotid endarterectomy (CEA), 10 patients had carotid artery stenting (CAS). CES was divided into 9 stages: 1- Pre-procedure, 2- Dissection, 3- IC clamp, 4- Shunt placement, 5- Shunt open, 6- Endarterectomy, 7- Clamped, 8- IC opened, 9- Post-procedure. Similarly, CAS was divided into 9 stages: 1- Pre-procedure, 2- Arch-carotid angiography, 3- Wire insertion, 4- Filter deployment, 5- Pre-dilation, 6- Stent deployment, 7- Post-dilation, 8- Final angiography, 9- Post-procedure. Patients were monitored continuously with TCD to detect pre-procedural, intra-procedural and post-procedural MES rates. Results: Intraplaque hemorrhage was observed in 18 patients (60%). Patients with intra plaque hemorrhage had more MES during carotid artery dissection/arch-carotid angiography (p=0.028) and IC clamping/wire insertion (p=0.009) compared to patients without intra plaque hemorrhage in the pre-procedural stage. Conclusions: Carotid plaques with intra plaque hemorrhage is associated with higher MES during carotid artery revascularization procedures.

Short-term outcomes after selective shunt during carotid endarterectomy: A propensity score matching analysis

Introduction and objectivesCarotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. Material and methodsFrom January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. ResultsNinety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien–Dindo≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). ConclusionsIn this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien–Dindo≥2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

Reliability of tomographic 3D ultrasound in measuring internal carotid artery plaque volume.

Tomographic 3D ultrasound (t3DUS) is a promise imaging technique for quantifying carotid plaque through measuring the degree of stenosis and plaque volume. Carotid plaque volume (CPV) could add benefit in predicting the potential risk of stroke. To assess the reproducibility and accuracy of t3DUS for measuring CPV within the internal carotid artery in patients undergoing carotid endarterectomy. t3DUS was used to obtain CPV in vivo from 25 symptomatic patients prior to surgery. Ex vivo CPV from the carotid endarterectomy specimen was then measured using a validated saline displacement method as a reference standard. CPV for each patient was measured twice using both methods (total n = 50 per technique). Intraclass correlation coefficient (ICC) and Bland-Altman plot were used to establish bias and limit of agreement between CPV measurements. There was an excellent agreement between t3DUS and reference test with respect to measuring CPV with an ICC value of 0.98 (95% confidence interval=0.97-0.99, P < 0.001). Bias in measurements was 0.02 ± 0.11 cm3 (95% limit of agreement=-0.19 to 0.25). Intra-observer agreement of t3DUS CPV measurements was excellent with an ICC value of 0.95 (95% confidence interval=0.92-0.97, P < 0.001). Bias in measurements was 0.004 ± 0.07 cm3 (95% limit of agreement=-0.14 to 0.15). t3DUS is a reproducible imaging method and showed excellent agreement with the reference standard with respect to measuring CPV. These findings suggest that t3DUS has the potential to be a valuable non-invasive tool for assessing carotid plaque burden and predicting the risk of stroke.

Perioperative cerebral blood flow measured by arterial spin labeling with different postlabeling delay in patients undergoing carotid endarterectomy: a comparison study with CT perfusion.

Arterial spin labeling (ASL) is a non-invasive technique for measuring cerebral perfusion. Its accuracy is affected by the arterial transit time. This study aimed to (1) evaluate the accuracy of ASL in measuring the cerebral perfusion of patients who underwent carotid endarterectomy (CEA) and (2) determine a better postlabeling delay (PLD) for pre- and postoperative perfusion imaging between 1.5 and 2.0 s. A total of 24 patients scheduled for CEA due to severe carotid stenosis were included in this study. All patients underwent ASL with two PLDs (1.5 and 2.0 s) and computed tomography perfusion (CTP) before and after surgery. Cerebral blood flow (CBF) values were measured on the registered CBF images of ASL and CTP. The correlation in measuring perioperative relative CBF (rCBF) and difference ratio of CBF (DRCBF) between ASL with PLD of 1.5 s (ASL1.5) or 2.0 s (ASL2.0) and CTP were also determined. There were no significant statistical differences in preoperative rCBF measurements between ASL1.5 and CTP (p = 0.17) and between ASL2.0 and CTP (p = 0.42). Similarly, no significant differences were found in rCBF between ASL1.5 and CTP (p = 0.59) and between ASL2.0 and CTP (p = 0.93) after CEA. The DRCBF measured by CTP was found to be marginally lower than that measured by ASL2.0_1.5 (p = 0.06) and significantly lower than that measured by ASL1.5_1.5 (p = 0.01), ASL2.0_2.0 (p = 0.03), and ASL1.5_2.0 (p = 0.007). There was a strong correlation in measuring perioperative rCBF and DRCBF between ASL and CTP (r = 0.67-0.85, p < 0.001). Using CTP as the reference standard, smaller bias can be achieved in measuring rCBF by ASL2.0 (-0.02) than ASL1.5 (-0.07) before CEA. In addition, the same bias (0.03) was obtained by ASL2.0 and ASL1.5 after CEA. The bias of ASL2.0_2.0 (0.31) and ASL2.0_1.5 (0.32) on DRCBF measurement was similar, and both were smaller than that of ASL1.5_1.5 (0.60) and ASL1.5_2.0 (0.60). Strong correlation can be found in assessing perioperative cerebral perfusion between ASL and CTP. During perioperative ASL imaging, the PLD of 2.0 s is better than 1.5 s for preoperative scan, and both 1.5 and 2.0 s are suitable for postoperative scan.

Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis

Introduction and objectivesCarotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. Material and methodsFrom January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. ResultsNinety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien–Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). ConclusionsIn this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien–Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

1071 Examining Blood Lipid Profiles and Lipid Lowering Therapy in Carotid Surgery Patients in a 1-Year Follow-Up Study

Abstract Aim Stroke patients are at a high risk of future major adverse cardiovascular events. Focusing on lipid lowering therapy (LLT), current ESVS and NICE guidelines advise high intensity statin (HIS) treatment with a target LDL-C of less than 1.8mmol/L. Method This is a retrospective cohort study on 205 patients who underwent carotid endarterectomy or stenting from 01/01/18 to 31/12/20 at Leeds Vascular Institute. Prescriptions and lipid profiles prior to intervention, at discharge, and 1-year post-intervention were recorded. Differences between time points were assessed using the McNemar test. Results There were 137 men, the median age was 73, and 175 patients underwent carotid endarterectomy. Increases in prescriptions of statins (65%vs93%, p&amp;lt;0.001) and HIS (47%vs83%, p&amp;lt;0.001) were observed at discharge compared to pre-intervention but no differences were seen at 1 year. At 1 year, 8 patients were not on statin therapy; 6 were intolerant and 3 were prescribed Ezetimibe. At 1 year, there was a significant improvement in median LDL-C (2.4mmol/L IQR (1.9-3.3) vs. 1.6mmol/L (1.2-2.0)), and proportion of patients reaching target LDL-C of &amp;lt;1.8mmol/L (21%vs59%,p = 0.003) compared to pre-admission. In patients with LDL-C≥1.8mmol/L, 92% had scope for LLT up-titration. No significant differences were noted in the proportion of patients who underwent lipid profile monitoring prior to admission and at 1 year. Conclusions Admission to our local vascular unit is associated with an increase in the guideline-directed prescription of LLT, and subsequently attainment of target LDL-C. Reasons for suboptimal lipid monitoring in the community need to be understood to allow for optimal risk reduction.

Amplified inhibition of atherosclerotic plaque-induced platelet activation by glenzocimab with dual antiplatelet therapy

BackgroundAspirin and platelet P2Y12 inhibitors, such as ticagrelor, suboptimally inhibit microvascular thrombosis during ST-elevation myocardial infarction. Glycoprotein (GP) IIb/IIIa inhibitors may further inhibit this but cause excessive bleeding. ObjectivesWe investigated whether combination of glenzocimab, a GPVI inhibitor, with aspirin and ticagrelor provides additional antithrombotic effects, as GPVI has a critical role in atherothrombosis but minimal involvement in hemostasis. MethodsWe investigated the effects of glenzocimab (monoclonal antibody Fab fragment) using blood from healthy donors and patients with acute coronary syndrome treated with aspirin and ticagrelor. Platelets were stimulated with multiple agonists, including atherosclerotic plaque, from patients undergoing carotid endarterectomy. ResultsAspirin and ticagrelor partially inhibited atherosclerotic plaque-induced platelet aggregation by 48% compared with control (34 ± 3 vs 65 ± 4 U; P < .001). Plaque-induced platelet aggregation, adhesion, secretion, and activation were critically dependent on GPVI activation. Glenzocimab alone reduced plaque-induced aggregation by 75% compared with control (16 ± 4 vs 65 ± 4 U; P < .001) and by >95% when combined with aspirin and ticagrelor (3 ± 1 vs 65 ± 4 U; P < .001). Glenzocimab reduced platelet aggregation, adhesion, and thrombin generation when added to blood of aspirin- and ticagrelor-treated patients with acute coronary syndrome. Glenzocimab shared several antithrombotic effects with the GPIIb/IIIa inhibitor eptifibatide with less effect on general hemostasis assessed by rotational thromboelastometry. In a murine intravital model of ST-elevation myocardial infarction, genetic depletion of GPVI reduced microvascular thrombosis. ConclusionAddition of glenzocimab to aspirin and ticagrelor enhances platelet inhibition via multiple mechanisms of atherothrombosis. Compared with a GPIIb/IIIa inhibitor, glenzocimab shares multiple antithrombotic effects, with less inhibition of mechanisms involved in general hemostasis.

Serum sLOX-1 levels negatively correlate with gray-scale median (GSM) scoring in patients undergoing carotid endarterectomy

Serum sLOX-1 levels negatively correlate with gray-scale median (GSM) scoring in patients undergoing carotid endarterectomy