Treatment Of Carotid Artery Stenosis Research Articles

Carotid Artery Stenosis:Indications and Outcomes

Carotid artery stenting(CAS)has emerged as a less invasive alternative to carotid endarterectomy(CEA), the standard surgical treatment for carotid artery stenosis. Major international randomized control trials(RCTs)have demonstrated its non-inferiority to CEA, and it is now recommended in the Japanese stroke treatment guidelines for both symptomatic and asymptomatic severe stenotic lesions. To ensure safety, it is essential to use an embolic protection device to prevent ischemic complications and maintain the quality of physicians proficient in both techniques and devices. In Japan, these two essentials are guaranteed with the aid of a board certification system by the Japanese Society for Neuroendovascular Therapy. Furthermore, preprocedural carotid plaque evaluation using non-invasive methods such as ultrasonography and magnetic resonance imaging to detect vulnerable plaques, which are considered at high risk for embolic complications, is frequently performed, thereby determining therapeutic indications to avoid adverse events. Thus, the results of CAS in Japan are far superior to those of RCT abroad, making this procedure the first-line therapy for carotid revascularization for decades.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Long-term outcomes of carotid artery stenting in patients with carotid artery stenosis: A single-center 14-year retrospective analysis.

Carotid artery stenting (CAS) is currently widely used for the treatment of carotid artery stenosis. The objective of this study was to analyze the outcomes of CAS performed in a single institution. We retrospectively analyzed 313 CAS cases from January 2007 to December 2020, including 206 (66%) symptomatic and 107 (34%) asymptomatic cases. Procedure-related morbidity and mortality were assessed. Rates of periprocedural (≤30 days after CAS) and postprocedural ipsilateral strokes (>30 days after CAS) were also assessed. Logistic regression analysis was used to identify risk factors for the periprocedural complication, in-stent restenosis (ISR), and ipsilateral stroke. The success rate of CAS was 98%. Among 313 cases, 1 patient died due to hyperperfusion-related intracerebral hemorrhage (ICH). The CAS-related mortality rate was 0.31%. The overall incidence of periprocedural complications is 5.1%. A risk factor for periprocedural complication was a symptomatic carotid artery stenosis (7.3% vs. 0.9%, p=0.016). Twenty cases of ISR occurred during 63.7±42.1 months of follow-up. The overall incidence of ISR was 10.2% (20/196). A risk factors for ISR were diabetes mellitus (17.6% vs. 5.7%, p=0.008) and patients who used Open-cell stents (19.6% vs. 6.9%, p=0.010). The overall incidence of ipsilateral stroke is 5.6%. A risk factors for ipsilateral stroke was ISR (95% CI, p=0.002). CAS is a safe and effective procedure for carotid artery stenosis. Although the incidence of complications is low, fatal complication such as hyperperfusion- related ICH can occur. To prevent hyperperfusion-related ICH, several methods such as strict blood pressure (BP) control, intentional less widening of stenotic segment should be used. To prevent ISR or stroke occurrence, special attention should be paid to patients who have ISR or ipsilateral stroke risk factors.

Carotid artery bypass versus endarterectomy as an alternative treatment of carotid artery stenosis: A propensity score matching analysis

ObjectivesThe main focus of this study is to evaluate the reliability and durability of saphenous vein bypass grafting from common carotid artery to internal carotid artery (CBG) asan alternative treatment of patients with carotid artery stenosis. Methods459 patients with carotid artery stenosis underwent initial carotid endarterectomy (CEA) or CBG between 2009 and 2019. Propensity score matching was performed, and outcomes of two different surgical procedures were analyzed. ResultsOutcomes of the 142 pairs of matched patients were investigated. There were no significant differences in the preoperative characteristics of these matched groups. Overall mean time of follow-up was 91.364 ± 3.265 months. Mortality rate during the follow-up period was 18.309% (26 patients) in the CEA group, and 11.971% (17 patients) in the CBG group. Stroke was encountered in 8 patients in the CEA group (5.63%), and 3 patients in the CBG group (2.11%) during follow-up. Restenosis was detected in 11 patients in the CEA group (7.75%), and 3 patients in the CBG group (3.52%) during follow-up. There were no significant differences in the survival, stroke – free survival, and restenosis - free survival distributions of both groups. ConclusionsIn carotid artery stenosis, it is reasonable to consider CBG as an alternative surgical option when adequate disease-free inflow (common carotid artery) and outflow (distal internal carotid artery) segments are present.

Black Patients Are More Likely to Undergo Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis

INTRODUCTION: Black race has been associated with worse outcomes after carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS), but few studies have focused on procedural selection in these patients. We aimed to compare rates of TFCAS vs CEA in Black and White patients using the Vascular Quality Initiative (VQI) database. METHODS: We included subjects who underwent CEA and TFCAS in VQI between 2003-2021. Patients were divided based on race (Black or White). The primary outcome of interest was the choice of CEA or TFCAS. Secondary outcomes included in-hospital death, stroke, and myocardial infarction (MI). Propensity score matching was utilized to create a balanced cohort and univariate methods were utilized to compare outcomes. RESULTS: A total of 141,191 carotid revascularizations were performed [125,244 (88.7%) CEA, 15,947 (11.3%) TFCAS] in 133,840 (94.8%) White patients and 7,351 (5.2%) Black patients. Propensity matching achieved a well-matched cohort of 5,574 pairs. After matching, Black patients demonstrated higher likelihood of having undergone TFCAS (4.9% vs 3.7%, OR 1.36, 95% CI 1.04-1.78, p = 0.03) as well as higher risk of in-hospital stroke (1.7% vs 1.2%, OR 1.40, 95% CI 1.04-1.90, p = 0.03) driving stroke/death (2.0% vs 1.4%, OR 1.43, 95% CI 1.10-1.87) and stroke/death/MI (2.4% vs 1.8%, OR 1.36, 95% CI 1.04-1.77) (Table 1). Table 1. - Propensity-Matched Outcomes of Carotid Revascularization by Race Variable White (5,574, 50%) Black (5,574, 50%) Odds ratio (95% CI) p Value TFCAS 205 (3.7%) 275 (4.9%) 1.36 (1.04-1.78) 0.03 Death 16 (0.3%) 23 (0.4%) 1.44 (0.78-2.66) 0.25 Stroke 68 (1.2%) 95 (1.7%) 1.40 (1.04-1.90) 0.03 MI 22 (0.4%) 22 (0.4%) 1.00 (0.52-1.92) 1.00 Stroke/death 80 (1.4%) 114 (2.0%) 1.43 (1.10-1.87) 0.008 Stroke/death/MI 98 (1.8%) 132 (2.4%) 1.36 (1.04-1.77) 0.02 CONCLUSION: Black race was independently associated with selection for TFCAS compared to CEA as well as increased stroke risk after propensity score matching. Given that CEA is the gold standard for revascularization due to the perioperative stroke risk of TFCAS, this represents a potential contributor to racial disparities.

Roadsaver versus Wallstent for carotid artery stenting: a retrospective cohort study

Abstract Introduction Carotid artery stenting (CAS) is an established alternative option to surgical treatment for carotid artery stenosis, 3 main contemporary types of stent design being used for this purpose (open-, closed-cell, mesh-covered stents). So far, no definite conclusions have been reached on the superiority of any of those devices for CAS. With its new double-mesh design, the Roadsaver stent has emerged as an attractive option for use in CAS, aiming to further reduce neurological events. However, its efficacy as compared to other stents, such as Wallstent, has not been thoroughly explored. We thus aimed to compare the clinical outcomes of Roadsaver and Wallstent for use in CAS. Methods This retrospective cohort study included patients who underwent CAS and received either Wallstent or Roadsaver stent at a tertiary centre (centre A) in a Central European country during 2009–2021, and another tertiary centre (centre B) in the same country during 2016–2019. Patients with incomplete baseline clinical records were excluded. Patients were followed up for one year at centre A, and for 30 days at centre B. The primary outcomes were 30-day and 1-year major adverse cardiac or cerebrovascular events (MACCE), defined as a composite of myocardial infarction, stroke, and cardiovascular mortality. The secondary outcome was 30-day bradycardia. Baseline covariates were balanced between groups using inverse probability treatment weighting. Thirty-day outcomes were compared using logistic regression with odds ratio (OR) as the summary statistic, and 1-year MACCE was compared using Cox regression with hazard ratio (HR) as the summary statistic. Results In total, 982 patients were identified. After applying the exclusion criterion, 770 patients were included in the analysis (482 patients from centre A and 288 patients from centre B; 287 (37.3%) females, mean age 68±8 years old), of which 589 (76.5%) received Wallstent and 181 (23.5%) received Roadsaver. There was no loss to follow-up. Twenty-three (3%) patients had MACCE by 30 days, and 16 (3.3%) of those who completed one-year follow-up had MACCE by one year. No significant differences in MACCE were observed between the two stents at 30 days (OR 0.697 [0.374, 1.300], p=0.256) and one year (HR 0.512 [0.126, 2.073], p=0.348). Roadsaver was associated with significantly higher odds of 30-day bradycardia (OR 5.391 [4.089, 7.108], p<0.0001), which remained significant after adjusting for the number of post-dilatations performed (p<0.0001). Additionally, Roadsaver was associated with significantly lower risk of one-year MACCE among symptomatic patients (N=184; HR 0.131 [0.024, 0.723], p=0.020; Figure 1), but not among asymptomatic patients (N=298; HR 1.774 [0.332, 9.490], p=0.503). Conclusion There was no short- and long-term hazard difference between the 2 types of stent designs, however Roadsaver may be superior to Wallstent among symptomatic patients. Funding Acknowledgement Type of funding sources: None.

Identification of Metabolomics Biomarkers in Extracranial Carotid Artery Stenosis.

The biochemical identification of carotid artery stenosis (CAS) is still a challenge. Hence, 349 male subjects (176 normal controls and 173 stroke patients with extracranial CAS ≥ 50% diameter stenosis) were recruited. Blood samples were collected 14 days after stroke onset with no acute illness. Carotid plaque score (≥2, ≥5 and ≥8) was used to define CAS severity. Serum metabolites were analyzed using a targeted Absolute IDQ®p180 kit. Results showed hypertension, diabetes, smoking, and alcohol consumption were more common, but levels of diastolic blood pressure, HDL-C, LDL-C, and cholesterol were lower in CAS patients than controls (p < 0.05), suggesting intensive medical treatment for CAS. PCA and PLS-DA did not demonstrate clear separation between controls and CAS patients. Decision tree and random forest showed that acylcarnitine species (C4, C14:1, C18), amino acids and biogenic amines (SDMA), and glycerophospholipids (PC aa C36:6, PC ae C34:3) contributed to the prediction of CAS. Metabolite panel analysis showed high specificity (0.923 ± 0.081, 0.906 ± 0.086 and 0.881 ± 0.109) but low sensitivity (0.230 ± 0.166, 0.240 ± 0.176 and 0.271 ± 0.169) in the detection of CAS (≥2, ≥5 and ≥8, respectively). The present study suggests that metabolomics profiles could help in differentiating between controls and CAS patients and in monitoring the progression of CAS.

Correlation between morphological and biomechanical features and carotid atherosclerosis

The main cause of ischemic stroke is the atherosclerotic lesions of the carotid arteries. Unlike other arteries, carotid arteries have unique anatomical structure and hemodynamic characteristics, which are significantly related to the occurrence of atherosclerosis.&#x0D; Thus, a proper understanding of the functional anatomy, local hemodynamics of the carotid arteries and their relationship with the atherosclerotic process can improve the quality of early diagnosis and treatment of carotid artery stenosis, which, in turn, will reduce the risk of developing of the ischemic cerebrovascular diseases.

Quantification of New Intracerebral Lesions on Diffusion-weighted Magnetic Resonance Imaging After Transcarotid Artery Revascularization for Treatment of Carotid Stenosis

Quantification of New Intracerebral Lesions on Diffusion-weighted Magnetic Resonance Imaging After Transcarotid Artery Revascularization for Treatment of Carotid Stenosis

Characteristics from the 100 most influential articles on carotid stenosis.

There are three main competing treatment modalities for carotid artery stenosis (CS), i.e., carotid endarterectomy (CEA), carotid artery angioplasty/stenting (CAS), and medical treatment. In this study, we analyzed the performance and trends of CS research through bibliometric analysis. We searched the Thomson Reuters Web of Science citation indexing database. The key words used in the search were "carotid artery" and "carotid stenosis". The top 100 most cited manuscripts (T100) were analyzed based on title, author, institution, country of origin, year of publication, and topic. The T100 were published between 1990 and 2016. The Stroke published the most manuscripts (n=22) and the New England Journal of Medicine was the most cited (n=15,113). The United States had the greatest number of publications (n=43), and the University of Oxford was the institution with the most publications (n=7). Peter M. Rothwell was the corresponding author with the most publications (n=10). The main topics were in the following categories: CEA (n=22), medication (n=11), CAS (n=9), diagnosis (n=44), and CEA vs. CAS (n=14). This bibliometric analysis of CS research provides insight into publication trends and perspective on the treatment of CS.

Safety of Contemporary Carotid Artery Stenting and Associated Risk Factors for Treatment of Carotid Artery Stenosis

The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS. Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015-2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30days of CAS. Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death. These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS.

Adoption of Novel Nano Bio-vascular Stent in Carotid Artery Stenosis Stent Intervention and Perioperative Nursing Analysis.

This work was developed to explore the adoption value of bacterial cellulose (BC) and heparin (He) combined with novel nano bio-vascular stents in carotid artery stent implantation, as well as the nursing methods and effects during the perioperative period. Based on the BC artificial blood vessel preparation method, the BC-He novel nano bio-vascular stent was fabricated after the modification of the medium method. Infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS), and X-ray electron diffraction (XRD) were performed to analyze the crystal structure and chemical structure of the material. In addition, scanning electron microscope (SEM) and transmission electron microscope (TEM) were employed to observe the micro-morphology of the stent. The mechanical properties and thermal stability of the materials were also characterized. Then, with 98 patients undergoing carotid artery stenting (CAS) as the research object, BC-He novel nano bio-vascular stent was applied to treat patients with arterial stenosis. According to different nursing methods, patients were assigned to the conventional nursing group (group A) and perioperative nursing group (group B). The postoperative complications, nursing effect, and satisfaction degree of the two groups were compared. It turned out that the BC-He novel nano bio-vascular stent was a kind of micro-mesh structure. There were characteristic absorption peaks of BC and He in BC-He, and there were N and S from He. Moreover, it also contained BC and He characteristic diffraction peaks, its tensile strength was significantly lower than BC, and its thermal stability was higher than BC. The preoperative carotid artery stenosis ranged from 50 % to 75 %, and the postoperative stenosis rate of restenosis patients treated with BC-He novel nano bio-vascular stent was less than 10 %. In addition, there were 92 patients (93.88 %) whose symptoms improved or markedly improved within 1 to 2 weeks after the operation, and 78 patients (79.6 %) had improved hemodynamic parameters. The incidence of postoperative complications in group A was dramatically superior to that in group B (P < 0.05). The total effective rate of nursing care and the degree of nursing satisfaction in group B were better than those in group A (P < 0.05). In short, BC-He novel nano bio-vascular stent had good mechanical properties and thermal stability, which was a safe and effective material for the treatment of carotid artery stenosis. In addition, the perioperative nursing method was effective and was of certain clinical adoption value.

Transcarotid Artery Revascularization (TCAR) in the Frail

Transfemoral carotid stenting (TFCAS) fell dramatically out of favor with vascular surgeons after the results of the CREST trial showed higher rates of stroke compared to carotid endarterectomy (CEA). 1 Brott T.G. Hobson 2nd, R.W. Howard G. et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010; 363 ([published correction appears in N Engl J Med. 2010 Jul 29;363(5):498] [published correction appears in N Engl J Med. 2010 Jul 8;363(2):198]): 11-23 Crossref PubMed Scopus (2259) Google Scholar The emergence of TCAR presented a novel technology to stent carotid lesions in patients not suitable or considered high risk for a CEA. Multiple recent studies evaluating the outcomes of TCAR have been very encouraging. 2 Kashyap V.S. Schneider P.A. Foteh M. et al. Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease. Stroke. 2020; 51: 2620-2629 Crossref PubMed Scopus (55) Google Scholar , 3 Schermerhorn M.L. Liang P. Eldrup-Jorgensen J. et al. Association of transcarotid artery revascularization vs transfemoral carotid artery stenting with stroke or death Among patients with carotid artery stenosis. JAMA. 2019; 322: 2313-2322 Crossref PubMed Scopus (105) Google Scholar , 4 Kashyap V.S. King A.H. Foteh M.I. et al. A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy. J Vasc Surg. 2019; 70: 123-129 Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar This has led to fast and wide adoption of the technique. Impact of Frailty on Postoperative Outcomes in Patients Undergoing TransCarotid Artery Revascularization (TCAR)Annals of Vascular SurgeryVol. 84PreviewFrailty is a clinical syndrome characterized by a reduction in metabolic reserves leading to increased susceptibility to adverse outcomes following invasive surgical interventions. The 5-item modified frailty index (mFI-5) validated in prior studies has shown high predictive accuracy for all surgical specialties, including vascular procedures. In this study, we aim to utilize the mFI-5 to predict outcomes in Transcarotid Revascularization (TCAR). Full-Text PDF

\u201cReal-World Study of a Dual-Layer Micromesh Stent in Elective Treatment of Symptomatic and Asymptomatic Carotid Artery Stenosis (ROADSAVER)\u201d

PurposeEndovascular carotid artery stenosis treatment is associated with a higher peri- and early post-procedural stroke risk relative to surgery. Dual-layer micromesh carotid stents were specifically designed for improved plaque coverage to reduce the cerebral embolization risk and related ischemic events. ROADSAVER study aims to further confirm the safety and efficacy of the Roadsaver™ dual-layer micromesh stent for the treatment of elective patients with carotid artery stenosis.Materials and MethodsROADSAVER is a prospective, multi-center, observational study. Between January 2018 and February 2021, a total of 1967 patients featuring asymptomatic or symptomatic, non-occlusive and non-thrombotic carotid stenosis eligible for an elective stenting procedure were enrolled across 13 European countries (52 centers). Follow-up visits are scheduled at 30 days and at 12 months. The primary outcome measure is the major adverse event rate, i.e., cumulative incidence of any death or stroke up to 30 days post-procedure. All deaths, strokes and carotid revascularizations are adjudicated by an independent Clinical Events Committee. Sub-analyses are prespecified and focused on baseline patient characteristics (e.g., age, neurologic status), procedural features (e.g., access route, embolic protection use), advanced imaging, and treatment efficacy up to 12 months.ConclusionThe present study evaluates the Roadsaver™ dual-layer micromesh carotid stent in the real-world clinical practice aiming to provide valuable insights into the contemporary European treatment trends and outcomes of elective carotid artery stenting. The large study population and predefined sub-analyses should help identify the best practices and patient subsets to benefit most from the treatment.Trial RegistrationClinicaltrial.gov identifier: NCT03504228.

Bilateral asymptomatic common carotid artery stenosis: Mouse model for stroke research.

Background:Asymptomatic carotid artery stenosis has become more prevalent worldwide and is often associated with a poor prognosis. Numerous guidelines highlighted surgical interventions as treatment for carotid artery stenosis, but only a few recommendations were made regarding non-surgical interventions due to its limited data.Aims:This study aims to develop a mice model for research in non-surgical interventions of asymptomatic carotid artery stenosis.Methods:Adult male Rattus norvegicus, Wistar strain models with bilateral asymptomatic common carotid artery stenosis (BACAS) were created by ligating the common carotid artery with a 0.6 mm diameter needle and then removing the needle. The mice’s body weight, clinical signs and symptoms, and post-mortem brain analysis were compared between the sham-operated group and the BACAS group.Results:The mortality rate among the BACAS group is 11.11%. There is no significant difference in mean body weight before surgery, after the observation period, and percentage of weight decrease between sham-operated and BACAS groups (p = 0.710, 0.632, and 0.806, respectively). None of the surviving mice in this study exhibit signs of motor paralysis. Gross examination of the brain reveals no signs of infarction or hemorrhage.Conclusion:We have established a novel BACAS mouse model which is cost-efficient, easy to produce, and with no significant alteration in body weight, clinical parameters, and brain morphology.

Risk Factors for and Intraoperative Management of Intolerance to Flow Reversal in TCAR

BackgroundIn patients deemed high risk for carotid endarterectomy (CEA) who are indicated for treatment of carotid artery stenosis (CAS), transcarotid artery revascularization (TCAR) has been demonstrated as a safe and effective alternative to trans-femoral carotid artery stenting (TF-CAS). Compared to CEA, where approx. 12% of patients undergoing awake intervention do not tolerate internal carotid artery (ICA) clamping, only 1–2% of patients were observed to have intolerance to flow reversal during TCAR based on data from the ROADSTER1/2 trials. This study reviewed awake interventions from those trials to assess factors associated with intolerance to flow reversal and review how those cases were managed. MethodsThis is a retrospective review of prospectively collected data from Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial along with the subsequent post-approval (ROADSTER-2) trial. The subset of patients from both trials undergoing awake TCAR was analyzed to compare demographics, procedural details, and anatomic factors between patients who did and did not experience intolerance to reversal of flow to assess for predisposing factors. Patients were deemed intolerant to flow reversal at the discretion of the operator, often related to changes in completion of neurologic tasks, hemodynamic stability, or patient reported symptoms. ResultsA total of 103 patients from ROADSTER and 194 patients from ROADSTER-2 underwent TCAR under local/regional anesthesia. Of these, 8 patients had intolerance to flow reversal, though all cases were successfully completed. While intraoperative hemodynamic data was only available for 5 of the 8 intolerant patients, none experienced hypotension. 4 cases were completed under low flow reversal, 3 cases were successfully weaned from low to high flow over several minutes, and 1 case required general anesthesia. No significant association was found between intolerance to flow reversal and comorbidities including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), congestive heart failure (CHF), prior MI or angina, pre-op CAS-related symptoms, prior stroke, prior CAS or CEA, prior neck radiation, tandem stenosis, high cervical stenosis, or hostile neck. A trend towards significance was seen with chronic obstructive pulmonary disease (COPD) and contralateral carotid artery occlusion (P = 0.086 and 0.139, respectively). ConclusionsDespite intolerance to flow reversal, TCAR cases were successfully completed by adjusting reversal-of-flow rate and do not typically require conversion to GETA. While factors contributing to intolerance of flow reversal during TCAR remain poorly understood, this study identified a trend towards significance with an association of preexisting COPD and contralateral carotid artery occlusion. Given the low number of patients who experienced this issue, a larger sample size is required to better elucidate these trends.

Stroke Prevention with Extracranial Carotid Artery Disease.

Carotid artery stenosis is a major risk factor for ischemic stroke. Although effective treatment options exist, careful assessment of benefits and risks for individual patients is needed in clinical decision-making. This article reviews contemporary treatments for carotid artery stenosis, the underlying evidence, and areas of uncertainties. Specific recommendations are available to guide the standard of care of carotid artery stenosis. Nonetheless, significant uncertainties are noted in patient selection for surgical treatment of asymptomatic carotid stenosis and in optimal treatment targets for pharmacological therapies. Advanced imaging has been used to predict future risk of ipsilateral stroke and clarify mechanisms of actions of pharmacological therapies, primarily in observational studies. Pharmacological and surgical treatments for extracranial carotid artery stenosis continue to evolve with many relevant clinical trials completed and clinical guidelines updated in recent years. Future clinical trials to tackle the areas of uncertainties are warranted.

Lower Hospital and Operating Room Charges for Patients Undergoing Carotid Repair With Carotid Endarterectomy Versus Transcervical Carotid Artery Revascularization

Transcervical carotid artery revascularization (TCAR) has become an increasingly popular method for the treatment of carotid artery stenosis, especially because trial data have demonstrated a stroke risk comparable to that for carotid endarterectomy (CEA). Recent data have suggested that TCAR might be cost-effective; however, the costs associated with using this new technology have not been thoroughly evaluated. A retrospective cohort review was conducted of patients at a single institution undergoing either TCAR or CEA from January 2019 to December 2020. Patient demographics, including race, gender, comorbidities, length of stay, and complications, were recorded. Additionally, the total operating room (OR) charges and hospitalization charges were recorded. Patients who had undergone combined procedures (coronary artery bypass grafting or transcatheter aortic valve replacement during hospitalization) were excluded. Of 234 patients, 38 had undergone TCAR and 196 had undergone CEA. Both cohorts were well matched for demographics and comorbid conditions. The length of stay was similar between the TCAR and CEA cohorts (1.32 vs 1.57 days; P = .254). The overall OR charges were greater for the TCAR group than for the CEA group ($60,996.72 vs $49,078.75; P < .001). The total hospital charges were similar for the TCAR group vs the CEA group (67,921.38 vs 63,308.97; P = .317). When selecting for patients with a single-day length of stay, the total hospital charges were greater for TCAR than for CEA ($65,278.17 vs $55,865.73; P < .001; Fig). In the TCAR group, the primary reason for the overall difference in costs appeared to be the OR charges. The hospital charges after the exclusion of the OR charges were similar between the TCAR and CEA groups ($4188.71 vs $6604.38; P = .08). One notable difference was that the TCAR group was more likely to require a higher level of OR billing than the CEA group (15% vs 5%; P = .03). The hospital charges were similar for patients who had undergone TCAR vs CEA overall but were lower for the CEA group when examining patients with only 1 day in the hospital. The primary reason for this charge difference appeared to be the OR charges, which were significantly greater for the patients who had undergone TCAR ($60,996.72 vs 49,078.75; P < .001). Cost containing efforts for treating patients with carotid artery stenosis should focus on reducing the charges associated with TCAR.

Carotid Phase-Contrast Magnetic Resonance before Treatment: 4D-Flow versus Standard 2D Imaging

The purpose of this study was to evaluate the level of agreement between flow/velocity data obtained from 2D-phase-contrast (PC) and 4D-flow in patients scheduled for treatment of carotid artery stenosis. Image acquisition was performed using a 1.5 T scanner. We compared mean flow rates, vessel areas, and peak velocities obtained during the acquisition with both techniques in 20 consecutive patients, 15 males and 5 females aged 69 ± 5 years (mean ± standard deviation). There was a good correlation between both techniques for the CCA flow (r = 0.65, p < 0.001), whereas for the ICA flow and ECA flow the correlation was only moderate (r = 0.4, p = 0.011 and r = 0.45, p = 0.003, respectively). Correlations of peak velocities between methods were good for CCA (r = 0.56, p < 0.001) and moderate for ECA (r = 0.41, p = 0.008). There was no correlation for ICA (r = 0.04, p = 0.805). Cross-sectional area values between methods showed no significant correlations for CCA (r = 0.18, p = 0.269), ICA (r = 0.1, p = 0.543), and ECA (r = 0.05, p = 0.767). Conclusion: the 4D-flow imaging provided a good correlation of CCA and a moderate correlation of ICA flow rates against 2D-PC, underestimating peak velocities and overestimating cross-sectional areas in all carotid segments.

Outcomes in 1-year Cohort After Transcarotid Artery Revascularization in the ROADSTER2 Trial

Transcarotid artery revascularization (TCAR) is a novel and attractive alternative to carotid endarterectomy (CEA) or transfemoral carotid artery stenting for interventional treatment of carotid artery stenosis in high-risk patients. In a direct carotid approach, TCAR uses temporary reversal of cerebral arterial blood flow to offer neuroprotection from emboli during stent placement. At present, the optimal surgical management for high-risk patients is unknown. We aimed to evaluate the 1-year safety and efficacy of TCAR in a prospective clinical trial.