Significant Carotid Research Articles

Abstract 711: Plasma Carotenoids Are Not Independent Determinants Of Subclinical Atherosclerosis In Coronary And Carotid Arteries

The association between dietary intake and/or plasma carotenoids and increased risk of cardiovascular events is well-established. Carotenoids have been proposed to protect against atherosclerosis by regulating inflammation and oxidative stress, however, the association between carotenoids and subclinical atherosclerosis is sparsely documented. Here, we hypothesized that plasma carotenoids were independently associated with subclinical atherosclerosis in coronary and carotid arteries in a Swedish population-based cohort (50-64 years), thus supporting the therapeutic potential of high carotenoid intake. In total, 986 subjects (mean age 57, 50% females) without known cardiovascular disease received CT calcium scoring (CACS), CT coronary angiography and carotid ultrasonography. Major carotenoids (lutein + zeaxanthin, β-cryptoxanthin, lycopene, α- and β-carotene) were measured in plasma. Intake of β-carotene was calculated based on a food frequency questionnaire. Data on sedentary behavior was derived from tri-axial accelerometers. Multinominal logistic regression was used to compare lower and upper tertiles of carotenoids with regard to CACS and atherosclerosis. Of all 986 subjects, 103 (10.4%) had CACS > 100, 197 (20.0%) had significant carotid atherosclerosis (> 1 plaque in carotid arteries), 295 (29.9%) had any coronary atherosclerosis and 37 (3.8%) had significant coronary atherosclerosis (≥ 50% stenosis in any coronary artery). In unadjusted models, low levels of total carotenoids, α- and β-carotene were significantly correlated with CAC > 100, coronary and carotid atherosclerosis. Low lutein correlated with carotid plaques and low intake of β-carotene with coronary and carotid plaques only. However, all associations lost significance after adjustment for age, sex, smoking status, abdominal obesity, BMI, sedentary behavior, hypertension, diabetes, total cholesterol, HDL cholesterol, triglycerides and C-reactive protein. To conclude, major carotenoids were not independent determinants of subclinical atherosclerosis. Data indicate that low levels of carotenoids depend on several other risk factors, such as male sex, obesity and sedentarism, and highlight the need of multifactorial lifestyle interventions.

Clinical effect of carotid stenting on cognitive abilities - possible evaluation using candidates for biomarkers.

Micro- and macrovascular consequences of atherosclerosis, arterial hypertension, dyslipidemia, and smoking can affect neurotransmission and markers for neuronal activity. The potential direction and specifics are under study. It is also known that optimal control of hypertension, diabetes, and dyslipidemia in midlife may positively affect cognitive functioning later in life. However, the role of hemodynamically significant carotid stenoses in neuronal activity markers and cognitive functioning is still being debated. With the increased use of interventional treatment for extracranial carotid disease, the question of whether it might affect neuronal activity indicators and whether we can stop or even reverse the path of cognitive deterioration in patients with hemodynamically severe carotid stenoses naturally emerges. The existing state of knowledge provides us with ambiguous answers. We sought the literature for possible markers of neuronal activity that can explain any potential difference in cognitive outcomes and guide us in the assessment of patients throughout carotid stenting. The combination of biochemical markers for neuronal activity with neuropsychological assessment and neuroimaging may be important from practical point of view and may provide the answer to the question for the consequences of carotid stenting for long-term cognitive prognosis.

Best Medical Treatment in Patients with Asymptomatic Carotid Stenosis: Myth or Reality?

Approximately 1.4 million strokes/year causing about 1.1 million deaths annually occur in Europe and 10-15% of those strokes are result of thromboembolism from a previously significant asymptomatic carotid stenosis (ACS). Medical treatment has improved considerably in the last 15 years however its success depends on patient compliance. The aim of our study was to evaluate, in patients with ACS, the implementation and patient adherence to best medical treatment (BMT). Additionally, we sought to determine the "real world" incidence of cerebrovascular/coronary events in a cohort of non-operated ACS patients and weighing this risk against surgical complications in patients with ACS undergoing surgical treatment at our Department. Patients with ACS ≥ 60% identified by a carotid ultrasound performed at our Department were retrospectively evaluated. Patients selected to BMT were excluded if the follow-up period was inferior to 2 years, as well as patients lost in follow-up, with missing clinical information and submitted to carotid stenting. Patients' data collection was supported by hospital reporting system and data were introduced into a database created for the purpose. Statistical analysis was performed using SPSS-25 software. After exclusion criteria were applied, the last 120 consecutive patients (60 with ACS submitted do carotid endarterectomy and 60 with ACS under BMT) were retrospectively evaluated. 21 patients had had ipsilateral events for more than 6 months. Most patients had hypertension (n=107; 89%), dyslipidemia (n=101; 84%), 40% had diabetes, 33% diagnosed coronary disease, 32% were overweight or obese and 17% were current smokers. Blood pressure control, normal weight, statin with/without ezetimibe association and antiaggregant therapy was only achieved in 33 patients and only 5 had additionally low-density-lipoprotein levels < 70 mg/dL, hemoglobin A1c < 7% and were non-smokers. Of the 60 patients assigned to medical treatment, 3 (5%) had a stroke at 2 years follow-up, which was fatal in 1 patient. Among patients submitted to carotid endarterectomy perioperative stroke was documented in 3% of the patients, none of them disabling or fatal. Although some recent studies report a risk of ipsilateral stroke of only 0.34% per year in patients with ACS ≥ 50% under BMT therapy in our everyday practice strict compliance to medical treatment fails in the majority of patients. In consequence, we think that a "one-size-fits-all" guideline policy may not be appropriate for all patients and the management of specific ACS patients may need to be individualized.

Recovery of visual function after endarterectomy - series of cases report

Carotid arteriosclerosis is the main cause of the stroke but it can also lead to ophthalmic symptoms. In this article, we aim to present four patients. All of them had hemodynamically significant but asymptomatic unilateral carotid stenosis and underwent internal carotid endarterectomy. Postoperatively, their visual function improved. Mean deviation in perimetry and values of amplitudes in pattern visual evoked potentials increased. Two patients improved visual acuity; in the other two, it remained stable.

Partial Eversion Carotid Endarterectomy versus Conventional Techniques for Significant Carotid Stenosis

To compare the outcomes of patients who were submitted to partial carotid endarterectomy (P-CEA) to those of patients who underwent standard conventional CEA with patch closure (C-CEA) and eversion CEA (E-CEA) for a significant carotid stenosis. Data of patients who consecutively underwent CEA from January 2014 to December 2018 for a significant carotid stenosis were retrospectively collected. Primary outcomes included mortality and the occurrence of neurologic and cardiologic complications, both at 30 days and during follow-up. Secondary outcomes included the occurrence of perioperative local complications (i.e. cranial nerve injuries, hematomas) and restenosis during follow-up. P values<0.5 were considered statistically significant. Three-hundred twenty-seven patients (241 males, 74%) underwent CEA for carotid stenosis (28.6% symptomatic). P-CEA was performed in 202 patients (61.8%), while C-CEA and E-CEA were performed in 103 and 22 cases respectively. At 30days, neurologic complications were not significantly different among the 3 groups (2.8% in the group of C-CEA, 2.4% after P-CEA and 0% in E-CEA patients, P=0.81), neither during follow-up. Perioperative local complications also were not significantly different among the 3 groups (P=0.16). P-CEA had similar outcomes if compared to C-CEA and to E-CEA in terms of perioperative mortality, occurrence of neurologic and cardiologic complications, and occurrence of local complications. Also, in the long-term, P-CEA, C-CEA, and E-CEA were burdened by similar rates of mortality, neurologic, and cardiologic complications and restenosis.

The Association between Apolipoprotein B, Cardiovascular Risk Factors and Subclinical Atherosclerosis-Findings from the SEPHAR National Registry on Hypertension in Romania.

The present study aimed to investigate the association between apolipoprotein B (Apo B) and classical features associated with clinical or subclinical atherosclerosis. A total of 811 adult patients from the general Romanian population, included in the national SEPHAR registry on hypertension, were divided into two groups based on Apo B value (low versus high Apo B with a cut-off established at 130 mg/dL) and subsequently into four subgroups according to the cut-offs recommended by the 2021 ESC Guidelines on Cardiovascular Disease Prevention. In all patients, lipid profile, uric acid, full blood count and presence of significant carotid plaques were assessed. Apo B levels were positively correlated with proatherogenic lipids (total cholesterol, triglycerides and LDL-cholesterol, p < 0.0001) and negatively correlated with HDL cholesterol (all p < 0.05). In comparison with patients with low Apo B levels, those with elevated Apo B levels more frequently presented significant carotid plaques (17% vs. 19% vs. 28% vs. 46%, p < 0.0001). Univariate regression analysis identified a strong association between the level of uric acid and increased value of Apo B in the four subgroups (uric acid 4.8 +/- 1.3 vs. 5 +/- 1.6 vs. 5.1 +/- 1.5 vs. 5.8 +/- 1.6, r = 0.2, p < 0.0001). The results of this nationwide registry on hypertension in Romania indicate that high Apo B may be considered as a risk factor for CVD, promoting atherosclerosis and associated with increased expression of classical markers of clinical or subclinical CVD.

Association of glomerular hyperfiltration with carotid artery plaque in the general population

Background and aimsGlomerular hyperfiltration (GHF) is a hemodynamic change of the kidney as an adaptive response to nephron loss. Although GHF is associated with metabolic risk factors and cardiovascular disease (CVD), the mechanisms that explain these relationships remain largely unknown. This is partially caused by a non-unified definition of GHF based on pathophysiologic vascular changes. Thus, the objective of this study was to evaluate the association between various definitions of GHF and carotid plaque in a health checkup cohort. MethodsA total of 4493 individuals without history of CVD who had carotid ultrasonography (USG) results available between January 2016 and June 2018 were enrolled. GHF was defined as >90th percentile of eGFR residuals after adjusting for confounding factors. Carotid plaque score was calculated based on carotid USG results. ResultsOf 4493 individuals (mean age, 52.3 ± 10.1 years; 3224 [71.8%] males), 449 subjects were included in the GHF group (mean eGFR, 107.0 ± 7.1 ml/min/1.73 m2) and 4044 subjects were included in the non-GHF group (mean eGFR, 92.5 ± 12.3 ml/min/1.73 m2). When the GHF group was compared to the non-GHF group, GHF was associated with the presence of significant carotid plaque (carotid plaque score ≥2) (adjusted OR: 1.46; 95% CI: 1.16 to 1.83; p = 0.001). GHF defined in this study showed higher sensitivity to the presence of carotid plaque than other definitions of GHF. ConclusionsGHF status was associated with risk of carotid plaque in individuals without history of CVD. Presence of subclinical carotid plaque was associated with risk of future CVD. Therefore, GHF based on creatinine could be a useful surrogate marker for surveillance of CVD in asymptomatic individuals.

Effectiveness of carotid council in the treatment of carotid artery disease: Early-term outcomes of the multidisciplinary approach.

Carotid arterial stenosis could be treated by surgical or percutaneous stenting. In this study, we aimed to investigate the effectiveness of the carotid council on the outcomes of patients with carotid artery disease. In this retrospective study, we analyzed the patients who had undergone carotid arterial revascularization from April 2014 to July 2022 in our hospital. All patients were evaluated in carotid council, which is constituted by neurologist, cardiologist and cardiovascular surgeon. Patient-specific treatment procedure was decided in the council. Demographics and early-term follow-up results of the patients were evaluated. Totally 95 procedures in 85 patients were analyzed during the study period. 27.4 % of the patients had significant contralateral carotid arterial stenosis. In 88 (92.6%) procedures, patients were treated by carotid endarterectomy, and 5 procedures were performed under regional anesthesia. Shunt usage was 6.0% during the surgery, and arteriotomy was repaired with primary sutures in 87.3%. Stent implantation was performed in 7 patients. There were 5 neurological adverse events after the carotid endarterectomy and 2 neurological events were after carotid arterial stenting. In each treatment group, one patient died after the procedure. In the follow-up period, restenosis was observed just in a patient who was treated with carotid endarterectomy and primary repair. Although carotid artery disease could be treated in accordance with the guidelines, treatment procedures should be patient-specific. Carotid councils might be helpful in giving patient-specific decisions, thereby providing the patient-based treatment procedure and improving the outcomes of the patients with carotid artery disease.

Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass

ObjectiveOptimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. MethodsThe Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. ResultsThere were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). ConclusionsIn patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.

Low-Density Lipoprotein Cholesterol Levels Are Associated With Subsequent Stented-Territory Ischemic Stroke After Carotid Artery Stenting: A Single Center Retrospective Study.

The role of low-density lipoprotein cholesterol (LDL-C) after carotid artery stenting (CAS) is not well known with respect to stented-territory infarction (STI) and in-stent restenosis (ISR). We hypothesized that LDL-C levels after CAS might be independently associated with STI and ISR. We conducted a retrospective study for patients with significant extracranial carotid stenosis who were subjected to CAS between September 2013 and May 2021. LDL-C levels were measured after 6 and 12 months following CAS. The association between STI and ISR, and LDL-C was explored using Cox proportional-hazard model. Of 244 patients enrolled, STI and ISR were observed in 11 (4.5%) and 10 (4.1%) patients, respectively. In multivariable analysis, higher white blood cell count (hazard ratio [HR], 1.408 per 103/mm3; 95% confidence interval [CI], 1.085-1.828; p=0.010), higher LDL-C levels after 12 months (HR, 1.037 per 1 mg/dL; 95% CI, 1.011-1.063; p=0.005), and ISR (HR, 13.526; 95% CI, 3.405-53.725; p<0.001) were independent predictors of STI. Diabetes (HR, 4.746; 95% CI, 1.026-21.948; p=0.046), smaller stent diameter (HR, 0.725 per 1 mm; 95% CI, 0.537-0.980; p=0.036), and higher LDL-C levels after 12 months (HR, 1.031 per 1 mg/dL; 95% CI, 1.007-1.055; p=0.011) were independent predictors of ISR. We showed that LDL-C levels after 12 months independently predict STI and ISR after CAS. It is necessary to investigate the optimal target LDL-C level for STI prevention through well designed research in the future.

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.

A Case of Orthotopic Renal Transplant in a Patient with Diffuse Atherosclerosis

A 60-year-old male with long-standing diabetes, hypertension, and smoking developed an end-stage renal disease that necessitated hemodialysis. His drive-by angiograms revealed significant carotid and iliac calcifications and a triple-vessel disease on cardiac assessment. The abdominal aorta, common iliac, and the vascular tree below were all heavily calcified, according to a computed tomography angiography. Concerned about the location of the donor renal artery anastomosis, the decision was taken to do a left native kidney nephrectomy and orthotopic renal transplant. End-to-end anastomoses were made between the donor renal artery and splenic artery and between the donor renal vein and the recipient native kidney renal vein. The patient is doing well after the transplant, and the graft is functioning excellently with a creatinine of 0.9 mg/dl.

Risk of carotid plaques according to triglyceride-glucose index stratified by thyroid function: A cross-sectional study.

Recent studies have indicated that the triglyceride-glucose (TyG) index or subclinical thyroid dysfunction is associated with carotid plaques, a predictor of cardiovascular disease risk. However, evidence for this association is limited and inconsistent. This study aimed to evaluate the risk of carotid plaques according to TyG index and thyroid function status in the general population. A total of 2,931 individuals who underwent carotid ultrasound as part of a comprehensive health examination at the Health Promotion Center of Soonchunhyang University Hospital were retrospectively reviewed. Based on the TyG index and thyroid function status, the participants were divided into six groups: LoTyG-SHyper (low TyG index with subclinical hyperthyroidism), LoTyG-Eu (low TyG index with euthyroidism), LoTyG-SHypo (low TyG index with subclinical hypothyroidism), HiTyG-SHyper (high TyG index with subclinical hyperthyroidism), HiTyG-Eu (high TyG index with euthyroidism), and HiTyG-SHypo (high TyG index with subclinical hypothyroidism). A multivariate logistic regression analysis was conducted to determine the risk of carotid plaques. The proportion of participants with significant carotid plaques was significantly different among the six groups (p<0.001, p for trend<0.001). The odds ratio (OR) and 95% confidence interval (CI) for significant carotid plaques were significantly higher in the HiTyG-SHypo group than in the LoTyG-Eu group, even after adjusting for confounding variables including sex, age, smoking, obesity, hypertension and diabetes mellitus (OR 1.506, 95% CI 1.045-2.170, p = 0.028). The OR of significant carotid plaques was higher in the HiTyG-Eu group than in the LoTyG-Eu group; however no associations were observed after additional adjustment for confounding variables. The TyG index and thyroid function status are important predictors of the risk of carotid plaques in healthy individuals. Early evaluation of carotid plaques may be necessary for subjects with high insulin resistance and subclinical hypothyroidism.

Utility of carotid ultrasound on prediction of 1-year mortality in emergency department patients with neurological deficits: A 10-year population-based cohort study.

This study aimed to investigate the association between the carotid ultrasound results and 1-yr mortality of patients with neurological deficits in the emergency department (ED). This study included patients with neurological symptoms who presented to the ED between January 1, 2009 and December 31, 2018, and underwent sonographic imaging of the bilateral carotid bulb, common carotid artery (CCA), internal carotid artery (ICA), and external carotid arteries. A stenosis degree of >50% was defined as significant carotid stenosis. Carotid plaque score (CPS) was calculated by adding the score of stenosis severity of all segments. The association between carotid ultrasound results and 1-yr mortality was investigated using the Cox regression model. The analysis included 7,961 patients (median age: 69 yr; men: 58.7%). Among them, 247 (3.1%) passed away from cardiovascular (CV)-related causes, and 746 (9.4%) died within a year. The mortality group presented with more significant carotid stenosis of the carotid bulb, CCA, or ICA and had a higher median CPS. A higher CPS was associated with a greater 1-yr all-cause mortality (adjusted hazard ratio [aHR] = 1.08; 95% confidence interval [CI] = 1.03-1.13; p = 0.001; log-rank p < 0.001) and CV-related mortality (aHR = 1.13; 95% CI = 1.04-1.22; p = 0.002, log-rank p < 0.001). Significant stenosis of either carotid artery segment did not result in a higher risk of 1-yr mortality. We comprehensively investigated the utility of carotid ultrasound parameters on predicting mortality in this 10-yr population-based cohort, which included over 7,000 patients with acute neurological deficits presented to the ED. The result showed that CPS could be used as risk stratification tools for 1-yr all-cause and CV mortality.

The value of transcranial Doppler monitoring of cerebral blood flow changes during carotid endarterectomy performed under regional anesthesia - A case series.

Patients with unilateral hemodynamically significant carotid stenosis scheduled for elective CEAs were included. Ultrasound-guided intermediate plexus block was used for regional anesthesia. TCD monitoring of the middle cerebral artery mean blood flow velocity (MCAV) was performed throughout the procedure. MCAVs were offline analyzed during different phases of CEA: (1) resting state, before regional block, (2) after block, before incision, (3) before cross-clamp, (4) after cross-clamp, (5) 5 min after cross-clamp, (6) 10 min after cross-clamp, (7) after declamping, and (8) during the postoperative period (4-6 h). Shunt insertion based on the deterioration of neurological symptoms after cross-clamping was necessary for 11/66 patients (16.6%). In these symptomatic patients, the ipsilateral percent decrease of the MCAV was more than 70% in 8 out of 11 cases (72.7%). In asymptomatic patients, without shunt insertion, the average decrease of MCAV was less than 50%. Neurological symptoms referring to cerebral ischemia may be superior to TCD monitoring of cerebral blood flow for detecting the necessity of a shunt. Regional anesthesia enables reliable, symptom-based monitoring of CEAs.

888 THE USE OF QFR FOR THE FUNCTIONAL ASSESSMENT OF EXTRACRANIAL INTERNAL CAROTID ARTERY STENOSIS

Abstract Background In asymptomatic patients with haemodynamically significant internal carotid artery stenosis, if endarterectomy cannot be considered, a selective invasive angiography is indicated before deciding for percutaneous revascularization. Sometimes, the angiographic assessment of the stenosis might be discordant with the non-invasive assessment, usually performed with Doppler. Therefore, the use of an angiography-based method that allows a functional assessment of the stenosis could be useful to help the diagnostic-therapeutic process. The aim of this study was to evaluate the diagnostic accuracy of Quantitative Flow Ratio (QFR) in the assessment of extracranial internal carotid artery stenosis. Materials and methods This registry prospectively enrolled asymptomatic patients with an indication to perform a selective angiography of the supra-aortic trunks. The systolic peak velocity obtained by colour Doppler ultrasound was used to determine the hemodynamic significance of the carotid stenosis (PSV&amp;gt; 120 cm / sec), whereas it was defined angiographically significant a stenosis with a %DS &amp;gt; 60%, according to NASCET criteria (%DSNASCET). After three-dimensional reconstruction of the angiographic data, QFR, Area Stenosis (AS%) and the minimum luminal area (MLA, mm2) were obtained. Results 30 consecutive patients were enrolled, and 60 carotid arteries analysed, 8 of which were excluded because of previous percutaneous (n = 3) or surgical (n = 5) revascularization. On linear regression analysis, an inverse linear correlation was observed between QFR and PSV values ​​(r2 = 0.71, p &amp;lt;0.001) and% DSNASCET (r2 = 0.79, p &amp;lt;0.001) (Figure 1). Similarly, the MLA values ​​showed a significant correlation with both PSV and% DSNASCET (respectively, r2 = 0.67 and r2 = 0.75, p &amp;lt;0.001), as well as AS values, which also showed a significant correlation with both PSV and% DSNASCET (respectively, r2 = 0.68 and r2 = 0.88, p &amp;lt;0.001). The QFR and the% DSNASCET showed a comparable and high diagnostic accuracy (AUC = 0.99, p &amp;lt;0.001) using PSV as a reference, with a cut-off value of 0.95 for the QFR (Figure 2). However, considering the% DSNASCET cut-off values, the QFR showed higher diagnostic accuracy, sensitivity and negative predictive value as compared with % DSNASCET. Conclusions This study showed the feasibility of QFR for the assessment of extracranial internal carotid artery stenosis. It was effective indeed for predicting the functional significance of the stenosis considering the Doppler as standard of reference. However, whether revascularization of the carotid stenosis should be guided by QFR rather than the angiography alone has still to be evaluated.

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.

Predictors of Carotid Atherosclerosis Progression: Evidence from an Ultrasonography Laboratory.

The purpose of this study was to investigate the role of risk factors in predicting the variation in carotid atherosclerosis at ultrasonographic follow-up and, therefore, its role in the progression of large-vessel disease. This retrospective population study included all the outpatients that underwent at least two carotid ultrasonographies at our laboratory from 2001 to 2017. Demographic data, vascular risk factors, and the results at follow-up were analysed to determine if correlations exist between these risk factors and variation in carotid atherosclerosis. Data from 600 patients (327 males and 273 females with a mean age of 67 years) were collected. The mean follow-up period was 49 months (range: 1-195). We analysed each demographic variable and risk factor to assess its correlation with a worsening of carotid atherosclerosis; previous myocardial infarction (2.594), previous carotid surgical treatment (2.368), and hypertension (1.85) were found to have the highest odds ratios, respectively. Furthermore, the sample was divided into specific subpopulations (diabetes, hypertension, and smoking), and an association was found between age and worsening stenosis. Our results confirm the importance of carotid ultrasonographic follow-up in the monitoring and managing of large-vessel disease. Myocardial infarction, previous stroke, and previous surgical treatment were the strongest predictors of a worsening of carotid atherosclerosis. These findings suggest a strict follow-up is needed, even in the absence of significant carotid atherosclerosis at baseline.

Shear wave elastography to evaluate carotid artery elasticity in long-term drinkers with varying degrees of alcoholic fatty liver disease.

To evaluate carotid artery elasticity in long-term drinkers with varying degrees of alcoholic fatty liver disease (AFLD) by shear wave elastography (SWE). Of the 92 drinkers with alcohol drinking for greater than or equal to 5 years, were fell into three groups depending on the liver ultrasound results: group B (without AFLD), group C (with mild AFLD), and group D (moderate-to-severe AFLD). Another 32 healthy adults were selected as the control group (group A). All participants had no significant carotid plaque. Gray scale ultrasound and color doppler ultrasound were used to obtain the left common carotid peak systolic velocity (PSV), carotid diastolic internal diameter (Dd ), carotid intima-media thickness (IMT), carotid systolic internal diameter (Ds ) and the stiffness coefficient (β). Mean values of mean elastic modulus (MEmean ), minimum elastic modulus (MEmin ), and maximum elastic modulus (MEmax ) of the anterior wall of the left common carotid artery at end-diastole were measured by SWE. Dd , Ds , and PSV among the four groups showed no differences. (all P > 0.05). Compared with groups A and B, MEmin , MEmax , and MEmean were significantly higher in group C (all P < 0.05), while IMT and β were not statistically different (all P > 0.05). MEmean , MEmin , MEmax , IMT, and β were significantly higher in group D compared with the other three groups (all P < 0.05). No significant differences were observed in IMT, β, MEmean , MEmax , and MEmin between groups A and B (all P > 0.05). Shear wave elastography can provide a quantitative evaluation for the carotid artery elasticity in long-term drinkers with varying degrees of AFLD.