Symptomatic Internal Carotid Artery Stenosis Research Articles

Guideline for the management of symptomatic and asymptomatic internal carotid artery stenosis

Stenoses of the internal carotid artery (ICA) with a≥ 50% degree of stenosis are common in the German population with aprevalence of approx. 4.2%. Furthermore, about 15% of ischemic strokes are due to stenosis or occlusion of the ICA. There are currently three approaches to the treatment of ICA stenoses: conventional therapy, endovascular treatment and surgical treatment. Summary of the S3guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3February2020. Color-coded duplex sonography, computed tomography (CT) angiography and magnetic resonance (MR) angiography and, in exceptional cases, diagnostic subtraction angiography can be used to diagnose ICA stenoses, including the stenosis grade. The classification is into symptomatic and asymptomatic ICA stenoses. ICA stenoses can be treated conservatively, endovascularly with stenting or surgically by carotid endarterectomy. Invasive treatment should be carried out under inpatient conditions, whereby the hospital stay should be kept as short as possible. Color-coded duplex sonography should be performed regularly before discharge and at regular intervals thereafter to detect recurrent stenosis at an early stage and, if necessary, to initiate further invasive therapy. When choosing the treatment modality, particular attention must be paid to whether the stenosis is symptomatic or asymptomatic and the degree of stenosis. The S3guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3February2020 provides guidance here.

Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience.

Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG. Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30days. Additionally, the composite endpoint of these events was investigated. At 30days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patientssuffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62min vs. 84 ± 29min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint. Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.

Effect of collateral circulation in patients with multiple craniocervical artery stenoses.

Based on previous findings, collateral circulation in the brain is vital in mitigating cerebral ischemia's effects and influencing stroke risk. This retrospective study examined collateral circulation, admission ischemic stroke status, and long-term recurrence in patients with multiple craniocervical artery stenoses. Consecutive symptomatic internal carotid artery (ICA) stenosis patients from the First Affiliated Hospital of Soochow University were recruited. Baseline data including medical histories and neurological function at admission were collected. Imaging techniques assessed collateral compensative capacity. Multivariate logistic regression analysis was used to investigate the association between collateral circulation and case status. A total of 559 patients with symptomatic ICA stenosis were included, among whom 153 (27.4%) had concurrent moderate to severe vertebro-basilar artery (VBA) stenosis. Dizziness, weakness/numbness, and slurring of speech were the primary symptoms in all patients. Over 36 months, 71 (12.7%) patients experienced a recurrence of acute ischemic stroke (AIS). In multivariate analysis, collateral circulation was found to be negatively associated with AIS (regional leptomeningeal collateral [rLMC] scores: OR: 0.798, 95% CI: 0.743-0.857, p < 0.001; Tan scores: OR: 0.478, 95% CI: 0.336-0.679, p < 0.001). Meanwhile, the collateral circulation scores were significantly associated with the recurrence of AIS within 3 years (rLMC scores: OR: 0.926, 95% CI: 0.860-0.997, p = 0.042; Tan scores: OR: 0.467, 95% CI: 0.306-0.712, p < 0.001). Most associations remained significant in the subgroup of patients with VBA stenosis. Favorable collateral circulation in multiple craniocervical artery stenosis patients reduced long-term ischemic event recurrence. Stratifying treatment risks is essential for optimizing outcomes.

Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study

Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P= 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P= 0.48) were low and did not differ significantly between groups Y and E. Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.

Risk of new cerebral ischemic events in patients with symptomatic internal carotid artery stenosis while awaiting carotid stent placement.

Although there is an emphasis on performing carotid artery stent (CAS) placement within 2weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with significant extracranial internal carotid artery (ICA) stenosis, the risks and characteristics of recurrent cerebral ischemic event while waiting for CAS placement are not well defined. We analyzed patients admitted to our institution over a 45-month period with symptomatic extracranial ICA stenosis. We identified any new cerebral ischemic events that occurred between index cerebral or retinal ischemic event and CAS placement and categorized them as TIA and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index cerebral or retinal ischemic event and CAS placement. The mean age of 131 patients analyzed was 67years (range: 47-94 years; 92 were men), and 94 and 37 patients had 70%-99% and 50%-69% severity of stenosis, respectively. The mean and median time intervals between index cerebral or retinal ischemic event and CAS performance were 28 (standard deviation [SD] 30) and 7 (interquartile range 33) days, respectively. A total of 9 of 131 patients (6.9%, 95% confidence interval 2.5%-11.2%) experienced new cerebral ischemic events over 3637 patient days of observation. The risk of new ipsilateral cerebral ischemic events was 2.5 per 1000 patient days of observation. We estimated the risk of new ipsilateral cerebral ischemic events in patients with ICA stenosis ≥50% in severity while waiting for CAS placement to guide appropriate timing of procedure.

Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis

BackgroundsPlaque protrusion is a common event among carotid artery stenting (CAS) patients and increases ischemic complication risk. Dual-layer stents (DLS) with micromesh technology may offer greater plaque protection compared to single-layer stents (SLS), but few data are available. The aim of the study is to compare clinical outcomes at 12 months for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. MethodsA retrospective analysis of consecutive symptomatic and asymptomatic patients treated with primary CAS for internal carotid artery (ICA) stenosis, with either DLS or SLS between 2015 and 2019, was performed. Primary endpoints included rates of ipsilateral transient ischemic attacks (TIA)/stroke and death within 1-year from CAS. Secondary endpoints included patency rates and survival according to stent type. ResultsOf the 301 patients who met inclusion criteria (74.8 % male; 73.6 mean age ± 8.7 years), most patients were asymptomatic (77.4 %). Among all patients DLS was most frequently deployed (66 %); also, among asymptomatic (62 %) and symptomatic patients (81 %), p < 0.01. Symptomatic patients had less comorbidities and severe disease than asymptomatic patients.Six peri-operative strokes were recorded and, within 1 year, 2 additional strokes were registered among symptomatic patients treated with SLS. No post-operative strokes were encountered in the DLS group (p = 0.04) among symptomatic patients. Higher rates of TIA were observed among asymptomatic patients treated with DLS compared to SLS while rates of TIA were reduced among symptomatic patients treated with DLS.There were no differences in patency rates for DLS and SLS in symptomatic and asymptomatic patients. Primary patency was similar among DLS stent types but differed among SLS stent types (p = 0.01).At a mean follow-up of 27 months ±17.6, survival was comparable between DLS and SLS groups (p = 0.98). ConclusionCAS with DLS seems to reduce the risk of post-procedural stroke for symptomatic patients compared to SLS whilst the choice of stent did not influence ipsilateral TIA, survival or patency rates. These data require confirmation from larger, randomized, prospective studies.

An Investigation of the Relationship Between Carotid Artery Stenosis and White Matter Hyperintensities.

Introduction White matter hyperintensities (WMHs) are frequently detected on magnetic resonance imaging (MRI) with age. Although the etiology of WMH has not been fully explained, it was reported to be associated with internal carotid artery (ICA) stenosis as well as small vessel diseases. The number and volume of these lesions might increase in cases of internal carotid artery (ICA) stenosis. The present study aimed to calculate the localization and volumes of white matter lesions in the VolBrain Program and investigate the relationship between age and sex in patients with symptomatic and asymptomatic internal carotid artery stenosis. Methods MRI scans of patients with carotid stenosis with T1-weighted and fluid-attenuated inversion recovery (FLAIR) sequences were performed retrospectively for the present study, which had a retrospective design. The patients were divided into two groups (<70% and ≥70%) because endovascular intervention was considered in patients with asymptomatic stenosis over 70%. Digital subtraction angiography was used to detect carotid artery stenosis. They were also divided into four groups.According to laterality and degree of stenosis, ICA stenosis was separated as those with <70% stenosis on both sides (group 1), right side ICA <70%, left side ≥70% stenosis (group 2), right side ICA ≥70%, left side <70% stenosis (group 3), and ≥70% stenosis on both sides (group 4). A total of 102 patient images were selected that met the inclusion criteria. The measurements of white matter lesion volumes were made using the LesionBrain application in the VolBrain Program. Results The MRI of 82 patients (mean age: 65.55 ± 9.28 years), 28 females and 54 males, were used in the present study. According to LesionBrain Analysis, the total WMH volume was seen in the first and third groups at most. When analyzed in regional terms, stenosis was mostly detected in the first and third groups in the periventricular region. WMH volume was less in all areas in group 4. When examined according to the number of lesions, the most lesions were detected in the third group in the juxtacortical region. When the difference between the groups was examined, a significant difference was detected only in the volume change in the deep white region (p=0.011). No significant differences were found between WMH volumes and age and gender (p>0.05). Conclusion Stenosis of the external internal carotid artery might cause hypoperfusion and silent embolization in the brain. As a result, as well as pathological conditions in cortical areas, ischemic areas in the white matter might also cause cognitive disorders.

Abstract WP142: Risk Of New Ischemic Events In Patients With Symptomatic Internal Carotid Artery Stenosis While Awaiting Carotid Artery Stent Placement

Introduction: Although there is emphasis on performing carotid artery stent placement (CAS) within two weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with cervical internal carotid artery (ICA) stenosis, the risk and characteristics of recurrent cerebral ischemic events while waiting for CAS are not well defined. Method: We analyzed patients admitted to our institution over a 45-month period with symptomatic cervical ICA stenosis. All patients were initiated on daily aspirin and clopidogrel 75mg on the day of admission. We identified any new cerebral ischemic events that occurred between index event and CAS and categorized them as TIA, and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS. Results: The mean age of 150 patients analyzed was 67 years (range: 46-94 years; 106 were men); and 94 and 56 patients had ≥ 70% and 50-69% stenosis, respectively. The mean and median time intervals between index event and CAS performance were 25 and 6 days, respectively. A total of 6 new cerebral ischemic events (5 TIAs and 1 major stroke) were observed over 3,776 patient days of observation. The risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS performance was 1.6 per 1000 patient days of observation. Conclucion: We identified a low risk of new ipsilateral cerebral ischemic events in patients with ≥ 50% ICA stenosis while waiting for CAS presumably due to early initiation of dual antiplatelets.

Complication Rate After Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure: Long-Term Outcome

Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching. Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy. Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05). In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003). Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

External carotid artery to ophthalmic artery flow associated with internal carotid artery stenosis

ABSTRACT Purpose One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease. Methods In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved. Results The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001). Conclusions ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke

BackgroundDouble-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion.MethodsWe retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months.ResultsIn 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0–2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%.ConclusionThe CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.

Early Carotid Endarterectomy for Symptomatic Internal Carotid Artery Stenosis in the Acute Ischemic Stroke

Objective: To research the results of the microsurgical treatment of symptomatic internal carotid artery stenosis by Carotid Endarterectomy in the acute period of a stroke that were performed in the Neurosurgery Department of IMSP IMU. Materials and Methods: A retrospective data collection was conducted on all consecutive patients surgically treated for an extra-cranial internal carotid artery (ICA) hemodynamic stenosis in the Neurosurgery Department of the Emergency Medicine Institute,in Chisinau (Rebublic of Moldova),between February 2019 and March 2021.All patients undergoing ICA endarterectomy for symptomatic carotid stenosis (SCS) within 48 hours and 14 days after the acute neurologic onset were included in the present study.Outcomes were evaluated by a prospective follow-up. Primary outcomes were the rate of postoperative ipsilateral stroke, myocardial infarction (MI), peripheral nerve injury, hematoma in the operating area and death.Secondary outcomes were the rate of local and systemic complications.The results were stratified according NIHSS score and comorbidities 30 days after surgery,and a multivariate analysis were performed in order to define any correlation between preoperative data and postoperative outcomes. Results: A total of 40 patients (10 %, n 4 bilateral and 90%, n 36 unilateral) underwent carotid endarterectomy (CEA) for hemodynamically significant ICA stenosis. According to inclusion criteria (22% women vs 78% men; median age 64 years, range: 54-76; median preoperative NIHSS score 4, range 0-18) all patients affected by SCS were enrolled in the present study. Median delay for surgery was 6 days (range: 2-14).During in-hospital post-operative period the combined death/stroke/MI rate was 0%.In-hospital NIHSS score improved post-operatively of more than 2 points (range 0-12) in 45.7% of cases.Microsurgical CEA is accompanied,in most cases by the regression of neurological symptoms and it is not correlated with the increased risk for a hemorrhagic transformation.No local and systemic complications were registered.The stratification of outcomes according to NIHSS status, sex, comorbidities did not show any statistical relation neither at 30 days nor at the long term-follow up. Conclusion: In properly selected patients with a SCS, affected by an acute ischemic stroke, early carotid endarterectomy can be performed without any complications or worsening of neurological status in comparison with similar cases in a longer period after a stroke.

Prediction of Long-Term Restenosis After Carotid Endarterectomy Using Quantitative Magnetic Resonance Angiography.

BackgroundTo detect restenosis after carotid endarterectomy (CEA), long-term monitoring is required. However, non-selective follow-up is controversial and can be limited by costs and logistical considerations.ObjectiveTo examine the value of immediate perioperative vessel flow measurements after CEA using quantitative magnetic resonance angiography (QMRA) to detect patients at risk of long-term restenosis.MethodsA prospective cohort study with long-term sonographic follow-up after CEA for symptomatic internal carotid artery stenosis (ICAs) > 50%. In all patients, vessel flow has been assessed both pre- and postoperatively using QMRA within ±3 days of surgery. Data on QMRA assessment were analyzed to identify patients at risk of restenosis for up to 10 years.ResultsRestenosis was recorded in 4 of 24 patients (17%) at a median follow-up of 6.8 ± 2.6 years. None of them experienced an ischemic event. Perioperative flow differences were significantly greater in patients without long-term restenosis, both for the ipsilateral ICA (p < 0.001) and MCA (p = 0.03), compared to those with restenosis (p = 0.22 and p = 0.3, respectively). The ICA mean flow ratio (p = 0.05) tended to be more effective than the MCA ratio in predicting restenosis over the long term (p = 0.35).ConclusionOur preliminary findings suggest that QMRA-based mean flow increases after CEA may be predictive of restenosis over the long term. Perioperative QMRA assessment could become an operator-independent screening tool to identify a subgroup of patients at risk for restenosis, in whom long-term monitoring is advised.

Angioplasty and Stenting for Carotid Artery Near-Occlusion

Carotid near-occlusion (CNO) is the type of severe atherosclerotic stenosis of the internal carotid artery (ICA) with or without collapse of the vessel distally to the narrow part. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), severity of ICA stenosis highly correlates with the risk of stroke, except for cases of extremely critical stenosis &gt; 94%, where the risk is lower, and, according to recent guidelines, conservative treatment is preferable. This consideration is questionable due to the recent data about early stroke recurrence and worldwide practice. Rapid improvement of endovascular technique during the last decade makes carotid angioplasty and stenting (CAS) a feasible option for the treatment of patients with CNO and is widely reported in the literature. However, in uncertain circumstances, more scientific data are necessary to fulfill the gap in indications, terms and risks of CAS for CNO.&#x0D; The aim. To evaluate the results of the treatment of patients with CNO after CAS.&#x0D; Materials and methods. Three hundred and fifteen patients were surgically treated at Scientific-Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine due to ICA stenosis between 2010 and 2020. Among them, 39 (12.4%) patients (11 woman / 28 men (age 57.9±2.1 years) had CNO and underwent CAS at our Center. Patient population, clinical and radiological investigations, procedure compli-cations were investigated. Procedure complications (stroke, hemodynamic depression [HD] and hyperperfusion syndrome [HPS]) were meticulously studied. All the patients had routine ultrasound and clinical check 30 days after the procedure.&#x0D; Results. All the patients with CNO were successfully stented with the improvement of the site of stenosis after CAS, with only minimal residual stenosis in cases of severe HD. We observed two procedural vascular accidents, first patient had transient ischemic attack (TIA) and one had stroke due to middle cerebral artery occlusion after stent placement and further urgent mechanical thrombectomy. The patient had no neurologic decline and was discharged home. We didn’t observe any cases of myocardial infarction (MI) or death in our series during the hospital stay. HD was seen in 13 (33.3%) patients, and mostly resolved after the procedure except for 3 casesthat required prolonged intensive care unit stay. HPS was diagnosed in 2 (5.1%) patients and also didn’t have anyneurologic consequences after supportive care. During 30 days of follow-up, one (2.6%) patient had TIA because of anti-platelets cessation and 1 (2.6%) patient had MI after 1 week since discharge. All control images revealedstents patency without the evidence of critical residual stenosis.&#x0D; Conclusions. CNO remains important diagnostic and therapeutic challenge. Recent data showed high risk ofrecurrent stroke in case of CNO on best medical therapy, especially at an early stage, but it remains a preferred option according to guidelines. Considering worldwide improvement of stroke rates after CAS in patients with symptomatic ICA stenosis, further studies are warranted to evaluate its risk-benefit in case of CNO, especially with full collapse. Our data shows that CAS with careful preoperative diagnosis and planning is an effective procedure for selected patients with CNO.

The Impact of the First 11 Months of the COVID-19 Pandemic on Vascular Patients’ Care and Hospitalisation Rate in the Vascular Surgery Divisions of Southern Italy

The Impact of the First 11 Months of the COVID-19 Pandemic on Vascular Patients’ Care and Hospitalisation Rate in the Vascular Surgery Divisions of Southern Italy

Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case.

BACKGROUNDPatients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. In general, for patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; however, some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. Likewise, delayed revascularization with anticoagulation may increase risk of recurrent stroke. Few reports on the management of FTT included the use of a transcarotid artery revascularization (TCAR) approach for carotid revascularization with mechanical aspiration thrombectomy.OBSERVATIONSThis report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery.LESSONSThe TCAR approach for mechanical thrombectomy and carotid stenting is a safe alternative for early revascularization with low periprocedural stroke risks.

A Case of Symptomatic Internal Carotid Artery Stenosis and Concomitant Ipsilateral Chronic Common Carotid Artery Occlusion Treated with Carotid Endarterectomy

A Case of Symptomatic Internal Carotid Artery Stenosis and Concomitant Ipsilateral Chronic Common Carotid Artery Occlusion Treated with Carotid Endarterectomy

A case of symptomatic left internal carotid artery stenosis caused by JAK2 mutation-positive true polycythemia

A case of symptomatic left internal carotid artery stenosis caused by JAK2 mutation-positive true polycythemia

Advanced vasospasm in carotid stenting using the distal filter-type embolic protection device: A case report

There are difficulties in the use of embolic protection devices (EPD) for carotid artery stenting (CAS), and various side effects can be observed. We presented a patient who underwent CAS with a distal filter-type (DF) EPD for symptomatic right internal carotid artery (ICA) stenosis and showed advanced vasospasm. A 68-year-old male patient was hospitalized with a pre-diagnosis of transient ischemic attack (TIA) in the form of left-sided weakness. Computed tomography angiography revealed 90% stenosis in the right ICA. On the 5th day, he underwent an angiography, which showed a plaque causing 90% stenosis. A 5F Spider FX (Medtronic Corp.; Minneapolis, MN, USA) was placed in the cervical ICA. At this time, mild vasospasm was observed in the cervical ICA, but the flow was normal. After pre-dilatation, a Protégé 8-6x40 stent was placed in the stenotic segment. Due to the 50% residual stenosis, a post-dilatation was performed. After post-dilatation, advanced vasospasm developed distal to the stent and the flow was completely obstructed. Vasospasm significantly regressed within a few minutes with intra-arterial nitrate administration. There was no change in the neurological examination of the patient during and after the procedure. Although vasospasm is usually a self-limiting complication that resolves without clinical symptoms, it may cause a TIA or an infarct. In CAS procedures, the possibility of a vasospasm should be kept in mind and if it occurs, the irritant should be removed. If there is no improvement, an intra-arterial vasodilator should be administered.

Persistent Primitive Hypoglossal Artery with Ipsilateral Symptomatic Carotid Artery Stenosis and Cerebral Aneurysm

ObjectivePersistent primitive hypoglossal artery (PPHA) is a rare type of persistent carotid-basilar anastomosis sometimes associated with other vascular lesions. We treated an extremely rare case of PPHA with concomitant ipsilateral symptomatic cervical internal carotid artery (ICA) stenosis and unruptured aneurysm. Case presentationA 67-year-old woman visited our institution with acute onset of diplopia. Magnetic resonance imaging revealed multiple acute infarctions in the right anterior and posterior circulations. Digital subtraction angiography demonstrated the right PPHA concomitant with ipsilateral cervical ICA stenosis and an unruptured ICA aneurysm with maximum diameter of 8 mm. The multiple infarctions were considered to result from artery-to-artery embolism due to microthrombi from the ICA plaque passed along the PPHA, so carotid endarterectomy was performed as the first step with preoperative modified Rankin Scale (mRS) grade 1. During the operation, the patient had impaired ICA perfusion due to internal shunt catheter migration into the PPHA followed by acute infarction in the right hemisphere causing mild left hemiparesis. The patient was transferred to the rehabilitation hospital with mRS grade 3. After 3 months of rehabilitation, the patient recovered to mRS grade 1 and clipping surgery for the unruptured right ICA aneurysm was performed as the second step with uneventful postoperative course. ConclusionThe treatment strategy should be carefully considered depending on the specific blood circulation for such cases of PPHA with unique vasculature.