Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis

Contralateral Stenosis and Echolucent Plaque Morphology are Associated with Elevated Stroke Risk in Patients Treated with Asymptomatic Carotid Artery Stenosis within a Controlled Clinical Trial (SPACE-2)

BACKGROUND

Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS.

METHODS

The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed.

RESULTS

Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%^ECST vs. 20%^ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%^ECST vs. 20%^ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS.

CONCLUSION

In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.

Mitophagy in Cerebral Ischemia and Ischemia/Reperfusion Injury

Ischemic stroke is a severe cerebrovascular disease with high mortality and morbidity. In recent years, reperfusion treatments based on thrombolytic and thrombectomy are major managements for ischemic stroke patients, and the recanalization time window has been extended to over 24 h. However, with the extension of the time window, the risk of ischemia/reperfusion (I/R) injury following reperfusion therapy becomes a big challenge for patient outcomes. I/R injury leads to neuronal death due to the imbalance in metabolic supply and demand, which is usually related to mitochondrial dysfunction. Mitophagy is a type of selective autophagy referring to the process of specific autophagic elimination of damaged or dysfunctional mitochondria to prevent the generation of excessive reactive oxygen species (ROS) and the subsequent cell death. Recent advances have implicated the protective role of mitophagy in cerebral ischemia is mainly associated with its neuroprotective effects in I/R injury. This review discusses the involvement of mitochondria dynamics and mitophagy in the pathophysiology of ischemic stroke and I/R injury in particular, focusing on the therapeutic potential of mitophagy regulation and the possibility of using mitophagy-related interventions as an adjunctive approach for neuroprotective time window extension after ischemic stroke.

Arterial collateral anatomy predicts the risk for intra-operative changes in somatosensory evoked potentials in patients undergoing carotid endarterectomy: a prospective cohort study

Background

During carotid endarterectomy (CEA), significant amplitude decrement of somatosensory evoked potentials (SEPs) is associated with post-operative neurological deficits.

Objective

To investigate the association between an incomplete circle of Willis and/or contralateral ICA occlusion and subsequent changes in intra-operatively monitored SEPs.

Methods

We performed a retrospective analysis of a single center, prospective cohort of consecutive patients undergoing CEA over a 42-month period after reviewing the collateral arterial anatomy on pre-operative radiological imaging. The primary endpoint was an intra-operative decline in SEPs > 50% compared to the baseline value during arterial cross-clamping. Univariate and multivariate logistic regression analyses were performed to investigate a potential association between contralateral ICA occlusion, incomplete circle of Willis, and subsequent alteration in SEPs.

Results

A total of 140 consecutive patients were included, of which 116 patients (82.9%) had symptomatic carotid stenosis of at least 50% according to the classification used in the North American Carotid Surgery Trial (NASCET) (Stroke 22:711–720, 1991). Six patients (4.3%) showed contralateral ICA occlusion, 22 patients (16%) a missing/hypoplastic anterior communicating artery (Acom) or A1 segment, and 79 patients (56%) a missing ipsilateral posterior communicating artery (Pcom) or P1 segment. ICA occlusion and missing segments of the anterior circulation (missing A1 and/or missing Acom) were associated with the primary endpoint (p = 0.003 and p = 0.022, respectively).

Conclusion

Contralateral ICA occlusion and missing anterior collaterals of the circle of Willis increase the risk of intra-operative SEP changes during CEA. Pre-operative assessment of collateral arterial anatomy might help identifying patients with an increased intra-operative risk.

Comparison the effects of carotid endarterectomy with carotid artery stenting for contralateral carotid occlusion

Background

There have been inconsistent results regarding the use of carotid artery endarterectomy (CEA) versus carotid artery stenting (CAS) for contralateral carotid occlusion (CCO). This study aimed to determine the optimal revascularization technique for patients with CCO.

Methods

We systematically searched the PubMed, Embase, and Cochrane Library databases to identify eligible studies published from inception to January 2, 2021. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate pooled effect estimates using a random-effects model. Sensitivity, subgroup, and publication bias analyses were also performed.

Results

Six studies involving 6,953 patients were selected for inclusion in this meta-analysis. Our results showed that while CEA was not associated with an increased risk of stroke compared to CAS (OR: 1.07; 95% CI: 0.75–1.51; P = 0.713), CEA was associated with a reduced risk of death compared to CAS (OR: 0.45; 95% CI: 0.29–0.70; P < 0.001). Furthermore, there were no significant differences between CEA and CAS for the risks of myocardial infarction (OR: 1.38; 95% CI: 0.73–2.62; P = 0.319) or major adverse cardiovascular events (OR: 1.03; 95% CI: 0.56–1.88; P = 0.926). Finally, the risk of myocardial infarction for CEA versus CAS was affected by disease status, while the risk of major adverse cardiovascular events was affected by the proportions of patients with male gender, coronary artery disease, and current or prior smoking.

Conclusion

This study found that CEA and CAS resulted in similar outcomes for patients with CCO, while the risk of death was reduced in patients treated with CEA. Further high-level evidence should be collected to verify the results of this study.

Ipsilateral hypoperfusion caused by intracerebral steal phenomenon after carotid artery stenting: a case report

Background

Abnormal hypoperfusion on the surgical side after carotid artery stenting is rare. Neurological deterioration caused by it is deceptive, which can easily lead to misdiagnosis. The mechanism of hypoperfusion has rarely been demonstrated. We present here a fully studied case with a high probability of intracerebral steal phenomenon.

Case presentation

A 68-year-old male with severe right internal carotid artery stenosis and left internal carotid artery occlusion underwent right stenosis stent implantation. Restlessness and left limb hemiplegia occurred within 24 h after the procedure, which was similar to hyperperfusion syndrome. However, postoperative computerized tomography perfusion (CTP) revealed abnormal hypoperfusion in the right hemisphere. Transcranial Doppler (TCD) also showed decreased flow velocity in the right middle cerebral artery, and increased flow velocity in the right anterior cerebral artery. We considered that intracerebral steal phenomenon might be the cause, then hypervolemic therapy was accepted and the symptoms completely resolved after 3 days.

Conclusions

Ipsilateral hypoperfusion is rarely seen after carotid artery stenting. Intracerebral steal phenomenon may be the underlying mechanism. CTP or TCD is helpful for the early detection of this adverse event.

Severe contralateral carotid stenosis or occlusion drive 30-day risk after carotid endarterectomy

OBJECTIVES

The significant effects on the treatment of severe carotid stenosis by carotid endarterectomy have been widely recognized. However, it is controversial whether patients with severe contralateral carotid stenosis or occlusion (SCSO) can benefit from carotid endarterectomy surgery. This study aimed to estimate the SCSO effects on early outcomes after carotid endarterectomy with selective shunting.

METHODS

Between August 2011 and October 2019, a total of 617 patients who underwent carotid endarterectomy with selective shunting were analyzed. SCSO was defined as >70% luminal narrowing of the contralateral extracranial carotid stenosis or occlusion. Of these patients, 116 were categorized into an SCSO group while the rest were assigned to the non-SCSO group. Primary study outcomes were the occurrence of major adverse events, defined as stroke, all-cause mortality, and myocardial infarction during the perioperative period after carotid endarterectomy. Traditional multivariable logistic regression model and logistic regression model adjusted for propensity scores were used to estimate the SCSO effects on primary outcomes. Interaction and stratified analyses were conducted according to age, sex, comorbidities (hypertension, diabetes), preoperative neurological deficit, preoperative symptoms, and shunt use.

RESULTS

Mean age was 68.5 ± 9.2 years (86.1% men). Overall major adverse events rate within 30 days was 2.5%. Major adverse events rates in SCSO and non-SCSO groups were 9.5% and 1.6%, respectively. This difference was statistically significant (p < 0.001). In multivariable regression analysis, patients with SCSO had a higher risk of major adverse events (non-SCSO vs. SCSO: aOR 5.05 [95% CI, 1.78-14.55]). In 342 propensity score matched patients, results were consistent (propensity score: aOR, 3.78 [95% CI, 1.13-12.64]).

CONCLUSIONS

SCSO is an independent predictor of 30-day major adverse events. Whether these patients with SCSO are suitable for carotid endarterectomy should be carefully considered.

Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

BACKGROUND

The presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA.

OBJECTIVES

The purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry.

METHODS

All patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes.

RESULTS

Among 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p < 0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p < 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64).

CONCLUSIONS

CCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature

BACKGROUND

In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are often described with controversial conclusions. Moreover, long-term results of mortality, MACCE and restenosis rate are scarcely reported. This study examined the association between a CCO and the short- and long-term outcomes after CAS.

METHODS

One hundred and forty-six patients with CCO and without (No-CCO) who underwent between 2010 and 2017 to a CAS procedure in a single institution were retrospectively evaluated. The primary aim of the study was to evaluate mortality and MACCE rates in the short-term (defined as the occurrence during hospitalization and within 30-day) and after 3-year follow-up. The secondary aim of the study was to examine the restenosis rates in the short- and long-term period.

RESULTS

The overall success of CAS was 99.3% and the 30-day all-cause mortality rate was 0.7% (one death). About MACCE, there were no major strokes in the CCO groups and 1 (1.4%) in the No-CCO group (P=1.00). The rate of 30-day minor strokes was 1.4% (1 patient) in the CCO group and 2.7% (2 patients) in the No-CCO group (P=1.00). In the 3-year follow-up, death occurred in 11 CCO vs. 6 No-CCO patients, respectively (15.1% vs. 8.2%, P=0.30). Regarding MACCE, major stroke occurred in 6 CCO vs. 2 No-CCO patients (8.2% vs. 2.7%, P=0.27), minor stroke in 6 CCO vs. 6 No-CCO (8.2% vs. 8.2%, P=1.0) and myocardial infarction in 6 CCO (8.2%) vs. 3 No-CCO patients (8.2 vs. 4.1%, P=0.49), respectively. Regarding the 30-day restenosis rate, it was observed in one patient (1.4%) in the CCO group while no cases were recorded in the No-CCO group, respectively (P=1.00). In the 3-year follow-up, greater than >50% restenosis was observed in 7 patients (9.6%) in the CCO group and in one patient (1.4%) in the No-CCO group (P=0.06), respectively. Kaplan-Meier survival analysis revealed that CCO patients had a lower 3-year freedom from restenosis rate with respect to the No-CCO group (87.6% vs. 98.6%, P=0.024). A Cox regression model on 3-year restenosis highlighted female gender and hypertension to be statistically significant predictors of restenosis.

CONCLUSIONS

Patients with a preexisting CCO did not show a significative increased risk of procedural adverse events after CAS both in the immediate and long-term follow-up, but on the long term they are more likely to experience restenosis. CCO condition should be considered always as a clinical manifestation of a more aggressive carotid atherosclerosis.

Does severe contralateral carotid artery stenosis affect the outcomes of carotid endarterectomy?

Background

This study aims to evaluate the effect of contralateral internal carotid artery stenosis on postoperative stroke and mortality rate and blood pressure alterations following carotid artery endarterectomy.

Methods

Between January 2009 and April 2017, a total of 152 carotid artery endarterectomy operations in 141 consecutive patients (30 females, 111 males; mean age 70.0±10.2 years; range, 48 to 92 years) with internal carotid artery stenosis were retrospectively analyzed. The patients were divided into two groups as those with contralateral internal carotid artery stenosis <70% (n=95) and contralateral internal carotid artery stenosis ?70% (n=26). Stroke and mortality rates in the early postoperative period (within the first 30 days), postoperative blood pressure alterations at six and 24 hours, non-neurological outcomes, and baseline demographic characteristics were analyzed and compared between the groups.

Results

Both groups showed similar results in terms of the demographic characteristics. There was no statistically significant difference in the postoperative blood pressure alterations at six (p=0.917) and 24 hours (p=0.6), stroke rate (7.6% vs. 3.1%, p=0.282), mortality rate (3.8% vs. 2.1%, p=0.519), non-neurological complications (15.3% vs. 11.4%, p=0.736), and length of hospital stay (p>0.05) between the groups. The patients with contralateral severe internal carotid artery stenosis were younger (p=0.005).

Conclusion

The present study shows that the presence of a contralateral severe internal carotid artery stenosis does not increase the risk of postoperative stroke and mortality rates and blood pressure alterations. Therefore, carotid artery endarterectomy can be performed with acceptable complication rates in patients with contralateral severe internal carotid artery stenosis with strict perioperative hemodynamic monitoring.

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I² test. I²>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I²=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I²=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I²=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I²=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I²=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I²=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I²=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I²=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I²=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I²=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.

Hemodynamic Surveillance of Unilateral Carotid Artery Stenting in Patients With or Without Contralateral Carotid Occlusion by TCD/TCCD in the Early Stage Following Procedure

Objective: To evaluate the cerebral hemodynamic variations in patients with unilateral carotid artery stenosis and contralateral carotid occlusion (CCO) in hours following carotid artery stenting (CAS) by transcranial Doppler (TCD) or transcranial color-code Doppler (TCCD).

Methods: Sixty-five consecutive patients who underwent unilateral CAS were enrolled. Among them, 14 patients had ipsilateral severe stenosis and CCO (CCO group) while the other 51 patients had only unilateral severe carotid stenosis without CCO (UCS group). All patients underwent TCD or TCCD monitoring before, at 1 and 3 h after CAS. We monitored bilateral middle cerebral artery (MCA) peak systolic velocity (PSV), pulsatility index (PI), and blood pressure (BP), and compared that data between two groups.

Results: In UCS group, ipsilateral MCA PSV increased relative to baseline at 1 h (96 ± 30 vs. 85 ± 26 cm/s, 15%, P < 0.001) and 3 h (97 ± 29 vs. 85 ± 26 cm/s, 17%, P < 0.001) following CAS. Significant PI increases were observed at 1 and 3 h following CAS on the ipsilateral side. In CCO group, ipsilateral MCA PSV increased relative to baseline at 1 h (111 ± 30 vs. 83 ± 26 cm/s, 35%, P < 0.001) and 3 h (107 ± 28 vs. 83 ± 26 cm/s, 32%, P <0.001) following CAS. The magnitude of ipsilateral MCA PSV increase was significantly higher in CCO group compared with UCS group at 1 h (P = 0.002) and 3 h (P = 0.024) following CAS, while BP similarly decreased between the two groups. On the contralateral side, significant MCA PSV increases were observed following CAS in CCO group but not in UCS group. Bilateral MCA PSV increases were higher in patients with a stenosis degree of ≥90% than in patients with stenosis degree of 70–89% only in CCO group.

Conclusion: The ipsilateral MCA PSV and PI increase moderately in the initial hours after unilateral CAS in patients without CCO. In patients with CCO, the ipsilateral, and contralateral MCA PSV increase significantly in the early stage following CAS. CCO is a factor of the increased blood flow velocity in ipsilateral MCA after unilateral CAS.

Comparison of postoperative results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid artery occlusion: A meta-analysis

Objectives

The purpose of this study was to conduct a meta-analysis to systematically compare the safety and efficacy of carotid endarterectomy and carotid artery stenting in contralateral carotid occlusion patients who needed reperfusion.

Methods

This study retrieved potential academic articles comparing results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid occlusion from the MEDLINE database, the PubMed database the EMBASE database, and the Cochrane Library from January 1990 to May 2018. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study.

Results

Four retrospective cohort study involving 6252 patients with contralateral carotid occlusion were included in our meta-analysis. During 30-day follow-up, there is significant difference in post-procedure mortality (odds ratio (OR) = 0.476, 95% confidence interval (CI) (0.306–0.740), P = 0.001); no significant differences are not found in post-procedure stroke (risk difference (RD) = 0.002, 95%CI (–0.007 to 0.011); P = 0.631), myocardial infarction (RD = 0.003, 95%CI (–0.002 to 0.008); P = 0.301), and transient cerebral ischemia (RD = 1.059, 95%CI (–0.188 to 5.964); P = 0.948).

Conclusions

Carotid endarterectomy was associated with a lower incidence of mortality compared to carotid artery stenting for patients with contralateral carotid occlusion. Regarding stroke, myocardial infarction, and transient ischemic attack, there was no significant difference between the two groups. More randomized controlled trials and prospective cohorts are necessary to help further clarify the ideal approach for these patients.

Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis

BACKGROUND

Results from studies investigating the effect of contralateral carotid occlusion (CCO) in patients with carotid artery stenosis undergoing carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) are variable in the literature. We sought to determine whether CEA or CAS is the optimal revascularization approach for patients with CCO.

METHODS

This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effects model meta-analysis was conducted, and the I² statistic was used to assess for heterogeneity. Subgroup and sensitivity analyses were performed as needed.

RESULTS

Five retrospective observational cohort studies comprising 6346 patients were included. Patients in the CEA group had a significantly lower risk of 30-day periprocedural mortality (odds ratio, 0.46; 95% confidence interval, 0.30-0.71; I² = 0%). However, no significant differences were identified in terms of stroke, myocardial infarction (MI), and major adverse cardiovascular events (MACEs) between the 2 groups. Subgroup analyses of symptomatic and asymptomatic patients did not yield significant differences for stroke, MI, and death.

CONCLUSIONS

Patients with CCO can safely undergo both CAS and CEA with similar risks of stroke, MI, and MACE. However, patients treated with CEA have a lower risk of 30-day periprocedural mortality. Future studies can help further clarify the ideal approach for these patients.

Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study

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.

Surgical Outcomes for Cervical Carotid Artery Stenosis: Treatment Strategy for Bilateral Cervical Carotid Artery Stenosis

BACKGROUND

Carotid endarterectomy (CEA) and carotid stenting (CAS) are beneficial procedures for patients with high-grade cervical carotid stenosis. However, it is sometimes difficult to manage patients with bilateral carotid stenosis. To decide the treatment strategy, one of the most important questions is whether contralateral stenosis increases the risk of patients undergoing CEA.

METHODS

This retrospective study included 201 patients with carotid stenosis who underwent a total of 219 consecutive procedures (CEA 189/CAS 30). We retrospectively analyzed outcomes in patients with carotid stenosis who were treated with either CEA or CAS and evaluated whether or not contralateral lesions increases the risk of patients undergoing CEA or CAS. Furthermore, we retrospectively verified our treatment strategy for bilateral carotid stenosis.

RESULTS

The incidences of perioperative complications were 5.3% in the CEA patients and 6.7% in the CAS patients, respectively. There was no significant difference between these 2 groups. The existences of contralateral occlusion and/or contralateral stenosis were not associated with perioperative complications in both the groups. There were 32 patients with bilateral severe carotid stenosis (>50%). Of those, 13 patients underwent bilateral revascularizations; CEA followed by CEA in 8, CEA followed by CAS in 3, CAS followed by CEA + coronary artery bpass grafting in 1, and CAS followed by CAS in 1.

CONCLUSIONS

Our date showed that the existence of contralateral carotid lesion was not associated with perioperative complications, and most of our cases with bilateral carotid stenosis initially underwent CEA.

Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.

Treatment strategy for bilateral carotid stenosis: 2 cases of carotid endarterectomy for the symptomatic side followed by carotid stenting

Since the introduction of carotid stenting (CAS), a combined treatment for bilateral lesions using carotid endarterectomy (CEA) and CAS has been developed. However, there has been only 1 report about CEA then CAS. Herein we describe 2 patients with bilateral severe carotid stenosis who were treated by CEA for the symptomatic side and CAS for the contralateral asymptomatic side. A 71-year-old man underwent CEA for the symptomatic side. Although the patient suffered hyperperfusion syndrome after CEA, he recovered fully after 3 weeks of rehabilitation. Two months later, CAS was performed for the asymptomatic side, and he was discharged with no deficit. A 67-year-old man underwent CEA for the symptomatic side. The patient developed no postoperative neurologic deficits except for hoarseness. Four weeks later, CAS was performed for the contralateral asymptomatic side. After the procedure, however, severe hypotension occurred, and treatment by continuous injection of catecholamine was necessary to maintain systematic blood pressure. The patient was ultimately discharged with no deficit. The combined therapy of CAS for the asymptomatic side and then CEA for the symptomatic side has been recommended by several authors. However, one of the problems of this strategy is the higher incidence of postprocedural hemodynamic complications, and hypotension after CAS may be dangerous for the symptomatic hemisphere. We suggest a combined therapy using CEA for the symptomatic side and then CAS for the asymptomatic side can be 1 beneficial treatment option for patients with bilateral carotid stenosis without coronary artery disease.

Bilateral reperfusion injury after carotid endarterectomy with contralateral carotid occlusion

Cerebral hyperperfusion syndrome represents a clinical spectrum characterized by severe unilateral headache, acute changes in mental status, vomiting, seizures, focal neurologic deficits, and, in its most severe form, intracranial hemorrhage. With the exception of one early case report, reperfusion injury to the brain following carotid endarterectomy has been reported only ipsilateral to the side of surgery. We report the unique case of a patient with symptomatic severe right internal carotid artery stenosis and contralateral carotid occlusion who underwent carotid endarterectomy complicated by cerebral hyperperfusion syndrome and associated bilateral intracranial hemorrhage.