Treatment Of Carotid Artery Stenosis Research Articles

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis

ImportanceAlthough many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment.ObjectiveTo explore evidence for provider-induced demand in the management of carotid artery stenosis.Design, Setting, and ParticipantsThe Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016.Main Outcomes and MeasuresThe odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand.ResultsOf 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001).Conclusions and RelevanceIndividuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting.

Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator's experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.

Use of Micropatterned Thin Film Nitinol in Carotid Stents to Augment Embolic Protection.

Stenting is an alternative to endarterectomy for the treatment of carotid artery stenosis. However, stenting is associated with a higher risk of procedural stroke secondary to distal thromboembolism. Hybrid stents with a micromesh layer have been proposed to address this complication. We developed a micropatterned thin film nitinol (M-TFN) covered stent designed to prevent thromboembolism during carotid intervention. This innovation may obviate the need or work synergistically with embolic protection devices. The proposed double layered stent is low-profile, thromboresistant, and covered with a M-TFN that can be fabricated with fenestrations of varying geometries and sizes. The M-TFN was created in multiple geometries, dimensions, and porosities by sputter deposition. The efficiency of various M-TFN to capture embolic particles was evaluated in different atherosclerotic carotid stenotic conditions through in vitro tests. The covered stent prevented emboli dislodgement in the range of 70%–96% during 30 min duration tests. In vitro vascular cell growth study results showed that endothelial cell elongation, alignment and growth behaviour silhouettes significantly enhance, specifically on the diamond-shape M-TFN, with the dimensions of 145 µm × 20 µm and a porosity of 32%. Future studies will require in vivo testing. Our results demonstrate that M-TFN has a promising potential for carotid artery stenting.

The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis.

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

LONG-TERM OUTCOMES OF CAROTID SURGERY VERSUS STENTING IN ONTARIO: A POPULATION-BASED ANALYSIS

Although carotid surgery and stenting are commonly employed in the treatment of carotid-artery stenosis, randomized trials have provided conflicting evidence for the relative efficacy of these two procedures in preventing events. There are currently no population-based data on the long-term comparative outcomes of these strategies.

Carotid stenting versus endarterectomy for the treatment of carotid artery stenosis: Contemporary results from a large single center study.

To compare the complication rates associated with carotid endarterectomy (CEA) versus carotid artery stenting (CAS). Carotid stenosis is a well-known cause of stroke and increased mortality. The safety of carotid revascularization may be related to symptom status, medical comorbidities, use of embolic protection devices, as well as operator experience and these factors may vary across patient populations within a single operating center. We retrospectively analyzed patients with carotid artery stenosis admitted to our hospital for carotid revascularization between January 1, 2007 and December 1, 2013. The primary end point was a composite endpoint of periprocedural death, stroke, and myocardial infarction (MI). Of the 718 patients admitted for carotid revascularization 525 (73.1%) underwent CEA and 193 (26.9%) underwent CAS. Both groups demonstrated similar rates of the composite endpoint, MI, and death; the stenting group demonstrated a higher rate of stroke (4.2% vs. 1.3%; P = 0.020). Adjusting for baseline medical comorbidities and symptom status mitigated this difference (P = 0.091 and 0.113, respectively). When stratified by department performing CAS, there was a significant difference in the occurrence of stroke (P = 0.033), which likewise disappeared in the multivariate regression analysis. The risk of the composite endpoint did not differ significantly between those undergoing CAS versus CEA. The stenting group demonstrated a higher rate of periprocedural stroke, which was also apparent when patients were stratified by stenting department. These differences were likely driven by variation in baseline medical comorbidities and symptom status. © 2016 Wiley Periodicals, Inc.

Carotid stenting and endarterectomy.

Stroke, either ischemic or hemorrhagic, remains the second commonest cause of death worldwide in the last decade. Etiologies for ischemic stroke (IS) vary widely. Atherothrombotic occlusion is an essential cause to which carotid artery stenosis (CAS) is a major contributor. Administration of anti-platelet agent to patients with CAS has been shown to reduce incidence of long-term IS. In additional, in patients with symptomatic CAS, clinical trials have demonstrated that carotid endarterectomy (CEA) is superior to medical therapy for prevention of future CAS-related IS. However, CEA is not suitable for CAS post-radiotherapy or those located at higher level of the internal carotid artery; and major complications of this procedure including cranial nerve injuries have stimulated the interest of using percutaneous transfemoral carotid stenting as an alternative approach. Although transfemoral arterial approach of carotid stenting is not inferior to CEA in improving clinical outcomes, it has been reported to be associated with vascular complication and has its limitations in patients with athero-occlusive disease of abdominal aorta or bilateral iliac arteries, level II or III aortic arch, or bovine type carotid arterial anatomy. Therefore, transradial/transbrachial arterial approach has emerged as a novel method for carotid stenting. This article provides a critical review on interventional approaches for the treatment of CAS.

Abstract 102: Carotid Endarterectomy versus Stenting in Patients on Chronic Hemodialysis

Introduction: There has been an increase in the number of hemodialysis (HD) patients seeking treatment for carotid artery stenosis in recent times. These patients suffer from a unique course of cardiac and vascular disease and are often considered high risk for surgery. In this study, we compare long-term outcomes after carotid endarterectomy (CEA) versus angioplasty and stenting (CAS) in a large contemporary cohort of HD patients. Methods: We studied all HD patients who underwent CEA and CAS in the United States Renal Disease System (USRDS) database between January 2006 and December 2011. Patient data were linked to the Medicare database to capture long-term outcomes. Univariable, multivariable cox regression, and propensity score matched analyses were employed to compare perioperative (stroke, death, MI) and long-term (stroke and death) outcomes following CAS vs. CEA. Results: There were 6183 (CEA: 5121; CAS: 1062) carotid revascularizations performed in this cohort with a mean age of 67 (S.D 10.1) years. The majority of patients were male (60%), white (76%) and asymptomatic (CEA: 83%; CAS: 83%). Mean follow-up was of 1.6±1.3 years. Thirty day stroke (3.2 vs 5.5%) and death (4.6 vs 5.5%) were significantly lower after CEA. However, 30-day MI was similar between groups (3.2 vs 3.5%). Propensity score matched analysis showed a significantly higher risk of perioperative stroke after CAS compared to CEA (Table 1). Symptomatic status was a significant predictor of perioperative stroke (OR: 1.92; 95%CI: 1.33-2.77; P&lt;0.001). Stroke-free survival for CEA vs CAS was 92% vs 90% at 1 year, 87% vs 85% at 2 years, and 81% vs 76% at 4 years. Conclusions: This is the first study to compare long-term outcomes after CEA and CAS in a large cohort of HD patients. CAS is associated with a significantly higher risk of perioperative stroke compared to CEA. Long term stroke free survival is similar between groups, and differences appear to be largely driven by perioperative stroke rates.

Abstract TP137: The Association Between MRI-detected Carotid Vulnerable Plaque and Coronary Artery Stenosis

It is now accepted that carotid artery stenosis should be treated as a part of systemic atherothrombosis. However, little is known about the association in atherosclerosis between the carotid and coronary arteries. We retrospectively investigated the association between carotid plaque vulnerability diagnosed on carotid magnetic resonance imaging (MRI) and coexisting coronary artery stenosis in patients scheduled for carotid endarterectomy (CEA) or carotid artery stenting (CAS). Eighty-nine consecutive cases that underwent carotid reconstruction for carotid artery stenosis at Kyoto University Hospital between 2010 and 2015 were enrolled in this study. Ten cases that received neither coronary angiography (CAG) nor coronary computed tomography angiography (CCTA) as preoperative examinations, 6 cases with restenosis after CEA or CAS, and 2 cases that did not undergo carotid MRI were excluded. We evaluated relative overall signal intensity (roSI) of the carotid plaque on T1-weighted imaging and coronary artery stenosis detected on CAG or CCTA in the remaining 71 cases. Carotid plaques with roSI &gt;1.5 were defined as MRI-detected vulnerable plaques. Thirty-one cases had a history of previous coronary intervention (stenting or bypass surgery), of which 26 (84%) showed carotid vulnerable plaques. In the cases with no history of coronary intervention, coronary artery stenosis was newly detected in 21 cases, and was not demonstrated in the other 19 cases. Fifteen of the 21 cases with coronary artery stenosis (71%) also showed carotid vulnerable plaques. On the other hand, only 4 of the 19 cases without coronary artery stenosis (21%) had carotid vulnerable plaques, representing a significant difference (P&lt;0.05). Among the cases with no history of coronary intervention, prevalence of coronary artery stenosis in cases with carotid vulnerable plaques was 79%, significantly higher than that in cases without carotid vulnerable plaques (29%). In conclusion, this study demonstrated that patients with carotid vulnerable plaques are more likely to have advanced coronary artery stenosis. Plaque characterization by carotid MRI is useful not only for treatment of carotid artery stenosis, but also for predicting coronary artery stenosis.

Long-term effects of Enterprise self-expanding intracranial stent implantation in the treatment of carotid artery stenosis in patients with ischemic stroke: study protocol for a randomized controlled trial

Background: The Enterprise stent system (Johnson & Johnson (Shanghai) Medical Equipment Co., Ltd., China) is a closed-loop, recoverable self-expanding stent that is effective in the treatment of intracranial aneurysm. However, most studies on the treatment of intracranial aneurysm after ischemic stroke are case series or case reports. Methods/Design: We will perform a single-center, double-blind, randomized parallel-controlled trial at the Department of Neurology, Beijing Chao-yang Hospital, Capital Medical University, China. A cohort of 100 patients with atherosclerotic ischemic stroke will be randomly allocated to undergo either Enterprise self-expanding intracranial stent implantation in combination with antiplatelet medication (stent implantation group, n = 50) or only antiplatelet medication (drug group, n = 50) for treatment of carotid artery stenosis. Four time points (0.5, 1, 2, and 3 years after stent implantation or antiplatelet medication) will be selected for outcome observation and evaluation. The primary outcome will be the National Institutes of Health Stroke Scale score, which is used to evaluate neurologic deficits. The secondary outcomes will be the Barthel index and carotid stenosis rate. Discussion: There is a lack of randomized controlled studies addressing the long-term effects of the Enterprise self-expanding intracranial stent system for carotid artery stenosis in patients with ischemic stroke. This study will investigate and further confirm the clinical significance of the Enterprise stent system in the treatment of carotid artery stenosis in patients with ischemic stroke. Trial registration: This trial was registered at ClinicalTrial.gov (NCT02802072). Ethics: The study protocol has been approved by the Ethics Committee of Beijing Chao-yang Hospital, Captical Medical University, China (approval number: GJCY16012) and will be performed in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association. Informed consent: Written informed consent will be obtained from participants or their guardians prior to inclusion in this study.

Carotid Endarterectomy for Patients over 80 Years Old

Objective: Carotid endarterectomy (CEA) is one of the surgical treatments for carotid artery stenosis. While a large clinical trial showed that advanced age is a risk factor for CEA, other studies reported contradictory results. The aim of this study was to evaluate the outcomes of CEA in patients aged over 80. Methods: Patients who underwent CEA between January 2012 and June 2015 in our hospital were included, and were divided into either the high age group (>80 years old) or standard group (<80 years old). CEA was the firstline surgical treatment, instead of carotid artery stenting (CAS), for all eligible cases, except where patients were not deemed amenable to general anesthesia or at patients’ request not to undergo CEA. Patient background and perioperative complications were assessed and compared statistically between the high age group and standard group. Results: Of a total of 127 patients, 20 (15.7%) were in the high age group. No significant differences in patient background were obtained between the high age group and standard group. Four (20%) cases in the high age group had perioperative complications which were all transient. No significant differences in perioperative complications were obtained between the high age group and standard group. Conclusions: It is possible for CEA to be performed safely in the elderly, provided adequate preoperative assessment of the general condition and perioperative management of patients are carried out. We recommend that CEA should not be avoided as a treatment option in the elderly, based solely on patient age.

The Early Effect of Carotid Artery Stenting on Antioxidant Capacity and Oxidative Stress in Patients with Carotid Artery Stenosis.

The treatment of carotid artery stenosis is associated with the risk of complications, which may include stroke after carotid artery stenting (CAS) and myocardial infarction after carotid endarterectomy (CEA). The imbalance between prooxidative mechanisms and antioxidant capacity creates a milieu of factors, which may increase the risk of complications after endovascular procedures. We have examined 43 consecutive patients with carotid artery stenosis. Sera were analyzed for the activity of paraoxonase (PON) and arylesterase (ARE), sulfhydryl groups (SG), malondialdehyde (MDA), and conjugated dienes (CD) concentrations by means of spectrophotometric methods before and next day after CAS. We have found lowered PON (P = 0.0032), increase in ARE activity (P = 0.0058), and decrease in sulfhydryl groups concentration (P = 0.0267). No effect on absolute MDA and CD concentrations was observed. The degree of carotid artery stenosis correlated negatively with PON/ARE ratio after CAS (r S = −0.507, P = 0.0268). To conclude, CAS influences both enzymatic (differently, PON and ARE activity) and nonenzymatic antioxidant defense. Females are more susceptible to lipid peroxidation after CAS. PON/ARE ratio after CAS correlated with the degree of carotid artery stenosis. The changes (deltas) in ARE activity, SG, and MDA concentrations correlated with the severity of neurological deficit and disability.

The efficacy of pharmacological preconditioning in carotid endarterectomy

To assess the efficacy of pharmacological preconditioning with actovegin in carotid endarterectomy. The study was based on the results of surgical treatment of 80 patients with hemodynamically significant uni- and bilateral lesions of carotid arteries. Half of the patients was operated immediately and others after pharmacological preconditioning with actovegin in dose of 1200 mg/daily during 1,5 months. Pharmacological preconditioning with actovegin increased the cerebral perfusion determined with one-photon emission computed tomography that improved significantly results of the surgery. There were significant changes in patient's state 7 days and 6 months after surgery. The improvement was correlated with the less number of asymptotic post-surgery ischemic strokes in different brain areas. A positive role of pharmacological preconditioning with actovegin in surgical treatment of carotid artery stenosis has been demonstrated.

Use of the Smart nitinol stent system for the treatment of severe atherosclerotic carotid stenosis: study protocol for a retrospective, non-randomized, long-term parallel controlled trial

Background: The carotid artery should be stented in patients with 70-90% stenosis owing to the high risk of stroke. The self-expanding Smart nitinol stent system is a popular treatment for carotid artery stenosis, because it is easy to manipulate and deploy, and endothelialization is rapid. Methods/Design: We conducted a retrospective, single-center, non-randomized, parallel controlled trial at Beijing Jishuitan Hospital, China. A cohort of 103 patients with severe atherosclerotic carotid stenosis was included in the analysis. Treatment was undertaken according to each patient's wishes after weighing the options: a Smart nitinol stent system (Cordis Corporation, Miami, FL, USA) was used in 40 patients, while 63 were managed conservatively with antiplatelet drugs. The primary outcome is the degree of disability and dependence 2 years after treatment, assessed by the modified Rankin Scale (mRS). The secondary outcomes are mRS score 90 days and 1 year after treatment, recurrence of cerebrovascular events, and severity of neurologic deficit measured using the National Institutes of Health Stroke Scale 1 and 2 years after treatment. Discussion: Previous studies of the Smart nitinol stent system for the treatment of carotid stenosis are mostly self-controlled case series or small cohort studies with short follow-up periods. Consequently, the long-term influence of Smart nitinol stent deployment on the risk of cerebrovascular events and long-term outcomes are not known. This trial illuminates the therapeutic benefits of the Smart nitinol stent system in a 2-year follow-up study of a large cohort of patients with severe atherosclerotic carotid stenosis. Trial registration: This trial was registered at ClinicalTrial.gov (NCT02800174). Ethics: The study protocol was approved by the Ethics Committee of Beijing Jishuitan Hospital, China (approval number: 201605-01) and conducted in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association. Informed consent: Written informed consent was obtained from participants or their guardians.

Surgical Treatment of Carotid Artery Stenosis.

The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) have not been established. CEA is more appropriate than CAS if soft atherosclerotic plaques are included in the stenotic lesion, since such soft plaques are associated with a high incidence of ischemic complications during CAS. This report presents our surgical methods and the clinical results of CEA and CAS, and suggests an appropriate treatment strategy using plaque diagnosis, especially for high-risk patients. From January 2001 until December 2013 we surgically treated carotid stenosis in 241 lesions by CEA, and 309 lesions by CAS. The average age of the patients was 70.5 in CEA and 71.4 in CAS. The symptomatic stenosis rate was 67 % and the average stenotic rate was 82 % in CEA; these were 61 % and 66 %, respectively, in CAS. Stenosis of carotid arteries was relieved in all cases after CEA or CAS. Peri-operative mortality with CEA and CAS was 0.4 % (1/241) and 0.3 % (1/309), respectively. Morbidity by ischemic stroke with CEA and CAS was 2.9 % (7/241) and 1.6 % (5/309), respectively. Surgical morbidity was not high in patients with medical risk factors. Carotid stenotic lesions can be treated with comparably low morbidity and mortality rates using CEA and/or CAS even with high risks when appropriate surgical methods are selected, considering each characteristic of carotid stenosis using plaque diagnosis.

Cognitive improvement in patients with carotid stenosis is independent of treatment type.

Treatment of carotid artery stenosis decreases the long-term risk of stroke and may enhance cerebral blood flow. It is therefore expected to have the potential to prevent cognitive decline or even improve cognition over the long-term. However, intervention itself can cause peri-interventional cerebral infarcts, possibly resulting in a decline of cognitive performance, at least for a short time. We investigated the long-term effects of three treatment methods on cognition and the emotional state one year after intervention. In this prospective observational cohort study, 58 patients with extracranial carotid artery stenosis (≥ 70%) underwent magnetic resonance imaging and assessment of cognition, mood and motor speed before carotid endarterectomy (n = 20), carotid stenting (n = 10) or best medical treatment (n = 28) (i.e., time-point 1 [TP1]), and at one-year follow-up (TP2). Gain scores, reflecting cognitive change after treatment, were built according to performance as (TP2 -TP1)/TP1. Independent of the treatment type, significant improvement in frontal lobe functions, visual memory and motor speed was found. Performance level, motor speed and mood at TP1 were negatively correlated with gain scores, with greater improvement in patients with low performance before treatment. Active therapy, whether conservative or interventional, produces significant improvement of frontal lobe functions and memory in patients with carotid artery disease, independent of treatment type. This effect was particularly pronounced in patients with low cognitive performance prior to treatment.

Endovascular treatment of carotid artery stenosis: evidences from randomized controlled trials and actual indications

Atherosclerotic stenosis of common and internal carotid arteries is a well-recognized risk factor for ischemic stroke, and revascularization has been proven to be the main tool of prevention, particularly for patients with stenosis-related symptoms. While for many years surgical carotid endarterectomy (CEA) has been considered the gold-standard strategy to restore vascular patency, recently the endovascular treatment through percutaneous angioplasty and stent implantation (CAS) has become a valid alternative. In the last years, interesting data about the comparison of these strategies have emerged. CAS seems to cause more peri-procedural strokes, but may also avoid many adverse events related to surgery and general anaesthesia, including peri-procedural myocardial infarction. For these reasons, it was initially considered a second-choice strategy to be adopted in patients for whom surgery was contraindicated. However, more recent trials have shown that CAS might be considered an effective alternative to CEA. Moreover, the rapid evolution of CAS technique and materials suggests its potential to improve outcome and possible superiority compared to CEA in the next future. Purpose of this review is to discuss the most recent clinical evidences concerning the treatment of carotid artery stenosis, with a special focus on the endovascular treatment.

Selective Patch Angioplasty and Intraoperative Shunting in Carotid Endarterectomy: A Single-Center Review of 141 Procedures.

Objective: Open surgical treatment of carotid artery stenosis, namely, carotid endarterectomy (CEA), has evolved since its inception in 1953. Despite improvements in the treatment of carotid occlusive disease through technological and surgical innovations, the use of patch grafting in CEA’s remains controversial. We evaluate the durability of the primary closure and the safety of selective shunting during carotid endarterectomy (CEA) as determined by intraoperative EEG and postoperative outcomes.Methods: A consecutive series of CEA’s performed by the senior author at a single academic medical center from 2001 to 2012 were reviewed. All cases were performed under continuous intraoperative electroencephalography (EEG). Patch angioplasty was used in cases where there was tortuosity of the vessel within the region of the endarterectomy and narrow vessel diameter at the distal end of the arteriotomy. Shunting was used when intraoperative EEG showed a > 50% reduction in a waveform in any lead. Patients were evaluated for restenosis via imaging or ultrasound at six months and subsequently annual follow-up.Results: One hundred and forty-one CEA’s were performed on 132 (76 male, 56 female) patients with an average age of 71 years (range: 40–95 years). Four (3%) cases required patch angioplasty and three (2%) required intraoperative shunts. The cross-clamp time ranged from 22 to 74 minutes, and the duration increased with the use of shunts and patches. Complications were rare and included recurrent stenosis (n=2), postoperative transient ischemic attack (n=1), ischemic stroke in (n=1), temporary hypoglossal nerve weakness (n=2), temporary marginal mandibular nerve weakness (n=6), and neck hematoma (n=1).Conclusion: Intraoperative EEG data suggests that primary closure and selective shunting in CEA can result in outcomes comparable with routine patch angioplasty and shunting.

Carotid artery stenting outcomes in high-risk patients receiving best medical therapy: Results from a single high-volume interventional cardiology practice

BackgroundCarotid artery stenting (CAS) is now being widely used in the treatment of carotid artery stenosis. Recent clinical studies have demonstrated low adverse event rates after CAS. This study evaluates the 30-day and 1-year results in patients treated with CAS and receiving intensive medical therapy in a high-volume percutaneous coronary intervention center. MethodsA total of 184 patients underwent CAS between January 2011 and December 2013. In addition to antiplatelet therapy, patients received intensive antihypertensive treatment, high intensity statin and heart rate normalization therapy. Patients were stratified according to age and symptomatic status. ResultsMost of the patients (86.4%) had at least one high surgical risk criteria. The procedural success rate was 98.4%. The 30-day and 1-year incidence of stroke were 4.1% and 4.5%, respectively. At 30 days the combined rate of stroke/cardiovascular (CV) death/myocardial infarction (MI) was 5.8% and 10.9% in 1 year. The 30-day incidence of stroke/CV death in asymptomatic and symptomatic patients was 5.4% and 4.2%, respectively. Age ≥80 years increased the risk of stroke/CV death/MI at 1 year (OR 4.41; 95% CI 1.06–18.36; P=0.04). ConclusionsThe study demonstrated acceptable clinical outcome results in patients with high medical comorbidities treated with CAS and intensive medical therapy. Adverse event rate in symptomatic patients did not exceed the guideline recommended range while in asymptomatic patients it was increased.

Carotid Bifurcation Resection and Interposition of a Polytetrafluorethylene Graft (BRIG) for Carotid Disease: A Retrospective Study of 153 Consecutive Procedures

Carotid endarterectomy (CEA) is the gold standard for treatment of carotid artery stenosis. CEA can be challenging, even technically impossible. Prosthetic carotid bypass grafting is a proven and safe alternative when CEA is hazardous. An alternative technique that is prosthetic carotid bifurcation resection and interposition of a polytetrafluorethylene graft (BRIG) is described in this article. In our Department of Vascular Surgery, between January 2007 and October 2014, 103 BRIG procedures were performed. The outcome of conventional CEA and patients treated by the BRIG procedure were compared. Within the same period of time 50 CEA procedures (32.7%) were performed. Morbidity, mortality, and postoperative restenosis were compared. The 30-day mortality was 1% for the BRIG group and 0% in the CEA group (P value, 0.4839). The 30-day stroke rate was 1.9% for the BRIG group and 0% in the CEA group (P value, 0.3222). One patient died in the early postoperative period from acute myocardial infarction. A total of 13 (8.5%) patients died during follow-up, none of which were surgery related. Median follow-up was 29.1 months. There was a statistically higher restenosis rate in the CEA group compared with the BRIG group (16.0% vs. 1.9%, P value, 0.0053). Other complications were comparable. Mean operating and clamping time were significantly shorter in the BRIG group. BRIG appears to be a safe and feasible surgical alternative to CEA. The technique allows for shorter operating time, shorter clamping time, and appears to result in lower restenosis rates. Complication rates seem to be comparable to CEA. Prospective, randomized controlled trials on this topic are needed. To perform bilateral procedures, a bifurcation graft should be created to revascularize both the internal and external carotid artery.