Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association

An Assessment of the Society for Vascular Surgery Appropriate Use Criteria for the Management of Intermittent Claudication: Key Findings and Considerations for Implementation

BACKGROUND

Several concerns have been raised over the past several years about the potential for overuse of vascular interventions for peripheral artery disease. These interventions can have serious complications, including limb loss. Given that the natural history of intermittent claudication rarely includes limb loss, it is critically important that interventions to treat it have appropriate indications.

METHODS

To address this matter, the Society for Vascular Surgery published an appropriate use criteria (AUC) document for the management of intermittent claudication in 2022. Using the rigorously studied University of California Los Angeles RAND Appropriateness Method, the rating panel assessed the appropriateness of 2,280 scenarios for [1] the initial management and [2] the management after a failed trial of exercise therapy.

RESULTS

The findings of the rating panel included that medical management and exercise therapy are appropriate initial management in all scenarios. There were several scenarios in which revascularization was also considered appropriate, mainly influenced by severity of physical limitations and favorable lesion characteristics. When considering management after a failed trial of exercise, guiding principles cited by the rating panel included durability of intervention, smoking cessation, and evidence of prior good-faith effort at exercise therapy. There were many scenarios which were indeterminate. With respect to the infrapopliteal segment, the rating panelists unanimously agreed to forgo individual scenario ratings, since they deemed the risks outweigh the benefits in all cases.

CONCLUSIONS

The Society for Vascular Surgery (SVS) AUC for intermittent claudication represents an important effort to identify and reduce overuse. There are several considerations for how they should be used. The simplest application is by practicing clinicians, at the bedside, as they engage in shared decision-making with patients. The matter of their use by payors is more complex. Ideally, decisions on how to best use AUC require additional study of their performance before they are used by payors for anything. Finally, these AUC have identified a myriad of areas where evidence is lacking. The AUC provide important targets for future research to improve the care of patients with intermittent claudication.

Pharmacological interventions for asymptomatic carotid stenosis

BACKGROUND

Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem.

OBJECTIVES

To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life.

AUTHORS' CONCLUSIONS

Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.

Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS.

METHODS

A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed.

RESULTS

Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA.

CONCLUSION

Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.

Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments

BACKGROUND

Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated.

OBJECTIVES

To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA).

SEARCH METHODS

We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data.

SELECTION CRITERIA

We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis.

DATA COLLECTION AND ANALYSIS

The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model.

MAIN RESULTS

We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included.

AUTHORS' CONCLUSIONS

This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.

Imaging High-Risk Atherothrombosis Using a Novel Fibrin-Binding Positron Emission Tomography Probe

BACKGROUND AND PURPOSE

High-risk atherosclerosis is an underlying cause of cardiovascular events, yet identifying the specific patient population at immediate risk is still challenging. Here, we used a rabbit model of atherosclerotic plaque rupture and human carotid endarterectomy specimens to describe the potential of molecular fibrin imaging as a tool to identify thrombotic plaques.

METHODS

Atherosclerotic plaques in rabbits were induced using a high-cholesterol diet and aortic balloon injury (N=13). Pharmacological triggering was used in a group of rabbits (n=9) to induce plaque disruption. Animals were grouped into thrombotic and nonthrombotic plaque groups based on gross pathology (gold standard). All animals were injected with a novel fibrin-specific probe ⁶⁸Ga-CM246 followed by positron emission tomography (PET)/magnetic resonance imaging 90 minutes later. ⁶⁸Ga-CM246 was quantified on the PET images using tissue-to-background (back muscle) ratios and standardized uptake value.

RESULTS

Both tissue-to-background (back muscle) ratios and standardized uptake value were significantly higher in the thrombotic versus nonthrombotic group (P<0.05). Ex vivo PET and autoradiography of the abdominal aorta correlated positively with in vivo PET measurements. Plaque disruption identified by ⁶⁸Ga-CM246 PET agreed with gross pathology assessment (85%). In ex vivo surgical specimens obtained from patients undergoing elective carotid endarterectomy (N=12), ⁶⁸Ga-CM246 showed significantly higher binding to carotid plaques compared to a D-cysteine nonbinding control probe.

CONCLUSIONS

We demonstrated that molecular fibrin PET imaging using ⁶⁸Ga-CM246 could be a useful tool to diagnose experimental and clinical atherothrombosis. Based on our initial results using human carotid plaque specimens, in vivo molecular imaging studies are warranted to test ⁶⁸Ga-CM246 PET as a tool to stratify risk in atherosclerotic patients.

Perioperative Stroke

PURPOSE OF REVIEW

This review overviews perioperative stroke as it pertains to specific surgical procedures.

RECENT FINDINGS

As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography

BACKGROUND

A three-dimensional (3D) cardiovascular magnetic resonance (CMR) vessel wall imaging (VWI) technique based on 3D T1 weighted (T1w) Sampling Perfection with Application-optimized Contrast using different flip angle Evolutions (SPACE) has recently been used as a promising CMR imaging modality for evaluating extra-cranial and intra-cranial vessel walls. However, this technique is yet to be validated against the current diagnostic imaging standard. We therefore aimed to evaluate the diagnostic performance of 3D CMR VWI in characterizing carotid disease using intra-arterial digital subtraction angiography (DSA) as a reference.

METHODS

Consecutive patients with at least unilateral > 50% carotid stenosis on ultrasound were scheduled to undergo interventional therapy were invited to participate. The following metrics were measured using 3D CMR VWI and DSA: lumen diameter of the common carotid artery (CCA) and segments C1-C7, stenosis diameter, reference diameter, lesion length, stenosis degree, and ulceration. We assessed the diagnostic sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curve of 3D CMR VWI, and used Cohen's kappa, the intraclass correlation coefficient (ICC), and Bland-Altman analyses to assess the diagnostic agreement between 3D CMR VWI and DSA.

RESULTS

The ICC (all ICCs ≥0.96) and Bland-Altman plots indicated excellent inter-reader agreement in all individual morphologic measurements by 3D CMR VWI. Excellent agreement in all individual morphologic measurements were also found between 3D CMR VWI and DSA. In addition, 3D CMR VWI had high sensitivity (98.4, 97.4, 80.0, 100.0%), specificity (100.0, 94.5, 99.1, 98.0%), and Cohen's kappa (0.99, 0.89, 0.84, 0.96) for detecting stenosis > 50%, stenosis > 70%, ulceration, and total occlusion, respectively, using DSA as the standard. The AUC of 3D CMR VWI for predicting stenosis > 50 and > 70% were 0.998 and 0.999, respectively.

CONCLUSIONS

The 3D CMR VWI technique enables accurate diagnosis and luminal feature assessment of carotid artery atherosclerosis, suggesting that this imaging modality may be useful for routine imaging workups and provide comprehensive information for both the vessel wall and lumen.

Comparison of Quantitative and Qualitative Oxygen Extraction Fraction (OEF) in Acute Stroke Patients with Large Vessel Occlusion

The superficial temporal artery-middle cerebral artery bypass (STA-MCA) bypass surgery developed by Donaghy and Yarsagil in 1967 provided relief for patients with acute stroke and large vessel occlusive vascular disease. Early reports showed low morbidity and good outcomes. However, a large clinical trial in 1985 reported a failure of extracranial-intracranial (EC/IC) bypass to show benefit in reducing the risk of stroke compared to best medical treatment. Problems with the study included cross overs to surgery from best medical treatment, patients unwilling to be randomized and chose EC/IC surgery, and loss of patients to follow-up. Most egregious is the fact that the study did not attempt to identify and select the patients at high risk for a second stroke. Based on these shortcomings of the EC/IC bypass study, a carotid occlusion surgery study (COSS) was proposed by Dr. William Powers and colleagues using qualitative hemispheric oxygen extraction fraction (OEF) by positron emission tomography (PET) between the contralateral and ipsilateral hemispheres with a ratio of 1.16 indicative of hemodynamic compromise. To increase patient enrollment, several compromises were made mid study. First. The ratio threshold was lowered to 1.12 and the level of occlusion in the carotid reduced from 70% to 60%. Despite these compromises the study was closed for futility, apparently because the stroke rate in the medically treated group was too low. Thus, the question as to the benefit of EC/IC bypass surgery remains unresolved. In our NIH funded study Quantitative Occlusive Vascular Disease Study (QUOVADIS), we used quantitative OEF to evaluate stroke risk and compared it to the qualitative count-rate ratio method used in the COSS study and found that these two methods did not identify the same patients at increased risk for stroke, which may explain the reason for the failure of the COSS study as our results show that qualitative OEF ratios do not identify the same patients as quantitative OEF.

The Role of Carotid Ultrasonography in Patients with High Risk of Atherosclerosis

Atherosclerosis is a systemic disease that most often affects the carotid arteries. Being usually asymptomatic in its early stages, it is diagnosed only in advanced stages, when treatment is more difficult and prognosis is poor. Carotid ultrasound (US) is the most commonly used method for diagnosing carotid artery disease and represents a proper method for screening in patients with cardiovascular (CV) risk factors. This paper shows the methodology and necessity of carotid imaging methods in patients at high risk of developing atherosclerotic lesions. We also review the findings that underline the need of carotid screening in patients with ischemic heart disease or with ischemic arteriopathy, showing that the carotid arteries are like ‘mirrors’ of the arterial system, which need to be assessed in every patient with CV risk factors, regardless of the presence or absence of symptoms.

Safety of Early Carotid Artery Stenting for Symptomatic Stenosis in Daily Practice

OBJECTIVE/BACKGROUND

In 2006, the American Heart Association recommended that for preference carotid endarterectomy (CEA) or, alternatively, carotid angioplasty and stenting (CAS) for symptomatic carotid artery stenosis should ideally occur within 14 days of an ischaemic event. The aim was to determine the safety of CAS according to those recommendations in daily practice.

METHODS

A retrospective analysis was performed of all consecutive patients (2000-16), with ipsilateral carotid symptoms who underwent CAS for extracranial carotid stenosis ≥70%, who were previously included in a prospective database. Thirty day morbidity was assessed (any stroke without transient ischaemic attack [TIA]/amaurosis fugax), along with mortality of the procedure in the early (≤14 days after stroke onset) and delayed phases (15-180 days after stroke onset). Patients who received CAS and/or mechanical thrombectomy for acute ischaemic stroke treatment were not included.

RESULTS

In total, 1227 patients with symptomatic carotid stenosis who underwent CAS were identified. Early and delayed CAS was performed in 291 and 936 patients, respectively. Morbidity (any stroke) and mortality was 2.2% (n = 27) in the whole cohort (n = 8 [2.7%] in early vs. n = 19 [2%] in delayed CAS; p = .47). There were no differences in morbidity between early and delayed CAS regarding TIA (n = 15 vs. 36 [5.2% vs. 3.9%]; p = .33), minor stroke (n = 4 vs. 5 [1.4% vs. 0.5%]; p = .14), or major stroke (n = 2 vs. 6 [0.7% vs. 0.6%]; p = .59). Two patients (0.7%) died after early CAS and eight (0.9%) after delayed CAS (p = .56).

CONCLUSION

CAS may be safely performed in the early phase after an ischaemic stroke with low clinical complication rates. Further studies are needed to validate CAS safety conducted even earlier in the acute phase of ischaemic stroke.

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to a chronically infected polyethylene terephthalate patch

Carotid endarterectomy (CEA) remains the treatment for significant carotid stenosis and stroke prevention. Approximately 100,000 CEAs are performed in the United States every year. Randomized trials have demonstrated an advantage of patch carotid angioplasty over primary closure. Complications from patches include thrombosis, transient ischemic attack, stroke, restenosis, pseudoaneurysm (PA), and infection. PA after CEA is rare, with a reported average of 0.37% of cases. We describe an unusual case of PA after polyethylene terephthalate (PTFE) patching for CEA. An 88-year-old female with Alzheimer's disease living in a nursing facility with a history of skin cancer on her right chest developed a new area of intermittent brisk bleeding on her right neck which was initially believed to be related to her skin cancer. She had a remote history of right CEA with a PTFE patch approximately a decade ago. A computed tomography angiograph-head-and-neck with showed a partially thrombosed PA in the region of her right common carotid artery bifurcation with a tract containing gas and fluid extending to the skin surface suspicious for a partially thrombosed, leaking PA. She was taken urgently to the operating room on broad-spectrum antibiotics where we performed a right neck exploration, ligation of a bleeding carotid PA by ligation of the right common, internal, and external carotid arteries, explantation of a chronically infected polyethylene terephthalate patch, and closure with a sternocleidomastoid advanced flap with multilayered closure. She was discharged to her nursing facility with 6 weeks of ceftriaxone intravenous (IV) and metronidazole IV through a peripherally inserted central catheter (PICC) line with no neurological sequelae.

Treatment of a symptomatic intrathoracic internal carotid artery

Intrathoracic common carotid artery bifurcations are an anatomic anomaly with such rarity that only six cases have been reported to date. The true incidence of and preferred treatment options for a diseased intrathoracic common carotid artery bifurcation or internal carotid artery (ICA) have not been clearly described. This case report describes a 72-year-old man who experienced a postoperative right hemispheric stoke after an aortic valve replacement, radiofrequency maze procedure, and left atrial appendage clip. Postoperative cerebrovascular evaluation revealed a severely diseased intrathoracic ICA that was treated by ligation of the diseased proximal ICA and transposition of the distal ICA to the disease-free external carotid artery. The patient provided written consent to present the history, data, and images in this manuscript.

Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy

BACKGROUND

Biliary fistula (BF) is a major surgical complication that can develop after pancreaticoduodenectomy (PD) whose risk factors remain unclear. Substantial atherosclerotic celiac axis stenosis (SACAS) has not been reported to be one of them.

METHODS

Data from 507 patients undergoing PD between Jan 1, 2013 and Dec 31, 2015 were retrospectively collected. Clinical data from patients with SACAS were studied, and the independent risk factors for BF underwent multivariate logistic regression analysis, including SACAS.

RESULTS

BF occurred in 22 (4.3%) patients, and the incidence of BF was significantly higher in patients with SACAS than in those without it (27.0% vs 2.6%, P < .001). In the univariate analysis, BF was significantly related to SACAS, older age, a higher ASA score, history of coronary disease, greater blood loss and RBC transfusion during surgery, smaller CBD diameter and higher POD 1 BUN level. The multivariate analysis showed that only SACAS (OR 8.91, 95% CI 2.36-33.69, P = .001), older age (OR 1.08, 95% CI 1.01-1.15, P = .028) and smaller preoperative CBD (OR 0.79, 95% CI 0.69-0.92, P = .002) were independent risk factors for postoperative BF.

CONCLUSION

Older age and a smaller preoperative CBD diameter are independent risk factors for BF after PD, which is consistent with the literature. In addition, SACAS is a new independent risk factor for BF. For patients with SACAS, postoperative drainage should be carefully managed to precisely observe the potential for BF.

Carotid artery stenting versus no stenting assisting thrombectomy for acute ischaemic stroke: protocol for a systematic review of randomised clinical trials with meta-analyses and trial sequential analyses

BACKGROUND

In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke.

METHODS

International and regional electronic databases will be searched to identify eligible randomised clinical trials. To identify further published, unpublished, or on-going and planned trials searches of Google Scholar, Worldwide Food and Drug Administrations, Worldwide Medicines Agencies, company homepages, reference lists, conference proceedings, and the Science Citation Index cited reference search index will be conducted. Manufacturers of relevant interventional equipment, authors, colleagues, and researchers active in the field will be contacted. No language restrictions will be applied to these searches. Randomised clinical trials will be included for assessing benefits and harms and quasi-randomised studies, and observational studies will be included for assessing harms of the intervention. Meta-analyses will be performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, and Trial Sequential Analyses will be conducted to control the risk of random errors and prevent premature statements of superiority of the experimental or control intervention or premature statement of futility. The quality of the evidence will be evaluated with the Grading of Recommendations Assessment, Development, and Evaluation.

DISCUSSION

This systematic review of carotid stenting in endovascular management of acute ischaemic stroke in patients with concomitant extracranial carotid lesions and intracranial embolism will assess benefits and harms of this intervention and assesses whether carotid stenting should be encouraged or avoided in acute ischaemic stroke and identify targets for further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033346.

Carotid Artery Stenting: Current Status and Future Directions

Carotid endarterectomy has been the mainstay of therapy for carotid occlusive disease in stroke prevention. Recent advances in endovascular technology has made carotid angioplasty and stenting a therapeutic modality in the treatment of carotid occlusive disease. The enthusiasm for this minimally invasive carotid intervention is hampered by the possibility of stentrelated cerebral embolization, which can result in neurologic complications. Although current available data indicate that the results regarding success and complication rates are similar between carotid stenting and endarterectomy, numerous prospective clinical trials are currently underway to evaluate the efficacy of carotid artery stenting using various forms of cerebral protection devices. This article reviews the current status of carotid stenting, including recent clinical studies and ongoing prospective trials. Strategies relating to cerebral embolization protection are also discussed.

Diagnostic vascular ultrasonography with the help of color Doppler and contrast-enhanced ultrasonography

The use of ultrasonography and especially of contrast-enhanced ultrasonography (CEUS) in the diagnosis of vascular pathologies before and after interventions has significantly increased over the past years due to the broader availability of modern ultrasound systems with CEUS capabilities and more trained user experience in this imaging modality. For the preinterventional and postinterventional work-up of carotid diseases, duplex ultrasound as well as CEUS have been established as the standard-of-care examination procedures for diagnosis, evaluation, and follow-up. In addition to its use for carotid arterial diseases, ultrasonography has also become the primary modality for the screening of vascular pathologies. This review describes the most common pathologies found in ultrasonography of the carotid arteries, the abdominal aorta, and the femoral arteries.

Angioplasty and Stenting of the Extracranial Carotid Arteries

Purpose:

To study the feasibility and safety of stent-supported angioplasty in the treatment of atherosclerotic stenoses of the extracranial carotid arteries.

Methods:

Carotid angioplasty was attempted in 174 arteries (163 patients: 126 males; mean age: 71 ± 10 years, range 47 to 93). Mean lesion length was 15.1 ± 4.1 mm, and mean percent stenosis was 83.8% ± 7.3% (reference diameter 5.8 ± 0.7 mm). The majority (106, 65%) were asymptomatic (51% of all patients had severe coronary disease, 32% had peripheral vascular diseases). Patients underwent independent neurological examination, computed tomography, duplex ultrasonography, and angiography preprocedurally, 24 hours after the procedure, and at 6-month follow-up intervals. Most (142, 82%) carotid arteries were treated without cerebral protection, but a protective triple coaxial catheter was used in 32 (18%) patients. Stents (primarily Palmaz and Wallstent) were deployed routinely in all cases; 18% were implanted without predilation.

Results:

Immediate technical success was 173 of 174 (99.4%) (1 access failure referred electively to surgery). Eight (4.6%) neurological complications occurred in the periprocedural period: 3 transient ischemic attacks, 2 minor strokes, and 3 major strokes (1 amaurosis and 2 hemiplegias). Two major complications developed despite cerebral protection. There were no deaths or myocardial infarctions and only 3 cervical access site hematomas. Over a mean 12.7 ± 9.2 month follow-up (range 1 to 36), no ipsilateral neurological complications have been seen. There were 4 (2.3%) restenoses (3 redilated, 1 treated medically) and 1 mild Palmaz stent compression, all found within the first 6 months. Primary and secondary patencies at 3 years are 96% and 99%, respectively.

Conclusions:

Angioplasty with routine stenting seems feasible and safe for treating certain types of carotid stenoses even in high-surgical risk patients; however, randomized trials are necessary before this treatment can be offered as an alternative to endarterectomy.

Stenting in the Carotid Artery: Initial Experience in 110 Patients

Purpose:

To evaluate the feasibility, safety, and efficacy of intravascular stents in the treatment of extracranial carotid artery occlusive disease.

Methods:

According to protocol, stent therapy was offered to symptomatic patients with ≥ 70% arteriographically defined carotid stenoses or ulcerative lesions and, after September 1994, to asymptomatic patients with ≥ 75% stenoses. From April 1993 to September 1995, 110 nonconsecutive patients (79 males; mean age 72 years, range 45 to 85) consented to participate in the study. The majority (79 [72%]) were asymptomatic. Lesions meeting the treatment criteria were in the proximal common (n = 3); mid common (n = 12); distal common (n = 8); internal (ICA) (n = 92); and external (n = 2) carotid arteries. Seven patients had bilateral ICA stenoses, and 17 patients were treated for postsurgical recurrent disease. The mean lesion length and diameter stenosis for all lesions were 12.4 ± 9.2 mm and 86.5% ± 10.6%, respectively. The procedures were performed either via direct percutaneous access to the cervical common carotid artery or through a retrograde femoral artery approach. Standard balloon dilation preceded deployment of balloon-expandable stents in most cases. No postprocedural anticoagulation was used (aspirin only).

Results:

In 110 patients (117 arteries) intended for treatment, 109 (99.0%) (116 arteries [99.1%]) were successfully treated with 129 stents (128 Palmaz, 1 Wallstent). One percutaneous procedure failed (0.9%) for technical reasons (stent could not be deployed) and was converted to carotid endarterectomy. Minor complications included 4 cases of spasm (successfully treated with papaverine); 1 flow-limiting dissection (stented); and 6 access-site problems. There were 7 strokes (2 major, 5 reversible) (6.4%) and 5 minor transient events (4.5%) that resolved within 24 hours. Three patients were converted to endarterectomy (2.7%) prior to discharge; 1 stroke patient expired (0.9%), and another patient died of an unrelated cardiac event in hospital. In the 30-day postprocedural period, 2 ICA stents occluded (patients asymptomatic). Clinical success at 30 days (no technical failure, death, endarterectomy, stroke, or occlusion) was 89.1% (98/110). Over a mean 7.6-month follow-up (range 2 to 31), no new neurological symptoms developed. Another stent occlusion at 2 months and one case of flow-limiting intimal hyperplasia at 7 months were detected on routine duplex scanning in asymptomatic patients. Life-table analysis shows an 89% cumulative primary patency rate.

Conclusions:

Based on this early experience, carotid stenting appears feasible from a technical standpoint, with good midterm patency. However, the incidence of neurological sequelae is a serious problem. Technical enhancements and a more aggressive antiplatelet regimen may have a positive impact on these events.

What Should We Do with Asymptomatic Carotid Stenosis?

The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue

OBJECTIVES

The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade.

METHODS

Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included.

RESULTS

Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively.

CONCLUSIONS

The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.

Hemodynamic Significance of Internal Carotid or Middle Cerebral Artery Stenosis Detected on Magnetic Resonance Angiography

PURPOSE

We evaluated hemodynamic significance of stenosis on magnetic resonance angiography (MRA) using acetazolamide perfusion single photon emission computed tomography (SPECT).

MATERIALS AND METHODS

Of 171 patients, stenosis in internal carotid artery (ICA) and middle cerebral artery (MCA) (ICA-MCA) on MRA and cerebrovascular reserve (CVR) of MCA territory on SPECT was measured using quantification and a 3-grade system. Stenosis and CVR grades were compared with each other, and their prognostic value for subsequent stroke was evaluated.

RESULTS

Of 342 ICA-MCA, 151 (44%) presented stenosis on MRA; grade 1 in 69 (20%) and grade 2 in 82 (24%) cases. Decreased CVR was observed in 9% of grade 0 stenosis, 25% of grade 1, and 35% of grade 2. The average CVR of grade 0 was significantly different from grade 1 (p<0.001) and grade 2 stenosis (p=0.007). In quantitative analysis, average CVR index was -0.56±7.91 in grade 0, -1.81±6.66 in grade 1 and -1.18±5.88 in grade 2 stenosis. Agreement between stenosis and CVR grades was fair in patients with lateralizing and non-lateralizing symptoms (κ=0.230 and 0.346). Of the factors tested, both MRA and CVR were not significant prognostic factors (p=0.104 and 0.988, respectively), whereas hypertension and renal disease were significant factors (p<0.05, respectively).

CONCLUSION

A considerable proportion of ICA-MCA stenosis detected on MRA does not cause CVR impairment despite a fair correlation between them. Thus, hemodynamic state needs to be assessed for evaluating significance of stenosis, particularly in asymptomatic patients.

Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: onset of new ischemic stroke

Background

The degree of stenosis of carotid arteries is recognized as an important risk factor for ischemic stroke. However, high-grade stenosis does not always cause cerebrovascular events, whereas low- to moderate-grade stenosis may often cause strokes. It has been reported that there is an association between carotid intraplaque hemorrhage (IPH) and new brain ischemic events.

Case presentation

We present three patients with asymptomatic moderate carotid artery stenosis and carotid IPH who underwent both neurological and MRI at baseline and after at least 1 year's follow-up. These patients were admitted to our hospital (after 15–35 months of follow-up) because of neurological deficits. Diffusion-weighted MRI of the brain showed ipsilateral new ischemic lesions due to carotid artery plaques. The patients were treated with carotid artery stenting and discharged uneventfully.

Conclusions

Whether plaques with severe stenosis already had severe stenosis at the onset of events or plaques with moderate stenosis progressed owing to an acute change, such as growth of an IPH, remains unclear, because no carotid imaging was carried out just before the events. This is the first case report which presents neurological symptoms and MRI at both baseline and follow-up in patients with asymptomatic moderate carotid artery stenosis and carotid IPH.

Lesion-Related Carotid Angioplasty and Stenting with Closed-Cell Design without Embolic Protection Devices in High-Risk Elderly Patients-Can This Concept Work Out? A Single Center Experience Focusing on Stent Design

To compare the performance differences of three carotid artery stents in high-risk elderly patients without embolic protection devices (EPDs) on the basis of stent design, procedure-related complications, conveniences in handling, in-stent restenosis, 30-day outcome, and long-term follow-up. A total of 101 symptomatic internal carotid stenoses of 94 patients were prospectively treated with stent-protected angioplasty to 94 patients. Three closed-cell stents, one of those being hybrid cell design, were chosen depending on vascular anatomy: curved vessel, lesion length > 1 cm: 64 Carotid Wallstent (Boston Scientific, Natick, MA); curved vessel, lesion length < 1 cm: 21 Cristallo Ideale (Invatec, Roncadelle, Italy); straight vessel, lesion length > 1 cm: 16 Xact (Vascular Abbott, Santa Clara, CA). Comparisons of demographics, procedures, and outcomes were performed. The mean age of patients was 73.1 years (standard deviation [SD], ± 7.9; range, 58-87 years), 71% of the patients were older than 70 years and 20% were octogenarians. Male/female ratio was 3.1:1. About 13.9% (14/101) had contralateral internal carotid artery occlusion. Overall peri-interventional complication rate was 2.9% and 30-day mortality rate was 1%. During the long-term follow-up (34 months, range 1-59) no ipsilateral stroke was documented. Ten deaths (three after MI) were recognized. Two in-stent restenosis were detected (> 70% North American Symptomatic Carotid Endarterectomy Trial) during follow-up, one patient was detected with previous carotid endarterectomy. Especially, if individual anatomical variance is considered, lesion-related stent-protected carotid angioplasty with lesion-adapted closed-cell design is an effective, reliable, safe, and comprehensible treatment option in symptomatic patients. Even without EPDs, the rate of complications is low, when compared with symptomatic carotid artery stenosis described in the literature. In-stent restenosis seems to play no significant role in follow-up.

Assessment of carotid artery atherosclerotic disease by using three-dimensional fast black-blood MR imaging: comparison with DSA

PURPOSE

To assess fast three-dimensional (3D) black-blood (BB) magnetic resonance (MR) imaging as a noninvasive alternative to intraarterial digital subtraction angiography (DSA) at quantifying moderate to severe carotid artery atherosclerotic disease.

MATERIALS AND METHODS

Local ethics committee approval and written informed patient consent were obtained for this study. Sixty-five carotid arteries from 52 patients with at least 50% stenosis underwent 3D BB MR imaging and DSA. Quantitative measurements, including stenosis, lesion length, and the presence or absence of plaque ulceration, obtained with the two modalities were independently determined. Sensitivity and specificity, the intraclass correlation coefficient (ICC), Cohen κ, and Bland-Altman analysis were used to assess the agreement.

RESULTS

Excellent agreement in measuring luminal stenosis was found between 3D BB MR imaging and DSA (ICC, 0.96; 95% confidence interval [CI]: 0.93, 0.97). Three-dimensional BB MR imaging was also found to have high sensitivity (91.7%), specificity (96.2%), and agreement (Cohen κ, 0.85; 95% CI: 0.66, 0.99) with DSA for detection of ulcers. Good agreement was found between lesion length measured by using 3D BB MR imaging and DSA (ICC, 0.75; 95% CI: 0.51, 0.84). However, lesion length measurements by using 3D BB MR imaging were, on average, 4.0 mm longer than those measured by using DSA (P < .001).

CONCLUSION

Three-dimensional BB MR imaging is a noninvasive and accurate way to quantify moderate to severe carotid artery atherosclerotic disease. With fast acquisition and large coverage, 3D BB MR imaging has the potential to become an alternative imaging approach in evaluating the severity of atherosclerosis.

Twenty-four hour staged carotid endarterectomy followed by off-pump coronary bypass grafting for patients with concomitant carotid and coronary disease

BACKGROUND

Carotid artery stenosis and coronary artery disease share common risk factors and often coexist in the same patient. Currently, no consensus exists regarding the optimal treatment strategy for patients with concomitant severe coronary and carotid disease. We reviewed the results of our experience performing off-pump coronary artery bypass grafting (CABG) within 24 hours of carotid endarterectomy (CEA) in this select patient population.

METHODS

In this single institution retrospective study we identified patients who underwent CEA followed by CABG from March 2001 to March 2012. Preoperative, intraoperative, and postoperative data were collected and analyzed.

RESULTS

Ninety patients underwent CEA followed by off-pump CABG. The duration between CEA and CABG was 1.8±5.6 days with 80 (89%) within 24 hours. Mean age was 69±9 years, 68% male. Perioperative comorbidities included hypertension (87%), diabetes (50%), previous myocardial infarction (24%), peripheral arterial disease (20%), and strokes and transient ischemic attack (16%). Extensive aortic atherosclerosis was noted in 15 patients (17%). The average number of vessels bypassed was 3.4±1.0, and the average number of proximal vein aortotomies was 1.7±0.92. Post-CEA surgical outcomes were myocardial infarction (1%), acute embolic cerebrovascular accident (1%), left upper extremity weakness (1%), and hypoglossal nerve injury (1%). Post-CABG surgical outcomes included atrial fibrillation (34%), anemia (12%), pneumothorax (7%), and postoperative bleeding (4%). No post-CABG cerebrovascular accident was identified. Patients were discharged 7.5±3.5 days after CEA.

CONCLUSIONS

Twenty-four hour staged CEA followed by CABG minimizes myocardial infarction post-CEA while minimizing cerebrovascular accident post-CABG in patients with concomitant severe coronary and carotid artery disease.

Impact of diabetes mellitus on characteristics of carotid plaques and outcomes after carotid endarterectomy

BACKGROUND

Published results for carotid endarterectomy (CEA) in symptomatic and asymptomatic severe carotid stenosis with diabetes mellitus (DM) are contradictory. To evaluate perioperative and long-term results of CEA in patients with DM, we retrospectively analyzed data of patients with or without DM who underwent CEA in our institute.

METHODS

Between January 2005 and December 2010, 281 consecutive CEAs were performed in 268 patients under general anesthesia. All patients were subject to cardiac work-ups before surgery, and coronary revascularization was performed prior to CEA if patients were diagnosed with significant coronary artery stenosis. Lesion characteristics were assessed by a duplex ultrasound scan, computed tomography angiography (CTA), and plaque imaging on magnetic resonance imaging (MRI) before surgery, and patients were followed-up by a duplex ultrasound scan at three, six, and 12 months, then yearly, after surgery.

RESULTS

Of 281 cases, 136 had DM (48 %). Diabetic patients more frequently had a history of coronary artery disease than non-diabetic patients (48.5 % vs. 36.6 %, P = 0.042). Coronary intervention prior to CEA was more frequently performed in diabetic patients than in non-diabetic patients (22.1 % vs. 11.0 %, P = 0.013). The incidence of perioperative (30 day) stroke (P = 1.000), death (P = 1.000), and cardiac complications (P = 0.484) did not differ among groups. Follow-up was available in 77.2 % of patients, with a median duration of 50 months (interquartile range, 32.1-67.2 months). The incidence of ipsilateral stroke (P = 0.720), death (P = 0.351), and severe restenosis (peak systolic velocity > 230 cm/sec) (P = 0.905) were not different between groups.

CONCLUSIONS

DM does not increase the risk of perioperative complications and does not influence long-term outcomes after CEA if preexisting vascular risk factors and cardiac diseases are appropriately evaluated and treated before surgery.

Prediction of high-risk plaque development and plaque progression with the carotid atherosclerosis score

OBJECTIVES

The goal of this prospective study was to evaluate the carotid atherosclerosis score (CAS) for predicting the development of high-risk plaque features and plaque burden progression.

BACKGROUND

Previous studies have shown that carotid intraplaque hemorrhage (IPH) and a disrupted luminal surface (DLS), as identified by using magnetic resonance imaging, are associated with greater risk for cerebrovascular events. On the basis of data from a large cross-sectional study, a scoring system was developed to determine which plaque features are associated with the presence of IPH and DLS. However, the predictive value of CAS has not been previously tested in a prospective, longitudinal study.

METHODS

A total of 120 asymptomatic subjects with 50% to 79% carotid stenosis underwent carotid magnetic resonance imaging scans at baseline and 3 years thereafter. Presence of IPH and DLS, wall volume, maximum wall thickness, and maximum percent lipid-rich necrotic core area were measured at both time-points. Baseline CAS values were calculated on the basis of previously published criteria.

RESULTS

Of the 73 subjects without IPH or DLS at baseline, 9 (12%) developed 1 or both of these features during follow-up. There was a significant increasing trend between CAS and the development of new DLS (p < 0.001) and with plaque burden progression (p = 0.03) but not with the development of new IPH (p = 0.3). Percent carotid stenosis was not significantly associated with new DLS (p = 0.2), new IPH (p = 0.1), or plaque progression (p = 0.6).

CONCLUSIONS

CAS was found to have a significant increasing relationship with incident DLS and plaque progression in this prospective study. CAS can potentially provide improved risk stratification beyond luminal stenosis.

United Kingdom carotid artery stent registry: short- and long-term outcomes

BACKGROUND

Carotid artery stenting (CAS) has evolved to treat carotid artery disease with the intention of prevent stroke. The British Society of Interventional Radiologists developed a voluntary registry to monitor the practice of this novel procedure. We present the data from the United Kingdom (UK) CAS registry for short and long-term outcomes for symptomatic and asymptomatic carotid disease.

METHODS

The UK CAS registry collected data from 1998 to 2010 from 31 hospitals across the UK for 1,154 patients. All interventions were enrolled in the registry for both asymptomatic and symptomatic patients. Initial entry forms were completed for each patient entered with data including indications, demographic data, CAS data (including stents and protection device details) and 30-day outcomes. Complications were documented. Follow-up data were collected at yearly intervals.

RESULTS

Nine hundred fifty-three (83 %) symptomatic and 201 (17 %) asymptomatic patients were enrolled into the registry. The 30-day all stroke and death rates for symptomatic patients were 5.5 and 2.2 % for those with asymptomatic disease. The 30-day mortality rate was 1.7 % for symptomatic and 0.6 % for asymptomatic patients. For symptomatic patients undergoing CAS, the 7-year all-cause mortality rate was 22.2 % and for asymptomatic patients 18.1 %. The 7-year all-cause mortality and disabling stroke rates were 25.3 and 19.4 %, respectively.

CONCLUSION

These data indicate that outside of the tight constraints of a randomised trial, CAS provides effective prophylaxis against stroke and death.

Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

OBJECTIVE

Outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) did not differ between carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the composite primary end point of stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years. Rigorous credentialing and training of interventionists, including vascular surgeons, were required for the randomization phase of CREST. Because the lead-in phase of CREST had suggested higher perioperative risks after CAS performed by vascular surgeons, the purpose of this analysis was to examine differences in outcomes after randomization between CAS and CEA performed by vascular surgeons.

METHODS

CREST is a prospective randomized controlled trial with blinded end point adjudication. Vascular surgeons performed 237 (21%) of the CAS procedures and 765 (65%) of the CEA procedures among 2320 patients who received their assigned treatment. Proportional hazards analyses were used to estimate the relative efficacy of CAS vs CEA for the composite primary end point and also for stroke and death.

RESULTS

Among 2502 randomized patients, 1321 (53%) were symptomatic and 1181 (47%) were asymptomatic. For procedures performed exclusively by vascular surgeons, the primary end point did not differ between CAS and CEA at 4-year follow-up (6.2% vs 5.6%, respectively; hazard ratio [HR], 1.30; 95% confidence interval [CI], 0.70-2.41; P = .41) In this subgroup, the periprocedural stroke and death rates were higher after CAS than CEA for symptomatic patients (6.1% vs 1.3%; P = .01). Asymptomatic patients also had slightly higher stroke and death rates after CAS (2.6% vs 1.1%; P = .20), although this difference did not reach statistical significance. Conversely, cranial nerve injuries (0.0% vs 5.0%; P < .001) were less frequent after CAS than CEA. The MI rates were slightly lower after CAS (1.3% vs 2.6%; P = .24). In performing CAS, vascular surgeons had outcomes for the periprocedural primary end point comparable to the outcomes of all interventionists (HR, 0.99; 95% CI, 0.50-2.00) after adjusting for age, sex, and symptomatic status. Vascular surgeons also had similar results after CEA for the periprocedural primary end point compared with other surgeons (HR, 0.73; 95% CI, 0.42-1.27).

CONCLUSIONS

When performed by surgeons, CAS and CEA have similar net outcomes, although the periprocedural risks vary (lower stroke with CEA and lower MI with CAS). These data suggest that appropriately trained vascular surgeons may safely offer both CEA and CAS for the prevention of stroke. The remarkably low stroke and death rates after CEA performed by vascular surgeons in CREST, particularly among symptomatic patients, represent the best outcomes ever reported after carotid interventions from a randomized controlled trial. ClinicalTrials.gov identifier: NCT0000473.

Long-term follow-up of patients after carotid stenting with or without distal protective device in a single tertiary medical center

OBJECTIVE

To evaluate the immediate and long-term clinical outcomes after carotid artery stenting (CAS) with and without protection devices (PDs), compared with carotid endarterectomy (CEA).

METHODS

A total of 116 patients with symptomatic carotid stenosis underwent CAS; 56 patients (48.3%) underwent CAS-PD; and 137 patients underwent CEA.

RESULTS

There were more ipsilateral transient ischemic attacks (TIAs) in the CEA group than in CAS-PD and CAS + PD (4 [3%] vs 1 [1.6%] and 0 respectively, P = 0.02). In the CAS-PD group there were more vertebrobasilar TIAs, ipsi- and contralateral strokes, myocardial infarctions, and death rates in the 30-day postprocedural period. After 8-year follow-up, there were 18 (30%) death cases in the CAS-PD group, 10 death cases (17%) in the CAS + PD patients, and 15 death cases (11%) in the CEA group of patients (P = .02).

CONCLUSION

Our data show that CAS + PD was associated with lower rate of vascular complications and mortality compared with CAS-PD and CEA.

Comparison of carotid atherosclerotic plaque characteristics by high-resolution black-blood MR imaging between patients with first-time and recurrent acute ischemic stroke

BACKGROUND AND PURPOSE

It has been shown that patients with a first ischemic stroke are at high risk of developing recurrent stroke due to carotid atherosclerotic plaque rupture. However, no one has defined the difference in plaques between initial and recurrent stroke. This study sought to investigate the characteristics of carotid plaque between patients with first-time and recurrent acute ischemic stroke by using MR imaging.

MATERIALS AND METHODS

Eighty-nine patients with recent acute ischemic stroke were recruited. All subjects underwent carotid high-resolution black-blood MR imaging. The index carotid arteries, defined as the arteries responsible for the ipsilateral stroke, were analyzed quantitatively and qualitatively. Carotid plaque burden and compositional features between patients with first-time and recurrent ischemic stroke were compared.

RESULTS

Of 89 recruited patients, 51 had first-time stroke and 38 had recurrent stroke. The mean WA, WT, and PWV were greater in patients with recurrent stroke than in patients with first-time stroke (all, P < .05). Compared with patients with first-time stroke, those with recurrent stroke showed significantly higher prevalence of calcification (44.7% versus 23.5%, P = .035) as well as a larger volume of LRNC (179.14 ± 254.81 mm(2) versus 71.65 ± 111.15 mm(2), P = .027). IPH or fibrous cap rupture or both were observed in 15.8% of patients with recurrent stroke and 3.9% of patients with first-time stroke.

CONCLUSIONS

Carotid plaques in patients with recurrent ischemic stroke are significantly aggravated compared with those in patients with first-time stroke, and monitoring carotid plaques in patients with initial stroke by MR imaging may be helpful for secondary stroke prevention.

Ultrasound assessment of brachial endothelial vasomotor function in addition to carotid plaque echolucency for predicting cardiovascular events in patients with coronary artery disease

BACKGROUND

Single assessment of either flow-mediated vasodilatation of the brachial artery (FMD) or carotid plaque echolucency provides prognostic information for both cerebrovascular and coronary events.

OBJECTIVES

This study tested the hypothesis that combined assessment using carotid plaque echolucency and FMD may have an additive effect when predicting cardiovascular events in patients with coronary artery disease (CAD).

METHODS

Ultrasound assessment of carotid plaque echolucency with integrated backscatter (IBS) analysis (calibrated IBS=intima-media IBS value-adventitia IBS) and FMD was performed in 547 consecutive patients with CAD. All the study patients were followed up prospectively for a period of ≤ 60 months until the occurrence of one of the following cardiovascular events: cardiac death, non-fatal myocardial infarction, unstable angina requiring coronary revascularization, or ischemic stroke.

RESULTS

During a mean follow-up period of 52 ± 10 months, 69 cardiovascular events occurred. A multivariate Cox proportional hazard model after 1000 bootstrapped resampling demonstrated that calibrated IBS and FMD were significant, independent predictors of future cardiovascular events after adjustment for known risk factors (calibrated IBS, HR 0.88, 95% CI 0.83-0.93; FMD, HR 0.76, 95% CI 0.68-0.85). The c-statistics, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) analyses showed that the combination of calibrated IBS and FMD values had a greater incremental effect on the predictive value of known risk factors for cardiovascular events.

CONCLUSIONS

Combined assessment of brachial endothelial function and carotid plaque echolucency is an independent predictor of cardiovascular events and improves risk prediction when added to known risks.

Carotid Artery Stenting Versus Carotid Endarterectomy: Post CREST

The risk of stroke associated with carotid artery stenosis can be reduced with carotid endarterectomy or carotid artery stenting in carefully selected patients. While surgery has been the traditional treatment there have been many trials comparing carotid endarterectomy with carotid artery stenting, and stenting has shown promising results for certain patient populations. This article reviews the natural history of carotid artery stenosis, the data supporting carotid endarterectomy, trials directly comparing surgery to stenting, and current recommendations for each modality.

Management of carotid disease in patients undergoing coronary artery bypass surgery: is it time to change our approach?

PURPOSE OF REVIEW

The management of concurrent severe carotid and coronary disease is a subject of ongoing debate in the absence of randomized clinical trials. Amidst the growing controversy, the clinician has to carefully tailor the best strategy for a given patient based on neurologic and cardiac symptoms. This review aims to compile current evidence in this area to help plan strategies for the optimal management of coexisting severe carotid and coronary disease.

RECENT FINDINGS

Carotid revascularization with carotid endarterectomy (CEA) or stenting (CAS) is frequently performed in conjunction with coronary artery bypass surgery (CABG) in the United States for asymptomatic carotid disease. The risk of perioperative stroke with unilateral asymptomatic 70-99% carotid stenosis is likely small based on several observational data. Moreover, the risk associated with both staged and combined CEA-CABG procedures in the asymptomatic population may outweigh any benefit. Carotid artery stenting is an alternative option in patients with severe coronary disease who are considered 'high risk' for CEA. Neurologically symptomatic patients require carotid revascularization prior to or in conjunction with CABG surgery. Ultimately, the choice of carotid revascularization or conservative management will depend on clinical characteristics, anatomy, and local expertise.

SUMMARY

Severe carotid disease in the CABG population is often unilateral and asymptomatic. Based on the available data, conservative carotid therapy in the low-risk asymptomatic individuals is likely the best treatment option. Carotid revascularization may be justified in symptomatic or high-risk patients such as those with contralateral carotid occlusion or bilateral severe stenosis.

The practice of carotid revascularization in a large metropolitan population

Carotid endartectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke when performed with acceptable perioperative morbidity and mortality. Studies from the 1980s in the greater Cincinnati/northern Kentucky population showed that perioperative risk after CEA exceeded the recommended boundaries of 3.0% for asymptomatic stenosis and 6.0% for symptomatic stenosis. We investigated the indications and outcomes for CEA and CAS in the same population during 2005. We identified all residents of the greater Cincinnati/northern Kentucky region who underwent CEA or CAS at any local hospital during 2005. Identified cases of transient ischemic attack or stroke occurring before or after CEA or CAS were abstracted by study nurses and reviewed by a study physician. The main outcome of interest was 30-day risk of stroke or death after CEA or CAS. Events were analyzed using Kaplan-Meier statistics. Among approximately 1.3 million greater Cincinnati/northern Kentucky residents, 525 CEAs were performed, 343 (65%) for asymptomatic stenosis and 182 (35%) for symptomatic stenosis. There were 43 CAS procedures, 23 (53%) for asymptomatic stenosis and 20 (47%) for symptomatic stenosis. The 30-day perioperative risk of stroke or death after CEA was 3.3% (95% confidence interval [CI], 1.8%-5.9%) for asymptomatic stenosis and 6.3% (95% CI, 3.5%-11.1%) for symptomatic stenosis. The 30-day perioperative risk of stroke or death after CAS was 4.6% (95% CI, 0.7%-28.1%) for asymptomatic stenosis and 21.1% (95% CI, 8.5%-46.8%) for symptomatic stenosis. Point estimates for perioperative risk after CEA were improved from previous studies but remained above the recommended benchmarks. The number of CAS procedures was low, but the perioperative risk was significant.

Carotid MRI: a tool for monitoring individual response to cardiovascular therapy?

Stroke remains a leading cause of morbidity and mortality. While stroke-related mortality has declined over the past four decades, data indicate that the mortality rate has begun to plateau. This change in trend may be attributable to variation in individual response to therapies that were derived from population-based studies. Further reductions in stroke mortality may require individualized care governed by directly monitoring the effects of cardiovascular therapy. In this article, carotid MRI is considered as a tool for monitoring in vivo carotid atherosclerotic disease, a principal etiology of stroke. Carotid MRI has been previously utilized to identify specific plaque features beyond luminal stenosis that are predictive of transient ischemic attack and stroke. To gain perspective on the possibility of monitoring plaque change within the individual, clinical trials and natural history studies that have used serial carotid MRI are considered. Data from these studies indicate that patients with a lipid-rich necrotic core with or without intraplaque hemorrhage may represent the desired phenotype for monitoring treatment effects in the individual. Advances in tissue-specific sequences, acquisition resolution, scan time, and techniques for monitoring inflammation and mechanical forces are expected to enable earlier detection of response to therapy. In so doing, cost-effective multicenter studies can be conducted to confirm the anticipated positive effects on outcomes of using carotid MRI for individualized care in patients with carotid atherosclerosis. In accordance, carotid MRI is poised to emerge as a powerful clinical tool for individualized management of carotid atherosclerotic disease to prevent stroke.