Significant Carotid Disease Research Articles

Rapid Carotid Screening by Duplex: A Prospective Single Centre Assessment.

A novel carotid quick scan (CQS) protocol was developed to rapidly screen for carotid atherosclerosis greater than 50% stenosis in a vascular outpatient setting. This study assessed accuracy and time saved. The CQS was developed by consensus agreement between vascular surgeons and accredited clinical vascular scientists through a modified Delphi technique. The protocol comprised a rapid B-mode then colour flow transverse sweep of the common and internal carotid arteries, with internal carotid artery velocity assessment. One hundred outpatients attending with peripheral artery disease or abdominal aortic aneurysm were recruited. CQS sensitivity, specificity and accuracy was assessed against a conventional full carotid duplex study, performed to UK and ESVS guidelines. Twenty four percent of patients (n = 100) had >50% carotid NASCET stenosis. CQS achieved an excellent accuracy of 96.5% in detecting >50% stenosis when compared to full duplex; Cohen's ƙ = .88, (95%CI .79-.97; P < .001), sensitivity 91.4%, specificity 97.6%, positive predictive value (PPV) 88.9% and negative predictive value (NPV) 98.2%. Median (IQR) time to complete the CQS was 13 sec (±12) per side, compared to 151 sec (±78) per side for the full carotid duplex. In the presence of >50% carotid disease, median CQS time was 25 sec (±31) per side compared to 214 (±104) by full scan. CQS as a carotid screening tool is rapid, accurate and acceptable to the population and workforce. It would be simple to roll out in all vascular laboratories to reduce the time and cost burden of excluding significant carotid disease in any group.

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.

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.

Radial and ulnar approach for carotid artery stenting with Roadsaver™ double layer micromesh stent:Early and long-term follow-up.

We aimed to evaluate the feasibility and safety of carotid artery stenting (CAS) with a newly designed double-layer micromesh stent using wrist approach in patients with significant carotid disease. Between January 2016 and December 2021, 105 patients undergoing CASwith Roadsaver™ stent were enrolled in a single center prospective study. Follow-up assessments included neurological exams, duplex ultrasound (DUS), and 12-lead ECG. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications, device success, target lesion revascularization, and in-stent restenosis evaluated with DUS. Long-term outcomes up to 72 months of follow-up were assessed in all eligible patients. The study population was predominantly male (69.5%) with a median age of 68 ± 8 years. Patients were symptomatic in 80% of the cases, and 35% fulfilled the high-risk criteria for surgical endarterectomy. The right internal carotid artery was the target artery in 56 (53.4%), and the left in 49 (46.6%) of the cases. All procedures were successfully completed from the right wrist, with right radial access in 94 (89.5%) cases and ulnar artery access with previous radial artery occlusion in 11 (10.5%) cases. All patients were treated successfully with the study device. The primary endpoint was met with a 30-day major adverse eventrate of 0.9% (1/105). Up to 72 months of follow-up (median 30 ± 20 months) there were no strokes, neurological deaths, or target lesion revascularization of the treated lesion. Doppler ultrasound examination revealed nonsignificant in-stent restenosis in two asymptomatic patients. There was no hand ischemia detected in any patient. Results from this study demonstrate the radial and ulnar access for CASwith double layer micromesh Roadsaver™ stent is safe and feasible and associated with favorable early and long-term follow-up.

DYNAMIC CEREBRAL BLOOD FLOW CHANGES ASSOCIATED WITH OFF PUMP CORONARY ARTERY BYPASS GRAFTING (OPCAB) ASSESSED BY A NOVEL, ROBOTIC ASSISTED, AUTONOMOUS, CONTINUOUS AND BILATERAL TRANSCRANIAL DOPPLER (TCD)

<h3>Background and Objectives</h3> There is ongoing controversy regarding the clinical and physiological benefit of OPCAB. While we have reported reduced perioperative mortality, neurological outcomes have not improved. Thus, further insights are needed to fully delineate the impact of OPCAB on the cerebral circulation. Here we present a novel strategy for continuous monitoring of mid cerebral artery (MCA) blood flow using the NovaGuide Robotic TCD system (NovaSignal Corp., Los Angeles CA USA) (figure 1). We have also employed cerebral tissue oximetry (Foresight, Edwards Lifesciences) to evaluate overall tissue oxygenation. <h3>Methods</h3> 7 elective OPCAB patients with no evidence of significant carotid disease were enrolled as part of our initial service evaluation. After anaesthesia induction, the patient head was stabilised in a specific cradle and robotic TCD probes were placed onto the patient's temporal region. The NovaGuide autonomously identified a transtemporal window, located the MCA vessels bilaterally and optimised the TCD signal. Baseline mean MCA flow was established prior to surgical manipulations and subsequent signals were automatically acquired for the entire duration of surgery. Data are reported as SEM +/- STD and group comparison was performed by ANOVA or t tests, as appropriate. <h3>Results</h3> There were no adverse events related to head positioning or access to central lines or placement of transoesophageal echo probes and routine monitoring. The device did not interfere with surgical conduct. Mean MCA flows at baseline were 43 +/-12 and 42 +/-13 cm/s for left and right MCA respectively. Pre-grafting events such as skin incision, sternotomy, and pericardiotomy increased LMCA flow by 14 +/- 35 24 +/- 27 and 17 +/- 20% with similar changes in RMCA flows. Mild Trendelenburg position and graded increase in MAP as pre-optimisation measures increased cerebral blood flow. While lifting and positioning the heart for grafting and placing the Octopus stabiliser generally reduced TCD levels, they remained higher than preoperative values (14+/-20; 31 +/- 36 and 9+/- 9 % increase for LAD, OM and PDA grafts, respectively). No significant changes were observed by clamping or anastomosing or reperfusing the respective coronary arteries. There was a transient increase in TCD signals upon replacing the heart in the pericardium after completing the anastomoses (28+/-7; 20 +/- 26 and 22 +/-29 % increase for LAD, OM and PDA positions, respectively). There were minor changes upon conducting the aortic anastomoses, but rare singular embolic events were noted occasionally upon releasing the aortic side clamp. Baseline left and right cerebral StO2 was identical (67+/-4 and 67+/-2) and showed little variation throughout surgery (<5%). <h3>Conclusion</h3> Continuous monitoring of bilateral TCD using the robotic TCD system is feasible during OPCAB. There are characteristic changes in TCD values at various phases of the operation, but our current optimisation strategy appears to preserve cerebral blood flow. Future validation studies are required which should address clinical correlates in high-risk patients including those with cerebrovascular disease.

Significant Stenosis of the Brachiocephalic Trunk and Moderate Stenosis of the Left Circumflex Artery in Computed Tomography Angiography Images.

Atherosclerosis, as a civilization disease, is a serious epidemiological problem. Significant carotid disease and significant coronary artery disease result in acute consequences, such as ischemic stroke and myocardial infarction, which are the major causes of cardiovascular mortality. Typically, atherosclerosis of the aortic arch branches involves the bulbs of the common carotid arteries and the proximal segments of the internal carotid arteries, and can be effectively assessed by ultrasonography. Computed tomography angiography enables the identification of patients with less typical clinical manifestations of atherosclerosis, e.g., brachiocephalic trunk stenosis with symptoms of the steal syndrome and moderate stenosis in the coronary arteries. We present examples of computed tomography angiography images of this type of changes.

Lessons learned during a 30-year experience with simultaneous carotid endarterectomy and coronary artery bypass grafting

ObjectiveA simultaneous operative approach to patients with significant carotid and coronary disease has been suggested as a safe, lower cost, and more convenient alternative to a staged approach. During the last three decades, spanning the career of our senior author, our group has pursued simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) in limited circumstances. We previously reported on our results in series from 1984 to 1994 and 1994 to 1999. Based on these prior results and the current literature, we liberalized our inclusion criteria. We are now reporting on a contemporary cohort of 91 patients operated on from 2006 to 2018. MethodsAll patients who underwent combined CEA/CABG in 2006 to 2018 were entered into the Vascular Quality Initiative database. We compared the current series of 91 patients (group 3) with the 74 patients (group 2) from 1994 to 1999 and the 100 patients (group 1) from 1984 to 1994 who also underwent combined CEA/CABG. We examined demographic and comorbid factors, presence of cerebrovascular symptoms, degree of contralateral carotid stenosis, perioperative stroke, and death. Statistical comparison was made with χ2 analysis. ResultsThe groups had similar demographics and comorbidities. Significant differences were noted in the preoperative diagnosis of hyperlipidemia (42%, 51%, 75%; P = .005) and the proportion of patients requiring urgent operations (24%, 47%, 56%; P = .002) during successive time periods. Patients in group 3 were much less likely to have preoperative symptoms from carotid stenosis before operation (55%, 31%, 4.4%; P < .001). Correspondingly, patients in group 3 were more likely to have asymptomatic unilateral carotid stenosis (20%, 55%, 78%; P < .001). The 30-day mortality rate remained stable compared with the first interval (8%, 3%, 2.2%; P = .11). Likewise, the overall stroke rate decreased in the later periods compared with the first series (9%, 1.4%, 2.2%; P = .016). Of the two perioperative strokes recorded for group 3, only one event was ipsilateral to the carotid artery operated on compared with the four ipsilateral strokes of nine total reported in group 1 and no ipsilateral stroke reported in group 2. ConclusionsBased on the favorable results of the previously reported series of CEA/CABG from our group, we continued to liberalize selection criteria for the combined procedure to essentially mirror the standard recommendations for CEA in patients without coronary disease. The current series using this treatment algorithm demonstrates the safety of this approach, with stroke and death rates equivalent to those of CABG alone. These excellent results were achieved in the face of increasingly urgent cardiac procedures. The fact that the majority of the perioperative strokes were contralateral to the carotid artery operated on reinforces the safety of our approach but underscores the significant burden of atherosclerosis in these patients.

Asemptomatik hastalarda karotis arter stentleme ve karotis endarterektominin prosedürel ve orta dönem sonuçları: Tek merkez deneyimi

Aim: Atherosclerotic carotid artery stenosis (CS) is responsible for ~20% of strokes. The management of CS in an asymptomatic patient has been less clear. In situations were carotid endarterectomy (CEA) is thought to be more risky, surgeons must also have enough experience and capability to perform carotid artery stenting (CAS) to provide suitable, patient-tailored treatment. In this study, the same investigator performed all interventions (CAS and CEA), and one type of stenting device and EPD was used. In addition, periprocedural monitoring was carried out for at least 24 h. The objective of this study was to compare procedural results and 12-month follow-up outcomes of patients who were treated by the same operator- either CAS or CEA- in one year. Material and Methods: A retrospective single-center review involving asymptomatic patients with severe stenosis of the ICA caused by atherosclerotic disease who was treated with either stenting with embolic protection (Group 1, n=17) or carotid endarterectomy (group 2, n=18) according to their clinical and anatomical risk profile between 1 January 2018 and 31 December 2018 at Numune Research and Training Hospital, Department of Cardiovascular Surgery, Ankara-Turkey was conducted. A duplex ultrasound (DUS) and neurological assessment was obtained prior to hospital discharge as a baseline, 30-days, 6 months, and 1 year thereafter. Patients’ demographic and clinical characteristics, angiographic variables, primary endpoints including the composite of death, stroke and myocardial infarction during the 30 days after the procedure or ipsilateral stroke during the 365 days after the procedure was compared. Primary endpoints also including primary technical success, periprocedural clinical success, primary patency, clinical failure, periprocedural adjunctive maneuvers and secondary endpoints including complications, freedom from clinically driven target-lesion revascularization at 12 months, freedom from death, freedom from all stroke and freedom from restenosis rates were assessed and compared between the groups. Results: High-risk anatomical criteria were present in 8 (47.0%) patients, high-risk clinical criteria were present in 11 (64.7%) patients. Group 2 patients were older (67.7±7.4 vs 71.2± 6.9, p&amp;lt;0.05), but hyperlipidemia (58.8% vs 44.4%, p&amp;lt;0.05), chronic renal insufficiency requiring hemodialysis (11.7% vs 0.0%, p&amp;lt;0.05) and left ventricular dysfuntion (17.6% vs 0.0%, p&amp;lt;0.05) were significantly more frequent in Group 1. CCDS of group 1 was significantly lower than group 2 (4.7 ± 1.3 vs 7.3 ± 1.2; p&amp;lt;0.05, respectively). The lesions of the patients undergoing CEA were significantly longer (12.7 ± 2.6 vs 18.5 ± 4.2 mm.; p&amp;lt;0.05) and more calcified (11.7% vs 50.0%, p&amp;lt;0.05) than the patients in group 1. Likewise, the degree of stenosis in group 2 was significantly more than that of group 1 (81.4 ± 4.2 vs 88.3±6.4 %; p&amp;lt;0.05, respectively). Primary technical success was 100% for both groups. Periprocedural clinical success was 100% for Group 1, and 94.4% for group 2. Primary patency rates at 1/6/12 months were 100%/ 94.1%/94.1% for group 1, and 100%/100%/94.4% for group 2. Freedom from restenosis and freedom from CD-TLR at 12 months was 94.1% and 94.4% for group 1 and group 2. No death, major strokes, miyocardial infarction and systemic complications occured. Conclusion: This study showed similar short and mid-term results for CEA and CAS in asymptomatic patients with significant carotid disease. Although we have shown good results for both CEA and CAS, CAS should be limited to those cases that are not suitable for open surgery and treatment of asymptomatic carotid artery disease with CEA should be considered for patients with few risk factors and long life expectancy. Both CEA and CAS reduce the long-term stroke risk in asymptomatic patients. The appropiate treatment strategy should be selected according to the patient’s individual risk factors and imaging data.

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization.

BackgroundStatins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization.Methods and ResultsIn this population‐level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002–2014). The primary outcome was a composite of 1‐year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five‐year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate‐ or high‐dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1‐year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70–0.83). Patients who were on persistent long‐term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71–0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose.ConclusionsContinuous statin therapy was associated with a 25% lower risk of long‐term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.

Relationship between Syntax Score and prognostic localization of coronary artery lesions with conventional risk factors, plasma profile markers, and carotid atherosclerosis (CAPP Study 2)

BackgroundData concerning the relationship between cardiovascular risk factors, plasmatic markers, carotid disease and extent of coronary lesions are lacking. ObjectivesTo evaluate the role of cardiovascular risk factors, plasmatic levels of high sensitivity C-reactive protein (hs-CRP), fibrinogen, lipoprotein(a), and carotid plaque extension in predicting the severity of coronary artery disease (CAD). MethodsWe analyzed 574 subjects undergoing first coronary angiography. For angiographic analysis, we used the Syntax Score and we defined the prognostic localization of CAD as a critical stenosis of the left main and/or proximal segment of left anterior descending artery. Levels of hs-CRP >3mg/L, lipoprotein(a) plasma levels >30mg/dL and plasma fibrinogen >300mg/dL were considered critical. Significant carotid disease (SCD) was defined by the presence of lesions producing a 50% diameter stenosis with a peak systolic velocity >125cm/s. A mean carotid intima media thickness (IMT) >0.9mm was considered abnormal. ResultsIn the adjusted analysis the presence of SCD was found to be an independent predictor of high Syntax Score (p<0.001), while high fibrinogen levels were independently associated with the presence of CAD in prognostic localization (p=0.04). In the sub-group of patients without SCD, IMT >0.9mm was found to be an independent predictor of the presence of CAD (p<0.001). ConclusionsSCD strongly predicts high Syntax Score, while IMT shows excellent positive predictive value for the presence of CAD. In addition, high plasma fibrinogen levels are associated with coronary stenoses in prognostic localization.

Abstract TP301: Outlier Analysis of NIHSS Change in a Regional Database of Acute Ischemic Stroke

Introduction: Change in NIH Stroke Scale from admission to discharge has been proposed as an outcome-based method of assessing quality of care in the inpatient setting. Using the Kentucky Appalachian Stroke Registry database, statistical outliers were identified as potential targets for investigation. We aimed to use the analysis of this subset of patients to identify characteristics favoring exceptionally good or poor outcome. Methods: De-identified patient data was obtained from the Kentucky Appalachian Stroke Registry for all acute ischemic stroke patients from January 1, 2013 to December 31, 2014 using discharge diagnoses. Statistical process control methodology was used to identify hospitalizations with positive or negative NIHSS change more than three standard deviations from the mean. The statistical outliers underwent manual chart review to validate the data obtained from the registry and supplement it qualitatively to identify common characteristics. Chi-square tests were conducted to assess the association between patient characteristics and being a positive or negative outlier. Results: Positive outliers were less likely to have hypertension and more likely to have received intravenous thrombolysis. Negative outliers were more likely to have carotid stenosis. Both groups were more likely to have a diagnosis of cardiac arrhythmia and to have received mechanical thrombectomy. Conclusions: Gathering registry data regarding NIHSS outliers is a feasible and potentially useful tool in understanding and improving care. The absence of hypertension may represent positive predictive recovery potential in severe stroke. Patients with significant carotid disease on presentation may be at risk of neurological decline. Furthermore, patients with large vessel occlusions undergoing thrombectomy represent a high-variance population with the greatest improvements and greatest deteriorations during inpatient hospitalization.

Staged or Combined Approach for Carotid Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting: A 5-Year-Long Experience.

Optimal surgical approach for patients with hemodynamically significant carotid and coronary disease remains controversial. We analyzed our 5-year experience and compared early and long-term outcome following staged and combined carotid and coronary artery bypass. 312 consecutive patients undergoing carotid endarterectomy and coronary artery bypass between 2008 and 2013 were prospectively enrolled in the study. Patients were scheduled for a staged (carotid endarterectomy followed by coronary artery bypass within 1 week) procedure (Group S) unless they were unstable in terms of cardiac status (were deemed to a combined procedure; Group C). All patient data including demographics, risk factors, immediate perioperative events, 30-day, and long-term outcome were prospectively recorded and then analyzed. Groups S and C were compared for pre- and perioperative data as well as immediate, 30-day, and long-term survival. A P value less than .05 was considered significant. Survival analysis was made using Kaplan-Meier method and log-rank test. Group S included 204 patients and Group C included 108 patients. Preoperative demographics and clinical data were similar in the two groups except that preoperative cerebrovascular events were more common in Group C (31.7% versus 22.22%, P = .036) and bilateral carotid disease was more common in Group S. The EuroSCORE was higher in Group C (2.91 versus 2.65, P = .013). Carotid surgery techniques were similar; intraluminal shunting was more frequent in group C than group S (33.33% versus 9.88%, P = .001). Additional cardiac procedures in addition to coronary surgery was predominant in Group C. 30-day neurological adverse event rates, ICU, and hospital stay were significantly higher in Group C. The 30-day mortality was also sigficantly higher in Group C (1.96% versus 4.62%, P = .001). Staged and combined surgical approaches yield comparable outcomes. A staged approach may provide a more favorable neurological outcome with significantly reduced need for intraluminal shunting. Long-term outcome is, however, similar.

Carotid endarterectomy for critical stenosis prior to cardiac surgery: Should it be done? A retrospective cohort study

IntroductionStroke remains a major cause of morbidity and mortality after cardiac surgery affecting 2% of patients. Extra-cranial carotid artery disease has been implicated in the aetiology of post cardiac surgery stroke. The aim of the study was to evaluate and compare the morbidity and mortality in patients undergoing cardiac surgery with or without staged carotid endarterectomy (CEA) in a tertiary referral centre. MethodsA 5 year retrospective study was performed. The primary endpoints were defined as peri-operative stroke and myocardial infarction (MI) with secondary outcome defined as death within 30 days of surgery. ResultsIn total 5924 cardiac procedures and 29 staged CEA's were performed. The rate of stroke and MI was significantly higher in patients undergoing staged CEA pre-cardiac surgery compared to patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries (10.34% vs 1.43%; P = .008 and 13.79% vs 0.38%; P < .0001, respectively). There was no significant difference in the stroke and MI rate in those patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries compared to those with significant carotid disease undergoing cardiac surgery with no prior carotid intervention (1.43% vs 3.16%; P > .05 and 0.38% vs 1.05%; P > .05, respectively). ConclusionsCarotid disease is associated with an increased risk of stroke post cardiac surgery. Staged carotid intervention cannot be justified based on these results. Increased risk of stroke post cardiac surgery in patients with significant carotid disease needs to be accepted, as the risk of stroke and MI during carotid intervention pre cardiac surgery is significantly higher.

Abstract 14702: Evaluation of Inflammation in Carotid Disease by New Imaging Modalities: Implications From 18-FDG PET/CT and Microwave Radiometry

Background and Purpose: Nowadays, 18F fludeoxyglycose Positron Emmision Tomography/computed tomography (18F-FDG PET/CT) is the leading modality for tracing inflammation within atherosclerotic plaques in vivo, but patients’ exposure to radiation, costs and availability limit its widespread use. We hypothesize that microwave radiometry (MWR), a safe noninvasive method allowing in vivo estimation of atherosclerotic process by measuring temperatures of tissues could be an accurate alternative tool for assessing lesional inflammation. Therefore, the aim of the present study was to investigate the relationship between temperature differences and FDG uptake assessed by MWR and 18F-FDG PET/CT respectively, in patients with significant carotid disease. Methods: Consecutive patients, scheduled for carotid endarterectomy due to significant carotid artery (CA) stenosis, underwent 18F-FDG PET/CT and MWR. PET/CT images were acquired 90 min after FDG injection. FDG uptake was measured as maximal standardized uptake value (SUVmax) in consecutive axial slices starting at the bifurcation and extending 2 cm superiorly and 2 cm inferiorly. During MWR evaluation, ΔΤ (maximal temperature across the carotid artery minus minimum) was calculated over the respective carotid segments. Results: In total, 44 CAs from 22 patients (18 male) were studied. There was a significant positive correlation between ΔT and SUVmax values in the operated arteries and also between the same parameters in all 44 vessels (R=0.44, p=0.05 and R=0.44, p=0.005, respectively). Operated and non-operated CAs demonstrated similar ΔT and SUVmax values (0.57±0.19 vs 0.59±0.17 °C, p=0.67 and 2.18±0.44 vs 2.28±0.41, p=0.48 respectively). In addition, there was no correlation between the degree of angiographic stenosis and ΔT values (R=0.07, p=0.65) or between lesional SUV measurements and the percentage of luminal stenosis (R=0.10, p=0.55). Conclusions: There is a significant correlation between FDG uptake and thermal heterogeneity, indicating that MWR is a promising marker of plaque inflammation. Moreover, there is discrepancy between stenosis severity and inflammation intensity assessed by FDG uptake and MWR, highlighting the diversity of processes involved in CA atherosclerosis.

SYNTAX Score II predicts carotid disease in a multivessel coronary disease population

BackgroundThe SYNTAX Score (SxScore) is an angiographic tool that evaluates CAD complexity, which we previously reported lacking correlation with the presence of carotid disease. Recently, SxScore II has been developed including both angiographic and clinical variables, which could increase the prognostic accuracy for detection of carotid disease. Methods and resultsFrom January 2013 to June 2014, 244 patients with multivessel CAD (mean age 65.37years, 84% males) underwent carotid ultrasound scan. At least one carotid lesion (CL) was found in 77% of patients with significant carotid disease (SCD) in 23.4% of cases. Logistic regression analysis revealed no relation between SxScore and CL/SCD (p=0.781 and p=0.368) while SxScore II well correlated with CL (SxScore II-PCI: odds ratio [OR] 1.036; 95% confidence interval [CI]:1.006–1.067; p=0.019; SxScore II-CABG: OR 1.045; 95% CI: 1.015–1.076, p=0.003) and SCD (SxScore II-PCI: OR 1.042; 95% CI: 1.012–1.073, p=0.006; SxScore-CABG: OR 1.054; 95% CI: 1.029–1.080, p<0.0001). The areas under the receiver-operating characteristic curves were: for SxScore 0.512 (95% CI: 0.448–0.577; p=0.77), for SxScore II-PCI and SxScore II-CABG 0.600 (95% CI: 0.536–0.662; p=0.01) and 0.645 (95% CI: 0.581–0.705; p=0.0008), respectively, and 0.527 (95% CI 0.462–0.591; p=0.56), 0.619 (95% CI: 0.555–0.681; p=0.01) and 0.681 (95% CI: 0.619–0.739; p=0.0001), respectively, for the identification of SCD. ConclusionsThe SxScore II, with inclusion of clinical variables over angiographic complexity, seems more suited to predict the presence of carotid disease than the SxScore.

PP.39.09

Objective: Completely different activation patterns were recently demonstrated for the renin-angiotensin-aldosteron system (RAAS) depending on whether renal artery stenosis (RAS) is unilateral or bilateral. Based on these premises, the present trial aimed to compare the prevalence of risk factors and the extension of atherosclerotic (ATS) disease in consecutive patients with significant (> 60%) uni- vs. bilateral RAS. Design and method: We prospectively enrolled 52 patients referred to renal angiography for suspected RAS and diagnosed with significant (> 60%) uni- or bilateral stenosis, subsequently resulting in 2 groups (27-unilateral RAS and 25-bilateral RAS). Before catheterization, he following parameters were assessed: demographics, cardiac history, known duration of hypertension, cardiovascular risk factors, features of extracoronary vascular disease, related comorbidities and associated cardiovascular drug therapy. In all patients, coronary artery disease (CAD) was confirmed during cardiac catheterization and an echocardiographic evaluation was performed in all patients. Results: No significant differences were established between the 2 groups regarding age, gender, body surface area, creatinine clearance, serum cholesterol, blood pressure, medication and left ventricle ejection fraction. The prevalence of conventional cardiovascular risk factors was similar in the 2 series: smoking, obesity, dyslipidemia, hypertension and diabetes. Moreover, similar outcomes were determined in the 2 study arms concerning the prevalence of coronary artery disease, as well as its severity (significant stenosis in single-vessel – 16% vs. 8%, two-vessel – 15% vs.16 % and three-vessel– 21% vs. 25%). However, the prevalence of significant ATS in extracardiac vessels was higher in the bilateral RAS group: carotid arteries and lower limb arteries (p < 0.01). Conclusions: The prevalence of conventional ATS risk factors and the CAD severity were similar in patients with either unilateral or bilateral RAS. However, a higher prevalence of significant carotid or peripheral vascular disease was found in bilateral RAS cases. As conventional cardiovascular risk factors were similarly distributed between groups, the present data may reflect a larger total body plaque burden in patients with bilateral RAS, thus possibly emphasizing a causal relationship between the specific RAAS activation pattern and an advanced generalized ATS. This paper is supported by the Sectional Operational Programme Human Resources Development (SOP HRD), finance from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/5/137390.

Transradial carotid artery stenting: examining the alternatives when femoral access is unavailable

Carotid artery stenting with embolic protection has been shown to be a proven alternative to carotid endarterectomy in patients with significant carotid disease. The transfemoral approach is the conventional access site for carotid stenting. Access site complications are the most common adverse event after carotid stenting from the femoral access and most technical failures are related to a complex aortic arch. As demonstrated in multiple studies, transradial approach reduces access site bleeding and vascular complications in coronary interventional procedures. It may offer a more direct and safer approach in cases involving a complex arch. Previous feasibility studies and case reports have demonstrated that transradial access may be a viable alternative strategy in these patients.

Bovine arch and carotid artery atherosclerosis: are they related?

ObjectivesThe prevalence of the “bovine” arch in the population is known (8–25%). However, its prevalence in patients with significant carotid atherosclerosis has never been investigated. Altered flow patterns or turbulence that may occur in these patients may play a causative role in the development of atherosclerotic lesions. The primary purpose of this study was to retrospectively compare the prevalence of aortic arch variants in patients with and without significant carotid artery atherosclerosis, as we hypothesize that carotid atherosclerosis may be more prevalent in patients with a bovine arch due to hemodynamic alterations. A secondary objective was to review radiologist reporting of arch anatomy. MethodsSingle-center, retrospective, case-control study in which 79 patients with hemodynamically significant carotid artery atherosclerosis who underwent computed tomography angiography, magnetic resonance angiography, or unenhanced computed tomography (CT) imaging including the aortic arch were identified. These patients were then compared with 95 randomly selected controls without carotid atherosclerosis that underwent similar imaging during the same time period. Images were independently reviewed by two blinded radiologists, who assessed arch anatomy as normal, bovine, or other variant. The original radiology reports were reviewed for reporting of arch anatomy. ResultsIn controls, 70% had normal arch anatomy, and 24% had a bovine arch. Among patients with significant carotid disease, these numbers were 70% and 20%, respectively. There was no statistically significant difference between incidence of arch variants in subjects with and without carotid artery atherosclerosis (P=.97). There was good interreader agreement. Among patients with aortic arch anomalies, 20% of the original radiology reports did not mention arch anatomy. ConclusionsIn our experience, percentage of bovine arch anomalies in patients with significant carotid atherosclerosis is not significantly different from those without disease. Clinicians should be aware of the high prevalence of arch anomalies, which can impact endovascular approach and management, and radiologists should be aware of the clinical importance of reporting such variants.

179 The Role Of Microparticles in Carotid Disease

IntroductionEndothelial microparticles (EMPs) are released from dysfunctional endothelial cells. We hypothesised that patients with unstable carotid plaque have higher levels of circulating microparticles compared to patients with stable plaques which...

Re: Simultaneous hybrid carotid stenting and coronary bypass surgery versus concomitant open carotid and coronary bypass surgery: a pilot, feasibility study

Stroke after coronary artery bypass grafting (CABG) is a rare but feared complication associated with significantly higher mortality and the potential for debilitating functional sequelae. All necessary measures should, therefore, be taken to decrease the rate of post-CABG stroke. Risk factors include: previous stroke, diabetes, hypertension, peripheral vascular disease and renal failure [1]. However, the aetiology of stroke after CABG is multifactorial, including manipulation of an atherosclerotic ascending aorta, diffuse cerebrovascular disease, atrial fibrillation and a perioperative inflammatory state. An embolic aetiology accounts for two-thirds of strokes after CABG, with hypoperfusion accounting for only 9% [2]. Carotid bifurcation stenosis is a recognized risk factor, but seems to be more of a marker of global atherosclerotic burden rather than a direct cause of stroke. Carotid stenosis is associated with increasing age, multiple cardiovascular risk factors and diffuse atherosclerotic disease extending to intracerebral territories and the ascending aorta. In this issue of the Eur J Cardiothoracic Surg ,M icovicet al. [3] have published results from a very small, randomized study of simultaneous hybrid carotid stenting (CAS) and CABG versus concomitant open carotid endarterectomy (CEA) and CABG involving only 20 low-risk patients with three-vessel or left main stem disease in addition to a carotid artery stenosis of >50% in symptomatic patients or >80% in asymptomatic patients. Patients were randomized to hybrid sequential CAS and CABG (N= 10), or concomitant CEA and CABG (N= 10). All except one patient underwent on-pump CABG. Only two and three patients (respectively) in each arm had suffered a previous stroke/transient ischaemic attack (i.e. the majority were asymptomatic), but the proportion of patients with severe bilateral stenosis was not reported. One patient died of multiorgan failure 42 days after combined surgery. A second patient (undergoing CEA + CABG) suffered a stroke 4 days after surgery, but in the territory of the non-operated contralateral carotid artery, which did not have significant carotid disease. Despite the trial being significantly underpowered, the authors concluded that CAS and coronary surgery was feasible and had similar early postoperative results compared with CEA + CABG. This study raises a number of important issues. First, it is unclear why the authors chose to undertake an interim analysis after only 20 patients had been recruited. This was entirely reasonable for safety analyses. However, no power calculations were presented and it should have been obvious that no meaningful conclusions could be drawn by reporting data from such a small cohort of heterogeneous patients. Second is the hypothesis upon which this study was based. The authors have clearly shown that either treatment strategy was ‘feasible’, but not whether any additional intervention was actually warranted for the majority of patients. The authors have based this study upon the premise that (i) predominantly asymptomatic carotid disease is an important cause of post-CABG stroke and that (ii) prophylactic CAS or CEA can reduce this risk. Neither, however, is sufficiently proved, especially in asymptomatic patients. The authors have cited post-CABG stroke rates of up to 11% in neurologically asymptomatic patients in order to justify intervention, but the latter statistic was observed only in patients with carotid occlusion (which is inoperable). In fact, a recent meta-analysis of all published data observed that the risk of procedural stroke in patients undergoing isolated CABG with a unilateral asymptomatic carotid stenosis was extremely small [4]. Second, three natural history studies (>23 500 patients undergoing isolated CABG) have now shown that 95% of observed strokes could not have been attributed to any underlying carotid disease [5–7]. These data seriously challenge any rationale for offering prophylactic CEA or CAS to CABG to patients with asymptomatic carotid disease (especially unilateral). The ESC/EACTS 2010 Guidelines on Myocardial Revascularization recommend carotid revascularization in patients presenting for CABG with a previous transient ischaemic attack or minor stroke in association with a 70–99% stenosis (Evidence Class IC). Conversely, in patients scheduled for CABG with asymptomatic carotid disease, carotid revascularization may be considered in males with bilateral 70– 99% carotid artery stenoses or contralateral occlusion, provided predicted life expectancy exceeds 5 years (Classes IIb and C) [8]. In summary, this trial confirms that prophylactic carotid interventions are feasible, but not whether they are warranted, especially in patients with unilateral asymptomatic carotid disease who