Symptomatic Carotid Artery Disease Research Articles

Carotid Artery Surgery: High-Risk Patients or High-Risk Centers?

Carotid angioplasty and stenting has been proposed as an alternative to carotid endarterectomy (CEA) in patients deemed as at high risk for this surgical procedure. To date, definitely accepted criteria to identify "high-risk" patients for CEA do not exist. Our objective was to assess the relevance of numerous supposed high-risk factors in our experience, as well as their possible effect on our early postoperative results. A retrospective review of 1,033 consecutive CEAs performed during a 5.6-year period at a single institution was conducted (Vascular Surgery Department, St. Etienne University Hospital, France). Early results in terms of mortality and neurologic events were recorded. Univariate and multivariate analyses for early risk of stroke, myocardial infarction, and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. The cumulative 30-day stroke and death rate was 1.2%. A total of 10 strokes occurred and resulted in three deaths. The postoperative stroke risk was significantly higher in the subgroup of patients treated for symptomatic carotid artery disease: 2,6% (P = 0,004). Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo surgery without increased complications. Those parameters should not be used as exclusion criteria for CEA.

Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (IN2-2.001)

Objective: To analyze the 1070 catheter-based angiograms performed on patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Background CAS may be useful as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. The angiographic predictors of stroke following CAS have been incompletely described. Design/Methods: Of the 1070 CAS patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed before and after CAS. Reviews were blinded to outcomes. Strokes were adjudicated by a committee blinded to results of angiography. The view showing the most severe stenosis was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results: The internal carotid artery mean reference diameter was 4.2 ± 0.8 mm, the minimal mean lumen diameter was 1.1 ± 0.6 mm, and the baseline mean % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke were lesion length (p=0.009), sequential lesions (p=0.007), severe distal tortuosity (p=0.025), and narrow mouth ulcer (p=0.05). Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05). Conclusions: In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option. Supported by: The National Institute of Neurological Disorders and Stroke (NINDS) and the NIH (R01 NS 038384) and by supplemental funding from Abbott Vascular Solutions (formerly Guidant). Disclosure: Dr.Roubin has received royalty payments from Abbott Vascular and Cook Inc. Dr. Popma has received personal compensation for activities with Boston Scientific as a consultant.Dr. Popma has received research support from Boston Scientific, Cordis, Abbott Vascular, and Medtronic. Dr. Almonacid has nothing to disclose. Dr. Morrish has nothing to disclose. Dr. Katzen has received personal compensation for activities with Boston Scientific, W.L. Gore, and Medtronic as a consultant and particpant on an advisory board. Dr. Chakhtoura has nothing to disclose. Dr. Lal has nothing to disclose. Dr. Voeks has nothing to disclose. Dr. Meschia has nothing to disclose. Dr. Brott has received personal compensation for activities with 3D Communications.

Exploration of a zero-tolerance regime on cerebral embolism in symptomatic carotid artery disease

Summary Background: Current protocols stress the importance of short-term diagnosis and treatment in recent TIA or minor stroke. The risk of a recurrent event can be predicted with embolus detection. Studies have shown that the presence of micro-emboli is associated with an increased risk of recurrent events. We explored in our patient population the effect of a zero-tolerance regime for cerebral embolism on outcome. Methods: Patients with a recent TIA or minor stroke were assigned to a study group or control group. Both groups were treated according to European Stroke guidelines, including prompt start of anti-thrombotic therapy, statins and short-term carotid arteries duplex scanning. The study group was subjected to TCD (Delica 9 series, Shenzen Delicate Electronics Co., LTD., China) embolus detection as soon as possible (EDS, SMT Medical, Wuerzburg, Germany). If emboli were detected, treatment was started immediately to stop cerebral embolization. This was achieved by either an altered drug regimen (clopidogrel) or angioplasty or carotid endarterectomy within one or two days. If carotid intervention was indicated in the control group, it was performed within two weeks, according to European guidelines. Results: 133 patients were enrolled in the study with three months follow-up. 61 patients were subjected to the control group, 72 patients were enrolled in the study group. Recurrent events occurred in 10.2% and 3.0%, respectively (p = 0.145). Conclusion: The current study shows a non-significant reduction in recurrent events in the study group. Probably sample size in this pilot study was insufficient to detect a significant decline. Nevertheless, the results show that embolus detection is feasible and the zero-tolerance regime may enhance the outcome of TIA and minor stroke patients. The findings support the start of a multicenter randomized trial to assess the clinical value of emboli detection in TIA and stroke care.

Effect of Combination Therapy with the Angiotensin Receptor Blocker Losartan plus Hydrochlorothiazide on Brain Perfusion in Patients with both Hypertension and Cerebral Hemodynamic Impairment due to Symptomatic Chronic Major Cerebral Artery Steno-Occlusive Disease: A SPECT Study

Background: While the combination of an angiotensin receptor blocker with thiazide diuretics produces a clinically beneficial reduction in blood pressure in patients who otherwise only partially respond to monotherapy with an angiotensin receptor blocker, blood pressure-lowering therapy with combination antihypertensive drug regimens in patients with cerebral hemodynamic impairment may adversely affect cerebral hemodynamics. The purpose of the present exploratory study was to determine whether blood pressure-lowering therapy with the combination of the angiotensin receptor blocker losartan plus hydrochlorothiazide (LPH) worsens brain perfusion in patients with both hypertension and cerebral hemodynamic impairment due to symptomatic chronic major cerebral artery steno-occlusive disease. Methods: Patients with losartan-resistant hypertension and reduced cerebrovascular reactivity (CVR) to acetazolamide due to symptomatic chronic internal carotid artery (ICA) or middle cerebral artery (MCA) steno-occlusive disease were prospectively entered into the present study and received 50 mg/day of losartan plus 12.5 mg/day of hydrochlorothiazideat 14 weeks after the last ischemic event. Cerebral blood flow (CBF) and CVR were measured before and 12 weeks after initiating LPH using N-isopropyl-p-[¹²³I]-iodoamphetamine single-photon emission computed tomography (SPECT). A region of interest (ROI) was automatically placed in the MCA territory on each SPECT image using a three-dimensional stereotactic ROI template. Results: None of the 18 patients who participated in the study experienced any new neurological symptoms or adverse effects related to antihypertensive drugs. Systolic (p < 0.001) and diastolic (p < 0.001) blood pressures were significantly reduced after the administration of LPH, with average reductions of 11 mm Hg in systolic blood pressure and 10 mm Hg in diastolic blood pressure. While in the affected hemisphere CBF did not differ between measurements taken before and after the administration of LPH, CVR was significantly higher after the administration of LPH than before (p = 0.007) and was significantly improved in 5 of 18 patients. In the contralateral hemisphere, CBF and CVR did not differ between measurements taken before and after the administration of LPH. There were no patients who experienced a significant deterioration in CBF or CVR in the affected or contralateral hemisphere after the administration of LPH. Conclusions: Although the present study was exploratory and its results were preliminary due to the small sample size, the current data suggest that blood pressure-lowering therapy with LPH apparently does not result in worsening of cerebral hemodynamics in patients with both hypertension and cerebral hemodynamic impairment due to symptomatic chronic ICA or MCA steno-occlusive disease.

Headache in Carotid Artery Stenting and Angiography

Carotid angioplasty headache and diagnostic criteria are based on scarce data and small series. Here, we aimed to determine presence, frequency, and characteristics of headache after carotid artery stenting and angiography headache and speculate on possible mechanisms of head and neck pain emerging during or after the carotid artery stenting procedure. The total of 64 patients who were admitted to our Neuroradiology Division of Radiology Department for primary percutaneous transluminal carotid interna stenting were included in the study. They had symptomatic or asymptomatic carotid artery disease with stenosis more than 70%. All patients were questioned by a neurologist regarding the presence, side, location, quality, severity, duration, and timing of headache after both angiography and stenting procedures. Frequency of headache after carotid interna stenting was 39.1%, it commonly arose in a short period after the procedure and relieved in 10 minutes. This type of headache was mild, ipsilateral, frontotemporal in location, pressing in nature, and arose frequently within 10 minutes after the procedure, whereas angiography headache had a frequency of 21.9% and it was ipsilateral, mild, burning-like headache. Angiography headache also relieved within 10 minutes. Both types of headache were related to severe stenosis. Our study clearly demonstrates that headache is seen after carotid artery stenting (39.1%) and angiography (21.9%). Although both types of headache have similar characteristics, they differ in that it is mostly pressing in the group of carotid artery stenting and burning in angiography group.

Abstract 4: Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy versus Stenting Trial

Background Carotid artery stent (CAS) placement may be used as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. Perhaps because stroke is an uncommon event after CAS, the angiographic predictors of stroke have been incompletely described. Methods A total of 1070 catheter-based angiograms were centrally reviewed in patients undergoing CAS enrolled in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Of these patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed using qualitative and quantitative methodology before and after CAS. Reviews were done blinded to patient outcomes and strokes were adjudicated by a central committee blinded to results of angiography. The view showing the greatest carotid stenosis severity was selected. Extreme tortuosity was defined as 2 severe bends &gt;90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results The internal carotid artery reference diameter was 4.2 ± 0.8 mm, the minimal lumen diameter was 1.1 ± 0.6 mm, and the baseline % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke are listed in the Table . Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p &gt; 0.05). Conclusion In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length &gt; 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option.

Abstract 2684: Clopidogrel Load For Emboli Reduction In Patients With Symptomatic Carotid Artery Stenosis Undergoing Urgent Carotid Endarterectomy (CEA): A Multicenter Pilot Feasibility Study

Background&amp;Purpose: Microembolic signals (MES) on transcranial Doppler (TCD) are an independent risk factor for recurrent stroke and neurological deterioration in patients with extracranial symptomatic and asymptomatic carotid artery disease (CARAD). Clopidogrel load (300mg) combined with dual antiplatelet therapy has been shown to reduce asymptomatic embolization in patients with symptomatic CARAD. We sought to determine feasibility of clopidogrel load in decreasing asymptomatic embolization in patients with symptomatic CARAD undergoing urgent CEA within the first 8 days from the index event. Subjects&amp;Methods: Consecutive patients with symptomatic CARAD (70%-99% stenosis) and presence of MES on 1-hour baseline (&lt;24 hours from the index event) TCD-monitoring of ipsilateral middle cerebral artery (MCA) were treated with clopidogrel load followed by clopidogrel 75mg±aspirin 100mg during the elapsed time period between hospital admission and urgent CEA at three tertiary care stroke centers. Repeat 1-hour TCD monitoring was performed the day before surgery. Bleeding complications during surgery and recurrent strokes/TIAs during the first month following the index event were prospectively documented. Functional independence at three months was evaluated using the modified Rankin Scale (mRS) Score. Results: A total of 9 symptomatic CARAD patients (mean age 66±6years, 89% men, 56% ischemic strokes, median NIHSS 4 points, interquartile range 0-8, 44% TIAs) were treated with clopidogrel load followed by dual (66%) or single (33%) antiplatelet therapy. MES count was significantly reduced between baseline (&lt;24 hours from index event, median count 8 MES/hr, interquartile range 6-17) and repeat (4-7 days from index event, median count 0 MES/hr, interquartile range 0-4; p=0.008 by Wilcoxon Signed Ranks Test) TCD-monitoring. The mean MES frequency reduction (compared to baseline) was 89% (95%CI:77%-100%). No bleeding complications (0%) or recurrent strokes (0%) were documented. All patients were functionally independent (mRS-scores of 0-1) at three months. Conclusions: Our pilot study shows feasibility of administering clopidogrel load followed by dual or single antiplatelet therapy to reduce asymptomatic embolization in patients with symptomatic CARAD who are scheduled to undergo urgent CEA. The present findings are subject of a larger ongoing multi-center study.

Circle of Willis anomalies in stroke patients related with symptomatic carotid artery disease

Circle of Willis anomalies in stroke patients related with symptomatic carotid artery disease

Outcomes of carotid artery stenting in high-risk patients; a single center retrospective review

In our study, we evaluated the safety and efficacy of carotid artery stenting(CAS) in high surgical risk patients. 22 consecutive patients who underwent carotid artery stenting(CAS) between March 2009 and December 2011 were eligible. Only symptomatic stenosis were studied in high surgical risk patients as defined by the SAPPHIRE(Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy) trial. The mean age was 77.8 (range 67-87). Of the study group, 17 male(77.27%) and 5 female(22, 72%). Procedural success was achieved in 21 patients(95.4%). The mean stenosis in patients was 90.68 ±5.4%. Reasons for stenting included cardiac/pulmonary risk(63%), contralateral carotid artery occlusion(72%), age older than 75(72%). None of the patients suffered from major stroke, MI or death due to CAS during their hospital stay. The overall rate of in-hospital adverse events (TIA, permanent bradycardia, hypotension) was 18.1 %(4 of 21). Bradycardia in 2(9.5%), hypotension in one(4.7%) and transient ischemic attack in one(4.7%) were observed during procedures. Our results support the use of CAS in high surgical risk patients with significant symptomatic carotid artery disease.

Carotid angioplasty is an alternative therapeutic option to carotid endarterectomy for a defined group of patients

Stroke is the third cause of death and the leading cause of disability worldwide. In the United States approximately 795000 cases of stroke are produced annually with a mortality rate of 17%. (1) Atherosclerotic disease of the extracranial internal carotid artery (ICA) is responsible for 20% to 25% of all ischemic strokes, and both medical therapy (MT) and carotid endarterectomy (CE) have been previously used to prevent them. Medical therapy is currently considered the first choice in the treatment of asymptomatic patients with ≤ 80% carotid obstruction. Regarding CE, both American and European guidelines recommend its use in symptomatic patients with stenosis between 70 % and 99% (Class I, level of evidence A). Carotid percutaneous transluminal angioplasty (PTA) is the third therapeutic option which started to be used 15 years ago and several randomised studies have attempted to better define its role with respect to MT and CE. CAVATAS (2) was the first multicentric, randomised study, which included 504 patients with symptomatic carotid artery disease for PTA and CE. There were no significant differences between both treatments in the endpoint of death or stroke at 30 days (10%) and at 3 years (14%). The surgical team had a greater rate of cranial nerve paralysis (CE: 8.7%, PTA: 0%; p < 0.0001). No cerebral protection (CP) system was employed and stenting was used only in 26% of the cases. SAPPHIRE (3) included 334 symptomatic and asymptomatic (70%) patients with high risk surgical criteria. According to protocol, CP was used in all PTA patients. The primary endpoint of death, stroke or acute myocardial infarction (AMI) at 30 days plus ipsilateral stroke or death due to neurological causes between 31 days and 1 year occurred in 12.2% of the PTA group patients and 20.1% of the CE group patients (p = 0.004 for noninferiority and p = 0.05 for superiority). The rates of stroke and death at 30 days were similar in both groups and in the CE group there was a greater proportion of infarction (6.6% vs. 1.9%; p = 0.04) and cranial nerve paralysis (5.3% vs. 0%; p = 0.003). SPACE (4) and EVA-3S (5) published in 2006, were multicentric, randomised and noninferiority studies. The SPACE study enrolled 1200 symptomatic patients and CP was used in 27% of the PTA group patients. The primary endpoint of ipsilateral stroke or death from any cause at 30 days, occurred in 41 patients of the PTA group (6.84%) and in 37 patients in the CE group (6.34%) (absolute difference 0.51%; p = 0.09 for noninferiority). No significant differences were found for death, global stroke, non-fatal ipsilateral ischemic stroke, disabling stroke and nonfatal ipsilateral intracerebral bleeding. Even though the SPACE study could not prove noninferiority of PTA compared with CE, the difference between both treatments was of only four events in almost 600 patients treated per group.

Nigel John Paul Lehmann

It has been known for more than a century that even slight hypoxemia reduces dark adaptation. We studied dark adaptation in symptomatic carotid artery disease. Twenty-one consecutive patients scheduled for...

Long-term success of vein-patch and carotid endarterectomy

Most patients with severe symptomatic carotid artery disease will benefit from a carotid endarterectomy to reduce the risk of a stroke. The long-term success of vein-patch angioplasty has been determined in this study. From 1974 to 1997, 507 patients had 587 carotid endarterectomies with a greater saphenous vein graft and 97 patients had 116 carotid endarterectomies with primary closure. Mean follow-up times were 3.6 and 3.7 years, respectively. Ten percent of the patients were followed for more than 10 years. Carotid duplex ultrasonography and/or angiography were used to determine patency. Graft occlusion or significant restenosis (>69%) of the carotid artery, and the occurrence of a stroke were determined. Life-table analyses of graft patency, stroke survival were done. Perioperative ipsilateral stroke rates were 0.5% and 2.6% with the vein patch graft and primary closure, respectively (p<0.01). At 14 years, ipsilateral stroke-free rates were 97% for patients with a patch graft and 94% with primary closure (p<0.001). The rates of freedom from restenosis were 94% with the patch graft and 70% with primary closure (p<0.001), and primary patency rates were 96% and 81%, respectively (p<0.002). Ipsilateral stroke-free survival rates were 52% and 37%, respectively for patients with a patch graft and primary closure (p<0.02). Carotid endarterectomy with the vein-patch angioplasty gave an excellent result. The long-term patency of the graft and artery, freedom from an ipsilateral stroke, and survival were good. The results with a primary closure were inferior.

Do Postmarketing Surveillance Studies Represent Real-World Populations?

Background— To evaluate outcomes after carotid artery stenting in larger real-world populations, the Food and Drug Administration mandated that companies conduct postmarketing surveillance (PMS) studies of approved stent systems. Whether PMS studies are representative of carotid artery stenting in routine clinical practice has not been established. Methods and Results— Within the National Cardiovascular Database Registry–Carotid Artery Revascularization and Endarterectomy (NCDR CARE) Registry, we compared patient and procedural characteristics, in-hospital outcomes, and subsequent all-cause mortality after carotid artery stenting in PMS study participants and nonparticipants. We conducted both crude and propensity score–adjusted comparisons for all outcomes between groups. Compared with nonparticipants, participants in PMS studies had lower rates of symptomatic carotid artery disease within the preceding 6 months, prior stroke, and acute evolving stroke at baseline. The PMS study participants had lower unadjusted rates of combined in-hospital death, stroke, or myocardial infarction (2.3% versus 4.1%; P &lt;0.001), driven by lower rates of stroke (1.7% versus 2.7%; P =0.005) and death (0.3% versus 1.4%; P &lt;0.001). Differences in survival persisted after propensity score adjustment (odds ratio, 0.44; 95% confidence interval, 0.21 to 0.95; P =0.04 for in-hospital mortality; and hazard ratio, 0.80; 95% confidence interval, 0.66 to 0.97; P =0.02 for 2-year mortality). Baseline differences in neurological history explained the largest proportion of the difference in outcomes between groups. Conclusions— Participants in PMS studies for carotid artery stenting have different clinical and procedural characteristics and lower mortality compared with nonparticipants. Extrapolating results from PMS studies of carotid artery stenting to larger real-world settings should be done only with great caution.

Intracranial Hemodynamics Is Altered by Carotid Artery Disease and After Endarterectomy

Carotid endarterectomy (CEA) has become a routine procedure to treat symptomatic carotid artery disease and reduce the risk of recurrent cerebral ischemic events. The purpose of this study was to use an arterial spin labeling dynamic magnetic resonance angiography technique to characterize intracranial hemodynamics before and after CEA. Thirty-seven carotid artery disease patients participated in this study, of whom 24 underwent magnetic resonance imaging before and after CEA. Seventeen control subjects spanning 5 decades underwent magnetic resonance imaging to assess age-related changes. Hemodynamic metrics (that is, relative time to peak and amplitude) were calculated with a γ-variate model. Linear regression was used to relate carotid artery disease burden to downstream hemodynamics in the circle of Willis. Relative time to peak increased with age in controls (P<0.020). For patients, relative time to peak was positively correlated with percent stenosis (P<0.050), independent of age. At 1 day after CEA, the middle cerebral artery ipsilateral to the CEA showed significant dynamic magnetic resonance angiography changes: relative time to peak decreased (P<0.017) and the flow amplitude increased (P<0.009). No pre- versus post-CEA changes were significant in the contralateral middle cerebral artery or posterior segments. This noninvasive, arterial spin labeling-based method produced time-resolved images that were used to characterize intracranial arterial flow associated with aging, extracranial carotid artery disease, and CEA. Results demonstrate that the technique has the sensitivity to detect hemodynamic changes after CEA.

Treating symptomatic carotid artery disease: deciding between carotid artery stenting and carotid endarterectomy – balancing the risks

Ischemic stroke is the third leading cause of death in the USA [1,2] and is an important cause of major morbidity and mortality both in the USA and worldwide. Carotid artery disease amenable to revascularization accounts for 5–12% of new strokes [3,4]. Carotid artery angioplasty and stenting (CAS) has evolved as an alternative therapeutic option for the treatment of extracranial carotid artery occlusive disease and the concept was first introduced in 1980 by Kerber et al. [5]. The initial problems associated with carotid angioplasty included vessel recoil and dissection and have been successfully addressed with the use of stents. The problems of luminal narrowing due to external compression forces and torsion, have been greatly reduced by the use of self-expanding stents, and distal embolization has been reduced by the use of embolic protection devices. However, CAS has raised much controversy regarding its safety, efficacy and criteria for patient selection.

Treatment strategies in severe symptomatic carotid and coronary artery disease

SummaryCoexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD.We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI).The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE – death, stroke or MI) reaches 10–12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4–4.5%.No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Recovery of Cerebrovascular Reserves after Stenting for Symptomatic Carotid Artery Stenosis

Although a decrease in cerebrovascular reserves (CVR) is known to enhance the risk of stroke, changes in this parameter after carotid artery stenting (CAS) have rarely been investigated. The present study is the first to compare CVR recoveries after applying CAS to patients with symptomatic carotid artery disease. CAS was performed for 31 consecutive patients with symptomatic carotid artery disease. They underwent acetazolamide-challenged single photon emission computed tomography (SPECT) before and after CAS to obtain data on resting stage cerebral blood flow (CBF(rest) values) in various regions of interest (ROIs) defined by a three-dimensional stereotactic ROI template. CVR values on ipsilateral and contralateral hemispheric sides were then calculated based on the CBF(rest) data. The 31 patients were dichotomized into unilateral (n=22) and bilateral (n=9) lesion groups, and no significant between-group differences were observed in CBF(rest) before and after CAS. In the unilateral group, there were no differences in CVR values before and after CAS. In the bilateral group, however, the CVR values significantly increased in nearly all the investigated ROIs on the contralateral side. Also, the hemispheric CVR values on both sides significantly increased after CAS in the bilateral group, while no such increase was observed in the unilateral group. CAS in patients with symptomatic bilateral carotid artery disease has the potential utility for their haemodynamic improvement even on the contralateral hemispheric side.

POS10 Variability in patient response to clopidogrel and effects on outcome from carotid stenting

Carotid stenting can be an alternative to carotid endarterectomy in patients with recent symptomatic carotid artery disease. Periprocedural complications can be significantly reduced with a dual antiplatelet regime that includes...

Carotid Artery Stenting: Lessons From CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial)

The results of the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) ([1][1]) were recently published, and they confirmed that there is clinical equipoise for stenting versus surgery for symptomatic carotid artery disease in average risk patients. The CREST is the largest

Association between Biomechanical Structural Stresses of Atherosclerotic Carotid Plaques and Subsequent Ischaemic Cerebrovascular Events – A Longitudinal in Vivo Magnetic Resonance Imaging-based Finite element Study

Background High-resolution magnetic resonance (MR) imaging has been used for MR imaging-based structural stress analysis of atherosclerotic plaques. The biomechanical stress profile of stable plaques has been observed to differ from that of unstable plaques; however, the role that structural stresses play in determining plaque vulnerability remains speculative. Methods A total of 61 patients with previous history of symptomatic carotid artery disease underwent carotid plaque MR imaging. Plaque components of the index artery such as fibrous tissue, lipid content and plaque haemorrhage (PH) were delineated and used for finite element analysis-based maximum structural stress (M-C Stress) quantification. These patients were followed up for 2 years. The clinical end point was occurrence of an ischaemic cerebrovascular event. The association of the time to the clinical end point with plaque morphology and M-C Stress was analysed. Results During a median follow-up duration of 514 days, 20% of patients ( n = 12) experienced an ischaemic event in the territory of the index carotid artery. Cox regression analysis indicated that M-C Stress (hazard ratio (HR): 12.98 (95% confidence interval (CI): 1.32–26.67, p = 0.02), fibrous cap (FC) disruption (HR: 7.39 (95% CI: 1.61–33.82), p = 0.009) and PH (HR: 5.85 (95% CI: 1.27–26.77), p = 0.02) are associated with the development of subsequent cerebrovascular events. Plaques associated with future events had higher M-C Stress than those which had remained asymptomatic (median (interquartile range, IQR): 330 kPa (229–494) vs. 254 kPa (166–290), p = 0.04). Conclusions High biomechanical structural stresses, in addition to FC rupture and PH, are associated with subsequent cerebrovascular events.