Severe Carotid Stenosis Research Articles

Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis.

Cerebral hyperperfusion syndrome is a fatal complication that can occur after stent angioplasty in patients with severe carotid artery stenosis. Staged angioplasty can prevent cerebral hyperperfusion syndrome. Conventional staged angioplasty consists of small balloon angioplasty in the first stage and carotid artery stenting in the second stage two to four weeks later. Sometimes, antegrade flow during stage 1 could hardly be maintained and stent will be needed. Solitaire stents were used in some patients in our center. This study aimed to examine the safety and effectiveness of Solitaire stents in staged angioplasty. A retrospective analysis was performed on patients with severe carotid artery stenosis and preoperative computed tomography perfusion indicating risk of cerebral hyperperfusion syndrome from 2011 to 2018. Small balloon angioplasty (<3 mm in diameter) only was performed in stage 1 (group 1). If antegrade flow during stage 1 is compromised, then a solitaire stent is deployed (group 2). After two to four weeks, cerebral angiography was undertaken in both groups to determine whether to perform stage 2. If the residual stenosis was more than 50%, carotid artery stenting was deployed. Angiographic results, clinical results, and follow-up results were collected and analyzed. Twenty-five patients were included in the study (group 1, n = 19; group 2, n = 6). After stage 1, no patient in group 2 and two patients in group 1 developed new symptomatic cerebral infarction (0.0% vs. 10.5%, p = 1.000). One patient in group 2 and three patients in group 1 (16.7% vs. 15.8%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome. One patient in group 2 (n = 4) and three patients in group 1 (n = 12) (25% vs. 25%, p = 1.000) developed hyperperfusion phenomenon. Two patients in group 2 and five patients in group 1 (33.3% vs. 26.3%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome or hyperperfusion phenomenon. One patient in group 1 developed symptomatic cerebral hyperperfusion syndrome and hyperperfusion phenomenon. After stage 2, no new cerebral infarction occurred in both groups. No patient in group 2 (n = 3) and one patient in group 1 (n = 17) developed symptomatic cerebral hyperperfusion syndrome (0.0% vs. 5.9%, p = 1.000). In the combined analysis of both stages, two patients (10.5%) developed new symptomatic cerebral infarction and four patients (21.1%) developed symptomatic cerebral hyperperfusion syndrome in group 1, no patient (0.0%) developed symptomatic cerebral infarction and one patient (16.7%) developed symptomatic cerebral hyperperfusion syndrome in group 2. There was no significant difference in symptomatic cerebral infarction and symptomatic cerebral hyperperfusion syndrome between the two groups (p = 1.000; p = 1.000). Three patients in group 2 and 17 patients in group 1 (50% vs. 89.5%, p = 0.070) underwent stage 2 angioplasty. No cerebral hemorrhage or cerebral infarction occurred in the Solitaire group during the one-year follow-up period. Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis.

SAFETY OF ADEQUATE PREDILATATION IN CAROTID ANGIOPLASTY

Objective: In carotid angioplasty a lot of interventionists avoid predilatation or perform predilatation using smaller diameter balloons to avoid distal embolization. The objective of our study was to determine the procedural safety and complications of predilatation of carotid artery using adequate diameter balloon in patients undergoing angioplasty. Methodology: Symptomatic patients with greater than 50% common carotid artery (CCA) or internal carotid artery (ICA) stenosis, asymptomatic patients with 80% or more carotid stenosis, asymptomatic patients planned for Coronary Artery Bypass Graft Surgery (CABG) with bilateral severe carotid stenosis (70-99%) or a unilateral severe carotid stenosis with a contralateral occlusion undergoing CABG, were selected for carotid artery angioplasty. Cerebral angiogram was performed before and after carotid intervention. Results: A total of 25 patients were included in this study. Adequate diameter balloon used for predilatation before stenting in all cases. Post dilatation was required in 6 (24%) patients. Distal embolic protection device was used in all patients. No complication was seen after predilatation in any case. No mortality or neurological deficit was seen in the study. Conclusion: This study shows that proper predilatation with adequate diameter balloon, sized according to diameter of internal carotid artery, before carotid stent implantation is an effective and safe procedure. We believe that this leads to good stent expansion and full apposition with better long term outcomes. Moreover it is now important to adequately predilate carotid arteries, for proper sizing of carotid stents with close cell design, to avoid unnecessary longitudinal stent lengthening due to inadequately prepared carotid bed.

Validity of ultrasound arterial wall vascularization for assessment of vascular inflammation

Abstract Background Vascular inflammation plays a fundamental role in most vascular diseases including atherosclerosis and vasculitis syndrome, in which arterial wall vascularization (AWV) frequently develops. Visualization of AWV is informative in detecting the vascular inflammation but is challenging. A new ultrasound technique (superb micro-vascular imaging [SMI]) allows the detection of extremely low-velocity flows. We examined an availability of SMI for assessment of the instability of atherosclerotic plaques and the activity of Takayasu arteritis (TA). Methods and results The study consists of two independent and consecutive parts A and B, examined in carotid stenosis (A) and TA (B), respectively. In part A, 12 patients with symptomatic severe carotid stenosis (CS group) scheduled for carotid endarterectomy were enrolled. In six of 12 patients, preoperative ultrasonography with SMI showed intraplaque neovascularization at the plaque shoulder. Postoperatively, histopathology confirmed the neovessels at the corresponding sites of visualized AWV. SMI had a sensitivity of 67%, specificity of 90% for detection of AWV in CS group. In SMI analysis, false positive findings were caused by motion artifact and arterial wall calcification, and a false negative finding is attributed by intraplaque hemorrhage. In part B, 10 patients with TA were enrolled. All patients underwent 18F-FDG-PET/CT, and its vascular uptake were compared with AWV detected by SMI. Bilateral common carotid arteries (CCA), internal carotid arteries and common iliac arteries were examined by SMI. Active vascular 18F-FDG uptake (max SUV &amp;gt;2.1) were found at five sites in three patients, which were not significantly correlated with the prevalence of macaroni sign, increase in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Of note, SMI revealed AWV at five sites corresponding to uptake of 18F-FDG, with a sensitivity/specificity of 100% and 98%, positive predictive value 71%, and a negative predictive value 100%. Conclusion SMI enables visualization of AWV at vulnerable plaque in CS patients and at 18F-FDG positive sites in TA patients. SMI has potential as a modality to detect the vascular inflammation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research, Japan

Outcomes of Carotid Revascularization versus Optimal Medical Treatment Alone for Asymptomatic Carotid Stenosis: Inverse-Probability-of-Treatment Weighting Using Propensity Scores

The benefits and necessity of revascularization for asymptomatic carotid stenosis remains under debate. This study aimed to determine the more durable and beneficial alternative between carotid revascularization and optimal medical treatment (OMT) alone for asymptomatic carotid stenosis. We performed a retrospective analysis of patients with asymptomatic severe carotid stenosis at a tertiary institution between 1994 and 2017. We compared revascularization (carotid endarterectomy [CEA] and carotid artery stenting [CAS]) with OMT alone by using inverse-probability-of-treatment weighting with propensity scores to account for selection bias. The primary end point was a composite of any stroke, myocardial infarction, and death within 30 days, plus ipsilateral stroke thereafter. A total of 1089 patients were included in the analysis (56% CEA, 25% CAS, 19% OMT alone). Patients who underwent CAS consistently showed greater risk regarding the primary composite end point compared with those who received OMT alone (hazard radio [HR] 3.32, 95% confidence interval 1.014-10.868; P= 0.047), but the CEA group showed no significant difference (HR 1.19, 95% confidence interval 0.385-4.584; P= 0.761). The CAS group had the greatest rates of any stroke within 30 days (4.0%, P= 0.0006) and ipsilateral stroke thereafter (3.68%, P= 0.0009). There was no death within 30 days. In the long-term outcomes, neither CEA nor CAS showed significant differences in HR compared with OMT alone. Our study suggests that for stroke prevention in asymptomatic severe carotid stenosis, CAS might be inferior to the other 2 options regarding early outcomes. However, further investigation is required regarding the efficacy and durability of OMT alone.

Early Diagnosis of Carotid Stenosis by Ultrasound Doppler Investigations: A Classification Method for the Hemodynamic Parameter

Pulsed Wave Doppler (PWD) is a traditional ultrasound technique used for the diagnosis of cardiovascular disease. The conventional diagnostic method is based on hemodynamic parameters obtained from the PW spectrum. However, it relies on the clinical experience of sonographers, and especially focusing on severe carotid stenosis. This paper proposes a classification method for the hemodynamic parameter using the RUSBoost algorithm. The proposed method improves the performance of RUSBoost by setting the empirical weight of each sample. The experimental results show that the proposed method reaches the accuracy of 90.1%, the sensitivity of 70%, and the specificity of 94%, which are 4%, 6%, and 2% higher than the original RUSBoost respectively. In addition, the proposed method is objective, since the empirical weights are computed based on Mahalanobis distance without any expert input. It can be used for the early detection of cardiovascular disease.

Anti-Apolipoprotein A-1 IgG Influences Neutrophil Extracellular Trap Content at Distinct Regions of Human Carotid Plaques.

Background: Neutrophils accumulate in atherosclerotic plaques. Neutrophil extracellular traps (NET) were recently identified in experimental atherosclerosis and in complex human lesions. However, not much is known about the NET marker citrullinated histone-3 (H3Cit) expression and functionality in human carotid plaques. Moreover, the association between the proatherosclerotic autoantibody anti-apolipoprotein A-1 (anti-ApoA-1 IgG) and NET has never been investigated. Methods: Atherosclerotic plaques have been obtained from 36 patients with severe carotid stenosis that underwent carotid endarterectomy for severe carotid stenosis. Samples were sectioned into upstream and downstream regions from the same artery segment. Plaque composition and expression of NET markers neutrophil elastase (NE) and H3Cit were quantified by immunohistochemistry. H3Cit expression and function was evaluated by immunofluorescence and confocal analysis in a subset of patients. Results: Pathological features of vulnerable phenotypes were exacerbated in plaques developed at downstream regions, including higher accumulation of neutrophils and enhanced expression of NE and H3Cit, as compared to plaques from upstream regions. The H3Cit signal was also more intense in downstream regions, with significant extracellular distribution in spaces outside of neutrophils. The percentage of H3Cit colocalization with CD66b (neutrophils) was markedly lower in downstream portions of carotid plaques, confirming the extrusion of NET in this region. In agreement, the maximum distance of the H3Cit signal from neutrophils, extrapolated from vortex distance calculation in all possible directions, was also higher in downstream plaques. The serum anti-ApoA-1index positively correlated with the expression of H3Cit in downstream segments of plaques. Expression of the H3Cit signal outside of neutrophils and H3Cit maximal distance from CD66b-positive cells increased in plaques from serum positive anti-ApoA-1 patients compared with serum negative patients. Conclusion: NET elements are differentially expressed in upstream versus downstream regions of human carotid plaques and may be influenced by circulating levels of anti-ApoA-1 IgG. These findings could warrant the investigation of NET elements as potential markers of vulnerability.

Associations Between Carotid Plaque Characteristics and Improvement of Cerebral Blood Perfusion in Patients With Moderate to Severe Carotid Stenosis Undergoing Carotid Endarterectomy

The relationship between plaque characteristics and their predictive value for perioperative cerebral blood flow (CBF) are unknown. To investigate the relationship between carotid plaque characteristics and perioperative CBF utilizing MRI. Prospective. In all, 131 patients with carotid moderate-to-severe stenosis referred for carotid endarterectomy (CEA). 3T, black-blood T1 - and T2 -weighted, 3D time-of-flight, and simultaneous noncontrast angiography intraplaque hemorrhage. The relative CBF (rCBF = CBFindex-hemisphere /CBFcontralateral-hemisphere ) and the CBF difference ratio (DRCBF = [CBFpost-CEA - CBFpre-CEA ]/CBFpre-CEA ) in the middle cerebral artery territory were measured. The pre- and post-CEA CTP data were used as the assessment standard for CBF change. Carotid lipid-rich necrotic core (LRNC), intraplaque hemorrhage, calcification, fibrous cap rupture, maximum wall thickness, normalized wall index (NWI), and stenosis were determined. Pearson or Spearman correlation, Mann-Whitney U-test, and linear regression. Patients with LRNC had higher rCBFpre-CEA than those without (1.0 ± 0.1 vs. 0.9 ± 0.1, P < 0.05). NWI was weakly correlated with rCBFpre-CEA (r = -0.213, P < 0.05) and DRCBF (r = 0.185, P < 0.05) and marginally correlated with rCBFpost-CEA (r = 0.166, P = 0.057). LRNC was weakly correlated with rCBFpre-CEA (r = 0.179, P < 0.05). NWI was associated with rCBFpre-CEA (β = -0.035; 95% confidence interval [CI] [-0.064, -0.006]; P < 0.05), rCBFpost-CEA (β = 0.042; 95% CI [0.002, 0.081]; P < 0.05) and DRCBF (β = 0.105; 95% CI [0.026, 0.185]; P < 0.05). After adjusting for confounding factors, associations of NWI with rCBFpost-CEA (β = 0.059; 95% CI [0.016, 0.103]; P < 0.05) and DRCBF (β = 0.110; 95% CI [0.021, 0.199]; P < 0.05) remained statistically significant, while the association between NWI and rCBFpre-CEA was no longer significant (β = -0.026; 95% CI [-0.058, 0.006]; P = 0.112).The associations of LRNC with rCBFpre-CEA (β = 0.057; 95% CI [-0.0006, 0.114]; P = 0.052) and DRCBF (β = -0.157; 95% CI [-0.314, 0.001]; P = 0.051) were close to statistical significance. After adjusting for confounding factors, these associations were statistically significant (of LRNC vs. rCBFpre-CEA : β = 0.060; 95% CI [0.003, 0.118]; P < 0.05; LRNC vs. DRCBF : β = -0.205; 95% CI [-0.375, -0.036]; P < 0.05). Carotid plaque burden and components, particularly LRNC, might be effective indicators for CBF change following CEA. Level of Evidence 1 Technical Efficacy Stage 5.

C-C Motif Chemokine 8 promotes angiogenesis in vascular endothelial cells.

Angiogenesis is an important progress associated with several pathological situations. Several chemokines have been reported to act as regulators of angiogenesis. The current study aimed to find whether C-C Motif Chemokine 8 is involved in angiogenesis regulation. To verify whether C-C Motif Chemokine 8 is related to angiogenesis in plaques, carotid plaques were collected from patients with severe carotid stenosis and analysed using CD31 immunohistochemistry and real-time PCR. To further clarify the relation between C-C Motif Chemokine 8 and angiogenesis, human umbilical vein endothelium cells and human dermal microvascular endothelial cells were treated with C-C Motif Chemokine 8 in the presence or absence of C-C motif chemokine receptor 2-Ab and extracellular regulated MAP kinase 1/2 inhibition (FR180204). Proliferation and migration of human umbilical vein endothelium cells and human dermal microvascular endothelial cells were examined with Cell Counting Kit-8 and Transwell chamber assay, respectively. In vitro angiogenesis stimulated by C-C Motif Chemokine 8 was examined using tube formation assay. Ex vivo and in vivo angiogenesis were assessed by mice aortic ring assay and Matrigel plug assay, respectively. C-C motif chemokine receptors of human umbilical vein endothelium cells were examined with real-time PCR, and C-C motif chemokine receptor 1, C-C motif chemokine receptor 2, extracellular regulated MAP kinase 1/2 and phosphorylation-extracellular regulated MAP kinase 1/2 were examined with western blotting assay. C-C Motif Chemokine 8 was increased in carotid plaques with severe angiogenesis in both RNA and protein level. C-C Motif Chemokine 8 (5 ng/ml) weakly increased human umbilical vein endothelium cell proliferation, but not on human dermal microvascular endothelial cells. Migration and tube formation could be induced by C-C Motif Chemokine 8 in both human umbilical vein endothelium cells and human dermal microvascular endothelial cells. In mice aortic ring assay and Matrigel plug assay, C-C Motif Chemokine 8 could promote angiogenesis compared to vehicle groups. Phosphorylation of extracellular regulated MAP kinase 1/2 was increased with C-C Motif Chemokine 8 stimulation. The migration and tube formation promoted by C-C Motif Chemokine 8 could be largely blocked by C-C motif chemokine receptor 2-Ab or extracellular regulated MAP kinase 1/2 inhibition (FR180204). C-C Motif Chemokine 8 could promote both in vitro and in vivo angiogenesis. C-C motif chemokine receptor 2 played an important role in the activation of C-C Motif Chemokine 8 and extracellular regulated MAP kinase 1/2 signalling pathway was involved in this mechanism.

Staged angioplasty versus regular carotid artery stenting in patients with carotid artery stenosis at high risk of hyperperfusion: a randomised clinical trial

Background and purposeHyperperfusion (HP) is a devastating complication associated with carotid artery stenting (CAS) or endarterectomy. The efficacy and safety of staged angioplasty (SAP) in patients with CAS at high...

Natural History of Non-operative Management in Asymptomatic Patients with 70%–80% Internal Carotid Artery Stenosis by Duplex Criteria

Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%–80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis.

Hypoglossal Nerve Palsy after Carotid Endarterectomy: Case Report

Carotid artery stenosis is the important causes of ischemic stroke, and it may result in death. Many complications can occur during carotid endarterectomy (CEA), which is the standard revascularization procedure for treating severe carotid artery stenosis. CEA is applied for prevention of stroke occurred by atherosclerotic plaque which is located at the common carotid artery bifurcation and, commonly, internal carotid artery. In addition to serious complications, such as stroke, infection, myocardial infarction, postoperative bleeding and death, non-fatal complications, such as cranial nerve palsy, can also occur rarely. Cranial nerve injury is a well-recognized complication' of carotid endarterectomy. Although major injuries are rare, in several series where thorough pre and postoperative neurologic examinations were performed, the incidence of cranial nerve dysfunction after carotid surgery ranged from 9.7% to 39% Here we present the an 80-year-old male patient with hypoglossal nerve palsy after carotid endarterectomy as it is a rare complication.

Intraoperative Electroencephalographic Changes During Transcarotid Artery Revascularization Are More Frequent Than Previously Reported

Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring require shunt placement because of EEG changes. Initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR. We conducted a retrospective review of patients from May 2017 to January 2020 who received TCAR at two urban hospitals within an integrated health care network. Data included demographic information, patient comorbidities, symptom status, prior carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction, and death) both initially and 30 days postoperatively. Fisher exact test was used for categorical data; continuous data were analyzed with Wilcoxon rank sum. A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) had intraoperative EEG neuromonitoring; 70.8% of patients were male. Median age was 75 years (interquartile range, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who had continuous neuromonitoring, 9 had EEG changes during TCAR (12.7%); changes resolved in 7 patients with pressure augmentation (2), low-flow toggle (2), and unclamping after completion of flow reversal (3). One patient who had sustained EEG changes had a new postoperative neurologic deficit. Median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .009). Neither symptomatic carotid stenosis nor 30-day events were associated with EEG changes during TCAR (P = .49 and P = .57, respectively). Overall, there were three postoperative strokes, two postoperative deaths, and one myocardial infarction for a 30-day stroke/death/myocardial infarction rate of 7.9%. Changes in continuous EEG neuromonitoring were more frequent in our study than previously reported. Less severe carotid stenosis may be associated with a higher incidence of EEG changes. There are limited data on the prognostic ability of electroencephalography to detect clinically relevant changes during TCAR, and further study is warranted.

Long-term stroke risk with carotid endarterectomy in patients with severe carotid stenosis

ObjectiveInformed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system. MethodsAll patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival. ResultsOverall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P < .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P < .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P < .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years. ConclusionsIn a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Natural History of Non-operative Management in Asymptomatic Patients with 70%–80% Internal Carotid Artery Stenosis by Duplex Criteria

Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p=.002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p=.020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p=.004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p<.001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p=.017), non-obese patients (HR 5.49, 95% CI 1.52-20; p=.009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p=.030). Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.

The Risk of Stroke and TIA in Nonstenotic Carotid Plaques: A Systematic Review and Meta-Analysis.

Severe carotid stenosis carries a high risk of stroke. However, the risk of stroke with nonstenotic carotid plaques (<50%) is increasingly recognized. We aimed to summarize the risk of TIA or stroke in patients with nonstenotic carotid plaques. We performed a comprehensive systematic review and meta-analysis in patients with acute ischemic stroke in whom carotid imaging was performed using MEDLINE and the Cochrane Database, including studies published up to December 2019. Included studies had >10 patients with <50% carotid plaques on any imaging technique and reported the incidence or recurrence of ischemic stroke/TIA. High-risk plaque features and the risk of progression to stenosis >50% were extracted if reported. We identified 31 studies reporting on the risk of ipsilateral stroke/TIA in patients with nonstenotic carotid plaques. Twenty-five studies (n = 13,428 participants) reported on first-ever stroke/TIA and 6 studies (n = 122 participants) reported on the recurrence of stroke/TIA. The incidence of first-ever ipsilateral stroke/TIA was 0.5/100 person-years. The risk of recurrent stroke/TIA was 2.6/100 person-years and increased to 4.9/100 person-years if intraplaque hemorrhage was present. The risk of progression to severe stenosis (>50%) was 2.9/100 person-years (8 studies, n = 448 participants). Included studies showed heterogeneity in reporting stroke etiology, the extent of stroke work-up, imaging modalities, and classification systems used for characterizing carotid stenosis. The risk of recurrent stroke/TIA in nonstenotic carotid plaques is not negligible, especially in the presence of high-risk plaque features. Further research is needed to better define the significance of nonstenotic carotid plaques for stroke etiology.

Relationship Between Risk Factors and Carotid Artery Stenosis Prevalence in Patients With Lower Extremity Peripheral Arterial Disease

Introduction: One of degenerative disease is atherosclerosis. Peripheral artery disease (PAD) and carotid artery stenosis (CS) broadly covers vascular disease, both of which can be caused by atherosclerosis. Given the general etiology of peripheral atherosclerosis that can occur in different vascular locations, the presence of disease in one place increases the frequency of symptomatic and asymptomatic disease in another. Because both have the same cause, there is a hypothesis that the two are correlated. The purpose of this study was to determine the risk factors associated with carotid artery stenosis (CS) in patients with lower extremity peripheral artery disease (PAD) and to determine the prevalence of carotid artery stenosis (CS) and the thickness of intimal media thickness (IMT) in patients with lower extremity peripheral artery disease (PAD). Method: This research was conducted at Cipto Mangunkusumo General Hospital during February-May 2018. This study was prospective. Data were taken from secondary data based on history and laboratory results, while the degree of stenosis and intimal media thickness were carried out by carotid duplex ultrasound (DUS) with united imaging ultrasound using a probe 8.5 Mhz. The receiver operating characteristic curve was used to assess the best cut point with sensitivity, specificity, positive predictive value, and negative predictive value. Results: A total of 50 subjects with an age range between 49-80 years (63.8 ± 8.8 years), of which there were 31 male males (62%) and 19 females (38%). There was a correlation between hypercholesterolemia and smoking history with the degree of carotid stenosis (p &lt;0.05), while risk factors for the degree of IMT was not found. The prevalence of mild carotid artery stenosis (CS) was 26 (52%), moderate carotid artery stenosis 15 (30%), severe carotid artery stenosis 9 (18%). In comparison, the IMT value in this study obtained 9 (18%) mild IMT, 22 (44%) moderate IMT, and 19 (38%) severe IMT. Conclusion: In patients with severe PAD, the highest incidence of carotid artery stenosis (CS) was in the mild category (52%). The highest rate of intimal media thickness (IMT) was a medium-size IMT (44%). Carotid artery stenosis (CS) was associated with hypertension, diabetes, hypercholesterolemia, smoking, and a family history of atherosclerosis. In statistical analysis, hypercholesterolemia and smoking history had a relationship with the severity of carotid stenosis. Keywords: Atherosclerosis, carotid artery stenosis (CS), carotid duplex ultrasound (DUS), intimal media thickness (IMT), peripheral arterial disease (PAD)

Atherosclerotic Extension of Carotid Arteries: An Insertion in Clinical Practice.

Introduction Atherosclerotic disease is a diffuse disease that is strongly associated with age, risk factors, and variable progression. The anatomical prevalence of atheromas does not always follow, a sequence by sectors, and in many cases are concomitant. Objectives This study is aimed at studying atherosclerosis in the arterial territories of the carotid and lower limbs, in order to correlate their extension as a form of primary prevention. Methods Participating patients with the main risk factors for atherosclerotic disease were composed of two groups: one with chronic peripheral obstructive arterial disease (PAD) and another without PAD. After performing carotid ultrasound Doppler (USD) of all patients, the occasional prevalence of the disease was evaluated. We performed by statistical tests the correlation between the findings in these patients and the risk factors. Obtaining n from 226 patients, in which 116 patients are from the PAD group and 110 patients are from the group without PAD. Results Our findings add up to 8.8% for lesions over 50% in patients with PAD, with 6.2% over 70% meeting the few published scientific findings. In this study, the correlation was evaluated between carotid stenosis and PAD, in which we observed a positive association. We observed in the studies that the prevalence of moderate and severe carotid stenosis was similar to patients with coronary artery disease (CAD). There are a number of nonclassical risk factors that we do not evaluate, but even studying the traditional ones, we find that they are less than 27% dependent. Conclusion Therefore, our study proposes an improvement in the clinical approach of patients with PAD for both the carotid and coronary territory, not using only 2 factors traditional risk factors, for the extension study and to consider the PAD that has 10% dependence alone, as effect and projection of the carotid atherosclerotic plaque.

Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis.

Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable. The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes. This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity. Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I2 = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I2 = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I2 = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I2 = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I2 = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I2 = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I2 = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I2 = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I2 = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I2 = 0.0%) after a mean follow-up of 47 months. The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.

Evaluation of Peripapillary and Subfoveal Choroid Thickness in Asymptomatic Carotid Artery Stenosis.

ObjectiveIn this study, it aims to investigate the effect of asymptomatic carotid artery stenosis on peripapillary and subfoveal choroid thickness using enhanced depth imaging optical coherence tomography.Patients and MethodsWhile investigating for coronary artery disease, 76 patients with asymptomatic carotid artery stenosis and 35 patients with normal carotid artery (total = 111) were evaluated. Patients according to the degree of stenosis were divided into four categories as non-stenosis (n = 35), mild (n = 26), moderate (n = 27) and severe stenosis (n = 23). Subfoveal and peripapillary choroid thickness, ocular perfusion and intraocular pressures of all patients were measured using a Fourier-domain optical coherence tomography after general ophthalmological examination. In addition, hypertension, hyperlipidemia, and whether there is a relationship between smoking status and choroid thickness was compared.ResultsAs the degree of carotid artery stenosis increased, subfoveal and peripapillary choroidal thickness decreased significantly. However, no changes were detected in ocular perfusion and intraocular pressure values (p=0.935, p=0.519). Decrease in peripapillary and subfoveal choroid thickness values was found to be particularly between the group with severe stenosis and the group with control and mild stenosis (p = 0.003, p = 0.001). In addition, as the degree of carotid stenosis increased in patients with hypertension and smoking, peripapillary choroid thickness was found to be thinner (p=0.003).ConclusionWe believe that the possibility of carotid artery stenosis should be considered in cases with decreased choroid thickness. In addition, we think that even if it is asymptomatic, in cases with severe carotid stenosis, in the presence of choroidal thinning, a chance of surgical intervention should be given to the stenosis.

Outcomes of Transcarotid Artery Revascularization (TCAR) in Octogenarians and Older

Carotid revascularization, both endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS), are associated with an increased risk of adverse outcomes in patients aged ≥80years. Transcarotid artery revascularization (TCAR) is a technique that combines surgical principles of neuroprotection with less invasive endovascular techniques to treat severe carotid stenosis. Data from a recent registry study comparing TCAR with that of CEA and TFCAS demonstrated no significant difference in outcomes between TCAR and CEA in patients aged ≥80years, and a significant reduction in stroke and composite outcomes between TCAR and TFCAS in patients aged ≥80years. To add to these studies, a more in-depth analysis of demographic, procedural, and outcome factors is warranted for elderly patients aged ≥80years undergoing TCAR. At our center, with a large volume of elderly patients based on local demographics, we expect there will be no significant effect of age on outcome measures between patients aged <80 years and those aged ≥80years. Data were collected retrospectively for patients undergoing TCAR for symptomatic (≥50%) or asymptomatic (≥80%) extracranial carotid artery stenosis. Primary endpoints were the incidence of ipsilateral cerebrovascular ischemic event (stroke or transient ischemic attack), myocardial infarction (MI), cranial nerve injury, and death through 30days after the procedure. Secondary endpoints were postoperative length of hospital stay (LOS), procedure time, carotid artery clamp/flow reversal time, and fluoroscopy time. Subgroup analyses were performed to examine the effect of inpatient/outpatient status, carotid symptomatology, and type of anesthesia on secondary outcomes. Ninety-seven TCAR procedures were performed at our institution during the study period, of which 43 (44%) were on patients aged ≥80years. Technical success was achieved in all cases, with no incidence of cerebrovascular ischemic event, MI, cranial nerve injury, or mortality through 30days after procedure. In patients aged ≥80years, the mean procedure time was 47±12min, clamp/flow reversal time was 4.7±1.1min, fluoroscopy time was 4.1±1.6min, and median LOS was 2.0±1.0days. Procedure time, clamp/flow reversal time, and fluoroscopy time were not significantly different between the age groups. However, there was a significant difference in the LOS, with patients aged <80years demonstrating a median LOS of 1.0±0.0days (P = <0.001). Our experience with TCAR confirms that it can be performed successfully in both symptomatic and asymptomatic high-risk elderly patients, with our series finding no incidence of perioperative cerebral ischemic event, MI, or death.