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Kuipers S, Willemse SW, Greving JP, Bron EE, van Oostenbrugge RJ, van Osch MJ, Biessels GJ, Kappelle LJ. Lower haemoglobin concentrations are associated with impaired cognition in patients with carotid artery occlusion. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2023; 5:100169. [PMID: 37404564 PMCID: PMC10316002 DOI: 10.1016/j.cccb.2023.100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/01/2023] [Accepted: 06/09/2023] [Indexed: 07/06/2023]
Abstract
Background Patients with carotid artery occlusion (CAO) are vulnerable to cognitive impairment (CI). Anaemia is associated with CI in the general population. We hypothesized that lower haemoglobin is associated with cognitive impairment (CI) in patients with CAO and that this association is accentuated by cerebral blood flow (CBF). Methods 104 patients (mean age 66±8 years, 77% men) with complete CAO from the Heart-Brain Connection study were included. Anaemia was defined as haemoglobin < 12 g/dL for women and < 13 g/dL for men. Cognitive test results were standardized into z-scores (using a reference group) in four cognitive domains. Patients were classified as cognitively impaired when ≥ one domain was impaired. The association between lower haemoglobin and both cognitive domain z-scores and the presence of CI was assessed with adjusted (age, sex, education and ischaemic stroke) regression models. Total CBF (measured with phase contrast MRI) and the interaction term haemoglobin*CBF were additionally added to the analyses. Results Anaemia was present in 6 (6%) patients and was associated with CI (RR 2.54, 95% CI 1.36; 4.76). Lower haemoglobin was associated with the presence of CI (RR per minus 1 g/dL haemoglobin 1.15, 95% CI 1.02; 1.30). This association was strongest for the attention-psychomotor speed domain (RR for impaired attention-psychomotor speed functioning per minus 1 g/dL haemoglobin 1.27, 95% CI 1.09;1.47) and ß for attention-psychomotor speed z-scores per minus 1 g/dL haemoglobin -0.19, 95% CI -0.33; -0.05). Adjustment for CBF did not affect these results and we found no interaction between haemoglobin and CBF in relation to cognition. Conclusion Lower haemoglobin concentrations are associated with CI in patients with complete CAO, particularly in the domain attention-psychomotor speed. CBF did not accentuate this association. If validated in longitudinal studies, haemoglobin might be a viable target to prevent cognitive deterioration in patients with CAO.
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Affiliation(s)
- Sanne Kuipers
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Sean W. Willemse
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jacoba P. Greving
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Esther E. Bron
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - L. Jaap Kappelle
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
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Speranza G, Harish K, Rockman C, Gordon R, Sadek M, Jacobowitz G, Chang H, Garg K, Maldonado TS. The Natural History of Carotid Artery Occlusions Diagnosed on Duplex Ultrasound. Ann Vasc Surg 2023; 91:1-9. [PMID: 36574830 DOI: 10.1016/j.avsg.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is a paucity of literature on the natural history of extracranial carotid artery occlusion (CAO). This study reviews the natural history of this patient cohort. METHODS This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound between 2010 and 2021. Patients were identified by searching our office-based Intersocietal Accreditation Commission accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical record. Outcomes of interest included ipsilateral stroke, attributable neurologic symptoms, and ipsilateral intervention after diagnosis. RESULTS The full duplex database consisted of 5,523 patients who underwent carotid artery duplex examination during the study period. The CAO cohort consisted of 139 patients; incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female. Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most common comorbid conditions. Of the CAO cohort, 61.3% (n = 85) of patients were asymptomatic at diagnosis; 38.8% (n = 54) were diagnosed after a stroke or transient ischemic attack occurring within 6 months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1% occurring contralateral to the CAO. 7.2% (n = 10) had unclear symptoms or laterality at presentation. Of the CAO cohort, 95 patients (68.3%) had duplex imaging follow-up (mean 42.7 ± 31.3 months). Of those with follow-up studies, 7 patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ± 39.0 months postdiagnosis. In addition, 5 patients (3.6%) developed other related symptoms, including global hypoperfusion (2.4%) and transient ischemic attack (1.2%). Of those, 95 patients with follow-up duplex ultrasound imaging, 6 (4.3%) underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 4), transfemoral carotid artery stent (n = 1), and carotid bypass (n = 1), with mean occurrence 17.7 ± 23.7 months postdiagnosis. The aggregate rate of ipsilateral cerebrovascular accident, attributable neurologic symptoms, or ipsilateral intervention was 11.5%. Of 95 patients with follow-up duplex ultrasound imaging, 5 underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing intervention received periprocedural cross-sectional imaging (magnetic resonance angiography or computed tomography angiography). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings. CONCLUSIONS In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced cerebrovascular accident, related symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies among patients with CAO diagnoses and discrepancies between CAO diagnosis per duplex ultrasound and findings on cross-sectional imaging for those patients who underwent intervention. These results suggest that use of a single duplex ultrasound as a sole diagnostic tool in CAO may not be sufficient and that physicians should consider close duplex ultrasound surveillance of these patients, potentially in conjunction with additional confirmatory imaging modalities. Further investigation into optimal workup and surveillance protocols for CAO is needed.
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Affiliation(s)
| | - Keerthi Harish
- New York University Grossman School of Medicine, New York, NY
| | - Caron Rockman
- New York University Grossman School of Medicine, New York, NY
| | - Ryan Gordon
- Department of General Surgery, ChristianaCare, Wilmington, DE
| | - Mikel Sadek
- New York University Grossman School of Medicine, New York, NY
| | | | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Araújo A, Guimarães F, Miranda AM, Rodrigues M, Castro S, Ribeiro M. Endovascular Revascularization of an Unfavorable Type of Chronically Occluded Internal Carotid Artery Using a Balloon Guide Catheter. Clin Neuroradiol 2023; 33:565-568. [PMID: 36735019 DOI: 10.1007/s00062-022-01259-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/22/2022] [Indexed: 02/04/2023]
Affiliation(s)
- André Araújo
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal.
| | - Francisca Guimarães
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal
| | - André Miguel Miranda
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal
| | - Marta Rodrigues
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal
| | - Sérgio Castro
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal
| | - Manuel Ribeiro
- Cerebrovascular Interventional Neuroradiology Unit, Imagiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes S/N., Vila Nova de Gaia, Portugal
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Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions. J Stroke Cerebrovasc Dis 2023; 32:106797. [PMID: 36527943 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/18/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. MATERIALS AND METHODS We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. RESULTS 36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). CONCLUSIONS IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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Intracranial Flow Volume Estimation in Patients with Internal Carotid Artery Occlusion. Diagnostics (Basel) 2022; 12:diagnostics12030766. [PMID: 35328320 PMCID: PMC8947284 DOI: 10.3390/diagnostics12030766] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Carotid artery occlusion (CAO) in population studies has a reported prevalence of about 6 per 100,000 people; however, the data may be underestimated. CAO carries a significant risk of stroke. Up to 15% of large artery infractions may be secondary to the CAO, and in 27−38% of patients, ischaemic stroke is a first presentation of the disease. The presence of sufficient and well-developed collateral circulation has a protective influence, being a good prognostic factor in patients with carotid artery disease, both chronic and acute. Understanding the mechanisms and role of collateral circulation may be very important in the risk stratification of such patients. (2) Materials and Methods: This study included 46 patients (mean age: 70.5 ± 6 years old; 15 female, mean age 68.5 ± 3.8 years old and 31 male, mean age 71.5 ± 6.7 years old) with unilateral or bilateral ICA occlusion. In all patients, a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population >65 years old. (3) Results: In comparison with CBF values in the healthy population, three subgroups with CBF changes were identified among patients with ICA occlusion: patients with significant volumetric flow compensation (CBF higher than average + standard deviation for healthy population of the same age), patients with flow similar to the healthy population (average ± standard deviation), and patients without compensation (CBF lower than the average-standard deviation for healthy population). The percentage of patients with significant volumetric flow compensation tend to rise with increasing age, while a simultaneous decline was observed in the group without compensation. The percentage of patients with flow similar to the healthy population remained relatively unchanged. ICA played the most important role in volumetric flow compensation in patients with CAO; however, the relative increase in flow in the ICA was smaller than that in the ECA and VA. Compensatory increased flow was observed in about 50% of all patent extracranial arteries and was more frequently observed in ipsilateral vessels than in contralateral ones, in both the ECA and the VA. In patients with CAO, there was no decrease in CBF, ICA, ECA, and VA flow volume with increasing age. (4) Conclusions: Volumetric flow compensation may play an important predictive role in patients with CAO.
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7
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Yin H, Zhang J, Zhao W, Zheng M, Song Y, Sun L, Zhang J, Han J. Drug-Coated Balloon for the Treatment of Nonacute Symptomatic Intracranial Carotid Artery Terminus Occlusion: Initial Experience and Follow-Up Outcome. Front Neurol 2022; 13:840865. [PMID: 35222260 PMCID: PMC8879511 DOI: 10.3389/fneur.2022.840865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundStudies on the recanalization for occlusion of the internal carotid artery terminus are scattered. Recently, drug-coated balloon (DCB) has been increasingly applied in the intracranial artery occlusion and achieved encouraging results. However, there seems no convincing data for the nonacute symptomatic internal carotid artery terminus occlusion (sICATO).ObjectiveTo assess the feasibility and effectiveness (safety) of DCB for patients with nonacute sICATO refractory to medical therapy.ApproachThis study included 30 patients with nonacute sICATO treated with DCBs and/or remedial stenting. The rate of successful recanalization, periprocedural complications, and clinical and vascular imaging follow-up outcomes were retrospectively analyzed.ResultsDrug-coated balloon (DCB) dilatation of nonacute sICATO gives a 100% rate of successful recanalization, with a low complication rate (10.00%), good clinical outcomes (86.20%), low restenosis/reocclusion rate (3.45%), and one asymptomatic ipsilateral infarction (3.45%).ConclusionDrug-coated balloon dilation seems to be the promising treatment option for nonacute sICATO considering its safety and feasibility.
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8
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Elsharkawi M, Ghoneim B, Elsherif M, Sultan S. Bilateral external carotid artery stenting in symptomatic patient with complete occlusion of both internal carotid arteries. Clin Case Rep 2021; 9:540-542. [PMID: 33489211 PMCID: PMC7813021 DOI: 10.1002/ccr3.3577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
Completely occluded ICA should not always turn a symptomatic patient down for surgical intervention especially if medical treatment fails. Where bilateral ECA intervention is required, endovascular approach should be considered if feasible.
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Affiliation(s)
- Mohamed Elsharkawi
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Baker Ghoneim
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Mohamed Elsherif
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Sherif Sultan
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
- Department of Vascular and Endovascular SurgeryGalway ClinicGalwayIreland
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Fernandes e Fernandes J, Mendes Pedro L, Gonçalves I. The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1279. [PMID: 33178811 PMCID: PMC7607137 DOI: 10.21037/atm-2020-cass-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/24/2020] [Indexed: 01/27/2023]
Abstract
Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.
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Affiliation(s)
- José Fernandes e Fernandes
- Department of Surgery and Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal
- Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Luis Mendes Pedro
- Senior Consultant Vascular Surgeon, Cardiovascular Institute/Hospital da Luz Torres de Lisboa, Lisbon, Portugal
- Department of Vascular Surgery, Faculty of Medicine University of Lisbon, Lisbon, Portugal
- Vascular Surgery Department, Santa Maria University Hospital, Lisbon Academic Medical Center, Lisbon, Portugal
| | - Isabel Gonçalves
- Cardiology Department, Skåne University Hospital and Clinical Sciences Malmö, Lund University, Sweden
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Zhang J, Ding S, Zhao H, Sun B, Li X, Zhou Y, Wan J, Degnan AJ, Xu J, Zhu C. Evaluation of chronic carotid artery occlusion by non-contrast 3D-MERGE MR vessel wall imaging: comparison with 3D-TOF-MRA, contrast-enhanced MRA, and DSA. Eur Radiol 2020; 30:5805-5814. [PMID: 32529567 DOI: 10.1007/s00330-020-06989-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To analyze the accuracy of a non-contrast MR vessel wall imaging technique, three-dimensional motion-sensitized driven equilibrium prepared rapid gradient echo (3D-MERGE) for diagnosing chronic carotid artery occlusion (CCAO) characteristics compared with 3D time-of-flight (TOF) MRA, and contrast-enhanced MRA (CE-MRA), using digital subtraction angiography (DSA) as a reference standard. METHODS Subjects diagnosed with possible CCAO by ultrasound were retrospectively analyzed. Patients underwent 3.0-T MR imaging with 3D-MERGE, 3D-TOF-MRA, and CE-MRA followed by DSA within 1 week. Diagnostic accuracy of occlusion, occlusion site, and proximal stump condition were assessed independently on 3 MRI sequences and DSA. Agreement of the above indicators was evaluated in reference to DSA. RESULTS One hundred twenty-four patients with 129 suspected CCAO (5 with bilateral occlusions) met the inclusion criteria for our study. 3D-MERGE demonstrated a sensitivity, specificity, and accuracy of 97.0%, 86.7%, and 94.6%, respectively, with excellent agreement (Cohen's κ = 0.85; 95% CI, 0.71, 0.94) for diagnosing CCAO in reference to DSA. 3D-MERGE was superior in diagnosing CCAO compared with 3D-TOF-MRA (Cohen's κ = 0.61; 95% CI, 0.42, 0.77) and similar to CE-MRA (Cohen's κ = 0.93; 95% CI, 0.86, 1.00). 3D-MERGE also had excellent agreement compared with DSA for assessing occlusion sites (Cohen's κ = 0.85; 95% CI, 0.71, 0.97) and stump condition (Cohen's κ = 0.83; 95% CI, 0.71, 0.94). Moreover, 3D-MERGE provided additional information regarding the occluded segment, such as distal lumen collapse and vessel wall lesion components. CONCLUSION 3D-MERGE can reliably assess chronic carotid occlusive characteristics and has the ability to identify other vessel wall features of the occluded segment. This non-contrast MR vessel wall imaging technique is promising for assessment of CCAO. KEY POINTS • Excellent agreement was found between 3D-MERGE and DSA for assessing chronic carotid artery occlusion, occlusion site, and proximal stump condition. • 3D-MERGE was shown to be a more accurate and efficient tool than 3D-TOF-MRA to detect the characteristics of the occluded segment. • 3D-MERGE provides not only luminal images for characterizing the proximal characteristics of occlusion but also vessel wall images for assessing the distal lumen and morphology of occlusion segment, which might help clinicians to optimize the treatment strategy for patients with chronic carotid artery occlusion.
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Affiliation(s)
- Jin Zhang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shenghao Ding
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Huilin Zhao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Beibei Sun
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao Li
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yan Zhou
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Andrew J Degnan
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,American Institute for Radiologic Pathology, Silver Spring, MD, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jianrong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, USA
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11
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Tzameret A, Piontkewitz Y, Nitzan A, Rudoler N, Bruzel M, Zilberstein Y, Ziv H, Pri‐Chen S, Solomon AS. Mild carotid stenosis creates gradual, progressive, lifelong brain, and eye damage: An experimental laboratory rat model. J Comp Neurol 2020; 528:1672-1682. [DOI: 10.1002/cne.24851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Adi Tzameret
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Yael Piontkewitz
- Straus Center for Computational NeuroimagingTel Aviv University Tel Aviv Israel
| | - Anat Nitzan
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Nir Rudoler
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Marina Bruzel
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Yael Zilberstein
- The Sackler Cellular and Molecular Imaging Center, Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Hana Ziv
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Sarah Pri‐Chen
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Arieh S. Solomon
- Goldschleger Eye Research Institute, Faculty of MedicineTel Aviv University Tel Aviv Israel
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12
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Mulatti GC, Puech-Leão P, De Luccia N, da Silva ES. Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study. Ann Vasc Surg 2018; 53:44-52. [PMID: 30053548 DOI: 10.1016/j.avsg.2018.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/24/2018] [Accepted: 04/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up. METHODS Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments. RESULTS From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150). CONCLUSIONS Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.
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Affiliation(s)
- Grace Carvajal Mulatti
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil.
| | - Pedro Puech-Leão
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Nelson De Luccia
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Erasmo S da Silva
- Vascular and Endovascular Division, Surgery Department, University of São Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
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13
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Maltezos C, Anastasiadou C, Papapetrou A, Galyfos G, Sachmpazidis I, Papacharalampous G. Symptomatic Bilateral Carotid Artery Occlusion: An Uncommon Pattern of Carotid Pathology. Vasc Specialist Int 2018; 34:31-34. [PMID: 29984215 PMCID: PMC6027800 DOI: 10.5758/vsi.2018.34.2.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/03/2018] [Accepted: 03/16/2018] [Indexed: 11/30/2022] Open
Abstract
We report an unusual case of an 83-year-old man who was admitted with dizziness and repeated drop attacks. He was diagnosed with bilateral carotid artery occlusion and he underwent a left subclavian to left carotid bypass with ringed polytetrafluoroethylene graft. The patient’s postoperative course was uneventful and no symptoms presented during a 6-month follow-up. Finally, we discuss on proper management of such patients.
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Affiliation(s)
| | | | | | - George Galyfos
- Department of Vascular Surgery, KAT General Hospital, Athens, Greece
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14
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Usachev DY, Lukshin VA, Shmigel'skiy AV, Akhmedov AD, Shul'gina AA. [Carotid endarterectomy in patients with symptomatic occlusions of the contralateral internal carotid artery]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 81:5-15. [PMID: 29393281 DOI: 10.17116/neiro20178165-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The main aim of the study was to investigate the effect of carotid endarterectomy on the prognosis of chronic cerebral ischemia in patients with symptomatic occlusions of the contralateral internal carotid artery, assess risks of surgical complications, and substantiate the staged surgical approach for treatment of patients with this pathology. The article analyzes the experience in surgical treatment of 83 patients with symptomatic ICA occlusions who underwent surgery for contralateral carotid artery stenosis. In 40 patients, only carotid endarterectomy (CEA) was performed on the side of hemodynamically significant stenosis (group 1). In 43 (52%) cases, apart from CEA, extracranial-intracranial (EC-IC) bypass was performed at the second stage (23 cases, group 2) or the first stage (19 cases, group 3). A surgical treatment approach was chosen based on clinical symptoms, severity of contralateral carotid artery stenosis, and the magnitude of perfusion deficiency in the territory of carotid occlusion. The conducted analysis revealed that patients with symptomatic occlusions and contralateral carotid artery stenoses represented a heterogeneous group with a different efficacy of carotid endarterectomy and with risks of perioperative complications. As cerebrovascular insufficiency in the territory of carotid occlusion and a related neurological deficit worsen, the risks of complications of contralateral carotid endarterectomy increase, and its clinical efficacy decreases. In these cases, cerebral revascularization on the ICA occlusion side should be performed at the first stage.
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Affiliation(s)
- D Yu Usachev
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - V A Lukshin
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | | | - A D Akhmedov
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - A A Shul'gina
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
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15
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Takeuchi H, Okuyama M, Uchida HA, Kakio Y, Umebayashi R, Okuyama Y, Fujii Y, Ozawa S, Yoshida M, Oshima Y, Sano S, Wada J. Chronic Kidney Disease Is Positively and Diabetes Mellitus Is Negatively Associated with Abdominal Aortic Aneurysm. PLoS One 2016; 11:e0164015. [PMID: 27764090 PMCID: PMC5072712 DOI: 10.1371/journal.pone.0164015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 09/19/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND AIMS Chronic kidney disease (CKD) and diabetes mellitus (DM) are considered as risk factors for cardiovascular diseases. The purpose of this study was to clarify the relationship of CKD and DM with the presence of abdominal aortic aneurysm (AAA). METHODS We enrolled 261 patients with AAA (AAA+) and age-and-sex matched 261 patients without AAA (AAA-) at two hospitals between 2008 and 2014, and examined the association between the risk factors and the presence of AAA. Furthermore, in order to investigate the prevalence of AAA in each group, we enrolled 1126 patients with CKD and 400 patients with DM. RESULTS The presence of CKD in patients with AAA+ was significantly higher than that in patients with AAA- (AAA+; 65%, AAA-; 52%, P = 0.004). The presence of DM in patients with AAA+ was significantly lower than that in patients with AAA- (AAA+; 17%, AAA-; 35%, P < 0.001). A multivariate logistic regression analysis demonstrated that hypertension, ischemic heart disease and CKD were independent determinants, whereas, DM was a negatively independent determinant, for the presence of AAA. The prevalence of AAA in patients with CKD 65 years old and above was 5.1%, whereas, that in patients with DM 65 years old and above was only 0.6%. CONCLUSION CKD is a positively associated with the presence of AAA. In contrast, DM is a negatively associated with the presence of AAA in Japanese population.
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Affiliation(s)
- Hidemi Takeuchi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michihiro Okuyama
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Haruhito A. Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Kakio
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ryoko Umebayashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuka Okuyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Fujii
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Susumu Ozawa
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Masashi Yoshida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yu Oshima
- Department of Cardiovascular Surgery, Kure Kyosai Hospital, Hiroshima, Japan
| | - Shunji Sano
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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16
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Internal carotid artery occlusion should not exclude surgery. ACTA ACUST UNITED AC 2016; 1:e75-e77. [PMID: 28905025 PMCID: PMC5421529 DOI: 10.5114/amsad.2016.61495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022]
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17
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Lee CW, Lin YH, Liu HM, Wang YF, Chen YF, Wang JL. Predicting procedure successful rate and 1-year patency after endovascular recanalization for chronic carotid artery occlusion by CT angiography. Int J Cardiol 2016; 221:772-6. [PMID: 27428320 DOI: 10.1016/j.ijcard.2016.07.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/08/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Proper patient selection criteria for treatment of carotid chronic total occlusion (CTO) are unclear. This study was designed to predict procedure successful rate and 1-year patency after carotid artery stenting (CAS) for carotid CTO using pre-procedural CTA. METHODS Patients with CTO detected on CTA who underwent recanalization within 3months were divided into those with occlusions at (or distal to) the clinoid segment of the internal carotid artery (group A) and those with occlusions proximal to the clinoid segment (group B) and outcomes were compared between groups. RESULTS Technical success rates, major complications, and re-occlusions within 1-year were 52%, 22%, 91% in group A (N=23), and 89%, 0%, 0% in group B (N=19), respectively. Diabetes was more frequent in group A (43%) compared with group B (11%). CONCLUSION CTA may play a role in predicting successful rate and 1-year patency for endovascular recanalization in carotid CTO.
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Affiliation(s)
- Chung-Wei Lee
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan; Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Hon-Man Liu
- Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
| | - Yu-Fen Wang
- Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Jaw-Lin Wang
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
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18
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Liu Y, Jia L, Liu B, Meng X, Yang J, Li J, Zhou Y, Jiao L, Hua Y. Evaluation of Endarterectomy Recanalization under Ultrasound Guidance in Symptomatic Patients with Carotid Artery Occlusion. PLoS One 2015; 10:e0144381. [PMID: 26636827 PMCID: PMC4670099 DOI: 10.1371/journal.pone.0144381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/17/2015] [Indexed: 11/18/2022] Open
Abstract
Rigorous screening and good imaging would help perform surgery on carotid artery occlusion CAO safely and effectively. The purpose of this study was to retrospectively evaluate carotid endarterectomy (CEA) recanalization in patients with common carotid artery occlusion (CCAO) or internal carotid artery occlusion (ICAO) with color Doppler flow imaging (CDFI). A total of 59 patients undergoing CEA were enrolled. According to the results of CEA, the patients were divided into successful recanalization (group A) and unsuccessful recanalization (group B) groups. The original diameter, lesion length, proximal-to-distal diameter ratio and echo characteristics of the lesion within the lumen of the carotid artery were recorded before CEA and compared between the two groups. In regards to the achievement of repatency by CEA, the overall success rate was 74.6% (44/59), the success rate in CCAO patients was 75.9% (22/29) and the success rate in ICAO patients was 73.3% (22/30). There was no significant difference in the success rates between the CCAO and ICAO patients (χ2 = 0.050, P = 0.824). The overall rate of stroke and death within 30 postoperative days was 5.1% (3/59). For the CCAO patients, the lesion length in group A was shorter than that in group B (t = 3.221, P = 0.004). For the ICAO patients, the original diameter of the distal ICA was broader (t = 6.254, P = 0.000) and the proximal-to-distal ICA diameter ratio was smaller (t = 8.036, P = 0.000) in group A than in group B. The rate of recanalization for lumens with a homogeneous echo pattern (hypoecho or isoecho) was significantly higher than that for lumens with echo heterogeneity for both the CCAO and ICAO patients (χ2 = 14.477, P = 0.001; χ2 = 10.519, P = 0.003). However, for both the CCAO and ICAO patients, there was no difference in the rate of recanalization between patients with hypoecho and isoecho lesions (χ2 = 0.109, P = 0.742; χ2 = 0.836, P = 0.429). The original diameter, proximal-to-distal ICA diameter ratio, lesion length and echo characteristics may affect the success of CEA recanalization in patients with CCAO and ICAO. CDFI is helpful in screening patients with carotid artery occlusion and may improve the success rate of CEA.
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Affiliation(s)
- Yumei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiufeng Meng
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Yang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingzhi Li
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yinghua Zhou
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail:
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19
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Schneider J, Sick B, Luft AR, Wegener S. Ultrasound and Clinical Predictors of Recurrent Ischemia in Symptomatic Internal Carotid Artery Occlusion. Stroke 2015; 46:3274-6. [DOI: 10.1161/strokeaha.115.011269] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 08/24/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Occlusion of the internal carotid artery puts patients at risk of recurrent ischemic events because of hemodynamic compromise. Our goal was to characterize clinical and duplex parameters indicating patients at risk of recurrent ischemia.
Methods—
We retrospectively identified patients with symptomatic internal carotid artery occlusion. Clinical characteristics and ultrasound parameters, including collateral networks, were analyzed. Predictors for recurrent ipsilateral ischemia were investigated by Cox regression analysis.
Results—
Of 68 patients, at least 1 recurrent ischemic event within the same vascular territory was observed in 14 patients (20.6%) within 2 to 92 days (median, 29.5 days). The median follow-up period was 6 months. Diabetes mellitus and previous transient ischemic attack were associated with recurrence, as was activation of the maximum number of collateral pathways on transcranial ultrasound (28.6% versus 5.6%;
P
=0.03). Furthermore, flow in the posterior cerebral arteries was higher in patients with recurrence in ipsilateral and contralateral posterior cerebral artery P2 segments (76 IQR 37.5 versus 59, IQR 22.5 cm/s and 68, IQR 35.6 versus 52, IQR 21 cm/s;
P
<0.01 and 0.02).
Conclusions—
Flow increases in both posterior cerebral artery P2 segments suggest intensified compensatory efforts when other collaterals are insufficient. Together with the presence of diabetes mellitus and a history of transient ischemic attack, this duplex parameter indicates that patients with internal carotid artery are at particular risk of recurrent ischemia.
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Affiliation(s)
- Juliane Schneider
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich and University of Zurich (J.S., A.R.L., S.W.) and Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention (B.S.), University of Zurich, Switzerland; and Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
| | - Beate Sick
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich and University of Zurich (J.S., A.R.L., S.W.) and Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention (B.S.), University of Zurich, Switzerland; and Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
| | - Andreas R. Luft
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich and University of Zurich (J.S., A.R.L., S.W.) and Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention (B.S.), University of Zurich, Switzerland; and Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
| | - Susanne Wegener
- From the Division of Vascular Neurology and Rehabilitation, Department of Neurology, University Hospital Zurich and University of Zurich (J.S., A.R.L., S.W.) and Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention (B.S.), University of Zurich, Switzerland; and Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland (A.R.L.)
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20
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Serum levels of anticyclic citrullinated peptide antibodies, interleukin-6, tumor necrosis factor-α, and C-reactive protein are associated with increased carotid intima-media thickness: a cross-sectional analysis of a cohort of rheumatoid arthritis patients without cardiovascular risk factors. BIOMED RESEARCH INTERNATIONAL 2015; 2015:342649. [PMID: 25821796 PMCID: PMC4363501 DOI: 10.1155/2015/342649] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 01/22/2023]
Abstract
The main cause of death in rheumatoid arthritis (RA) is cardiovascular events. We evaluated the relationship of anticyclic citrullinated peptide (anti-CCP) antibody levels with increased carotid intima-media thickness (cIMT) in RA patients. Methods. Forty-five anti-CCP positive and 37 anti-CCP negative RA patients, and 62 healthy controls (HC) were studied. All groups were assessed for atherogenic index of plasma (AIP) and cIMT. Anti-CCP, C-reactive protein (CRP), and levels of tumor necrosis factor alpha (TNFα) and interleukin-6 (IL-6) were measured by enzyme-linked immunosorbent assay (ELISA). Results. The anti-CCP positive RA patients showed increased cIMT compared to HC and anti-CCP negative (P < 0.001). Anti-CCP positive versus anti-CCP negative RA patients, had increased AIP, TNFα and IL-6 (P < 0.01), and lower levels of high density lipoprotein cholesterol (HDL-c) (P = 0.02). The cIMT correlated with levels of anti-CCP (r = 0.513, P = 0.001), CRP (r = 0.799, P < 0.001), TNFα (r = 0.642, P = 0.001), and IL-6 (r = 0.751, P < 0.001). In multiple regression analysis, cIMT was associated with CRP (P < 0.001) and anti-CCP levels (P = 0.03). Conclusions. Levels of anti-CCP and CRP are associated with increased cIMT and cardiovascular risk supporting a clinical role of the measurement of cIMT in RA in predicting and preventing cardiovascular events.
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21
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Lee JI, Jander S, Oberhuber A, Schelzig H, Hänggi D, Turowski B, Seitz RJ. Stroke in patients with occlusion of the internal carotid artery: options for treatment. Expert Rev Neurother 2014; 14:1153-67. [PMID: 25245575 DOI: 10.1586/14737175.2014.955477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.
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Affiliation(s)
- John Ih Lee
- LVR-Klinikum Düsseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
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22
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Preiss JE, Itum DS, Reeves JG, Duwaryi Y, Rajani R, Veeraswamy R, Salam A, Dodson TF, Brewster LP. Carotid duplex criteria for patients with contralateral occlusion. J Surg Res 2014; 193:28-32. [PMID: 25255726 DOI: 10.1016/j.jss.2014.08.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 06/20/2014] [Accepted: 08/22/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contralateral occlusion (CLO) occurs in approximately 8% of patients undergoing intervention for carotid artery stenosis. Patients with CLO have increased stroke risk compared with patients without CLO, but standard carotid duplex ultrasonography (CDUS) criteria are not a reliable manner to screen or follow patients with CLO. Because appropriate duplex criteria for these patients are not well understood, this article defines CDUS parameters that accurately predict carotid artery stenosis at our institution. METHODS Sixty-five patients with ipsilateral carotid stenosis and CLO were identified from our institutional database. Fifteen of sixty-five patients had arteriography, computed tomography angiography, or magnetic resonance angiography within 6 mo of CDUS. We determined accuracy of our laboratory's criteria for determining stenosis category compared with three-dimensional imaging. Receiver operating characteristic curves were used to determine optimal peak systolic velocity (PSV), end diastolic velocity (EDV), and systolic ratio (SR) cutoff values for diagnosing ≥50% stenosis in this pilot cohort. Finally, the revised criteria were prospectively applied to a validation cohort (n = 8) from the same institution. RESULTS Categorization of stenosis by standard PSV, EDV, and SR criteria saw similar accuracy trends in both pilot (46.7, 53.3, and 66.7%) and validation (25, 25, and 62.5%) cohorts. Receiver operating characteristic curve analysis in the pilot cohort identified optimized PSV, EDV, and SR cutoffs (≥250, ≥90, and ≥2.3 cm/s, respectively) for diagnosing ≥50% stenosis. In the pilot cohort, new PSV criteria increased specificity (60%-100%) with minimal decreased sensitivity (90%-80%), whereas new EDV criteria increased specificity (40%-71.4%) and maintained 100% sensitivity. New SR criteria failed to improve sensitivity or specificity above 80%. Similar trends for the new CDUS velocity criteria were observed in the validation cohort. CONCLUSIONS Increasingly stringent ultrasound parameters can provide reliable criteria for determining ≥50% carotid stenosis in patients with CLO. Further prospective validation that includes more patients with high-grade ipsilateral stenosis will help identify the role of SR in segregating high-grade versus moderate stenosis in CLO patients.
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MESH Headings
- Aged
- Angiography
- Carotid Artery, Common/diagnostic imaging
- Carotid Artery, Common/physiology
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/physiology
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/epidemiology
- Carotid Stenosis/physiopathology
- Databases, Factual
- Female
- Humans
- Magnetic Resonance Angiography
- Male
- Middle Aged
- Predictive Value of Tests
- Prospective Studies
- Reproducibility of Results
- Risk Factors
- Sensitivity and Specificity
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Duplex/methods
- Ultrasonography, Doppler, Duplex/standards
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Affiliation(s)
| | - Dina S Itum
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | | | - Yazan Duwaryi
- Department of Surgery, Emory University, Atlanta, GA
| | - Ravi Rajani
- Department of Surgery, Emory University, Atlanta, GA
| | | | - Atef Salam
- Department of Surgery, Emory University, Atlanta, GA; Surgical and Research Services, Atlanta VA Medical Center, Atlanta, GA
| | | | - Luke P Brewster
- Department of Surgery, Emory University, Atlanta, GA; Surgical and Research Services, Atlanta VA Medical Center, Atlanta, GA.
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23
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Shah B, Rockman CB, Guo Y, Chesner J, Schwartzbard AZ, Weintraub HS, Adelman MA, Riles TS, Berger JS. Diabetes and vascular disease in different arterial territories. Diabetes Care 2014; 37:1636-42. [PMID: 24705616 PMCID: PMC4030086 DOI: 10.2337/dc13-2432] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between diabetes and different phenotypes of peripheral vascular disease (lower extremity peripheral artery disease [PAD], carotid artery stenosis [CAS], and abdominal aortic aneurysm [AAA]). RESEARCH DESIGN AND METHODS Prevalence of vascular disease was evaluated in 3,696,778 participants of the Life Line Screening survey between 2003 and 2008. PAD was defined as ankle-brachial pressure index <0.90 or prior revascularization, CAS as ≥50% stenosis or prior revascularization, and AAA as infrarenal aortic diameter ≥3 cm or prior repair. Odds ratios (ORs) and 95% CIs were assessed using logistic regression modeling. RESULTS Diabetes mellitus was present in 10.8% of participants (n = 399,884). Prevalence of PAD, CAS, and AAA was significantly higher (P < 0.0001) in participants with compared with those without diabetes. After multivariate adjustment for baseline demographics and clinical risk factors, a significant interaction existed between diabetes and vascular disease phenotype (P < 0.0001). Diabetes was associated with increased odds of PAD (OR 1.42 [95% CI 1.41-1.4]; P < 0.0001) and CAS (1.45 [1.43-1.47]; P < 0.0001) but decreased odds of AAA (0.86 [0.84-0.88]; P < 0.0001). The strength of association increased with increasing severity of disease in each vascular phenotype, and this association persisted in the population with asymptomatic vascular disease. CONCLUSIONS In a large population-based study, the association between diabetes and vascular disease differed according to vascular phenotype. Future studies exploring the mechanism for these vascular-specific differences are needed.
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Affiliation(s)
- Binita Shah
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Caron B Rockman
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Yu Guo
- Department of Population Health, Division of Biostatistics, New York University School of Medicine, New York, NY
| | - Jaclyn Chesner
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Arthur Z Schwartzbard
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Howard S Weintraub
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY
| | - Mark A Adelman
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NY
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NYDepartment of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, NYDepartment of Medicine, Division of Hematology, New York University School of Medicine, New York, NY
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24
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Fokkema M, Reichmann BL, den Hartog AG, Klijn CJ, Schermerhorn ML, Moll FL, de Borst GJ. Selective external endarterectomy in patients with ipsilateral symptomatic internal carotid artery occlusion. J Vasc Surg 2013; 58:145-51.e1. [DOI: 10.1016/j.jvs.2012.12.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 11/30/2022]
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