Severe Carotid Artery Disease Research Articles

In-stent restenosis estimation following carotid artery stenting: The robust predictive value of atherogenic index of plasma and other non-traditional lipid profiles.

Atherosclerotic carotid artery stenosis is a significant contributor to ischemic strokes, and carotid artery stenting (CAS) has emerged as a pivotal treatment option. However, in-stent restenosis (ISR) remains a concern, impacting the long-term patency of CAS. This study aimed to investigate the predictive value of non-traditional lipid profiles, including the atherogenic index of plasma (AIP), in ISR development. This retrospective single-center study involved patients presenting at a tertiary healthcare facility with severe carotid artery disease between 2016 and 2020 who subsequently underwent CAS. A total of 719 patients were included in the study. The study cohort was divided into ISR and non-ISR groups based on restenosis presence, confirmed by angiography following ultrasonographic follow-up assessments. Non-traditional lipid indices, such as AIP, atherogenic index (AI), and lipoprotein combined index (LCI), were evaluated along with traditional risk factors. During a 24-month follow-up, ISR occurred in 4.03% of patients. To determine the predictors of restenosis, three different models were constructed in multivariate analysis for non-traditional lipid indices. Multivariate analysis revealed AIP as a robust independent predictor of ISR (OR: 4.83 (CI 95 % 3.05-6.63, p < .001). Notably, AIP demonstrated superior predictive accuracy compared to AI and LCI, with a higher Area Under the Curve (AUC) of 0.971. Non-traditional lipid profiles, especially AIP, were found to be associated with an increased risk of ISR and may serve as predictors of ISR in patients undergoing CAS.

ALT Free Flap Coverage after Carotid Endarterectomy in the Setting of Severe Radiation Changes

Summary: Carotid endarterectomy with patch angioplasty is commonly performed for severe atherosclerotic disease to reduce stroke risk. After neck radiation, loss of tissue planes; reactive fibrosis of skin; contraction; and rarely, necrosis of skin may occur, leading to severe wound complications and possible exposure of carotid artery reconstruction. Historically, local myocutaneous flaps have been performed to provide soft tissue coverage; however, these procedures may be associated with increased donor site morbidity and can be affected by radiation changes. This report describes the novel use of a fasciocutaneous free flap for durable vascularized soft tissue, and the associated secondary benefit of improved suppleness and range of motion. Additionally, the distant location of the donor site allows for an efficient two-team approach. Here, we describe a patient with severe carotid artery disease with a history of multiple surgical procedures and radiation, which was successfully treated with a carotid endarterectomy and bovine patch angioplasty by vascular surgery and immediate free anterolateral thigh flap coverage by our team.

Abstract 116: Reversal of Acute Ocular Ischemic Syndrome Following Rescue Carotid Revascularization: A Case Report

Introduction Ocular ischemic syndrome (OIS) is a rare, vision‐threatening condition resulting from severe carotid artery disease secondary to severe atherosclerosis or arteritis. Common clinical features include acute/subacute to gradual vision loss, ocular pain, amaurosis fugax, photophobia and diplopia. We are presenting a case of acute ocular ischemic syndrome secondary to acute re‐occlusion of the right internal carotid artery (RICA) post Carotid Endarterectomy (CEA), that reversed with carotid revascularization. Methods Case Summary: 59‐year‐old male with history of T2DM, hyperlipidemia, tobacco use presented to an outside hospital with complaints of dizziness, blurry vision, left upper extremity weakness and multiple falls with head trauma. Exam revealed left lower quadrantanopia, mild left arm weakness and left hemineglect. Computed Tomography (CT) Head showed scattered right middle cerebral artery (MCA) territory infarcts. CT Angiography (CTA) revealed ulcerated plaque with a small focus of thrombus intraluminally in the RICA. Subsequently, the patient was initiated on heparin infusion and underwent CEA. On postoperative day (POD) 2, the patient experienced severe stabbing right eye pain with reduced visual acuity and worsening of left arm weakness. Imaging revealed complete occlusion of the right common carotid artery (RCCA). Perfusion imaging did not reveal a core or a penumbra. Given acute loss of vision likely secondary to ocular ischemic syndrome, decision was taken to proceed with rescue stenting. Using a transfemoral approach, an 8‐French balloon guide catheter was advanced into the proximal RCCA. A primary suction thrombectomy was performed under proximal flow arrest. After achieving a complete recanalization in one pass, we started the patient on cangrelor 30 mcg/kg intravenous bolus followed by 4 mcg/kg/min infusion. Post bolus, we placed a tandem closed‐cell carotid stent measuring 8x36mm &amp; 10x37mm. The patient reported immediate relief of ocular pain, vision and weakness following the procedure. He transitioned from cangrelor infusion to ticagrelor 90 mg twice daily and aspirin 81 mg daily. On post‐stenting day 7, the patient experienced acute onset headache, and imaging revealed re‐occlusion of the entire carotid artery sparing only the ophthalmic segment of the RICA which now filled retrograde via anterior communicating artery (AcoA) from the contralateral carotid artery. However, his visual acuity remained unchanged and reported no ocular pain. At one month follow‐up the patient remains symptom‐free. Results Discussion: Incidence of OIS is estimated to be 7.5 cases per million every year. Carotid artery atherosclerosis is the most common etiology. Majority of OIS (∼90%) present with gradual vision loss and approximately 40% present with ocular pain. Gradual vision loss is predominantly related to chronic ocular hypoperfusion and resultant iris neovascularization and glaucoma. In this case, patient suffered acute vision loss secondary to acute ICA occlusion following CEA. Emergent carotid revascularization resulted in restoration of vision and resolution of ocular pain. Conclusion Our main goal is to emphasize the importance of rescue stenting to address symptoms of aOIS. Immediately post‐stenting, there was remarkable improvement in ocular pain and visual acuity. Although, the carotid re‐occluded within seven days post‐stenting, we hypothesize that gradual re‐occlusion while on DAPT provided enough time recruit and preserve collaterals into the right ophthalmic artery via retrograde flow into the ophthalmic segment of RICA from the contralateral carotid artery via the AcoA which was subsequently confirmed on imaging.

Carotid Artery Involvement in Patients Undergoing Coronary Angiography with Diabetes Mellitus

Background: Carotid artery disease would be high in patients having coronary artery disease with diabetes mellitus. Objective: The purpose of the present study was to see frequency, pattern and severity of carotid artery disease among patients with IHD and diabetes mellitus. Methodology: This case-control study was conducted in Department of Cardiology, UCC, BSMMU from July, 2007 to June 2009. Total 100 patients were included in this study. Of them 50 patients were coronary artery disease with diabetes mellitus and another 50 patients were coronary artery disease without diabetes mellitus. Both group were underwent coronary and carotid angiography. Coronary artery stenosis is assessed by different scoring system and carotid artery stenosis are categorized as mild (&lt; 50% stenosis) moderate (50-69% stenosis) and critical (&gt;_ 70% stenosis). Moderate and critical stenosis was considered as significant carotid artery disease. Morphological character of the lesion was also assessed. Results: The mean age was found 57.48 years with 6.04 standard deviation (SD) in DM and 55.64 years with 6.34 standard deviation in NDM group and also 56.56 years with 6.49 standard deviation in the whole study population. the indications of CAG were Post MI evaluation, unstable angina, stable angina, chest pain evaluation and positive ETT were 42.0%, 20.0%, 18.0%, 10.0% and 10.0% in DM group and 32.0%, 28.0%, 20.0%, 8.0% and 12.0 in NDM group respectively. LAD was the commonest artery involved (86.0%), followed by RCA (82.0%), LCX (68.0%) and LM (6.0%) in DM study subjects. Among the NDM LAD artery involved (76.0%), followed by RCA (72.0%), LCX (64.0%) and LM (4.0%) in NDM study subjects. Conclusion: In conclusion, patients of coronary artery disease with diabetic mellitus are having higher frequency and severity of Carotid artery disease than non-diabetic coronary artery disease patients. Journal of National Institute of Neurosciences Bangladesh, January 2023;9(1):30-34

Relationship between blood viscosity and existence and severity of carotid artery plaque.

Accumulating evidence shows that the increase in blood viscosity (BV) is an independent risk factor for atherosclerosis and its related diseases, but as far as we know, there are few studies on the relationship between blood viscosity and carotid plaque severity. Therefore, we aimed to investigate the relationship between blood viscosity and the presence of carotid plaques, and further explore its relationship with the severity of carotid plaques. We retrospectively analyzed the data of consecutive subjects in the physical examination center of the Affiliated Hospital of Ningbo University Medical College from January 2022 to May 2022.The parameters of blood viscosity include the whole blood viscosity (WBV) at high, middle, and low shear rate, plasma viscosity (PV), hematocrit (HCT), rigidity "k", rigidity index (RI), aggregation index (AI) and electrophoresis rate (ER), and standardized BV calculated by Quemada's equation were included in the study. Carotid plaque score (CPS) was used to measure the severity of carotid artery disease, and participants were divided into mild, moderate, and severe groups according to the quartile of the score. Independent samples t-test and one-way ANOVA were used to compare normally distributed continuous variables between two or more independent groups, respectively. Binary logistic regression was used to evaluate the risk factors of carotid plaque. 314 men were enrolled in the study, of which 165 participants were diagnosed with Carotid artery plaque (CAP) (66.9%). Compared with the CAP- group, the WBV and PV of the CAP+group decreased, but the difference only existed in the PV (p = 0.001). However, standardized BV values (HCT set at 0.45) were higher in the CAP+group than in the CAP- group (3.8643±0.35431vs 3.9542±0.64871, p = 0.188). Regarding the rigidity and aggregation of RBC, the parameters including rigidity "k", RI, AI and ER increased in the CAP+group compared with the CAP- group. The difference was statistically significant in k and ER (p = 0.04, p = 0.009). To assess the severity of carotid plaque, we divided the participants into mild, moderate, and severe groups by using the tertile of CPS value. The mild group was defined as CPS≤0.5 (n = 108), the moderate group as 0.5 < CPS≤1.7 (n = 105), and the severe group as CPS > 1.7 (n = 101). It was found that WBV and PV decreased with the increase of plaque severity, but the difference among the three groups was significant in PV (F = 8.073, p < 0.0001). In addition, with the severity of plaque from mild to severe, standardized BV gradually increased, which were 3.8611±0.34845, 3.8757±0.36637, 3.9007±0.38353 respectively. The difference between the groups was close to statistically significant (F = 2.438, p = 0.089). The values of parameters describing erythrocyte aggregation and rigidity increased among the mild, moderate, and severe groups. The difference was statistically significant in RBC rigidity "k" and ER of RBC (F = 3.863, p = 0.022; F = 5.897, p = 0.003, respectively). Increased blood viscosity is a risk factor for carotid plaque, but its increase may be hidden by decreased hematocrit. Therefore, it is necessary to comprehensively analyze various parameters of blood viscosity, such as the standardized BV calculated by Quemada's equation, which may provide more useful reference value.

Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery

There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB. A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation. From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days. Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.

Subclavian to carotid artery bypass for a case of ocular ischemic syndrome.

Ocular Ischemic Syndrome (OIS) is a rare, vision threatening condition associated with severe carotid artery disease. There are few cases of OIS reported in the literature. We present the case of a 54-year-old male with history of multiple previous carotid interventions including a right carotid stent, who presented with right-sided OIS. CTA and angiogram showed a severe calcific plaque causing restenosis of the right carotid stent, with a patent right internal carotid artery (ICA) in the very distal neck. The right common carotid artery (CCA) was patent but diseased with ulcerated plaque extending proximally to below the level of the clavicle. The left CCA was chronically occluded from its origin all the way to the bifurcation. Given our patient's surgical history, the imperative to revascularize the ipsilateral carotid, and a diffusely diseased ipsilateral CCA, he was successfully treated with an ipsilateral subclavian to internal carotid bypass. There is paucity of data regarding the best approach for carotid revascularization in OIS. This case report discusses our unique perioperative decision making as well as relevant literature.

Quantification of new intracerebral lesions on diffusion-weighted magnetic resonance imaging after transcarotid artery revascularization for treatment of carotid artery stenosis

Transcarotid artery revascularization (TCAR) has been used with increasing prevalence for treatment of carotid artery stenosis. TCAR holds potential benefits over traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting by its nature of being less invasive than CEA but more neuroprotective than transfemoral carotid artery stenting. The purpose of this pilot study is to evaluate the effectiveness of the neuroprotection system of TCAR with flow reversal by quantifying the incidence and degree of new intracerebral lesions using diffusion-weighted magnetic resonance imaging (DW-MRI). This study is the first to evaluate these findings in a real-world, high-risk cohort, who would have been excluded from the ROADSTER and ENROUTE transcarotid neuroprotection system DW-MRI studies. Patients undergoing unilateral TCAR for symptomatic or asymptomatic severe internal carotid artery disease were eligible and prospectively enrolled in the study. All patients had high risk features, including comorbidities or medications, which excluded them from industry-sponsored DW-MRI trials. Patients underwent a preoperative DW-MRI to obtain a baseline intracerebral evaluation within 1 week of the scheduled surgery. The follow-up DW-MRI occurred within 48hours postoperatively. The primary outcome was new, acute postoperative lesion(s) identified on DW-MRI. Secondary outcomes include any major stroke, myocardial infarction, or death during hospitalization. Five consecutive patients underwent TCAR with preoperative and postoperative imaging. All five patients were on dual antiplatelet therapy before their procedure and verified to be therapeutic on these agents. All patients underwent a right-sided TCAR and three were symptomatic as the indication for their procedure. All five patients demonstrated chronic lesions on the preoperative DW-MRI. Technical success was achieved in all five patients, with one operative complication involving a dissection of the common carotid at the access site, which was stented using the TCAR system. Postoperative DW-MRI did not identify any new intracerebral lesions in any patient following the procedure. No patient had a stroke, myocardial infarction, or death during hospitalization. In this real-world, high-risk cohort, TCAR was completed with no evidence of new, postoperative DW-MRI lesions. These data further demonstrate that TCAR with flow reversal is an effective neuroprotective strategy for carotid revascularization. Further study is warranted to evaluate DW-MRI differences between TCAR and CEA.

Impact of neighborhood social disadvantage on carotid artery disease presentation, management, and discharge outcomes

ObjectiveRecent studies have highlighted that race and socioeconomic status serve as important determinants of disease presentation and perioperative outcomes in carotid artery disease. However, these investigations only focus on individual factors of social disadvantage, and fail to account for community factors that may drive disparities. Area Deprivation Index (ADI) is a validated measure of neighborhood adversity that offers a more comprehensive assessment of social disadvantage. We examined the impact of ADI ranking on carotid artery disease severity, management, and postoperative outcomes. MethodsWe identified patients who underwent carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR) in the Vascular Quality Initiative registry between 2016 and 2020. Patients were assigned ADI scores of 1 to 100 based on zip codes and grouped into quintiles, with higher quintiles reflecting increasing adversity. Outcomes assessed included disease presentation, intervention type, and discharge patterns. Logistic regression was used to evaluate independent associations between ADI quintiles and these outcomes. ResultsAmong 91,904 patients undergoing carotid revascularization, 9811 (10.7%) were in the lowest ADI quintile (Q1), 18,905 (20.6%) in Q2, 25,442 (27.7%) in Q3, 26,099 (28.4%) in Q4, and 11,647 (12.7%) in Q5. With increasing ADI quintiles, patients were more likely to present with symptomatic disease (Q5, 52.1% vs Q1, 46.6%; P < .001), and stroke vs transient ischemic attack (Q5, 63.1% vs Q1, 53.5%; P < .001); they also more frequently underwent CAS vs CEA (Q5, 46.4% vs Q1, 33.9%; P < .001), and specifically tfCAS vs TCAR (Q5, 54.2% vs Q1, 33.9%; P < .001). In adjusted analyses, higher ADI quintiles remained as independent risk factors for presenting with symptomatic disease and stroke and undergoing CAS and tfCAS. Across ADI quintiles, patients were more likely to experience death (Q5, 0.8% vs Q1, 0.4%; P < .001), stroke/death (Q5, 2.1% vs Q1, 1.6%; P = .001), failure to discharge home (Q5, 11.5% vs Q1, 8.0%; P < .001) and length of stay >2 days (Q5, 33.3% vs Q1, 26.3%; P < .001) following revascularization. ConclusionsAmong carotid revascularization patients, those with greater neighborhood social disadvantage had greater disease severity and more frequently underwent tfCAS. These patients also had higher rates of death and stroke/death, were less frequently discharged home, and had prolonged hospital stays. Greater efforts are needed to ensure that patients in higher ADI quintiles undergo better carotid surveillance and are treated appropriately for their carotid artery disease.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery

The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Is thyroid-stimulating hormone a predictor of severity of carotid artery disease?

The relationship between thyroid function and carotid artery stenosis in euthyroid patients is controversial. Therefore, we aimed at evaluating the relationship between the severity of carotid artery disease (CAD) and thyroid-stimulating hormone (TSH) levels in euthyroid patients. A total of 90 euthyroid patients with CAD were trichotomized into three groups based on CAD severity. Group 1 comprised patients who had one internal carotid artery with total stenosis and the other with more than 50% stenosis. In Group 2, patients had one internal carotid artery with total stenosis and the other with less than 50% stenosis. Group 3 comprised patients with less than 50% stenosis in both internal carotid arteries. Demographic data, complete blood count, biochemical parameters, and thyroid function parameters were compared between the groups. No significant relationship was noted between the severity of CAD and demographic data and comorbidity rates. A comparison of the biochemical parameters revealed that TSH levels were significantly different between the groups. Post-hoc analysis showed that Group 1 and Group 3 differed significantly with respect to TSH levels (0.75 ± 0.37 IU/mL vs. 1.39 ± 1.00 IU/mL, p=0.002). A cut-off value of 0.65 yielded 46.67% sensitivity and 81.67% specificity, whereas a cut-off value of 0.70 yielded 53.33% sensitivity and 75.00% specificity. The area under the curve was 0.691 (95% CI, 0.576-0.806) (p=0.003). TSH can be demonstrated to predict severe carotid artery disease. Therefore, the severity of CAD can be assessed using TSH levels.

Quantification of New Intracerebral Lesions on Diffusion-weighted Magnetic Resonance Imaging After Transcarotid Artery Revascularization for Treatment of Carotid Stenosis

Quantification of New Intracerebral Lesions on Diffusion-weighted Magnetic Resonance Imaging After Transcarotid Artery Revascularization for Treatment of Carotid Stenosis

Sex is a critical factor in the timing of surgical intervention in men and women with severe carotid artery disease: protocol for a systematic review and meta-analysis

article: Sex is a critical factor in the timing of surgical intervention in men and women with severe carotid artery disease: protocol for a systematic review and meta-analysis - Italian Journal of Vascular and Endovascular Surgery 2021 December;28(4):125-30 - Minerva Medica - Journals

Effect of haemodynamics on the risk of ischaemic stroke in patients with severe vertebral artery stenosis

ObjectivesEndovascular treatment strategies to optimise individualised care for patients with vertebral artery (VA) stenosis need to be revisited. This study aimed to investigate the relationship between net VA flow volume...

Cohort study examining the relationship between remoteness and requirement for surgery to treat peripheral artery disease at a tertiary hospital in North Queensland

To assess whether outcomes of peripheral artery disease (PAD) were related to remoteness from the treating tertiary vascular centre. Participants with a variety of types of occlusive and aneurysmal diseases were recruited from a tertiary hospital in North Queensland, Australia. Remoteness was assessed by residence outside Townsville and estimated distance to the vascular centre. Cox proportional hazard analyses were used to examine the association of remoteness with outcome. Cohort study. The primary outcome was requirement for surgery to treat PAD. Secondary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. Of 2487 patients recruited, 1274 (51.2%) had at least one PAD surgery, 720 (29.0%) at least one MACE, and 909 (36.6%) died during a median of 4.2 (inter-quartile range 1.3-7.7) years. Compared to Townsville residents (n=1287), those resident outside Townsville (n=1200) had higher rates of PAD surgery (hazard ratio, HR 1.55, 95% confidence intervals, CI, 1.39, 1.73) but no increased risk of MACE (HR 1.00, 95% CI 0.86, 1.16) or death (HR 1.03, 95% CI 0.90, 1.17). This association was attenuated when adjusting for distance from the vascular centre (HR 1.31, 95% CI 1.14, 1.51). Patients in the highest quartile of distance presented with lower ankle-brachial pressure index, more severe carotid artery disease and larger aortic diameter. People with PAD in North Queensland residing furthest from the tertiary hospital presented with more severe artery disease and had greater rates of PAD surgery.

Lipoprotein(a) and Cardiovascular Outcomes after Revascularization of Carotid and Lower Limbs Arteries.

Background: Despite high-intensity lipid-lowering therapy, there is a residual risk of cardiovascular events that could be associated with lipoprotein(a) (Lp(a)). It has been shown that there is an association between elevated Lp(a) level and cardiovascular outcomes in patients with coronary heart disease. Data about the role of Lp(a) in the development of cardiovascular events after peripheral revascularization are scarce. Purpose: To evaluate the relationship of Lp(a) level with cardiovascular outcomes after revascularization of carotid and lower limbs arteries. Methods: The study included 258 patients (209 men, mean age 67 years) with severe carotid and/or lower extremity artery disease, who underwent successful elective peripheral revascularization. The primary endpoint was the composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The secondary endpoint was the composite of primary endpoint and repeated revascularization. Results: For 36-month follow-up, 29 (11%) primary and 128 (50%) secondary endpoints were registered. There was a greater risk of primary (21 (8%) vs. 8 (3%); hazard ratio (HR), 3.0; 95% confidence interval (CI) 1.5–6.3; p < 0.01) and secondary endpoints (83 (32%) vs. 45 (17%), HR, 2.8; 95% CI 2.0–4.0; p < 0.01) in patients with elevated Lp(a) level (≥30 mg/dL) compared to patients with Lp(a) < 30 mg/dL. Multivariable-adjusted Cox regression analysis revealed that Lp(a) was independently associated with the incidence of cardiovascular outcomes. Conclusions: Patients with peripheral artery diseases have a high risk of cardiovascular events. Lp(a) level above 30 mg/dL is significantly and independently associated with cardiovascular events during 3-year follow-up after revascularization of carotid and lower limbs arteries.

Correlation between SYNTAX score and carotid intima-media thickness in patients with chronic coronary syndrome

Abstract Background In most cases coronary artery disease (CAD) and carotid artery disease exist at the same time and both represent the most serious manifestation of systemic atherosclerosis. Chronic coronary syndrome (CSS) includes six different clinical scenarious, and patients with stable angina symptoms and/or dyspnoea were comprised in our study. A previous studies have demonstrated that patients with myocardial infarction have more severe carotid artery disease, but there are no available data regarding association between SYNTAX I score (SS) and carotid intima-media thickness (CIMT) in patients with CSS. SS is known as universal angiographic scoring system, entirely based on coronary anatomy and lesion characteristics. CIMT measurement is a non-invasive tool to diagnose early atherosclerosis. Purpose The aim of this study was to determine the correlation between SS and CIMT in patients with with CSS. Methods A total of 82 CSS patients (average age 61±12 years, 28.9% females) underwent exercise ECG or stress echocardiography. Coronary angiography and ultrasonography of internal carotid artery were performed and patients were divided into three groups according to SS: Group I (&amp;lt;22, n=42), Group II (23–32, n=20), Group III (&amp;gt;33, n=20). We also estimate the severity of CAD according to clinical SYNTAX. Simultaneously, we evaluate whether biomarkers of hemostasis and thrombosis, such as fibrinogen, plasminogen activator inhibitor (PAI-1), D dimer, coagulation factor VIII and von Willebrand factor (VWF), as well as homocysteine and C reactive protein (hs CRP) were associated with CAD complexity. Results There were significant correlation between severity of CAD according to SYNTAX I score and CIMT (Group I: 1.23±0.27, II: 1.56±0.43, III 1.43±0.21, Kruskal Wallis p=0.000). In order to estimate the impact of atherosclerosis burden on CAD complexity, patients were divided into 3 groups according to CIMT: low (&amp;lt;0.90 mm), intermediate (0.91–1.30 mm) and high (≥1.31 mm). SS according to the CIMT were: Group I: 12.57±5.71, Group II: 21.20±11.36, Group III: 28.38±10.92, KW, p=0.004. We demonstrated significant correlation between SS and values of fibrinogen (I: 3.53±0.70, II: 3.59±0.62, III 3.93±0.56, p=0.018), VWF (I: 1.16±0.59, II: 1.52±0.62, III 1.49±0.80, p=0.040), factor VIII (I: 2.25±0.75, II: 2.21±0.53, III 2.97±0.95, p=0.009), homocysteine (I: 11.21±3.78, II: 13.66±4.61, III 13.87±5.34, p=0.019) and CRP (I: 3.75±4.10, II: 3.82±4.86, III 7.28±5.75, p=0.013), but not with PAI-1 and D dimer (p&amp;gt;0.05). We didn't find positive association between clinical SYNTAX I score and CIMT (p&amp;gt;0.05). Conclusion Patients with chronic coronary syndrome and severe carotid artery disease according to CIMT (≥1.31) had higher SS and more complex CAD. Elevated biomarkers of hemostasis and thrombosis such as fibrinogen, VWF and factor VIII, as well as homocysteine and CRP may be a mutual casual factors for associated polyvascular disease. Correlation between CIMT and SS Funding Acknowledgement Type of funding source: None

Diabetes and carotid artery disease: a narrative review.

Diabetes mellitus (DM) has been linked to an increased prevalence and severity of carotid artery disease, as well as polyvascular disease. Carotid disease is also associated with obesity and abnormal peri-organ and intra-organ fat (APIFat) deposition (i.e., excess fat accumulation in several organs such as the liver, heart and vessels). In turn, DM is associated with APIFat. The coexistence of these comorbidities confers a greater risk of vascular events. Clinicians should also consider that carotid bruits may predict cardiovascular risk. DM has been related to a greater risk of adverse outcomes after carotid endarterectomy or stenting. Whether modifying risk factors (e.g., glycaemia and dyslipidaemia) in DM patients can improve the outcomes of these procedures needs to be established. Furthermore, DM is a risk factor for contrast-induced acute kidney injury (CI-AKI). The latter should be recorded in DM patients undergoing carotid stenting since it can influence both short- and long-term outcomes. From a pathophysiological perspective, functional changes in the carotid artery may precede morphological ones. Furthermore, carotid plaque characteristics are increasingly being studied in terms of vascular risk stratification and monitoring short-term changes attributed to treatment. The present narrative review discusses the recent (2019) literature on the associations between DM and carotid artery disease. Physicians and vascular surgeons looking after patients with carotid disease and DM should consider these links that may influence outcomes. Further research in this field is also needed to optimise the treatment of such patients.

Investigation of the Predictive Values of Triglyceride/HDL Cholesterol Ratio and Whole Blood Viscosity with Regard to Severe Peripheral or Carotid Artery Disease in Patients Scheduled for Coronary Bypass.

The incidence of atherosclerotic cardiovascular diseases, which constitute an important disease group, is expected to rise with increasing life expectancy. The aim of this study was to investigate the predictive values of triglyceride/HDL cholesterol (TG/HDL-C) ratio and whole blood viscosity on possible severe carotid or peripheral arterial disease in patients who were admitted to our clinic and scheduled for coronary artery bypass graft (CABG) surgery. This study retrospectively examined 299 patients who were admitted to our clinic and scheduled for CABG between August 1, 2015, and August 1, 2019. Patients with severe carotid or peripheral arterial disease were included in group 2; those in whom peripheral arterial disease and stenosis were not detected were included in group 1. Group 1 consisted of 255 patients, mean (± standard deviation) age 58.1 ± 8.9 years; the 44 patients in group 2 had a mean age of 64.1 ± 10.6 years (P = .018). The incidence of diabetes mellitus and tobacco use were significantly higher in group 2 (P < .001 and P = .034, respectively). Triglyceride values, TG/HDL-C, and whole blood viscosity at high and low shear rates were significantly higher in group 2 (P = .017, P < .001, P < .001, and P < .001, respectively). Receiver operator characteristic analysis revealed that the cutoff value of TG/HDL-C was 3.2 with 77% sensitivity and 72% specificity; that of high-shear-rate viscosity was 16.1 with 73% sensitivity and 69% specificity; and that of low-shear-rate viscosity was 59.2 with 70% sensitivity and 63% specificity. It is possible to predict severe additional arterial diseases in patients scheduled for CABG with whole blood viscosity and TG/HDL-C ratios, both of which can be obtained with simple blood tests.

Safety and Feasibility of Simultaneous Transcarotid Revascularization With Flow Reversal and Coronary Artery Bypass Grafting for Concomitant Carotid Artery Stenosis and Coronary Artery Disease.

The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.