Significant Carotid Stenosis Research Articles

An Audit of Carotid Dopplers in Sligo University Hospital

Abstract Background Stroke is a common and often disabling condition impacting thousands of individuals in Ireland annually 1. Timely screening for underlying etiologies is important in all patients presenting with stroke or transient ischaemic attack (TIA) to reduce recurrence risk. Carotid artery disease is frequently implicated as the cause 3. The 2023 National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends carotid imaging be completed within one week of diagnosis of ischemic stroke or TIA for patients in whom potential carotid intervention would be appropriate. We aimed to assess the timing of Carotid Doppler scans in our hospital for patients presenting clinically with stroke or TIA. Methods The National Integrated Medical Imaging System (NIMIS) was used to generate a list of patients that had a Carotid Doppler scan over a six- month period (1st July 2022 to 31st December 2022). NIMIS was also used to identify the indication, setting, requesting department and timeliness of scans. Results A total of 96 Carotid & Vertebral Dopplers were performed. Majority of studies were performed on males (65%). The mean age of patients was 70 (±11.5) years. Most studies (55%) were done in an inpatient setting. Of all Carotid Dopplers performed, 94 (97%) had an appropriate indication. With regards to timeliness of carotid imaging, the median time from order to study completion varied between inpatients [2 days (IQR 1-3)] and outpatients [16 days (IQR 9-38)]. The majority (95%) of inpatient studies were completed within 7-days of order, while only 14% of outpatient studies were performed in this timeframe. Of the untimely outpatient scans done to investigate stroke or TIA, 2/33 (6%) had significant carotid stenosis. Conclusion Majority of Carotid Dopplers were done for appropriate indications. While inpatients studies were largely done in a timely manner, there is a significant delay in the completion of most outpatient studies.

Importance of brain MRI to evaluate immediate intracranial complications after carotid stenting in patients with significant carotid stenosis

Importance of brain MRI to evaluate immediate intracranial complications after carotid stenting in patients with significant carotid stenosis

Improved cognition and preserved hippocampal fractional anisotropy in subjects undergoing carotid endarterectomy “CEA preserves cognition & hippocampal structure”

ObjectivesA growing body of data indicates that extracranial carotid artery disease (ECAD) can contribute to cognitive impairment. However, there have been mixed reports regarding the benefit of carotid endarterectomy (CEA) as it relates to preserving cognitive function. In this work, diffusion magnetic resonance imaging (dMRI) and neurocognitive testing are used to provide insight into structural and functional brain changes that occur in subjects with significant carotid artery stenosis, as well as changes that occur in response to CEA. Materials and MethodsThe study design was a prospective, non-randomized, controlled study that enrolled patients with asymptomatic carotid stenosis. Thirteen subjects had severe ECAD (≥70% stenosis in at least one carotid artery) and were scheduled to undergo surgery. Thirteen had asymptomatic ECAD with <70% stenosis, therefore not requiring surgery. All subjects underwent neurocognitive testing using the Montreal Cognitive Assessment test (MoCA) and high angular resolution, multi-shell diffusion magnetic resonance imaging (dMRI) of the brain at baseline and at four-six months follow-up. Changes in MoCA scores as well as in Fractional anisotropy (FA) along the hippocampus were compared at baseline and follow-up. ResultsAt baseline, FA was significantly lower along the ipsilateral hippocampus in subjects with severe ECAD compared to subjects without severe ECAD. MoCA scores were lower in these individuals, but this did not reach statistical significance. At follow-up, MoCA scores increased significantly in subjects who underwent CEA and remained statistically equal in control subjects that did not have CEA. FA remained unchanged in the CEA group and decreased in the control group. ConclusionsThis study suggests that CEA improves cognition and preserves hippocampal white matter structure compared to control subjects not undergoing CEA.

Optimizing Treatment of Significant Carotid Artery Stenosis in Times of Logistic Restraints as a Result of COVID-19 Pandemic

BackgroundCOVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints. PurposeTo evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach. MethodsRetrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post COVID (patient tailored approach). Primary outcome was the composite endpoint of stroke, TIA or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis or occlusion. ResultsA total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (p = .27; p = 1.00; p = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (p = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs CAS, 12.7% vs 7.9% and 23.9% vs 4.8% with a p-value of .03 and .03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic. ConclusionOutcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.

Carotid Artery Doppler: A Possible Non-invasive Diagnostic Approach to Assessing the Severity of Coronary Artery Disease.

Carotid artery Doppler ultrasound is being explored for its potential as a non-invasive tool for evaluating coronary artery disease (CAD) severity and cardiovascular risk. This study aimed to investigate the association between carotid Doppler parameters and CAD severity, as determined by the Gensini score (GS) and multi-vessel disease presence. Ninety patients undergoing coronary angiography (CAG) and carotid ultrasound were retrospectively analysed. Carotid Doppler parameters and CAD severity were assessed through bivariate and multivariable analyses. Among the patients studied, 80% were male, with a mean age of 65.24 years (±9.91). Triple vessel disease (68.9%) and dominant vessel disease (73.3%) were prevalent coronary findings, with a mean GS of 139.2 (±76.6). Increased intima-media thickness (IMT) in the common carotid artery (CCA) and internal carotid artery (ICA) showed significant associations (CCA IMT: OR = 0.312, p = 0.037; ICA IMT: OR = 0.354, p = 0.017) with high GS (>125) and multi-vessel disease. Significant carotid stenosis (>50% diameter stenosis) emerged as an independent predictor of CAD severity. Fibrocalcific plaques, detected in 62.2% of cases, correlated significantly with elevated GS. Plaque burden, especially plaques in >3 locations, indicated a higher likelihood of triple vessel disease and a higher GS. Carotid Doppler parameters, particularly IMT and significant stenosis, are robust predictors of CAD severity, including high GS and multi-vessel disease. Integrating carotid artery assessment into clinical protocols can aid in timely interventions and preventive strategies for CAD management.

The Role of TOMM40 in Cardiovascular Mortality and Conduction Disorders: An Observational Study.

Aims: TOMM40 single nucleotide polymorphism (SNP) rs2075650 consists of allelic variation c.275-31A > G and it has been linked to Alzheimer disease, apolipoprotein and cholesterol levels and other risk factors. However, data on its role in cardiovascular disorders are lacking. The first aim of the study is to evaluate mortality according to TOMM40 genotype in a cohort of selected patients affected by advanced atherosclerosis. Second aim was to investigate the relationship between Xg and AA alleles and the presence of conduction disorders and implantation of defibrillator (ICD) or pacemaker (PM) in our cohort. Materials and Methods: We enrolled 276 patients (mean age 70.16 ± 7.96 years) affected by hemodynamic significant carotid stenosis and/or ischemia of the lower limbs of II or III stadium Fontaine. We divided the population into two groups according to the genotype (Xg and AA carriers). We evaluated several electrocardiographic and echocardiographic parameters, including heart rate, rhythm, presence of right and left bundle branch block (LBBB and RBBB), PR interval, QRS duration and morphology, QTc interval, and left ventricular ejection fraction (LVEF). We clinically followed these patients for 82.53 ± 30.02 months and we evaluated the incidence of cardiovascular events, number of deaths and PM/ICD implantations. Results: We did not find a difference in total mortality between Xg and AA carriers (16.3 % vs. 19.4%; p = 0.62). However, we found a higher mortality for fatal cardiovascular events in Xg carriers (8.2% vs. 4.4%; HR = 4.53, 95% CI 1.179-17.367; p = 0.04) with respect to AA carriers. We noted a higher percentage of LBBB in Xg carriers (10.2% vs. 3.1%, p = 0.027), which was statistically significant. Presence of right bundle branch block (RBBB) was also higher in Xg (10.2% vs. 4.4%, p = 0.10), but without reaching statistically significant difference compared to AA patients. We did not observe significant differences in heart rate, presence of sinus rhythm, number of device implantations, PR and QTc intervals, QRS duration and LVEF between the two groups. At the time of enrolment, we observed a tendency for device implant in Xg carriers at a younger age compared to AA carriers (58.50 ± 0.71 y vs. 72.14 ± 11.11 y, p = 0.10). During the follow-up, we noted no statistical difference for new device implantations in Xg respect to AA carriers (8.2% vs. 3.5%; HR = 2.384, 95% CI 0.718-7.922; p = 0.156). The tendency to implant Xg at a younger age compared to AA patients was confirmed during follow-up, but without reaching a significant difference(69.50 ± 2.89 y vs. 75.63 ± 8.35 y, p = 0.074). Finally, we pointed out that Xg carriers underwent device implantation 7.27 ± 4.43 years before AA (65.83 ± 6.11 years vs. 73.10 ± 10.39 years) and that difference reached a statistically significant difference (p = 0.049) when we considered all patients, from enrollment to follow-up. Conclusions: In our study we observed that TOMM40 Xg patients affected by advanced atherosclerosis have a higher incidence of developing fatal cardiovascular events, higher incidence of LBBB and an earlier age of PM or ICD implantations, as compared to AA carriers. Further studies will be needed to evaluate the genomic contribution of TOMM40 SNPs to cardiovascular deaths and cardiac conduction diseases.

Outcome and prognosis of isolated carotid vasculitis

ObjectiveTo assess the prognosis and outcome of patients with isolated carotid vasculitis. MethodsWe performed a retrospective multicenter study of 36 patients (median age at diagnosis was 37 [IQR 27–45] years and 11 [31 %] patients were men) with initial presentation as isolated carotid vasculitis. Study endpoints included vascular complications, relapses, and progression to large vessel vasculitis (i.e. Giant cell arteritis or Takayasu). ResultsThe most frequent involvement was the left internal carotid artery (39 %), and 81 % had stenosis. After a median follow-up of 32 months [IQR 12–96], 21 (58 %) patients had a vascular event, including 31 % of new onset vascular lesions and 25 % of stroke/transient ischemic attack. Patients with stroke had less carotidynia at diagnosis (33 % vs 74 %, p = 0.046), higher significant carotid stenosis (i.e. > 50 %) (89 % vs. 30 %, p = 0.026) and higher severe carotid stenosis (i.e. >70 %) (67 % vs 19 %, p = 0.012), compared to those without stroke. Twenty (52 %) patients experienced relapses. High CRP at diagnosis was associated with relapses (p = 0.022). At the end of follow-up, 21 (58 %) patients were classified as having Takayasu arteritis, 13 (36 %) as isolated carotid vasculitis, and two (6 %) as giant cell arteritis. ConclusionCarotid vasculitis may occur as a topographically limited lesion and is associated with significant rate of vascular complications.

Evaluation of Burden of Carotid Artery Disease In Ischemic Stroke Patients With And Without Hypertension

Evaluation of Burden of Carotid Artery Disease In Ischemic Stroke Patients With And Without Hypertension

Noninvasive cardiac-specific biomarkers for the diagnosis and prevention of vascular stenosis in cardiovascular disorder.

The most frequent lesion in the blood vessels feeding the myocardium is vascular stenosis, a condition that develops slowly but can prove to be deadly in a long run. Non-invasive biomarkers could play a significant role in timely diagnosis, detection and management for vascular stenosis events associated with cardiovascular disorders. The study aimed to investigate high sensitivity troponin I (hs-TnI), cardiac troponin I (c-TnI) and high sensitivity C-reactive protein (hs-CRP) that may be used solely or in combination in detecting the extent of vascular stenosis in CVD patients. 274 patients with dyspnea/orthopnea complaints visiting the cardiologists were enrolled in this study. Angiographic study was conducted on the enrolled patients to examine the extent of stenosis in the five prominent vessels (LDA, LCX, PDA/PLV, RCA, and OM) connected to the myocardium. Samples from all the cases suspected to be having coronary artery stenosis were collected, and subjected to biochemical evaluation of certain cardiac inflammatory biomarkers (c-TnI, hsTn-I and hs-CRP) to check their sensitivity with the level of vascular stenosis. The extent of mild and culprit stenosis was detected during angiographic examination and the same was reported in the form significant (≥50% stenosis in the vessels) and non-significant (<50% stenosis in the vessels) Carotid Stenosis. Ethical Clearance for the study was provided by Dr. Ram Manohar Lohia Institute of Medical Sciences Institutional Ethical Committee. Informed consent was obtained from all the participants enrolled in the study. We observed that 85% of the total population enrolled in this study was suffering from hypertension followed by 62.40% detected with sporadic episodes of chest pain. Most of the subjects (42% of the total population) had stenosis in their LAD followed by 38% who had stenosis in their RCA. Almost 23% patients were reported to have stenosis in their LCX followed by OM (18% patients), PDA/PLV (13%) and only 10% patients had blockage problem in their diagonal. 24% of the subjects were found to have stenosis in a single vessel and hence were categorized in the Single Vessel Disease (SVD) group while 76% were having stenosis in two or more than two arteries (Multiple Vessel Disease). hs-TnI level was found to be correlated with the levels of stenosis and was higher in the MVD group as compared to the SVD group. hs-TnI could be used as a novel marker as it shows prominence in detecting the level of stenosis quite earlier as compared to c-TnI which gets detected only after a long duration in the CVD patients admitted for angiography. hs- CRP gets readily detected as inflammation marker in these patients and hence could be used in combination with hs-TnI to detect the risk of developing coronary artery disease.

Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis.

This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.

Thrombolysis treatment and multi- disciplinary management of central retinal artery occlusion in comparison with traditional ophthalmological treatment options

<p>The management of central retinal artery occlusion (CRAO) has long been conservative therapy with limited efficacy carried out in ophthalmology departments together with etiolo&shy;gi&shy;cal investigations lacking a standardised protocol. However, CRAO is analogous to ischemic central nervous system stroke and is associated with increased stroke risk, thus, systemic thrombolysis treatment and multidisciplinary management can be beneficial. Since May 2022, at Semmelweis University CRAO patients diagnosed within 4.5 hours are given intravenous thrombolysis therapy and undergo etiologic workup based on current stroke protocols. Here we report our experience with the multidisciplinary, protocol-based management of CRAO in comparison with former non-protocol based ophthalmological conservative treatment.</p>. <p>We reviewed CRAO patients&rsquo; data treated conservatively and with paracentesis within 6 hours at the Department of Ophthalmology between 2013 and 2022 including changes in visual acuity, neurolo&shy;gical and cardiovascular findings compared to those in the thrombolysis project.&nbsp;</p>. <p>Of the 78 patients receiving non-protocol care, visual improvement was seen in 37% with natural course, 47% with conservative treatment and 47% with paracentesis. Four patients had significant carotid stenosis (2 underwent endarterectomy), 1 carotid dissection, 6 cardioembolism and 1 giant cell arteritis. Of the 4 patients within 4,5 hours, 3 gave their consent to the clinical trial and were treated with thrombolysis and underwent a full etiological assessment.&nbsp;<br>2 pa&shy;tients had improved visual acuity, 2 pa&shy;tients had significant carotid stenosis and underwent endarterectomy, 1 patient was started on anticoagulation for newly diagnosed atrial fibrillation.</p>. <p>CRAO patients presenting within 4,5 hours are rare and more patients are needed in our study to establish the efficacy of thrombolysis. However uniform protocollized evaluation helps identifying embolic sources thus, avoiding further and potentially more serious thromboembolic events.</p>.

Assessment of atherosclerotic plaque morphology using contrast-enhanced ultrasound and its impact on primary cardiovascular events following simultaneous carotid endarterectomy and coronary artery bypass grafting.

The incidence of stroke after on-pump cardiac surgery during the perioperative period can affect up to 2% of patients, and is frequently linked to carotid artery disease. Notably, in patients with significant unilateral carotid artery stenosis of 80%-99%, the risk of stroke reaches 4%. Among individuals undergoing coronary artery bypass grafting (CABG), 3% to 10% exhibit significant carotid artery stenosis. To mitigate the risk of stroke and mortality, patients can undergo either simultaneous or staged carotid endarterectomy and CABG. The aim of this study was to assess whether early postoperative complications, including stroke, following simultaneous CABG/CAE procedures, correlate with morphological attributes of carotid plaque, assessed via contrast-enhanced ultrasound. A single centre retrospective analysis was performed including 62 patients who underwent simultaneous CABG/CEA between 2019 and 2022. Our study excluded patients who underwent staged carotid endarterectomy and CABG procedures, off-pump CABG, or those necessitating urgent CABG. Our analysis focused on patients meeting elective CABG criteria, diagnosed with symptomatic triple-vessel or left main trunk coronary artery disease (CAD), alongside asymptomatic carotid stenosis (a. carotis internae) exceeding 70% or symptomatic ipsilateral carotid stenosis surpassing 50%. The extent of contralateral carotid artery stenosis was not taken into account. Prior to the CEA/CABG procedure, each patient underwent contrast-enhanced ultrasound to assess atherosclerotic lesions, which were classified using Nakamura et al.'s classification. Among the patients, 37.1% exhibited no neovascularisation within the atherosclerotic plaque, 56.5% showed insignificant neovascularisation, and 6.5% displayed notable neovascularization within the plaque. Our study aimed to establish a connection between the degree of plaque vascularisation identified through contrast-enhanced ultrasound and subsequent postoperative complications. Upon evaluating postoperative complications occurring within 30 days after the surgery and the plaque morphology identified through contrast-enhanced ultrasound, a statistically significant correlation was observed between a higher grade of plaque vascularisation and the occurrence of ischaemic stroke (r = 0.329, p = .008). Monte Carlo calculations of the Chi-square test indicated a significant association between a higher grade of plaque vascularisation and the presence of peripheral artery disease (χ2 = 15.175, lls = 2, p = .003). Within 30 days of surgery, a significant correlation exists between the occurrence of ischaemic stroke following carotid endarterectomy subsequent to CABG and the presence of a higher grade plaque vascularisation as identified by contrast-enhanced ultrasound.

Assessing the impact of internal carotid artery stenosis on choroidal thickness using Cirrus optical coherence tomography

Aims: The choroid, one of the body's most highly vascularized tissues, receives its blood supply from the ophthalmic and posterior ciliary arteries, which stem from the internal carotid artery. The utilization of spectral-domain optical coherence tomography (SD-OCT) for both qualitative and quantitative assessment of the retina is increasing. The recent introduction of enhanced depth imaging OCT (EDI-OCT) has offered a novel approach to evaluate the choroid using commercially accessible SD-OCT devices. EDI-OCT enables the in vivo examination and measurement of the choroid. The main objective of our study is to evaluate choroidal thickness using EDI-OCT in patients with unilateral significant carotid stenosis; the secondary objective is to observe whether hemodynamic changes affect choroidal thickness. Methods: The study is prospectively designed as a cross-sectional, controlled, and single-blind study, encompassing patients who underwent neck computed tomographic angiography within a one-year period due to any disease. Included patients had carotid stenosis of 50% or more on one side and less than 50% on the other side. The eyes on the side with higher carotid stenosis constituted the study group, while the other side formed the control group. Anterior and posterior segment examinations of the patients, visual acuity according to Snellen Chart, and choroidal thickness were measured. Results: A total of 30 eyes of 15 patients were evaluated. Of the patients included in the study, 9 were men and 6 were women; the average age was 67.9 years (49-85). In the study group, the average choroidal thickness measurements were 211 µm in the nasal, 221 µm in the central and 209 µm in the temporal; in the control group, they were measured as 223 µm in the nasal, 243 µm in the central, and 231 µm in the temporal, respectively. Despite the choroidal thickness being thinner in the study group, the difference did not reach statistical significance. Conclusion: Additional research is required to pinpoint the factors contributing to the dynamics of choroidal thickness and to delineate its significance in carotid artery stenosis more comprehensively.

Study protocol - Prospective case-control trial - Impact of significant carotid stenosis on retinal perfusion measured with automated retinal oximetry.

Large vessel carotid stenosis is a significant cause of ischaemic stroke. Indications for surgical revascularisation depend on the severity of the stenosis and clinical symptoms. However, mild symptoms such as TIA (Transient ischaemic attack), amaurosis fugax or minor stroke precede large strokes in only 15% of cases. The aim of this prospective study is to evaluate whether retinal perfusion is impacted in significant carotid stenosis. Automated retinal oximetry will be used to better assess perfusion in the post-stenotic basin. We presume the more stenotic the blood vessel, the more reduced the retinal perfusion is, resulting in adaptive changes such as greater arteriovenous saturation difference due to greater oxygen extraction. This could broaden the indication spectrum for revascularisation for carotid stenosis. We plan to enroll yearly 50 patients with significant carotid stenosis and cross-examine them with retinal oximetry. The study group will provide stenotic vessels and, non-stenotic vessels will form the control group. Patients with significant carotid stenosis will undergo an MRI (Magnetic Resonnance imaging) examination to determine the presence of asymptomatic recent ischaemic lesions in the stenotic basin, and the correlation to oximetry parameters. The stenosis severity and retinal oximetry parameters will be compared for study and control groups with a threshold of 70%, respectively 80% and 90% stenosis. Results will be then reevaluated with emphasis on MRI findings in the carotid basin. This prospective case control study protocol will be used to launch a multicentre trial assessing the relationship between significant carotid stenosis and retinal perfusion measured with automated retinal oximetry. Despite these differences, the findings indicate the potential of retinal oximetry for noninvasive real-time measurements of oxyhaemoglobin saturation in central nervous system vessels. Following calibration upgrade and technological improvement, verification retinal oximetry may potentially be applied to critically ill and anaesthesia care patients. The study on combined scanning laser ophthalmoscope and retinal oximetry supports the feasibility of the technique for oximetry analysis in newly born babies. ClinicalTrials.gov, ID: NCT06085612.

The role of periprocedural hemodynamic variables during carotid stenting for the mid-term general mortality in advanced age patients.

Carotid stenting may produce significant bradycardia and/or hypotension. This may have negative short- and long-term effects for the elderly high-risk patients. Their cerebral hemodynamics is with exhausted adaptive capacity because of the multiple cardiovascular risk factors, advanced age, and significant stenosis.

The Importance of the Circle of Willis in Carotid Interventions Outcomes: A Real-Life Study

ObjectiveThe main objective of this study is to evaluate and compare the outcomes regarding operative mortality rate, ipsilateral stroke and overall survival rate among patients with internal carotid artery (ICA) stenosis submitted to carotid endarterectomy or stenting regarding the completeness of Circle of Willis (CoW). MethodsProspective, consecutive cohort study of patients submitted to carotid interventions (carotid endarterectomy – CEA - and carotid stenting - CAS) for ICA stenosis diagnosis evaluated according complete or incomplete CoW. The patients were divided into two groups: group I - the patients with complete CoW and group II - the patients with incomplete CoW, with the disruption of anterior and/ or ipsilateral posterior circulation, regarding the ipsilateral significant carotid stenosis. ResultsOverall, 98 patients submitted to carotid intervention were evaluated. Two groups of patients were identified: group CoW complete with 54 patients and group CoW incomplete with 44 patients. Regarding the type of intervention, the prevalence of CAS in CoW complete group and CoW incomplete group were statistically similar (54.1% versus 55.1%, p = 0.22). Notwithstanding, CEA was also statistically similar in CoW incomplete group and CoW complete group (44.2% versus 45.9%, p = 0.22). The perioperative mortality rate was 2% in total cohort (2 patients), with no differences among CoW complete and incomplete groups (3.7% versus 0%, p = 0.50, respectively). Furthermore, the incidence of post-operative stroke was 3.1% (asymptomatic 2%, symptomatic 1.1%), with no differences among CoW complete and incomplete groups (3.7% versus 2.3%, p = 0.68, respectively). A univariate and multivariate linear regression showed that among the factors evaluated, only chronic kidney failure was related with HR = 1.89, p = 0.003, CI 1.058-2.850. ConclusionThe completeness of the CoW, independently of the type of carotid intervention (CEA and CAS), did not interfere in the results regarding postoperative outcomes for stroke and death. Chronic Kidney disease was associated to increased risk of perioperative stroke.

Carotid endarterectomy compared with carotid artery stenting for extracranial carotid artery stenosis: a retrospective single-centre study

Aim: One of the main risk factors for an ischemic stroke is significant carotid artery stenosis, and extracranial severe carotid artery stenosis accounts for 20% of ischemic strokes. Prior to the development of carotid artery stenting (CAS), the only effective and reliable treatment for carotid artery stenosis was carotid endarterectomy (CEA). This study compares the results of CAS and CEA in patients with significant carotid artery stenosis. Methods: Between 2018 and 2022, hospital records of all patients who underwent carotid artery revascularization at the institution were retrospectively analyzed. Patients were divided into two groups depending on whether CEA or CAS was performed for carotid revascularization. Propensity score matching was performed to reduce bias by equating the baseline clinical characteristics of the groups. To compare 30-day, 1-year, and long-term outcomes, rates of transient ischemic attack (TIA), myocardial infarction, stroke, all-cause mortality, and composite endpoints were analyzed. Results: After PSM, 76 patients each in the CEA and CAS groups were compared. The mean age was 69.80 years ± 11.35 years and 121 (80%) were male. The patients were followed up for a mean of 33 months ± 6 months. The incidence of TIA in the perioperative period [9 (12%) vs. 4 (5%); P &lt; 0.05], TIA and composite endpoint at 1-year period [11 (15%) vs. 2 (3%); P &lt; 0.05 and 27 (36%) vs. 16 (21%); P &lt; 0.05, respectively] were significantly higher in the CAS group than in the CEA group. No difference was observed between the groups in the long-term. Conclusions: There was no noticeable difference between the CEA and CAS groups in the examination of cases with severe carotid artery stenosis in terms of 1-month, and 1-year results (apart from TIA and composite endpoints), or long-term outcomes. Extracranial carotid artery stenosis can be treated safely and effectively also by CAS.

Inflammatory activity of vulnerable plaques in asymptomatic, non-hemodynamically significant carotid artery stenoses: preliminary results of the carotid artery multi-modality imaging prognostic study

Abstract Background [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a valid technique to quantify carotid plaque inflammation and can improve identification of patients at high risk for stroke. There are few data on the inflammatory plaque activity in asymptomatic patients and of its association with other characteristics of plaque vulnerability. Purpose To assess the inflammatory carotid plaque activity and its correlations with patient characteristics and features of plaque vulnerability detected by other imaging techniques in a population of patients with asymptomatic mild/moderate degree of stenosis. Methods Seventy-five asymptomatic patients with 40-60% unilateral carotid stenosis at Doppler ultrasound (DUS) were prospectively evaluated with [18F]FDG-PET, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Regions of interests were drawn using fused PET/CT slices on the most diseased segment (MDS), defined as the single hottest slice of [18F]FDG uptake. Background blood pool activity was obtained from regions of interests placed in the lumen of the jugular vein. The target-to-background ratio (TBR) was calculated by dividing maximum standardized uptake value (SUVmax) of the MDS to SUVmax of ipsilateral blood pool activity. Plaque vulnerability was defined as the presence of an echolucent plaque at DUS, plaque ulceration at CTA, intraplaque hemorrhage, and lipid-rich necrotic core at MRA. Results Patients with a TBR ≥median (1.75), compared with those below the median, were significantly more frequently male and on statin therapy, had higher prevalence of ulcerated plaque at CTA (61% vs 35%, p=0.03) and intraplaque hemorrhage at MRA (33% vs 10%, p=0.03), while the prevalence of a lipid-rich necrotic core at MRA was not significantly different (p=0.16). TBR and SUVmax of the MDS were similar in those with or without a ≥50% stenosis, and peak velocities indices at DUS were not significantly correlated with TBR or SUVmax. Log(TBR) was significantly higher in ulcerated, rather than non-ulcerated, plaque (0.27 vs 0.21, p=0.03) and numerically higher in plaques with an intraplaque hemorrhage (0.22 vs 0.30, p=0.06). Log(TBR) and Log(SUVmax) were similar in plaques with and without a lipid-rich necrotic core (p=0.86 for both). Conclusions Higher TBR or SUVmax, indicating a high inflammatory activity, are associated with an ulcerated plaque and the presence of intraplaque hemorrhage but not with either the degree of stenosis or the presence of a lipid-rich necrotic core.

Imaging methods in assessing the surveillance of type 2 diabetes mellitus for cerebrovascular reserve and brain disease in patients with hemodynamically significant carotid stenosis

Introduction. Type 2 diabetes is the most common form of endocrine disease. Diabetes is a well-established risk factor for stroke. Carotid endarterectomy (CEE) is the main method of preventing a serious complication of stroke in patients with carotid stenosis. Consequently, the assess of type 2 diabetes on the results of CEE is an urgent problem of angiosurgery.Aim: To assess effect of type 2 diabetes on cerebrovascular reserve capacity and brain structure in patients with carotid atherosclerosis by ultrasound and magnetic resonance diagnostic.Material and Methods. 44 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), who underwent ultrasound and magnetic resonance examinations of the carotid arteries at the pre- and postoperative stages were included in this study. Two groups were formed: group I (n =15) – with a verified diagnosis of type 2 diabetes, group II (n = 29) – without diabetes. To assess the cerebrovascular reserve, functional hypercapnic and hyperoxic tests were performed.Results. The analysis of the results showed statistically significant differences in the ICA blood flow in both groups. Intergroup comparison before surgery in the middle cerebral artery on the side of hemodynamically significant stenosis revealed a statistically significant difference in pulsation and peripheral resistance index. In the common carotid arteries on both sides, significant intergroup differences were found in the velocity parameters of blood flow after the CEE operation. The reactivity index in patients with surgical stenosis with type 2 diabetes in the hyperoxic test was statistically significantly different on the side of the stenosis compared to the same indicator in the group without diabetes. There were no statistically significant differences in the hypercapnic test. The value of reactivity index indicates a negative or paradoxical reaction.Conclusion. The use of simple and accessible functional tests to assess cerebrovascular reserve, plaque structure and changes in the brain in patients with type 2 diabetes at the stage of preoperative preparation according to ultrasound and MRI studies allows us to correct the treatment and subsequent protection of the brain at the stage of surgery to prevent possible complications.

Importance of assessment of carotid plaques in the managementof acute ischemic stroke: floating intracarotid plaque

Mobile atheromatous plaques affecting large arteries are a major risk factor for embolic strokes. We report a case of extensive embolic cerebral infarction secondary to a vulnerable internal carotid artery plaque. A 67-year-old female was admitted with sudden left-sided weakness. A computed tomography brain scan revealed early ischemic changes in the right middle cerebral territory. The ultrasound Doppler showed soft mobile plaque with thrombus in the right internal carotid artery causing 90% stenosis. Magnetic resonance imaging brain scan performed later showed extensive right cerebral infarction. A computed tomography angiogram revealed ulcerated non-occlusive soft tissue plaque in the right internal carotid artery. She was also diagnosed with bladder cancer during this admission and was managed medically due to her performance status. Unstable vulnerable plaques can be symptomatic even in the absence of significant carotid stenosis. Hence, early identification of the plaque vulnerability, using new imaging modalities, and its medical stabilization can help to reduce the risk of cerebrovascular insults. The etiopathogenesis of inflammation within unstable vulnerable plaques and its concordance with inflammatory markers is still unclear. It is feasible in our case the malignantprocess could also be contributing to the inflammation within the blood vessels promoting vulnerability of the plaques.