Tandem Carotid Research Articles

Chitinase-3-like Protein 1 Reduces the Stability of Atherosclerotic Plaque via Impairing Macrophagic Efferocytosis.

CHI3L1 is strongly associated with atherosclerosis, but its role in macrophages remains unknown. In this study, we observed a significant up-regulation of CHI3L1 in both carotid plaques and serum of symptomatic patients, and demonstrated that CHI3L1 impairs the efferocytosis of macrophages by down-regulatingcrucial efferocyticmediator MFGE8 through inhibiting ATF2, which binds directly to the enhancer of MFGE8. In human plaques, we observed a negative correlation between CHI3L1 expression and both ATF2 and MFGE8 levels, further proved their involvement in plaque destabilization. Using Ldlr-/-mice with tandem carotid stenosis surgery, we demonstrated that administration of CHI3L1 protein resulted in enlarged atherosclerotic necrotic cores and decreased MFGE8 and ATF2 levels. Conversely, treatment witha CHI3L1 blocking antibody exhibited the opposite trend.In conclusion, CHI3L1 destabilizes atherosclerotic plaque by impairing macrophagic efferocytosis through the down-regulation of ATF2-induced MFGE8 expression. Targeting CHI3L1 may offer a promising therapeutic strategy for the treatment ofatherosclerosis.

Effect of plaque micro-watershed changes on carotid atherosclerosis.

The study aims to elucidate the mechanisms underlying plaque growth by analyzing the variations in hemodynamic parameters within the plaque region of patients' carotid arteries before and after the development of atherosclerotic lesions. The study enrolls 25 patients with common carotid artery stenosis and 25 with tandem carotid artery stenosis. Based on pathological analysis, three-dimensional models of the actual blood vessels before and after the lesion are constructed for two patients within a two-year period. Computational fluid dynamics is employed to conduct unsteady periodic non-Newtonian fluid numerical simulations, enabling an in-depth investigation into the changes in the micro-environment of blood flow. During the systolic phase of the cardiac cycle, vortex regions are particularly prone to developing at the bifurcation point between the common carotid artery and the distal end of the internal carotid artery. In the early diastolic phase, blood reflux phenomena can be observed within the carotid artery. Towards the end of diastole, there is an expansion of vortex regions at the bifurcation point of the carotid artery. The shoulder region of initial small plaques within the blood vessel is susceptible to developing a low-speed recirculation zone, characterized by significantly reduced shear stress compared to the surrounding areas. Following vascular stenosis, the wall shear stress within the plaque domain generally increases; however, it maintains a consistent pattern of high central values and low upper shoulder values. The shear stress at the upper shoulder of the plaque of tandem carotid stenosis is below 0.4 Pa, whereas the central and lower shoulder regions exhibit shear stress exceeding 40 Pa. The dynamic parameters of the blood flow micro-environment exhibit variations throughout the cardiac cycle, and temporal disparities exist in local lesions within the carotid artery. Both common and tandem carotid artery stenosis are particularly prone to developing lesions at the shoulder of initial small plaques. The micro-flow characteristics within the plaque domain undergo alterations prior to and following the onset of carotid artery disease. Furthermore, the occurrence of restenosis and rupture is associated with the location of plaque growth.

Functional Outcomes and Complications of Carotid Tandem Lesions After Mechanical Thrombectomy for Treatment of Large-Vessel Occlusion Stroke.

Large Vessel Occlusion (LVO) stroke patients with tandem lesions (TLs) have been observed to have worse outcomes when compared to patients with simple isolated intracranial occlusions. To examine the difference in post-operative functional status at discharge for patients treated with mechanical thrombectomy for an acute LVO stroke based on the presence of a tandem carotid lesion. This is a retrospective cohort study of 589 patients presenting within the first 24hours of stroke onset who underwent mechanical thrombectomy. The primary outcome was functional status quantified by modified Rankin Score (mRS) at time of discharge. The secondary outcomes were presence of hemorrhagic conversion, midline shift >5cm, malignant cerebral edema, reocclusion, Thrombolysis in Cerebral Infarction Scale (TICI), and discharge location. Patients with tandem occlusions and those with isolated intracranial lesions had similar baseline demographics. However, in patients with TLs, there was a significantly higher NIH stroke scale at admission and a longer time to recanalization. Modified Rankin Score prior to admission was similar for both groups, but was significantly higher in patients with TLs at discharge. The secondary outcomes were similar for hemorrhagic conversion, discharge to hospice, and a TICI scale of 0, but were significantly worse for patients with TLs for in-hospital mortality, midline shift >5mm, and malignant cerebral edema. The presence of a tandem lesion predicted a higher modified Rankin Score at discharge in univariate regression modeling (β = .45; P-value = .006). The two groups were similar in baseline characteristics and cardiovascular risk factors, yet patients with tandem carotid lesions experienced more complications during their hospitalization and had greater functional disability at discharge. Patients with a TL had a longer mean time to recanalization, representing a potential explanation for these differences in outcomes.

Abstract 375: Predictors of Good Clinical Outcomes After First Pass Effect in Anterior Circulation Tandem Occlusions

Introduction First pass effect (FPE) is an independent predictor of good clinical outcomes following mechanical thrombectomy (MT) in non‐tandem occlusions. A proximal tandem carotid steno‐occlusion introduces additional times and technical complexities which can influence recanalization and reperfusion dynamics and potentially, clinical outcomes in the long run. We evaluated the predictors of good clinical outcomes, specifically mRS0‐1 and mRS0‐2 at 90 days, in patients with anterior circulation tandem occlusions where recanalization was achieved through FPE from MT with emergent carotid artery angioplasty and stenting (eCAS), and had a baseline mRS0‐2.; Methods We perform a retrospective analysis of institutional thrombectomy database to identify univariate predictors. Significant predictors will be included in a multivariate logistic regression to determine significant predictors of mRS0‐1 and mRS0‐2 at 90 days post‐MT and eCAS.; Results We included 88 (66.2%) patients who achieved first pass effect among 133 anterior tandem occlusions undergoing MT with eCAS. Among patients with mRS0‐2 at 90 days, multivariate regression identified age (OR:0.857[0.772‐0.952],p=0.004), intravenous alteplase (OR:12.3[1.3‐114],p=0.027), use of a ballon guide catheter as opposed to conventional guides (OR:0.02[0.01‐0.63],p=0.027), time from arterial access to recanalization (OR:0.96[0.92‐0.999],p=0.043), pre‐eCAS oral aspirin/ticagrelor load as opposed to intravenous eptifibatide load (OR:0.017[0.001‐0.964],p=0.048) and symptomatic ICH (OR:0.025[0.001‐0.723],p=0.032) to be significant predictors. Significant predictors for mRS0‐1 at 90‐days were male sex (OR:41.33[1.45‐1179.31],p=0.03), hypertension (OR:0.03[0‐0.44],p=0.012), diabetes (OR:0.04[0‐0.63],p=0.023), use of a ballon guide catheter as opposed to conventional guides (OR:0.03[0‐0.66],p=0.027), distal embolization (OR:0.02[0‐1.71],p=0.082), time from arterial access to recanalization (OR:0.93[0.86‐0.99],p=0.026), residual carotid stenosis after eCAS (OR:0.003[0‐0.18],p=0.005), pre‐eCAS oral aspirin/ticagrelor load as opposed to intravenous eptifibatide load (OR:0.02[0‐0.25],p=0.016) and symptomatic ICH (OR:0.01[0‐0.38],p=0.012). Notably, heparin infusion post procedure predicted improved outcomes but was insignificant (OR: 55.54[0.59‐5226.65],p=0.083).; Conclusion The study highlights important considerations for eCAS, including the choice of antiplatelet loading agent, residual carotid stenosis and longer recanalization times which seem to impact good clinical outcomes.

Management of Severe Bilateral Symptomatic Internal Carotid Artery Stenosis: Case Report and Literature Review.

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient's characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician.

Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry

BackgroundThe optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as...

Open Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis.

The evidence regarding the treatment of open retrograde stenting of innominate artery (IA) or common carotid artery stenosis (CCA) is limited, and is suspected to carry a high risk of stroke and death. Therefore, the objective of this study was to evaluate the outcomes of such hybrid procedures. A retrospective, monocentric study of all patients who underwent retrograde stenting of proximal IA and CCA stenosis via surgical cutdown of the CCA, with or without concomitant CEA, between 2016 and 2023 was performed. Overall, 33 patients were treated. A total of 15 patients (45.5%) were male, with the mean age being 67 ± 9.1 years, and 58% (n = 19) of the patients presented with neurological symptoms. Open retrograde stenting was performed in 67% (n = 22) in ACC, and in 33% (n = 11) in IA stenosis. A total of 20 patients (61%) underwent retrograde stenting with synchronous ipsilateral CEA for concomitant stenosis of the carotid bifurcation. There was no 30-day mortality. The perioperative stroke rate was 3% (n = 1) with complete symptom recovery. During the follow up at 32 months (95% CI: 24-39), three late deaths (9.1%) and one symptomatic stent occlusion were observed and, in five patients (15.2%), re-intervention for restenosis was necessary. Open retrograde stenting for of proximal IA or CCA stenosis with or without CEA, in case of tandem carotid lesions, can be performed safely with a low rate of early adverse events. Continuous follow up examinations are necessary due to relevant instent re-stenosis rates.

Experience of stenting of the extracranial part of the internal carotid artery in patients with acute ischemic stroke

Aim. To present the experience of stenting of the extracranial internal carotid artery (ICA) in case of tandem steno-occlusive carotid lesion in the most acute phase of ischemic stroke.Materials and methods. From December 2018 to December 2021, 29 patients with acute ischemic stroke, because of tandem steno-occlusive lesions of the ICA and intracranial arteries, underwent endovascular surgery to restore cerebral blood flow.Results. Successful restoration of cerebral blood flow (according to the mTICI 2b–3 scale) achieved in 22 (75.9 %) patients. Four (13.8 %) patients had stent thrombosis in the early postoperative period. The incidence of symptomatic hemorrhagic transformation observed in 2 (6.9 %) patients. The frequency of a favorable functional outcome (Rankine 0–2) on the 30th day was 20.7 %, mortality – 24.1 %.Conclusion. Stenting of the extracranial ICA in patients with acute ischemic stroke improves the efficiency of restoration of cerebral blood flow. The use of low doses of glycoprotein receptor blockers prevents stent thrombosis in the early period after implantation and does not increase the incidence of symptomatic hemorrhagic complications.

Expansion and Subsequent Rupture of Carotid Pseudoaneurysm After Tandem Carotid and Middle Cerebral Artery Occlusion Treated With Mechanical Thrombectomy and Carotid Stenting.

Extracranial carotid artery pseudoaneurysm is a rare entity with potential etiologies including infection, blunt trauma, postsurgical atherosclerotic disease, and invasive neoplasia. Although the natural history of carotid pseudoaneurysm is difficult to determine because of its rarity, complications such as stroke, rupture, and local mass effect may occur at staggering rates. In this case, a middle-aged man presented with a tandem carotid, middle cerebral artery occlusion that was treated with a carotid stent and mechanical thrombectomy. He returned 3 weeks later with a ruptured carotid pseudoaneurysm that was then treated with a covered stent. He made a full recovery and was neurologically intact on follow-up. This case illustrates a rare potential complication of carotid occlusion and stenting with possible catastrophic consequences. The goal of this report was to educate other clinicians in remaining vigilant in awareness of this complication and provide a framework for potential treatment if and when it occurs.

Evaluation of ocular blood flow in the assessment of symptomatic carotid stenosis.

The degree of internal carotid artery (ICA) stenosis determined by criteria from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) is not the most accurate index to assess distal flow compromise. Distal ICA perfusion is also determined by factors such as tandem carotid stenosis and collateral circulation. Quantification of end-organ ocular perfusion using non-invasive laser speckle flowgraphy (LSFG) may provide insights into distal ICA flow. This study prospectively assessed the degree of ICA flow using LSFG. Eighteen patients with symptomatic carotid stenosis underwent LSFG evaluation. LSFG was used to extract ocular blood flow metrics recorded simultaneously in the retina, choroid, and optic nerve head. The following ocular flow parameters were measured with LSFG: mean blur rate (MBR), flow acceleration index (FAI), and rising rate (RR). Syngo iFlow perfusion imaging was used to objectively quantify contrast flow in the ICA and brain parenchyma during digital subtraction angiography. Time to peak (TTP) and contrast delay were extracted from seven different regions of interest (ROIs). MBR, FAI, and RR were correlated with NASCET degree of stenosis. FAI and RR also improved after stenting. TTP improved after stenting in three ROIs. A moderate negative correlation was observed between FAI and contrast delay. LSFG non-invasively quantifies end-organ blood flow distal to the ICA origin. LSFG metrics have the potential to quantify end-organ perfusion and determine if a proximal carotid stenosis is symptomatic.

Abstract TP149: Balloon Mounted Drug Eluting Stents For Treatment Of Intracranial Atherosclerosis In Emergent Large Vessel Ichemic Stroke

Introduction: Intracranial atherosclerotic disease (ICAD) is an important etiology of ischemic stroke, and often poses a challenge to successful endovascular reperfusion in the setting of emergent large vessel stroke (ELVS). We aimed to evaluate the safety and efficacy of balloon-mounted drug eluting stents (DES) in the treatment of ELVS. Methods: Retrospective review of endovascular database from our comprehensive stroke center from Jan 2021 - Aug 2022. Patients undergoing endovascular therapy for anterior circulation ELVS with ≥70% stenosis in the target vessel treated with DES were included. Patients with tandem cervical carotid lesions requiring stenting were excluded. Primary outcomes were symptomatic intracranial hemorrhage (sICH) within 72 hrs and mortality at 30 days. Secondary outcomes were feasibility of treatment with DES and recurrent stroke within 30 days. Results: Of 359 endovascular stroke interventions performed, 11 patients met the inclusion criteria. Mean age was 60 [51-78], and 7 (64%) were female. Target lesions included 8 M1 (73%), 1 M2 (9%), 1 cavernous ICA (9%), and 1 ICA/M1 junction (9%). Average time from last known well to arterial puncture was 14 hrs, 15 mins [1 hr, 9 mins to 25 hrs, 23 mins]. 2 patients (18%) received IV alteplase. Average ASPECT score 8.3 [5-10], average core infarct 10 mL [0-48] and average mismatch 68 mL [12-179]. 5 procedures (45%) performed via radial access and 6 via femoral (55%), all under general anesthesia. 5 patients (45%) underwent mechanical thrombectomy and 6 (55%) underwent angioplasty prior to DES. 3 (27%) underwent primary DES treatment. Average pre-treatment stenosis was 83% [70-95%], average post-treatment stenosis was 14% [0-45%]. All DES were delivered successfully with no procedural complications. All patients achieved successful reperfusion (8 TICI 3 [73%], 2 TICI 2C [18%], and 1 TICI 2B [9%]). Average NIHSS score was 12.4 [5-28] at presentation and 7.5 [0-20] at 7-10 days. There were no sICH at 72 hrs, and no deaths at 30 days. 1 patient returned with stroke secondary to stent occlusion at 29 days, with successful TICI 3 recanalization following angioplasty. Conclusions: Endovascular treatment of ICAD-related ELVS with DES is safe and effective, and warrants further investigation.

Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR

Introduction: Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry. Methods: Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance. Results: Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P<0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups. Conclusion: The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Transcarotid revascularization in obese patients.

Transcarotid revascularization (TCAR) is a minimally invasive hybrid surgical carotid stenting technique which utilizes cerebral flow reversal as embolic protection during carotid lesion manipulation. This investigation was performed to define the perioperative risks associated with this operation in the obese patient. A retrospective review of tandem carotid revascularization databases maintained at two high-volume health systems was performed to capture all TCARs performed between 2015 and 2022. A threshold of body mass index of 35kg/m2 defined the "obese" patient. Demographics, intraoperative, perioperative, and follow-up characteristics were compared using univariate analysis. We performed 793 TCAR procedures that qualified for study inclusion within the prespecified time. After applying our obesity definition, 129 patients qualified as obese and were compared to the remainder. There were no significant differences in baseline demographics as comparable Charlson Comorbidity Indices were noted between groups; however, obese patients had a significantly higher prevalence of hypertension, hyperlipidemia, and diabetes. Intraoperative, case complexity in the obese patients did not seem to be increased, as measured by operative time (68.4 ± 23.0 vs 64.2 ± 25.8min, p = 0.09), fluoroscopic time (4.9 ± 3.2 vs 4.6 ± 3.6min, p = 0.38), and estimated blood loss (40.6 ± 49.0 vs 46.6 ± 49.4min, p = 0.22). Similarly, no disparities were observed with respect to ipsilateral stroke (3.1 vs. 1.7%, p = 0.29), contralateral stroke (0 vs. 0.2%, p > 0.99), death (0 vs. 1.1%, p = 0.61), and stroke/death (3.1 vs. 3.0%, p > 0.99) in the 30-day perioperative period. Both cohorts were followed for approximately 1year (12.0 ± 13.4 vs 11.6 ± 13.4months, p = 0.76). During this period, rates of ipsilateral stroke (3.1% vs. 2.7%, p > 0.99), contralateral stroke (1.1 vs. 0.8%, p > 0.99), and death (4.7 vs. 6.2%, p = 0.68) were similar. TCAR performed in the obese population was not more challenging by intraoperative characteristics and did not result in a statistically higher incidence of adverse events in the perioperative phase.

Surgical treatment of tandem stenosis of the internal carotid artery

This review article presents an analysis of the world literature devoted to treating patients with tandem stenosis of the intra- and extra-cranial parts of the internal carotid artery. We indicate the frequency of tandem lesion occurrence and describe the applied instrumental methods of its diagnosis. The review demonstrates the results of tandem stenosis surgical treatment in both early and more modern studies and describes the possibilities of endovascular correction of extra- and intra-cranial stenosis of the internal carotid artery. The authors emphasise the lack of large-scale studies — including randomised studies — regarding combined, tandem carotid stenosis and the need for further studies.Received 30 March 2021. Revised 8 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes

Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes

Carotid double jeopardy

Tandem carotid artery stenoses, one at the carotid bifurcation and one more proximal in the common carotid artery or innominate artery, are rare. I suspect that their incidence may increase with the ubiquitous availability of computed tomography angiography. Treatment of these lesions with a hybrid approach with stent placement or angioplasty of the proximal lesion and open endarterectomy of the carotid bifurcation was first reported in 1996.1 A prior meta-analysis showed excellent results.2 More recent reports have urged caution because the stroke and death rate were almost reaching unacceptable levels.

Addition of common carotid intervention increases the risk of stroke and death after carotid artery stenting for asymptomatic patients

BackgroundA recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. MethodsVascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. ResultsThere were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P < .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42). ConclusionsThe addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes

BackgroundAddition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study. MethodsVQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis>70%. Long-term outcomes were compared with Kaplan-Meier Analysis. ResultsThere were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P < 0.001), less likely to have diabetes (29.5% vs. 38.2%; P P< 0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P< 0.001), less likely to be symptomatic (34.6% vs. 52.8%; P < 0.001), and less likely to have >70% stenosis (77.3% vs. 95.6%%; P < 0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27). ConclusionAlthough simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach. Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.

Abstract P477: A Meta-Analysis of Carotid Stenting and Angioplasty for Treatment of Tandem Occlusion Stroke

Introduction: Acute ischemic stroke (AIS) in the setting of tandem extracranial carotid disease and intracranial large vessel occlusion (TO) is associated with poor functional outcome. It remains unclear whether the extracranial lesion requires acute stenting or angioplasty alone. Meta-analyses to date have included predominantly retrospective non-comparative series. Our meta-analysis aimed to investigate if emergent carotid stenting plus endovascular thrombectomy (EVT) is more effective than angioplasty alone plus EVT at reducing incomplete recanalization (TICI &lt;2b/3), symptomatic ICH (sICH) rate, or poor functional outcome (mRS&gt;2 90 days). Methods: Systematic review identifying TO studies comparing those undergoing carotid angioplasties alone to stenting. Results were pooled using inverse variance random effects meta-analyses. Conclusions accounted for the magnitude of effect, precision and risk of bias in the studies using the modified GRADE process of the American Academy of Neurology. Results: Ten non-blinded, observational studies totaling 1006 TO patients met inclusion criteria. Baseline patient characteristics were without significant confounders. Mean initial NIHSS was 15.3 and 15.0 and symptom onset-to-recanalization time was 332 and 337 minutes in the stenting and angioplasty groups, respectively. Overall, poor functional outcome at 90 days occurred in 44.6% of patients and death occurred in 13.0% of patients. There was a significant decrease in the rate of mRS&gt;2 (OR=0.55, CI 95% 0.40 –0.76) and death (OR=0.47, CI 95% 0.24–0.94) in patients treated with stenting vs angioplasty. TICI &lt;2b/3 occurred in 21.5% of patients overall with no statistical difference in patients treated with stenting vs angioplasty (OR=0.67, CI 95% 0.42—1.07). sICH occurred in 5.7% of patients overall and there was no statistical difference in patients treated with stenting vs angioplasty (OR=1.19, CI 95% 0.53—2.67). Conclusion: Emergent stenting possibly decreases the risk of mRS&gt;2 and mortality at 90 days. There is insufficient evidence to conclude whether stenting increases the risk of TICI &lt;2b/3 and sICH. Confidence in the evidence is low, anchored by observational study designs and absence of blinding. A randomized controlled study is warranted.