Symptomatic Carotid Artery Disease: Revascularization

Changes in retinal vascular density measured by optical coherence tomography angiography in patients with carotid artery stenosis after carotid artery stenting and angioplasty

PURPOSE

The aim of this study was to compare the effect of carotid artery stenting and angioplasty (CASA) on retinal vascular density (VD) in patients with severe carotid stenosis with a healthy control group and to evaluate using optical coherence tomography angiography (OCTA).

METHODS

For this prospective study, eyes on the operated side constituted the ipsilateral eye group, and the other eye constituted the contralateral eye group. 40 eyes of 40 patients with ipsilateral eye of carotisid artery stenosis (CAS), 34 eyes on contralateral side, and 30 healthy eyes (control group) were included in this study. We performed quantitative OCTA analyses of retinal VD changes, before and after CASA. The main outcome measures were the quantitative changes of VD of superficial capillary plexus (SCP) and deep capillary plexus (DCP).

RESULTS

We evaluated the VD of ipsilateral eyes and contralateral eyes separately before and after the procedure. All patients did not have visual symptoms. There was no significant difference in the VD of SCP in all groups before the procedure. No significant change was observed in all groups when the VD of the SCP was compared before and after the procedure. The VD of the DCP in the ipsilateral and contralateral group improved significantly after CASA.

CONCLUSION

OCTA could noninvasively detect retinal VD improvements after CASA in CAS patients. Quantitative changes in VD evaluated using OCTA are thought to be early indicators in the diagnosis of CAS and in the follow-up of treatment success.

Quantitative Assessment of Retinal and Choroidal Microvasculature in Asymptomatic Patients with Carotid Artery Stenosis

SIGNIFICANCE

Carotid disease contributes to 15 to 20% of all ischemic strokes, one of the leading causes of permanent disabilities and mortality globally. With its growing prevalence and the inflicted disability rates, screening for anomalies that precede the onset of its serious complications is of crucial global significance.

PURPOSE

This study aimed to assess the relationship between retinal and choroidal perfusion changes with the degree of stenosis using quantitative swept-source optical coherence tomography angiography in patients with internal carotid artery stenosis.

METHODS

A retrospective cohort study was conducted in 72 eyes with carotid stenosis. According to the degree of stenosis, the participants were divided into a healthy group (group 1: 34 eyes), a mild-moderate stenosis group (group 2: 22 eyes), and a severe stenosis group (group 3: 16 eyes). Swept-source optical coherence tomography angiography was performed to scan macular fovea. Capillary density values in the different retinal and choroidal layers were the major measurements for our study.

RESULTS

Mean vessel density in the midchoroid layer was significantly higher in groups 2 and 3 compared with group 1. Deep choroid disclosed significantly superior vascular density values in group 3 compared with groups 2 and 1. Superficial and deep capillary plexus showed decreased vascular density values when comparing group 3 with groups 1 and 2, although they were not significant.

CONCLUSIONS

Our report provides the first evidence that choroidal microvascular changes were correlated with severity of carotid artery stenosis. Optical coherence tomography angiography can sensitively detect subtle, early changes in the ocular blood in carotid disease representing a useful, noninvasive, and objective approach to the retinal microvasculature.

Carotid artery stenting: still burdened by early trial results

The early randomized trial experience (CAVATAS, SPACE, EVA-3S, ICSS) comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been burdened by the limited experience of the interventionalists performing CAS. The periprocedural stroke excess with CAS observed in those trials has ever since affected carotid revascularization, especially in symptomatic carotid disease. Accordingly, no trial dedicated to this patient population has followed. In asymptomatic carotid disease, CREST, ACT-1 and ACST-2 have shown an equivalence in terms of combined periprocedural events as well as long-term protection from ipsilateral stroke or repeat revascularization between the two techniques. The management of patients with carotid stenosis should be multidisciplinary and decision to pursue medical management or proceed to revascularization in an individual patient should be based on his estimated stroke risk on medical management and his suitability for CEA and CAS. Since the majority of patients with carotid stenosis may qualify for both techniques, patient's perspective should be central in decision making.

Circulating miR-342-5p serves as a diagnostic biomarker in patients with carotid artery stenosis and predicts the occurrence of the cerebral ischemic event

BACKGROUND

Carotid artery stenosis (CAS) is an important risk factor for cerebral ischemia events (CIE). Previous studies have shown that microRNAs (miRNAs) are involved in the occurrence and development of CAS.

AIMS

The purpose of this study was to reveal the clinical diagnostic value of miR-342-5p for asymptomatic CAS (ACAS) and to evaluate its predictive value for the occurrence of CIE in patients.

METHODS

A total of 92 ACAS patients and 86 healthy controls were enrolled as subjects. The expression level of serum miR-342-5p was detected by qRT-PCR. The receiver operating characteristic (ROC) curve was used to detect the diagnostic value of miR-342-5p in ACAS. Kaplan-Meier survival and Cox regression analysis assessed the predictive value of miR-342-5p for the occurrence of CIE in ACAS patients.

RESULTS

The level of serum miR-342-5p in ACAS patients was significantly higher than that in healthy controls (P < 0.05). ROC curve showed the high diagnostic value of serum miR-342-5p, which could distinguish ACAS patients from healthy controls. Multivariate Cox regression analysis confirmed that miR-342-5p was an independent predictor (HR = 5.512, 95%CI = 1.370-22.176, P = 0.016). What is more, Kaplan-Meier analysis confirmed that patients with high miR-342-5p expression develop more CIE (log-rank, P = 0.020).

CONCLUSIONS

miR-342-5p was significantly overexpressed in ACAS. And the upregulation of serum miR-342-5p is a valuable diagnostic biomarker and can predict the occurrence of CIE.

Changes in retinal flow density measured by optical coherence tomography angiography in patients with carotid artery stenosis after carotid endarterectomy

The aim of the study presented here was to evaluate retinal and optic nerve head (ONH) perfusion in patients with severe asymptomatic carotid artery stenosis (CAS) compared with healthy controls and to analyze the impact of carotid endarterectomy using optical coherence tomography angiography (OCT-A). 25 eyes of 25 patients with CAS (study group) and 25 eyes of 25 healthy controls (control group) were prospectively included in this study. OCT-A was performed using RTVue XR Avanti (Optovue, Inc, Fremont, California, USA). The flow density data in the superficial and deep retinal OCT-angiogram of the macula and in the radial peripapillary capillary network (RPC) of the ONH were extracted and analyzed. The flow density in the superficial retinal OCT angiogram of the macula and in the ONH were significantly lower in the study group compared with the control group (macula: p = 0.003) (ONH: p = 0.013). The flow density in the ONH improved significantly after carotid endarterectomy (p = 0.004). A reduced flow density was observed in patients with CAS when compared with healthy controls. The flow density also improved after carotid endarterectomy. Quantitative changes in the microvascular density, as measured using OCT-A, could well be useful in the diagnosis of CAS and the evaluation of therapy success.

Emergent treatment of carotid stenosis: an evidence-based systematic review

INTRODUCTION

Stroke is one of the major causes of death in the world, but above all is the condition most associated with severe long-term disabilities. It is clear that this condition therefore requires the best therapeutic approach possible to minimize the consequences that this can lead to. The major issues concern the type of treatment to be used for revascularization (carotid endarterectomy [CEA] or stenting of the carotid artery [CAS]) and the timing of the treatment itself. Many studies have been conducted on this issue, but a definitive and unanimous verdict has not yet been reached on account of the great variety of results obtained from the various study group. The aim of this review is to analyze the latest scientific findings focused on revascularization following a symptomatic carotid stenosis (SCS).

EVIDENCE ACQUISITION

We searched all publications addressing treatments and timing of approach to SCS. Randomized trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Medline and Science Direct were searched from January 2013 to April 2017.

EVIDENCE SYNTHESIS

Of the 819 records found, 76 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 54 manuscripts because of the following reasons: 1) no innovative or important content; 2) insufficient data; 3) no clear potential biases or strategies to solve them; 4) no clear endpoints; and 5) inconsistent or arbitrary conclusions. The final set included 22 articles.

CONCLUSIONS

CEA is considered a less problematic method than CAS, especially for patients over the age of 75; CAS remains recommended in patients with a favorable anatomy or high surgical risks. Studies that showed more solid results seem to lead to the conclusion that optimal timing may be between 2 days and the end of the first week from the onset of symptoms in patients who are appropriate candidates for surgery.