Previous Carotid Endarterectomy Research Articles

704 Different Therapeutic Effects on the Ipsilateral Retinal-choroidal Blood Flow and the Visual Acuity Between Carotid Endarterectomy and Carotid Artery Stentinga

INTRODUCTION: We previously reported that ipsilateral retinal-choroidal blood flow increased, and ipsilateral visual acuity improved after carotid endarterectomy (CEA) for internal carotid artery stenosis. METHODS: Twenty-eight patients who underwent CAS at participating centers were enrolled for this prospective observational study. Retinal-choroidal blood flow was evaluated by Mean Blur Ratio (MBR) with Laser Speckled Flowgraphy before and after CAS. In addition, visual acuity was measured precisely with the CSV-1000 before and after surgery. The MBR was defined as an increase in retinal blood flow above 1.14 based on the results of measurements in normal subjects. RESULTS: MBR significantly increased after CAS (MBR 34.2 vs 34.3, p = 0.02), but there was no improvement in the CSV-1000 score observed after CEA as shown in our previous CEA study (4.8 vs 4.9, p = 0.57). Furthermore, the CSV-1000 score did not improve after CAS even when the evaluation was limited to the group with a significant increase in MBR. CONCLUSIONS: The improvement in visual function after CEA that we have shown in the past was not observed after CAS. One reason for this is that postoperative MRI showed scattered microembolic infarctions after CAS in 17.9% (5 patients), whereas 7.3% after CEA in our previous study, which may have caused micro-occlusion of the retinal arteries. Although a direct comparison cannot be conducted, postoperative microembolism occurred in only 7.3% (3/41 patients) in our previous study that demonstrated improved vision after CEA. We also cannot rule out the possibility that intraoperative microemboli caused the deterioration of higher brain functions such as visual cognition, leading to the decreased score of the CSV-1000. This study might provide details on the therapeutic effects of carotid revascularization other than stroke prevention and may contribute to optimizing treatment choices for individual patients.

Long-term outcomes after lower extremity bypass in the actively smoking claudicant

ObjectiveSmoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. MethodsWe queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). ResultsPropensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS. ConclusionsClaudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.

Long-term Outcomes in the Smoking Claudicant After Elective Lower Extremity Bypass

Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is in general surgery. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. We queried the Vascular Quality Initiative VISION LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 25 clinical variables (age, gender, race, ethnicity, treatment setting, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass grafting, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from target lesion reintervention (FTR) and amputation-free survival (AFS). Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.70-1.24; P = .61), LS (HR, 1.08; 95% CI, 0.63-1.82; P = .80), FTR (HR, 0.95; 95% CI, 0.73-1.23; P = .69), or AFS (HR, 0.93; 95% CI, 0.71-1.2; P = .62) (Fig 1). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI, 0.94-1.97; P = .10) or FTR (HR, 1.02; 95% CI, 0.87-1.19; P = .85). However, we did find a significant increase in OS (HR, 1.37; 95% CI, 1.15-1.64; P < .001) and AFS (HR, 1.38; 95% CI, 1.18-1.62; P < .001) (Fig 2) in FS compared to CS. Claudicants represent a unique nonemergent vascular patient population who can require LEB. Our study found that former smokers have better overall survival and amputation free survival when compared to current smokers, while former smokers mimic never smokers at 5-year outcomes for OS, LS, FTR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before and after LEB and can even be considered a requirement prior to elective LEB procedures in claudicants.Fig 2Amputation-free survival (AFS) (5 years) for former smokers (FS) and current smokers (CS) after propensity score matching.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 14484: Shockwave Lithotripsy as a Non Surgical Modality for Calcified Carotid Stenosis

An 80-year-old gentleman with significant bilateral carotid artery stenosis and previous right carotid endarterectomy underwent a CT Angiogram of the Head and Neck due to multiple episodes of syncope. The study revealed heavily calcified atherosclerotic disease at the left carotid bulb and bifurcation, causing high-grade luminal stenosis of 80 to 82% at the origin of the internal carotid artery. Hence, a decision was made to obtain a cerebral angiogram. Aortic arch angiogram revealed a type III arch, following which a cerebral catheter wire was engaged in the left carotid artery. A selective angiogram showed 80% calcified stenosis at the level of bifurcation, with the left external carotid artery being 100% occluded. Given the heavily calcified lesion, supra core guidewire was crossed across the lesion, followed by advancement of protection device into the distal segment of the left internal carotid artery. Balloon angioplasty was performed twice from the ostial to the proximal segment of the left internal carotid artery. An attempt was made to place a stent without any success. Subsequently, a decision was made to proceed with shockwave lithoplasty. We inserted a transvenous pacemaker with a backup rate of 40 bpm. A Shockwave catheter was inserted and shockwaves were delivered with multiple inflation techniques at 4 atmospheric pressure for 15 seconds each. Periodic neuro assessments were normal. This was followed by the placement of stents in the distal left common carotid and ostial to proximal left internal carotid artery reducing the calcified 80% stenosed lesion to 10% with excellent angiographic results. Subsequently, the filter and the catheter were removed and the femoral artery access site was secured. The patient tolerated the procedure very well without any immediate or delayed complications. The intracerebral vasculature remained intact as confirmed by a cerebral angiogram. TVP was removed and the patient was discharged in a stable condition after 2 days. Hence, Shockwave lithotripsy can be successfully used for critical carotid artery stenosis in patients that pose a high surgical risk. It helps soften the lesion for better dilatation of the vessel and achieve improved luminal gain for appropriate stent expansion.

A single-center experience of 30-day perioperative and one year clinical outcomes of transcarotid artery revascularization in 100 consecutive patients.

Transcarotid Artery Revascularization (TCAR) using the ENROUTE system (Silk Road) has been proposed as a safe and effective alternative to both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Two large registries (ROADSTER 1 and ROADSTER 2) have shown that TCAR has acceptable/low rates of perioperative stroke/death. This study will analyze the 30-day perioperative and 1-year clinical outcomes from a single-center. This is a retrospective analysis of prospectively collected data from SVS/VQI TCAR surveillance project (TSP) of 100 consecutive patients (102 TCAR procedures) done in our institution. These procedures were done for high-risk patients for CEA, which included anatomical (previous CEA, high cervical lesion, neck radiation, stoma, arch type, etc.), physiological (CHF, severe coronary artery disease, COPD on O2 therapy, etc.) and combined anatomical/physiological reasons. These procedures were done by vascular surgeons after receiving the appropriate training. The perioperative stroke, death, and MI rates were analyzed. Kaplan Meyer analysis was used to estimate rate of freedom from stroke/death and the incidence of ≥50% and ≥80% in-stent restenosis at 1year. 100 consecutive high-risk patients for CEA included: 38% anatomical, 44% physiological, and 18% combined anatomical and physiological reasons. The mean age was 72.5years (range 52-90years). Indications for TCAR were 34% for symptomatic lesions (TIA/stroke) and 66% for asymptomatic lesions. Mean ipsilateral treated stenosis was 80.4%. Contralateral ≥50% stenosis/occlusion was present in 31% of patients. Technical success rate was 100%. 92% had pre-stenting PTA and 26% had post-stenting PTA. The mean flow reversal time was 8.5min (range 3-26min). The 30-day perioperative stroke rate was 2.9% (1/67, 1.5% for asymptomatic patients), the stroke/death rate was 2.9%, and stroke/death and MI rate was 3.9% (4/102). Other perioperative complications included cranial nerve injury 3/102 (2.9%), carotid artery dissection (2%), and major hematoma (necessitated operation evacuation) (5.9%). Freedom from stroke rates and stroke/death rates at 1year were: 90% and 89%. Freedom from ≥50% and ≥80% in-stent restenosis rates at 1year were 82% and 90%, respectively. None of these restenosis were symptomatic except two (2/13). Freedom from reintervention rate at 1 year was 98%. Although the perioperative events were somewhat higher than what has been reported in previous registries, TCAR for patients who are high-risk for CEA has a low perioperative stroke and stroke/death rates with satisfactory outcome at 1year. Further long-term data is probably needed to verify long-term outcome.

Anesthetic choice during transcarotid artery revascularization and carotid endarterectomy affects the risk of myocardial infarction

ObjectivePrevious studies have shown no differences in the outcomes of transcarotid artery revascularization (TCAR) performed with general anesthesia (GA) vs local or regional anesthesia (LRA). To date, no study has specifically compared the outcomes of TCAR to those of carotid endarterectomy (CEA) stratified by anesthetic type. The aim of the present study was to identify the effect of the anesthetic type on the outcomes of TCAR vs CEA. MethodsPatients undergoing CEA and TCAR for carotid artery stenosis from 2016 to 2019 in the Vascular Quality Initiative were included. We excluded patients who had undergone concomitant procedures, patients with more than two stented lesions, and patients who had undergone the procedure for a nonatherosclerotic indication. Propensity score matching was performed between the two procedures stratified by the anesthetic type for age, sex, race, presenting symptoms, major comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease), previous coronary artery bypass grafting or percutaneous transluminal coronary intervention, previous CEA or carotid artery stenting, degree of ipsilateral stenosis, the presence of contralateral occlusion, and preoperative medications. Intergroup differences between the treatment groups and differences in the perioperative outcomes were tested using the McNemar test for categorical variables and the paired t test or Wilcoxon matched pairs signed rank test for continuous variables, as appropriate. The relative risk (RR) and 95% confidence intervals (CIs) were estimated as the ratio of the probability of the outcome event for the patients treated within each treatment group. ResultsA total of 65,337 patients were included. Of the 65,337 patients, 59,664 had undergone carotid revascularization under GA (91%). When performed with LRA, TCAR and CEA had similar rates of stroke, death, and MI. However, when performed with GA, patients undergoing TCAR had a 50% decreased risk of MI compared with those undergoing CEA under GA (0.5% vs 1.0%; RR, 0.50; 95% CI, 0.32-0.80; P < .01). When stratified by symptomatic status, patients undergoing TCAR with GA for symptomatic carotid disease had a 67% decreased risk of MI compared with those undergoing CEA with GA for symptomatic disease (0.4% vs 1.2%; RR, 0.33; 95% CI, 0.15-0.75; P < .01). In contrast, no difference was found in the risk of MI between patients undergoing CEA vs TCAR for asymptomatic carotid disease (0.6% vs 0.9%; RR, 0.64; 95% CI, 0.37-1.14; P = .13). ConclusionsThe results from the present study have confirmed previous studies suggesting that TCAR confers a lower risk of MI compared with CEA. However, our findings demonstrated no differences in the MI rates between TCAR and CEA when performed with LRA. Patients undergoing TCAR under GA had lower rates of MI compared with patients undergoing CEA under GA. When stratified by symptomatic status, the benefit of TCAR persisted only for the symptomatic patients.

Transcervical Carotid Artery Stenting With Conduit and Flow Reversal: Pushing the Transcarotid Envelope

The transcervical approach to carotid artery stenting (TCAR) has demonstrated lower periprocedural stroke risk compared to transfemoral access, particularly when using the flow reversal technique. The indications for use of the existing system limit its safe application in cases with unfavorable neck anatomy where the carotid bifurcation is less than 5 cm above the clavicle. We present our initial experience with five patients who underwent TCAR using an adjunctive prosthetic conduit technique augmented with flow reversal. The common carotid artery (CCA) was exposed and a 6-mm transcervical polytetrafluoroethylene conduit was sutured to the proximal CCA and brought out to the anterior chest wall (Figure). This created a long, sTable platform accessible to the conventional TCAR platform. The conduit also allowed for improved control and pushability in short common carotid arteries and difficult internal carotid lesions. Flow reversal was employed via access of the common femoral vein, and each patient was stented without technical complication. The conduit was suture ligated at the CCA with a small stump of prosthetic material left in place. All patients had an American Society of Anesthesiology score of 3. The indication for three of the five cases was asymptomatic restenosis following previous carotid endarterectomy with the other two cases involving symptomatic stenosis in reoperative or previously radiated necks. All procedures were performed under local with sedation with successful deployment of stents and resolution of the stenosis on completion angiogram and postoperative duplex scan. Average operative time was 2 hours and 16 minutes. All patients were discharged home with a less than 48-hour stay. Demographic, procedural, and outcomes information is presented in the Table. There were no periprocedural strokes or mortality. All patients recovered from their procedure without incident and are free from restenosis, major adverse cardiovascular events, or nerve injuries at a median of 7.6 months of follow-up (range 1.5-11.4 months). Transcervical carotid artery stenting with flow reversal via arterial conduit is a safe and feasible technique. This simple modification to existing embolic protection strategies expands the number of patients who are candidates for TCAR and presents an excellent option in patients with complex and challenging cervical and aortic arch anatomy.TableDemographic, procedural, and outcomes informationCase no.Age, yearsSexSide and stenosisOperative indicationComorbidities a and HistoryComplicating factor(s)Operative timeSurveillance, monthsComplications163FLeft80%-99%Asymptomatic RestenosisHTN, AS, obesity, Hx left CEAShort CCA, reoperative, hostile arch1' 45"11None276MLeft <70% (w/ ulcer)Symptomatic CCA ulcerHTN, AFib, Hx CABG, CVA, Hx left CEAShort CCA, hostile arch, reoperative, cardiac risk1' 46"10None386FLeft80%-89%Asymptomatic restenosisHTN, Hx PCI, Hx left CEAShort CCA, hostile arch, reoperative2' 01"5None463MRight80%-99%Symptomatic StenosisHx non-Hodgkins Lymphoma and neck radiationCCA stenosis, irradiated field, contrast allergy, tortuous CCA3' 48" (converted from initial transfemoral access)8Seroma, reoperation at 8 weeks postoperative570FLeft80%-89%Asymptomatic RestenosisHTN, Diabetes, Hx PCI, COPD, chronic kidney disease, Hx Bilateral CEAShort CCA, reoperative2' 00"1.5NoneAFib, Atrial fibrillation; AS, CABG, coronary artery bypass grafting; CCA, common carotid artery; CEA, carotid endarterectomy; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; F, female; HTN, hypertension; Hx, history; M, male; PCI, percutaneous coronary intervention. Open table in a new tab

Treatment of Carotid Restenosis Using Transcarotid Revascularization.

Transcarotid artery revascularization (TCAR) using the ENROUTE Neuroprotection System (Silk Road Medical) is a United States Food and Drug Administration-approved treatment modality for stroke risk reduction in the setting of carotid artery stenosis. The goal of this investigation was to define the real-world outcomes associated with the application of this technique to patients presenting with restenosis after previous carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TF-CAS). Retrospective review of prospectively maintained institutional databases capturing all nontrial TCARs performed between August 2013 and July 2018 using the ENROUTE Neuroprotection System was completed at 3 unaffiliated hospital systems and unified for descriptive outcomes analysis. During the study period, 237 combined TCARs were performed at our respective institutions. Of these procedures, 55 stents were implanted for the indication of restenosis after previous carotid revascularization (47 CEA, 8 TF-CAS). Within the 30-day perioperative period, we observed no ipsilateral strokes or deaths; one patient experienced perioperative myocardial infarction (MI; 1.8%). We noted a 4.8% incidence of postoperative hematoma, but none of these events were clinically significant as no reinterventions were performed in any of the 55 patients. Additionally, we did not observe any cases of stent thrombosis or pulmonary embolus. Mean length of stay was 2.2 ± 2.8 days. Our mean follow-up duration was 15.0 ± 9.2 months. Throughout the follow-up period, we did not observe any additional stroke or MI events. Additionally, there were no cases of in-stent restenosis, thrombosis, or reinterventions. Transcarotid artery revascularization can be performed in patients with restenotic carotid arteries with acceptable rates of ipsilateral stroke, MI, and death as demonstrated in this small multi-institutional series.

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

As the risk of a recurrent neurological event in patients with symptomatic carotid stenosis requiring carotid endarterectomy (CEA) is highest in the early phase after the first neurological event, guidelines recommend operating on these patients as soon as possible or at least within 14 days of their initial event. However, in real world practice this is often not met. The aim of this study is to identify factors that cause hospital dependent delay to CEA. All consecutive patients with symptomatic carotid stenosis undergoing CEA registered in the mandatory Dutch Audit for Carotid Interventions from January 2014 up to and including December 2017 were included in the current analysis. Univariable followed by multivariable logistic regression was used to identify independent factors associated with hospital dependent waiting time, defined as time from the first consultation at any hospital to CEA of more than 14 days. A total of 8620 patients were included. The median time to CEA was 11 days (IQR 8-14). Seventy-eight per cent of patients underwent CEA within 14 days of first hospital consultation. Factors associated with a hospital dependent waiting time longer than 14 days were age (OR 0.99 per year, 95% CI 0.98-0.99), any previous CEA (OR 1.67, 95% CI 1.32-2.09), ocular symptoms as index event (OR 1.31, 95% CI 1.15-1.50), and indirect referral (OR 1.53, 95% CI 1.34-1.73). Hospital surgical volume was not identified as a factor for delay, except for the delay of indirectly referred patients where high volume hospitals reported the shortest delay. This cohort derived from a validated nationwide prospective audit identified younger age, previous CEA, ocular symptoms, and indirect referral as hospital dependent factors for delay. High volume hospitals had a similar hospital dependent waiting time to middle and low volume hospitals. However, high volume hospitals had more indirect referrals, implying that their logistics are more efficiently organised.

Carotid artery stenting: Current state of evidence and future directions.

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.

Autologous Reconstruction of the Carotid Bifurcation: Should We Just Because We Can?

Autologous Reconstruction of the Carotid Bifurcation: Should We Just Because We Can?

Surgical management of extracranial carotid artery aneurysms.

We present the methods and results of the surgical management of extracranial carotid artery aneurysms (ECCA). Postoperative complications including early and late neurological events were analysed. Correlation between reconstruction techniques and morphology of ECCA was assessed in this retrospective study. In total, 32 reconstructions of ECCA were performed in 31 symptomatic patients with a mean age of 59.2 (range 33-84) years. The causes of ECCA were divided among atherosclerosis (n = 25; 78.1%), previous carotid endarterectomy with Dacron patch (n = 4; 12.5%), iatrogenic injury (n = 2; 6.3%) and infection (n = 1; 3.1%). In 23 cases, intervention consisted of carotid bypass. Aneurysmectomy with end-to-end suture was performed in 4 cases. Aneurysmal resection with patching was done in 2 cases and aneurysmorrhaphy without patching in another 2 cases. In 1 case, ligature of the internal carotid artery (ICA) was required. Technical success defined as the preservation of ICA patency was achieved in 31 cases (96.9%). There was one perioperative death due to major stroke (3.1%). Two cases of minor stroke occurred in the 30-day observation period (6.3%). Three patients had a transient hypoglossal nerve palsy that subsided spontaneously (9.4%). At a mean long-term follow-up of 68 months, there were no major or minor ipsilateral strokes or surgery-related deaths reported. In all 30 surviving patients (96.9%), long-term clinical outcomes were free from ipsilateral neurological symptoms. Open surgery is a relatively safe method in the therapy of ECCA. Surgical repair of ECCAs can be associated with an acceptable major stroke rate and moderate minor stroke rate. Complication-free long-term outcomes can be achieved in as many as 96.9 % of patients. Aneurysmectomy with end-to-end anastomosis or bypass surgery can be implemented during open repair of ECCA.

Commentary: The Role of Carotid Angioplasty With Stenting in the Treatment of Restenosis Following Previous Carotid Endarterectomy

Commentary: The Role of Carotid Angioplasty With Stenting in the Treatment of Restenosis Following Previous Carotid Endarterectomy

Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions

Purpose: To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA). Methods: A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s. Results: The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1–180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043). Conclusion: The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.

Lesion-Related Carotid Angioplasty and Stenting with Closed-Cell Design without Embolic Protection Devices in High-Risk Elderly Patients—Can This Concept Work Out? A Single Center Experience Focusing on Stent Design

To compare the performance differences of three carotid artery stents in high-risk elderly patients without embolic protection devices (EPDs) on the basis of stent design, procedure-related complications, conveniences in handling, in-stent restenosis, 30-day outcome, and long-term follow-up. A total of 101 symptomatic internal carotid stenoses of 94 patients were prospectively treated with stent-protected angioplasty to 94 patients. Three closed-cell stents, one of those being hybrid cell design, were chosen depending on vascular anatomy: curved vessel, lesion length > 1 cm: 64 Carotid Wallstent (Boston Scientific, Natick, MA); curved vessel, lesion length < 1 cm: 21 Cristallo Ideale (Invatec, Roncadelle, Italy); straight vessel, lesion length > 1 cm: 16 Xact (Vascular Abbott, Santa Clara, CA). Comparisons of demographics, procedures, and outcomes were performed. The mean age of patients was 73.1 years (standard deviation [SD], ± 7.9; range, 58-87 years), 71% of the patients were older than 70 years and 20% were octogenarians. Male/female ratio was 3.1:1. About 13.9% (14/101) had contralateral internal carotid artery occlusion. Overall peri-interventional complication rate was 2.9% and 30-day mortality rate was 1%. During the long-term follow-up (34 months, range 1-59) no ipsilateral stroke was documented. Ten deaths (three after MI) were recognized. Two in-stent restenosis were detected (> 70% North American Symptomatic Carotid Endarterectomy Trial) during follow-up, one patient was detected with previous carotid endarterectomy. Especially, if individual anatomical variance is considered, lesion-related stent-protected carotid angioplasty with lesion-adapted closed-cell design is an effective, reliable, safe, and comprehensible treatment option in symptomatic patients. Even without EPDs, the rate of complications is low, when compared with symptomatic carotid artery stenosis described in the literature. In-stent restenosis seems to play no significant role in follow-up.

Carotid Artery Stenting for Recurrent Carotid Artery Restenosis After Previous Ipsilateral Carotid Artery Endarterectomy or Stenting: A Report From the National Cardiovascular Data Registry

The purpose of this study was to evaluate and compare outcomes of patients undergoing carotid artery stenting (CAS) for ipsilateral restenosis, after either previous CAS or carotid artery endarterectomy (CEA) (CAS-R group), with those of patients who had CAS performed for de novo carotid atherosclerotic stenosis (CAS-DN group). Therapeutic revascularization strategies to reduce stroke include CAS and CEA. Limited data exist concerning the outcomes of CAS in the setting of previous ipsilateral carotid revascularization. Patients enrolled in the CARE (Carotid Artery Revascularization and Endarterectomy) registry who underwent CAS were identified and separated into 2 groups: those undergoing CAS after previous ipsilateral CEA or CAS (CAS-R group, n = 1,996) and those who had CAS performed for de novo atherosclerotic carotid stenosis (CAS-DN group, n = 10,122). We analyzed the clinical and procedural factors associated with CAS-R and CAS-DN between January 1, 2005, and October 8, 2012. Propensity score matching using 19 clinical and 9 procedural characteristics was used, yielding 1,756 patients in each CAS cohort. The primary endpoint composite of in-hospital death or stroke or myocardial infarction (MI) occurred less often in the CAS-R compared with CAS-DN patients (1.9% vs. 3.2%; p = 0.019). In-hospital adverse cerebrovascular events (stroke or transient ischemic attack) occurred less frequently in the CAS-R cohort (2.2% vs. 3.6%; p < 0.001). However, there was no significant difference in the composite of death, stroke, or MI at 30 days between both groups. Patients who underwent CAS for restenosis after previous ipsilateral revascularization had lower periprocedural adverse event rates and comparable 30-day adverse event rates compared with CAS for de novo carotid artery stenosis.

The effect of ballooning following carotid stent deployment on hemodynamic stability

While patient eligibility for carotid artery stenting (CAS) is well established, the intraoperative technique remains widely varied. The decision to perform poststent ballooning (PSB) is operator-dependent and often influenced by the interpretation of poststent angiography. While visually creating a greater luminal diameter, it is unclear whether PSB has immediate risks or long-term benefits. The purpose of this report is to determine whether PSB has any effects on periprocedural hemodynamic stability. A retrospective analysis of all patients that underwent CAS between 2005 and 2012 at a tertiary care center was performed. The primary end point was hemodynamic instability, defined as bradycardia (a heart rate of <60 beats/min) or hypotension (systolic blood pressure of <90 mm Hg) during the intraoperative or postoperative period. Binary logistic regression model was performed to determine the effect of PSB on the occurrence of hemodynamic instability, adjusting for patient's age, sex, hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, recent myocardial infarction, previous carotid endarterectomy, high-risk status, and symptomatic status. A total of 103 (51 men and 52 women) patients underwent placement of a unilateral carotid stent between 2005 and 2012 at our institution. All patients underwent prestent dilatation. However, 70% (n = 72) underwent PSB whereas 30% (n = 31) did not. PSB was a significant predictor of hemodynamic depression (odds ratio [OR], 3.8; 95% confidence interval, 1.3-11; P < .01). Symptomatic status, recent myocardial infarction, hyperlipidemia, and coronary artery disease were associated with a length of stay exceeding 24 hours postoperatively (OR, 6.6; P < .01, OR, 6.1; P < .01, OR, 5.4; P = .04, and OR, 9.3; P < .01, respectively). At follow-up, 97% (83/86) stents were patent. Two stent stenoses occurred in the group that received PSB, while one stent stenosis occurred in the group that did not receive PSB. PSB increases the risk of intra- or postoperative hemodynamic depression in CAS and might increase the risk of major adverse cardiovascular events. Given the added complications and the lack of evidence supporting long term patency, PSB should be only selectively used.

Risk factor impact on blood flow velocities and clinical outcomes of stented cervical and intracranial stenoses: preliminary observations

ObjectivesThe role of angioplasty/stenting procedures, neurointerventionist experience, vascular risk factors, medical treatment and blood flow velocities were analysed to identify possible causes of intra-stent restenosis (ISR) following stenting of cervical and/or intracranial arteries, assuming progressive atherosclerosis to be the shared mechanism in both territories.Patients. 26 cerebrovascular patients subjected to stenting of severe (≥85%) symptomatic or asymptomatic carotid stenoses or moderate-to-severe (≥50%) intracranial or vertebral stenoses were included. MethodsClinical, radiological and ultrasonographic follow-up data were analysed retrospectively. ResultsOverall, stenting of the internal carotid artery (ICA) induced significant reductions in peak systolic velocities at 2 years (96±31cm/s vs. 358.2±24.9cm/s at baseline). The procedure-related ischemic complications rate was 7.4% (one hemispheric stroke and one TIA). The rate of ISR≤50% was 8% in the ICA at 2 years; was 50% in the common carotid artery (CCA) at 1 year, with concomitant distal ICA stenosis in 75% of CCA stenting, but all ISR were asymptomatic. Patients with ISR of the ICA were significantly younger (56.8±4.5 vs. 71.3±3.6 years, P=0.042) and had significantly more risk factors (5.5±0.9 vs. 3±0.3, P=0.012). No ISR≥70% was detected. ConclusionsISR is relatively infrequent and, when present, it is mild and asymptomatic. Restenosis is more frequent in younger patients and those with several risk factors, and it may also be related to stenting of previous carotid endarterectomy.

Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting

This study evaluated the timing of carotid endarterectomy (CEA) in the prevention of stroke in patients with asymptomatic carotid stenosis >70% receiving a coronary artery bypass graft (CABG). From January 2004 to December 2009, 185 patients with unilateral asymptomatic carotid artery stenosis >70%, candidates for CABG, were randomized into two groups. In group A, 94 patients received a CABG with previous or simultaneous CEA. In group B, 91 patients underwent CABG, followed by CEA. All patients underwent preoperative helical computed tomography scans, excluding significant atheroma of the ascending aorta or aortic arch. Baseline characteristics of the patients, type of coronary artery lesion, and preoperative myocardial function were comparable in the two groups. In group A, all patients underwent CEA under general anesthesia with the systematic use of a carotid shunt, and 79 patients had a combined procedure and 15 underwent CEA a few days before CABG. In group B, all patients underwent CEA, 1 to 3 months after CABG, also under general anesthesia and with systematic carotid shunting. Two patients (one in each group) died of cardiac failure in the postoperative period. Operative mortality was 1.0% in group A and 1.1% in group B (P = .98). No strokes occurred in group A vs seven ipsilateral ischemic strokes in group B, including three immediate postoperative strokes and four late strokes, at 39, 50, 58, and 66 days, after CABG. These late strokes occurred in patients for whom CEA was further delayed due to an incomplete sternal wound healing or because of completion of a cardiac rehabilitation program. The 90-day stroke and death rate was 1.0% (one of 94) in group A and 8.8% (eight of 91) in group B (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.01-0.91; P = .02). Logistic regression analysis showed that only delayed CEA (OR, 14.2; 95% CI, 1.32-152.0; P = .03) and duration of cardiopulmonary bypass (OR, 1.06; 95% CI, 1.02-1.11; P = .004) reliably predicted stroke or death at 90 days. This study suggests that previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis undergoing CABG could prevent stroke better than delayed CEA, without increasing the overall surgical risk.

Effect of carotid sinus nerve blockade on hemodynamic stability during carotid endarterectomy under local anesthesia

To find out whether routine carotid sinus nerve blockade with lidocaine during carotid endarterectomy under local anesthesia results in perioperative changes in blood pressure and heart rate. This was a prospective, randomized, single-center study, conducted in a university hospital. A total of 120 patients undergoing carotid endarterectomy under local anesthesia were randomly assigned to three equal groups. Patients with previous carotid endarterectomy were excluded from the study. During the operation the carotid sinus area was infiltrated as follows: group 1 received 2 mL of 1% lidocaine; group 2 received 2 mL of 0.9% NaCl; and group 3 received no infiltration. The carotid sinus nerve was spared in all patients. Blood pressure and heart rate were invasively monitored during the operation and 12 hours postoperatively over the radial artery cannula. Preoperative values were calculated as a mean of three noninvasive measurements on the day before surgery. Data comprised of arterial blood pressures and heart rates from 32 time point measurements for each patient were analyzed. There was no significant difference among the groups regarding the mean arterial blood pressures and mean heart rates during the follow-up period. There was no significant difference among groups regarding the number of patients that required vasoactive therapy at any time of measurement. Routine infiltration of carotid sinus area with 1% lidocaine during carotid endarterectomy performed under local anesthesia has no significant impact on mean arterial blood pressure and heart rate during the operative procedure and the following 12 postoperative hours.