Carotid Disease Management: Surgery, Stenting, or Medication

Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment

PURPOSE

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment.

MATERIALS AND METHODS

Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention.

RESULTS

A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group.

CONCLUSIONS

The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Observation on the Efficacy of Ginkgo Ketone Ester Drop Pill in Improving Hypertension Combined with Carotid Atherosclerotic Plaque

Purpose. To observe and analyze the efficacy of Ginkgo ketone ester drop pill intervention in patients with hypertension combined with carotid atherosclerotic plaque. Methods. The subjects were 300 patients with hypertension complicated with carotid atherosclerotic plaque treated in our hospital from January 2019 to September 2021. The grouping was done by the random number table method and 300 patients were divided equally into 2 groups. One group was treated with Western medicine alone (clopidogrel sulfate tablets, phenyl amlodipine tablets, irbesartan tablets, and resorvastatin) as the Western medicine group (WM group, n = 150), and one group was added to this intervention with Ginkgo ketone ester drop pill as the Chinese medicine group (CM group, n = 150). The observation indexes were the improvement of blood pressure (systolic blood pressure (SBP) and diastolic blood pressure (DBP)), blood lipids (low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), and total cholesterol (TC)), vascular endothelial function (nitric oxide (NO) and endothelin-1 (ET-1)), inflammatory factors (C-reactive protein (CRP) and interleukin-6 (IL-6)), plaque (intimal medial thickness (IMT) of carotid artery and plaque area), and efficacy after intervention and adverse effects during intervention in both groups. Results. After intervention, SBP, DBP, LDL-C, TG, and TC levels were lower and HDL-C levels were higher in both groups than before intervention in the same group, and both CM groups improved significantly compared with the WM group ( $P<0.05$ ). After intervention, NO levels were higher and ET-1 levels were lower in both groups than before the intervention in the same group, and both CM groups improved significantly compared with the WM group ( $P<0.05$ ). After intervention, CRP and IL-6 levels were lower in both groups than before intervention in the same group, and both CM groups improved significantly compared with the WM group ( $P<0.05$ ). After intervention, IMT and plaque area were lower in both groups than before intervention in the same group and both CM groups improved significantly compared with the WM group ( $P<0.05$ ). The total effective number of the CM group was better than the WM group ( $P<0.05$ ), and there was no significant difference in the adverse reactions number in both groups ( $P>0.05$ ). Conclusions. The treatment of hypertension combined with carotid atherosclerotic plaque with Ginkgo ketone ester drop pill helps to improve the blood pressure, blood lipid, and vascular endothelial function of patients and helps to inhibit the inflammation level and atherosclerotic plaque of patients, with significant efficacy and no significant adverse effects in patients, which is worthy of clinical promotion.

Similarities and differences in ultrasound of extracranial brachiocephalic atherosclerotic lesions in patients with ischemic anterior and posterior circulation stroke

Aim. To establish similarities and differences in ultrasound of extracranial brachiocephalic atherosclerotic lesions in patients with ischemic anterior and posterior circulation stroke.

Material and methods. The study involved 668 patients (men, 370; women, 298) with carotid territory IS aged 63±11 and 69±9 years, respectively, and 235 patients (men, 129; women, 106) with vertebrobasilar (VB) territory IS aged 59±12 and 63±10 years, respectively, who underwent duplex ultrasound.

Results. Atherosclerotic plaques (ASP) in the internal carotid arteries (ICA) were diagnosed significantly more often (p<0,05) (right ICA (ICAr) — 44,0% of cases; left ICA (ICAl) — 48,4%) and the degree of stenosis of ICA mouths was significantly higher (p<0,05) (ICAr —53±23%, ICAl — 54±24%) in carotid territory IS than in VB territory IS (ICAr — 34,0% of cases; average degree of stenosis — 47±18%; ICAl — 33,6%, average degree of stenosis — 46±18%. There were no significant differences in the prevalence of ASP in vertebral arteries and related stenosis in IS in both territories. Also, there were no significant intergroup differences in the prevalence of homogeneous anechoic or hypoechoic and heterogeneous with hypoechoic predominance ASPs in the ICA mouths: in carotid territory IS, such ASPs were detected in each ICA in 33,5% of cases; in VB territory IS, in 29,6% of cases.

Conclusion. In patients with carotid and VB territory IS, risky ASPs were recorded with the same frequency, while the overall prevalence of ASPs and the stenosis degree of ICA mouths was significantly higher in carotid IS.

 

The Role of White Matter Damage in the Risk of Periprocedural Diffusion-Weighted Lesions after Carotid Artery Stenting

Background

White matter hyperintensities (WMH) are a common finding in aged individuals affected by carotid artery disease and are a risk factor for first-ever and recurrent stroke. We investigated if white matter damage increases the risk of brain microembolism during carotid artery stenting (CAS), as evaluated by the appearance of new areas of restricted diffusion on diffusion-weighted images (DWI).

Methods

We evaluated 47 patients with severe internal carotid artery (ICA) stenosis undergoing CAS, comparing preprocedural clinical, ultrasound and radiological characteristics. WMH volume was computed on FLAIR images before CAS. After CAS, the DWI scan was looked over for areas of restricted diffusion (DWI lesions). A first univariate analysis was adopted to compare groups according to the occurrence of DWI lesions. Then, the variable DWI lesion was modelled by means of a logistic regression model.

Results

Seventeen patients developed at least 1 DWI lesion after CAS. Compared with non-DWI, DWI patients were more commonly treated in the left ICA (p = 0.007) and had a more severe WMH damage (p = 0.027). Indeed, the risk of a DWI lesion was higher in left versus right stenosis (OR = 9.0, 95% CI 1.9-42.7, p = 0.005) and increased for each log-unit of WMH lesion load (OR = 7.05, 95% CI 1.07-46.49, p = 0.042). A WMH lesion load of at least 5.25 cm³ had a 50% probability of occurrence of a new DWI lesion.

Conclusions

Treated side and preexisting white matter damage are risk conditions for brain microembolism during CAS. This should be taken into account to optimize severe carotid artery disease management.