Symptomatic High-grade Stenosis Research Articles

Update Karotisstenose

Stenosis of the extracranial carotid artery is a treatable cause of ischemic stroke and can reliably be detected and graded by vascular ultrasound. The differentiation between symptomatic and asymptomatic stenosis, the perioperative risk and the estimated life expectancy of the patient guide the therapy. Therapy is based on an optimal treatment of cardiovascular risk factors and antiplatelet drugs. Revascularization using surgical carotid endarterectomy is efficient for the prevention of stroke in patients with a high grade symptomatic stenosis. Endovascular therapy using stent-protected angioplasty of the carotid artery is an alternative in patients with a higher surgical risk with low complication rates when performed in experienced centres. Patients with asymptomatic carotid artery stenosis are primarily treated conservatively and revascularization is indicated in patients with a low surgical and global cardiovascular risk.

Carotid angioplasty and stenting for symptomatic carotid kinking combined with stenosis

Background Carotid endarterectomy (CEA) is currently the preferred treatment for severe carotid kinking and stenosis. Kinking is generally believed to be a relative contraindication for endovascular stent placement. This article aims to study the necessity, feasibility and security of carotid angioplasty and stenting (CAS) for symptomatic carotid kinking combined with stenosis, and summarize clinical experience of this disease according to therapeutic results. Methods Twenty-two cases with symptomatic carotid kinking and high-grade stenosis demonstrated by digital subtraction angiography (DSA) were performed CAS. Their clinical manifestations, imaging features, procedure safety and follow-up data were collected and retrospectively analyzed. All patients understood CEA and voluntarily received CAS. Results Twenty-two cases with carotid kinking and stenosis were all successfully performed CAS (the success rate was 100%) without stent-related disability or mortality. Twenty-four self-expandable stents were implanted. The mean degree of stenosis was reduced from 85.63% before stenting to 11.25% after stenting and the angles of kinking were improved from 120° (Metz' category). During the period of hospitalization, no transient ischemic attack (TIA) or cerebral infarction occurred, and the clinical symptoms and signs of ischemia, such as dizziness and headache, were improved or disappeared. Besides, no permenant complications or deaths happened. All cases were followed up from 6 to 72 months, among whom 1 patient experienced contralateral carotid TIA, and 2 patients experienced ipsilateral carotid TIA (one indicated aspirin resistance in platelet aggregation test and the other showed restenosis in DSA). Computed tomography angiography (CTA) of 10 patients and Duplex scan of 7 patients during the follow-up demonstrated carotid in good morphology and fluent blood flow, without kinking or restenosis. Conclusion CAS is a feasible and safe therapeutic method and maybe helpful to lower the risk of cerebral ischemia for the patients with symptomatic kinking and stenosis. However, further study is still needed.

Intravenous Flat-Detector Computed Tomography Angiography for High-Grade Carotid Stenosis

The significant feature of intravenous flat-detector computed tomography (IV FDCT) angiography is its role in neurointerventional setting without patient transfer. However, few studies have addressed the accuracy of IV FDCT in estimating carotid stenosis and length. This study examined the reliability of IV FDCT in the diagnosis of high-grade carotid stenosis and stenosis length with digital subtraction angiography (DSA) as the reference. Intravenous flat-detector CT and DSA were conducted simultaneously for 33 patients with 42 stenosed carotid arteries who were suspected of having symptomatic high-grade stenosis by carotid duplex ultrasound, magnetic resonance angiography, or CT angiography. The degree of stenosis and length discrepancy between 2 tests were recorded by 2 readers. The intraobserver and interobserver agreements were excellent for measuring high-grade carotid stenosis (κ = 0.87 and 0.82). Intravenous flat-detector CT had a sensitivity of 96.3%, specificity of 93.3%, and negative predictive value of 93.3% for detecting high-grade stenosis (≥70%) compared with DSA. Bland-Altman plots demonstrated excellent correlation of the degree of stenosis IV FDCT with DSA. Length discrepancy (IV FDCT - DSA, in millimeters) did not differ significantly according to degree of stenosis (Spearman rank test; r = 0.18, P = 0.26). Intravenous flat-detector CT can be a feasible and time-saving test for evaluating high-grade carotid stenosis and stenosis length.

Acute Intracranial In-Stent Thrombosis After Angioplasty of Middle Cerebral Artery Symptomatic Stenosis

Intracranial atherosclerotic disease is one of the major risk factors of ischemic stroke. Percutaneous transluminal angioplasty with stent deployment may be effective for the treatment of symptomatic intracranial stenosis, however its value is yet to be determined. High possibility of serious periprocedural complications, such as acute in-stent thrombosis or stroke, narrows the current recommendations for this treatment to patients with high-grade stenosis (>70%), and to experienced neurointerventional centers. We present a 44-year-old male with symptomatic high-grade stenosis of the M1 segment of left middle cerebral artery, treated with percutaneous transluminal angioplasty with stenting. The procedure was complicated with acute in-stent thrombosis treated with intra-arterial thrombolysis, which resulted in a nondisabling stroke. The procedure-related stroke in this patient was probably caused by middle cerebral artery perforator ostium occlusion with balloon predilatation and transient in-stent thrombosis related to insufficient antiplatelet pretreatment. Exhausted cerebrovascular reserve due to long-lasting high-grade intracranial stenosis should also be considered as a factor contributing to ischemic complications.

Late carotid artery stent erosion and pseudoaneurysm after accidental hyperextension of the neck

A 75-year-old man was referred to our unit complaining of a large pulsatile neck mass that appeared 2 days after an accidental fall and hyperextension of the neck. One month earlier, he was submitted to left carotid artery stenting for symptomatic high-grade stenosis. His medical history included diabetes mellitus, coronary artery disease, and a right femoropopliteal bypass for critical limb ischemia. At the time of admission, he was afebrile and had no evidence of local erythema, draining sinus, or leukocytosis. Moreover, C-reactive protein was 1 mg/dL. The clinical examination revealed a large swelling in the region of the left carotid bifurcation and mild dyspnea. Arterial duplex imaging and computed tomography angiography demonstrated a pseudoaneurysm arising from the posterior wall of the left carotid bifurcation with the stent struts protruding outside of the vessel (A). An urgent endovascular procedure was carried out. In a dedicated angiography suite, a short 9F sheath was inserted through a left femoral approach and selective catheterization of the left common carotid artery was undertaken (B). The catheter was gently placed distal to the pseudoaneurysm over a 0.035-inch soft wire. The soft wire was then exchanged for a superstiff 0.035-inch wire and a 9-mm 40-mm Fluency stent graft (Bard, Tempe, Ariz) overlapped proximal to the first stent. A final angiogram showed complete exclusion of the pseudoaneurysm (C). The patient was discharged after 1 week without complication. At computed tomography angiography 1 month later, the stents were patent (D) and the mass had reduced in size. Late onset of post-stenting carotid pseudoaneurysm is extremely rare. To our knowledge, this is the first report describing a carotid artery pseudoaneurysm caused by traumatic stent erosion and its endovascular management. Infection and stent fracture have been reported as the causes of two late carotid pseudoaneurysms. In both cases, the aneurysmal segment, including the indwelling stent, was surgically excised and a vein interposition graft was performed. Percutaneous stent graft placement is increasingly being used to treat noninfected pseudoaneurysms at a number of sites. The advantages of this approach include the use of local anesthesia, no tracheal intubation or intensive care requirement, and a shortened hospital stay.

Percutaneous and Open Retrograde Endovascular Stenting of Symptomatic High-Grade Innominate Artery Stenosis: Technique and Follow-Up

Angioplasty and stenting of the IA have been reported with high technical and clinical success rates, low complication rates and good mid-term patency rates. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure of the CCA are used. The purpose of this study was to determine safety, efficacy and mid-term clinical and radiological outcome of the stent-assisted treatment of atherosclerotic stenotic disease of the IA with special focus on the different technical approaches. Between 1996 and 2008, 18 patients (12 men, 6 women) with symptomatic high-grade stenosis (>80%) of the IA were treated with endovascular stent placement. Their mean age was 60.4 years (range, 48-78 years). Mean angiographic and clinical follow-up was 2.7 years (range, 0.3-9.1 years). Clinical follow-up was performed by using the mRS at hospital discharge, routine follow-up controls, and a questionnaire. In 11 patients, a percutaneous approach was used. In 7 patients, the lesions were accessed retrogradely through a cervical cut-down with common carotid arteriotomy. In 2 patients, a simultaneous ipsilateral carotid endarterectomy was performed. In all patients, primary stent placement was performed. There were 2 procedure-related transient complications (11.1%) due to cerebral embolism without permanent morbidity or mortality. During the follow-up, all patients showed improvement of the preprocedural symptoms. At the latest clinical follow-up (mean, 2.7 years), all patients showed an excellent or good outcome (mRS, 0 or 1). In 2 patients (11.1%), a secondary stent placement was needed due to a significant symptomatic in-stent stenosis. Percutaneous and open retrograde stenting of high-grade stenosis of the IA is a viable less invasive alternatives to open bypass surgery with good midterm clinical results and patency rates.

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Endarterectomy is generally recommended for symptomatic high-grade (70 to 99%) stenosis of the internal carotid artery, but whether this procedure is beneficial among patients with chronic kidney disease (CKD) is unknown. In this re-analysis of data from the North American Symptomatic Carotid Endarterectomy Trial, we included patients with symptomatic stenosis and either stage 3 CKD (n = 524) or preserved kidney function (n = 966; estimated GFR > or = 60). For medically treated patients with high-grade stenosis, risk for ipsilateral stroke at 2 yr was significantly higher in patients with CKD than in those with preserved renal function (31.6 versus 19.3%; P = 0.042); carotid endarterectomy significantly reduced this risk by 82 and 51%, respectively. To prevent one ipsilateral stroke, the number needed to treat by endarterectomy was four for patients with CKD and 10 for patients with preserved renal function. Compared with patients with preserved renal function, those with CKD had similar rates of perioperative stroke and death but higher rates of cardiac events. In conclusion, patients with stage 3 CKD and symptomatic high-grade carotid stenosis gain a large benefit in stroke risk reduction after endarterectomy.

Kathetergestützte Aortenklappenimplantation aus chirurgischer Sicht

The technology of catheter- based aortic valve implantation is a new, less invasive therapeutic option for patients with symptomatic high-grade aortic stenosis. The present paper aims to demonstrate that optimal therapy should be provided by a multidisciplinary team consisting of cardiac surgeons, cardiologists and cardioanesthesiologists in a hybrid suite. From June 2007 to April 2009, 234 patients have been treated by transcatheter aortic valve implantation through different access sites (n = 168 femoral artery, n = 56 left ventricular apex, n = 7 subclavian artery, n = 3 ascending aorta) at the German Heart Center Munich, Germany. An algorithm for the choice of the most appropriate access site for the individual patient was established. The 30-day mortality was 11.2% in this high-risk patient cohort. A certain number of periprocedural complications required surgical management. There was a considerable clinical improvement of the patients 6 months after the procedure. Integrating the new methods of aortic valve implantation into a cardiac surgery program, all kinds of surgical and interventional treatment options may be offered to the patient with aortic stenosis by one multidisciplinary team. A qualified and safe performance of transcatheter aortic valve implantation and the management of potential complications require the presence of a hybrid suite.

Thrombotic Restenosis After Minimally Invasive Implantation of Aortic Valve Stent

An 84-year-old woman underwent successful, minimally invasive, transapical aortic valve implantation (Edwards SAPIEN 23 mm) to address symptomatic high-grade aortic stenosis and logistic EuroScore of 22%. Echocardiographic control after 11 and 41 days demonstrated the valve in good position without relevant paravalvular leakage or aortic regurgitation. Mean gradients over aortic valve implant were 17 mm Hg and 19 mm Hg, respectively. At echocardiographic follow-up at 6 and 8 months, mean gradient increased to 40 mm Hg and 53 mm Hg, respectively. The patient also developed dyspnea on exertion again. Transesophageal echocardiography at 8 months demonstrated 1 well opening aortic valve leaflet at the septal side, whereas an echodense structure was visible at the opposite side (Figure 1 …

New data about stenting versus endarterectomy for symptomatic carotid artery stenosis

Patients with symptomatic carotid artery stenosis should be counseled on diet, exercise, moderation of alcohol consumption, smoking cessation, and avoidance of environmental tobacco smoke. Medical therapy generally includes a platelet antiaggregant, blood pressure control, and a statin. Other medical therapy depends on specific patient characteristics. Carotid endarterectomy in addition to best medical therapy is of proven benefit in reducing the risk of ipsilateral stroke compared with best medical therapy alone in patients with symptomatic high-grade stenosis, provided the operation can be performed safely. Although limited, data are available to support carotid angioplasty/stenting in patients with symptomatic high-grade stenosis in whom endarterectomy is not feasible because of anatomic or other technical factors. Whether carotid angioplasty/stenting is as efficacious as endarterectomy in patients with average periprocedural risk remains uncertain and is under investigation.

A Systematic Review on Outcome After Stenting for Intracranial Atherosclerosis

Angioplasty and stenting is increasingly being used for the treatment of intracranial stenoses. Based on a literature search (01/1998 to 04/2008) we sought to determine the immediate and long-term outcomes, as well as the durability of this procedure. We identified 31 studies dealing with 1177 procedures, which had mainly been performed in patients with a symptomatic (98%) intracranial high-grade stenosis (mean: 78+/-7%) at high technical success rates (median: 96%; interquartile range [IQR]: 90% to 100%). The periprocedural minor or major stroke and death rates ranged from 0% to 50% with a median of 7.7% (IQR: 4.4% to 14.3%). Periprocedural complications were significantly higher in the posterior versus the anterior circulation (12.1%, versus 6.6%, P<0.01, odds ratio [OR]: 1.94, 95% confidence interval [CI]: 1.21 to 3.10), but did not differ between patients treated with a balloon-mounted (n=906) versus those who had been treated with a self-expandable stent (n=271; 9.5% versus 7.7%, P=0.47, OR: 1.15, CI:0.76 to 2.05). Restenosis >50% occurred more frequently after the use of a self-expandable stent (16/92; 17.4%, mean follow-up time: 5.4 months) than a balloon-mounted stent (61/443; 13.8%, mean follow-up time: 8.7 months; P<0.001, log-rank test). Although intracranial stenting appears to be feasible, adverse events vary widely. Against the background of the results of this review yielding a high rate of restenoses and no clear impact of new stent devices on outcome, the widespread application of intracranial stenting outside the setting of randomized trials and in inexperienced centers currently does not seem to be justified.

The Probability of Restenosis, Contralateral Disease Progression, and Late Neurologic Events following Carotid Endarterectomy: A Long-Term Follow-Up Study

Background: Most studies that have reported on the progression of ipsilateral and/or contralateral internal carotid artery (ICA) stenosis are restricted to a few years. Methods: Based on a single-center carotid endarterectomy (CEA) registry, we sought all patients with CEA for symptomatic high-grade ICA stenosis between 1970 and 2002. 361 CEA patients (mean age 66 years, 73% male) with annual carotid ultrasound and clinical follow-up were identified. Kaplan-Meier analysis was used to estimate the occurrence of (i) progressive ICA stenosis or restenosis of either the operated or contralateral side, and (ii) cerebrovascular events over time of either the operated or contralateral side. Results: Progressive ICA disease was more likely on the contralateral than on the ipsilateral ICA (hazard ratio 2.71; CI 1.8–4.1, p < 0.001). After 5 years, the probability for progressive ICA disease was 5.2% for the ipsilateral versus 15.8% for the contralateral ICA. After 15 years, the likelihood was 37% for both sides. In the presence of progressive restenosis of the ipsilateral ICA, the 20-year probability of further ischemic cerebrovascular events was 50% compared to 18% in patients without ICA disease progression. For the contralateral ICA, the probability of further ischemic events was 24.5% in patients with ICA disease progression compared to 9.6% without ICA disease progression (15 years). Conclusion: 15 years after CEA, one third of the patients can be expected to develop progressive ICA disease. While ICA disease progression seems to be more prominent on the contralateral ICA within the first years, this difference fades out after 15 years. One out of 2 patients with ipsilateral ICA disease progression can be expected to have a recurrent cerebral ischemic event within 15 years. It remains to be determined whether consequent application of high-dose statins, optimal blood pressure management and antithrombotic therapy can reduce this rate.

Prevalence of Micro-Emboli in Symptomatic High Grade Carotid Artery Disease: A Transcranial Doppler Study

Background and purpose: Echolucent carotid plaques, as well as downstream micro-embolisation, may be associated with an increased risk of stroke. However, the relationship between carotid plaque ultrasound characteristics and micro-embolic signals (MES) detected in the middle cerebral artery (MCA) is still controversial. The purpose of this study was to investigate the prevalence of MES in patients with symptomatic high-grade internal carotid artery (ICA) stenosis and to identify predisposing factors, such as plaque echogenicity and intra stenotic blood flow velocity pattern. Methods: 197 patients (mean age 69.5 ± 8.6, 161 males) with confirmed symptomatic high-grade ICA stenosis and anti-platelet treatment underwent bilateral MES monitoring for 30 minutes within the anterior circulation, using Power M-mode transcranial Doppler techniques (TCD). Carotid artery plaques were characterized by Gray-Weale scaling. Results: In 32.0% of the patients, we detected MES by TCD within the MCA on the symptomatic side, but the same finding was made in only 4.5% on the corresponding asymptomatic site (p < 0.0001). The presence or absence of MES was associated with neither ultrasonic plaque characteristics nor the intrastenotic blood flow velocities at peak systole and end diastole. The median time since the last ischemic event symptoms was shorter in the patient group with MES [+] than in MES [−] (p = 0.013). Conclusions: Despite optimum standard anti-platelet therapy, cerebral micro-embolisation occurs in 30% of patients with symptomatic carotid artery disease, which might therefore be a possible risk factor for recurrent neurological symptoms. However, the presence of MES is independent of intrastenotic blood flow disturbances and grey scale ultrasound plaque characteristics. The presence of MES as an indicator of unstable plaque and thereby a possible risk factor for stroke should be evaluated prospectively using various algorithms for plaque classifications.

Prevalence of Micro-Emboli in Symptomatic High Grade Carotid Artery Disease: A Transcranial Doppler Study

Echolucent carotid plaques, as well as downstream micro-embolisation, may be associated with an increased risk of stroke. However, the relationship between carotid plaque ultrasound characteristics and micro-embolic signals (MES) detected in the middle cerebral artery (MCA) is still controversial. The purpose of this study was to investigate the prevalence of MES in patients with symptomatic high-grade internal carotid artery (ICA) stenosis and to identify predisposing factors, such as plaque echogenicity and intra stenotic blood flow velocity pattern. 197 patients (mean age 69.5+/-8.6, 161 males) with confirmed symptomatic high-grade ICA stenosis and anti-platelet treatment underwent bilateral MES monitoring for 30 minutes within the anterior circulation, using Power M-mode transcranial Doppler techniques (TCD). Carotid artery plaques were characterized by Gray-Weale scaling. In 32.0% of the patients, we detected MES by TCD within the MCA on the symptomatic side, but the same finding was made in only 4.5% on the corresponding asymptomatic site (p<0.0001). The presence or absence of MES was associated with neither ultrasonic plaque characteristics nor the intrastenotic blood flow velocities at peak systole and end diastole. The median time since the last ischemic event symptoms was shorter in the patient group with MES [+] than in MES [-] (p=0.013). Despite optimum standard anti-platelet therapy, cerebral micro-embolisation occurs in 30% of patients with symptomatic carotid artery disease, which might therefore be a possible risk factor for recurrent neurological symptoms. However, the presence of MES is independent of intrastenotic blood flow disturbances and grey scale ultrasound plaque characteristics. The presence of MES as an indicator of unstable plaque and thereby a possible risk factor for stroke should be evaluated prospectively using various algorithms for plaque classifications.

Carotid artery stenting versus carotid endarterectomy - a prospective randomised controlled single-centre trial with long-term follow-up (BACASS)

Background and objective: Safety and effectiveness of carotid artery stenting (CAS) was compared with carotid endarterectomy (CEA) in a single-centre prospective randomised controlled trial in symptomatic high-grade stenosis of the ICA. Material and methods: Twenty patients with symptomatic ICA stenosis ≥70% were prospectively randomised to either CAS or CEA. Primary outcome measures were periprocedural stroke, death or myocardial infarction. Secondary outcome measures were peri-interventional transient TIA, bleeding complications, cranial nerve paralysis, length of stay and ICA patency as well as stroke or death during long-term follow-up. Results: CAS patients had no peri-interventional complications. In the CEA group 1/10 had an ipsilateral non-disabling stroke after 16 days. During long-term follow-up (48.1 ± 21.3 months with CAS and 43.5 ± 19.5 months with CEA) neither strokes nor myocardial infarctions occurred in both groups. Length of stay was 3.5 ±1.8 days for CAS versus 7.3 ± 3.3 days for CEA patients. CEA and CAS groups did not differ in other secondary outcome measures. Conclusion: CAS and CEA seem to be comparably safe in our setting. More importantly, data useful for a systematic meta-analysis are provided, which include long-term results.

Immediate CEA for symptomatic carotid disease preferably performed under local anaesthesia is safe

Previous general reservations against carotid endarterectomy (CEA) early after stroke, which were primarily based on concerns of postoperative intracerebral hemorrhage, are resolved. Moreover, a delay of surgery is proofed to be associated with a risk of recurrent cerebral ischemia. However, the complication rate of CEA seems to increase with less time interval to the onset of symptoms. The main purpose of this study was to assess the safety of very early CEA. Patients having a symptomatic high-grade (> 70%) internal carotid artery (ICA) stenosis were referred by neurologists for CEA within different timeframes, so that they were later differentiated depending on whether surgery was performed within 2 days (immediate CEA = iCEA) or 2 weeks (urgent CEA = uCEA) after neurological deficits have occurred primarily. The perioperative complication rate in these groups was than evaluated and compared. From January 2000 until August 2006 130 consecutive patients (median age 68 years, range: 42-90; 66% male, 34%female)presenting with an ipsilateral TIA (n = 80), stroke (n = 50) underwent iCEA (n = 40) or uCEA (n = 90). Demographic and clinical characteristics were equally distributed between treatment groups. Mostly (121/130), CEA was performed under local anaesthesia with selective shunt use which became necessary in 26%. Besides postoperative hemorrhage (n = 4), cardiac complications (n = 2) and temporary cranial nerve lesions (n = 2), new perioperative neurological deficits occurred in total in 8 patients of which 6 were temporary. The other 2 patients developed strokes of which one patient died. Therefore, the combined stroke- and mortality rate was 1.5% (2/130) for the whole study population. With regard to the timing of surgery, a single incident was observed after iCEA (1/40) which also was the only intracerebral hemorrhage. It seems that patients with a symptomatic high-grade ICA stenosis can undergo CEA particularly under local anaesthesia as soon as possible without anticipating an increased complication rate.

Evaluation of haemodynamic impairment and collateral flow in symptomatic carotid artery disease using arterial spin labelling MRI

Introduction: Arterial spin labeling (ASL) is a new MRI technique that provides information on cerebral hemodynamics by consecutive readout of labeled blood captured in arteries or in the microvasculature. The aim of the present study was to analyze the feasibility of ASL-MRI for the evaluation of both intracranial collateral pathways and hemodynamic compromise in patients with symptomatic high-grade stenosis or occlusion of the internal carotid artery (ICA). Therefore, we used a combination of a dynamic ASL-based MR angiography (DynAngio), and of ASL time series optimized for microvascular perfusion analysis.

Association of the Fibrinolytic System and Hemorheology with Symptoms in Patients with Carotid Occlusive Disease

Background and Objectives: The risk of stroke caused by a symptomatic high-grade carotid stenosis (CS) is high. Disturbed balance between the procoagulant and fibrinolytic activity in blood associated with unfavorable hemorheology could render CS symptomatic. We wanted to assess whether hemostatic and fibrinolytic plasma markers as well as basic indicators of hemorheology differentiate asymptomatic and symptomatic patients with a high-grade CS and whether they are associated with the macroscopic appearance of the plaque and the rate of microembolization. Methods: We recruited 92 consecutive consenting patients referred to the neurological or the surgical department of our university teaching hospital for treatment of their high-grade CS. Blood samples were collected before surgery for determination of prothrombin fragments F1 and 2, thrombin-antithrombin complex, tissue-type plasminogen activator (tPA) activity and antigen, plasminogen activator inhibitor-1 (PAI-1) activity and antigen, D-dimer, homocysteine, fibrinogen, in plasma, and hematocrit in blood, and the patients underwent transcranial Doppler ultrasonology for evaluation of microembolic signals (MES). Results: Patients with symptomatic plaques had higher hematocrit levels (p = 0.04), as well as trends for higher tPA antigen and MES rate (p = 0.07). Hematocrit, tPA antigen, and PAI-1 antigen and activity were positively correlated with the degree of stenosis. Ulceration was more common in symptomatic plaques but did not reflect variables of hemostasis or fibrinolysis. In multivariate analysis, tPA antigen and hematocrit were risk factors for a symptomatic high-grade stenosis. Conclusion: Mediators of fibrinolysis and unfavorable hemorheology may contribute to the development of a symptomatic disease in patients with a high-grade CS.