Carotid Artery Stenting: Analysis of a 12-Year Single-Center Experience

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System

BACKGROUND

Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization.

AIM

To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent.

METHODS

Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure.

RESULTS

Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%).

CONCLUSIONS

As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

miR-28-5p improved carotid artery stenosis by regulating vascular smooth muscle cell proliferation and migration

OBJECTIVES

Abnormal proliferation and migration of vascular smooth muscle cells (VSMCs) are involved in carotid artery stenosis. The purpose of this study was to investigate the diagnostic value of serum miR-28-5p in asymptomatic carotid artery stenosis and its regulation on the proliferation and migration of VSMCs.

METHODS

Serum miR-28-5p levels in 65 healthy controls and 68 asymptomatic carotid artery stenosis patients were detected by qRT-PCR. The receiver-operating characteristic curve was applied to elucidate the diagnostic value of serum miR-28-5p for carotid artery stenosis patients. The specificity of miRNA targets was detected by luciferase reporter assay. CCK-8 and Transwell assay were applied to detect proliferation and migration of cells. Pearson correlation test was used to investigate the correlation between Forkhead box subclass O 1 (FOXO1) and serum miR-28-5p.

RESULTS

Serum miR-28-5p was significantly reduced in asymptomatic carotid artery stenosis patients. Moreover, miR-28-5p could distinguish asymptomatic carotid artery stenosis patients from healthy controls, with sensitivity and specificity of 86.8% and 81.5%, respectively, indicating its high diagnostic value. The overexpression of miR-28-5p inhibited the proliferation and migration of VSMCs, while inhibition of miR-28-5p resulted in the opposite effect. What is more, FOXO1, a direct target of miR-28-5p, was significantly increased in asymptomatic carotid artery stenosis patients. Inhibition of miR-28-5p in VSMCs reversed the reduction of FOXO1 levels in patients.

CONCLUSIONS

miR-28-5p is a valuable diagnostic biomarker for asymptomatic carotid artery stenosis and can affect the proliferation and migration of VSMCs by regulating FOXO1.

Dysregulation of lncRNA SNHG1/miR-145 axis affects the biological function of human carotid artery smooth muscle cells as a mechanism of carotid artery restenosis

Carotid angioplasty and stenting have developed into reliable options for patients with carotid stenosis. However, postoperative restenosis remains a serious and unresolved problem. Restenosis is partly caused by the proliferation of vascular smooth muscle cells. As certain long non-coding RNAs (lncRNAs) affect cell proliferation and migration, the present study aimed to investigate them as novel biomarkers for restenosis development and to further reveal the potential underlying mechanisms. The expression of lncRNA small nucleolar RNA host gene 1 (SNHG1) and microRNA145 (miR-145) in human carotid artery smooth muscle cells (hHCtASMCs) was analyzed using reverse transcription-quantitative PCR. In addition, a luciferase reporter assay was performed to investigate the interaction between SNHG1 and miR-145. The effects of the SNHG1/miR-145 axis on the proliferation and migration of hHCtASMCs were evaluated by Cell Counting Kit-8 and Transwell assays. Serum SNHG1 and miR-145 expression levels were increased and decreased, respectively, in patients with restenosis (all P<0.001). High SNHG1 and low miR-145 were identified as risk factors for restenosis onset (all P<0.01). Furthermore, decreasing SNHG1 expression levels in hHCtASMCs inhibited cell proliferation and migration. The luciferase reporter assay and expression results demonstrated that miR-145 may be a target of SNHG1 and mediated the effects of SNHG1 on hHCtASMC proliferation and migration. The results obtained suggested that abnormal expression of SNHG1 and miR-145 may be risk factors for restenosis. The present study revealed that the SNHG1/miR-145 axis regulates hHCtASMC proliferation and migration, indicating its potential for restenosis prevention and treatment.

Long non-coding RNA cyclin-dependent kinase inhibitor 2B antisense ribonucleic acid 1 is associated with in-stent restenosis and promotes human carotid artery smooth muscle cell proliferation and migration by sponging miR-143-3p

Carotid angioplasty and stenting (CAS) is an efficient therapeutic approach for carotid stenosis. However, in-stent restenosis (ISR) frequently occurs and seriously affects the therapeutic efficacy of CAS. Certain non-coding (nc)RNAs serve potential roles in ISR development and progression. Thus, the goals of the present study were to investigate novel biomarkers for ISR development and to further uncover the mechanisms underlying the progression of ISR. The expression of long ncRNA cyclin-dependent kinase inhibitor (CDKN)2B-antisense 1 (AS1) and microRNA (miR)-143-3p in patients with ISR and human carotid artery smooth muscle cells (hHCtASMCs) was analyzed using reverse transcription-quantitative PCR. A luciferase reporter assay was performed to examine the interaction between CDKN2B-AS1 and miR-143-3p. The effects of the CDKN2B/miR-143-3p axis on hHCtASMC proliferation and migration were assessed using Cell Counting Kit-8 and Transwell assays. The results indicated that serum CDKN2B-AS1 was increased and miR-143-3p was decreased in patients with ISR as compared with that in patients with no ISR (all P<0.001). CDKN2B-AS1 and miR-143-3p were identified as risk factors for ISR onset (all P<0.05) and knockdown of CDKN2B-AS1 in hHCtASMCs led to inhibited cell proliferation and migration. Furthermore, the luciferase reporter assay and expression analysis indicated that miR-143-3p is a target of CDKN2B-AS1 and may mediate the effects of CDKN2B-AS1 on hHCtASMC proliferation and migration. In conclusion, dysregulation of CDKN2B-AS1 and miR-143-3p may represent risk factors for the occurrence of ISR. The in vitro results suggested that the CDKN2B-AS1/miR-143-3p axis may regulate the proliferation and migration of hHCtASMCs, indicating its potential to be developed as a target for preventative measures and therapies for ISR.

Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation?

INTRODUCTION

The prevention of atherosclerotic plaque fragmentation during carotid artery stenting is a fundamental problem in decreasing the risk of disability of patients. The goal of this review is to clarify whether the stent design can have a decisive impact on the rate of intraoperative and postoperative complications.

AREAS COVERED

Different designs of the carotid stents are briefed and the advantages and disadvantages of different stent designs are discussed as well as the results of their clinical use. Various solutions are presented to reduce cerebral embolism during carotid artery stenting.

EXPERT OPINION

There is no conclusive evidence for the benefits of closed cell and hybrid stents. The stent design cannot completely resolve the problem of cerebral embolism. Most of the events of cerebral microembolism occur at the stages of stent delivery rather than protrusion of an atherosclerotic plaque in the long-term follow-up. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery. Abbreviations: CAS, carotid artery stenting; CE, carotid endarterectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; ECA, external carotid artery; ICA, internal carotid artery; IVUS, intravascular ultrasound examination; OCT, optical coherence tomography.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio: novel markers for the diagnosis and prognosis in patients with restenosis following CAS

Aim: In this study, we investigated the effect of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio on restenosis status in patients undergoing carotid angioplasty stenting (CAS). Methodology & results: Clinical imageology and receiver operating characteristic analysis were utilized to study the prognostic significance of NLRs/platelet-to-lymphocyte ratios and their correlation with survival. NLR of restenosis (+) patients was evidently increased after the CAS procedures, while the NLR of restenosis (-) patients before the CAS procedures being the lowest. Area under the curve of pre-CAS NLR or/and post-CAS NLR were all evidently higher than 50%. Also, restenosis incidence was the highest in patients with both high pre-CAS and high post-CAS values. Conclusion: Therefore, NLR can be utilized as an independent prognostic indicator to predict the incidence of restenosis after CAS procedures.

The association between carotid intraplaque hemorrhage and outcomes of carotid stenting: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

The purpose of this systematic review and meta-analysis was to determine whether carotid stenting patients with intraplaque hemorrhage (IPH) identified on preoperative MRI were more likely to suffer perioperative ischemic complications compared with patients without IPH.

METHODS

We conducted a comprehensive literature search of studies published between January 1, 2005 and December 31, 2015 reporting perioperative outcomes of carotid stenting among patients with and without IPH on hemorrhage sensitive carotid MRI sequences. Clinical outcomes included perioperative (≤30 days post-stenting) minor stroke, major stroke, death, and a composite outcome combining stroke, death, and myocardial infarction (MI). We also compared the rate of silent ischemia on diffusion weighted imaging (DWI) between groups. Statistical analysis was performed using a random effects meta-analysis.

RESULTS

9 studies with 491 unique patients (198 in the IPH group and 293 in the non-IPH group) were included. The rate of the composite outcome of any stroke, death, or MI within 30 days was 8.1% (13/160) in the IPH group and 2.1% (5/239) in the non-IPH group (OR=4.45, 95% CI 1.61 to 12.30, p<0.01). There were no significant differences between groups in the rates of minor stroke, major stroke, or death when considered individually. The rate of postoperative infarct on DWI was 49.7% (75/161) for the IPH group and 33.6% (81/241) for the non-IPH group (OR=2.01, 95% CI 1.31 to 3.09, p<0.01).

CONCLUSIONS

Our systematic review and meta-analysis demonstrated that patients with IPH on pre-carotid stenting MRI had higher rates of silent ischemia as well as of a composite outcome of perioperative stroke, death, and MI compared with those without IPH.

Outcomes of 1000 Carotid Wallstent Implantations

Purpose: To evaluate the outcomes of carotid artery stenting (CAS) with Wallstents in a single-center experience. Methods: From January 2003 to December 2013, 1000 carotid artery lesions were treated with Carotid Wallstents under cerebral protection in 877 patients (mean age 71.7±8 years; 621 men). Indications for treatment were de novo lesions (>70% asymptomatic and >60% symptomatic); stenoses following carotid endarterectomy, radiation, or neck surgery; contralateral laryngeal nerve palsy; and high surgical risk. All the patients underwent duplex ultrasound and clinical evaluation during follow-up; radiography was performed when fracture or stent migration was suggested by ultrasound. Results: Procedure success was achieved in 99.3% of patients. Major and minor 30-day adverse events occurred in 2.1% of patients, including stroke (1.8%: 1.3% minor, 0.5% major), myocardial infarction (0.1%), and death (0.2%). Plaque morphology, nature of stenosis, and symptomatic status were significantly associated with the risk of postoperative neurologic events. Restenosis occurred in 3.2% at a mean 45.5-month follow-up and was significantly associated with diabetes, smoking, symptomatic stenosis, de novo stenosis, and calcification (plaque III/IV). No fracture or migration was registered during follow-up. Conclusion: CAS is a valid method for treating carotid artery disease, with very low rates of major adverse events and neurologic complications. The Carotid Wallstent seems to have excellent results, even with complex plaque morphology, and a low incidence of restenosis at follow-up.

Carotid endarterectomy versus stenting: Does the flow really change? An Echo-Color-Doppler analysis

To assess potential hemodynamic differences after carotid endarterectomy (CEA) and carotid artery stenting (CAS) and their eventual impact on clinical management. Between July 2012 and October 2013 two groups of 30 patients each referred for CEA or CAS were prospectively enrolled in two tertiary hospital care centers. Pre-procedural imaging assessment of carotid artery disease was performed with Echo-Color-Doppler (ECD) and computed tomography angiography (CTA). ECD was repeated within 24 h and 1, 6 and 12 months after surgical/endovascular procedures. Peak systolic velocity (PSV) and end diastolic velocity (EDV) were assessed at two standard sites: common carotid artery (CCA) and distal internal carotid artery (ICA). Twenty-four hours ECD findings highly differ between the two populations. CCA PSV in the CEA and CAS groups was respectively 44.88 ± 9.16 and 69.20 ± 20.04 cm/s (p = 0.002); CCA EDV was 16.11 ± 2.29 and 19.13 ± 6.42 cm/s (p = 0.065); ICA PSV was 46.11 ± 7.9 and 94.02 ± 57.7 cm/s (p = 0.0012); ICA EDV was 20.22 ± 4.33 and 30.47 ± 18.33 cm/s (p = 0.025). One month, 6 months and 1 year findings confirmed the different trend in the two cohorts; in particular, at 1 year: CCA PSV was 50.94 ± 12.44 and 60.59 ± 26.84 cm/s (p = 0.181); CCA EDV was 17.11 ± 3.46 and 19 ± 16.35 cm/s (p = 0.634); ICA PSV was 51.66 ± 10.1 and 70.86 ± 20.64 cm/s (p = 0.014); ICA EDV was 25.05 ± 8.65 and 32.66 ± 13 cm/s (p = 0.0609). ECD follow-up of patients undergone CEA or CAS may play a critical role in the clinical management. Strict surveillance of blood flow velocities allows reducing false positive re-stenosis diagnosis and choosing the best anti-aggregation therapies. Within the first month CEA patients benefit from a lower risk condition in comparison with CAS patients, due to a significantly faster PSV drop; moreover, long-term CCA PSV after CEA could be used as a surrogate marker of neointima formation.

Crosstalk between TGF-β/Smad3 and BMP/BMPR2 signaling pathways via miR-17-92 cluster in carotid artery restenosis

In the recent decades, carotid angioplasty and stenting (CAS) has been developed into a credible option for the patients with carotid stenosis. However, restenosis remains a severe and unsolved issue after CAS treatment. Restenosis is characterized by neointimal hyperplasia, which is partially caused by vascular smooth muscle cells (VSMC) proliferation. However, the molecular mechanism involved in the restenosis is still unclear. In this study, we demonstrated a functional crosstalk between two TGF-β superfamily signaling pathway members, Smad3 and BMPR2, in VSMC proliferation. Smad3 plays an important role in the TGF-β/Smad3 signaling pathway, and is significantly upregulated in the carotid artery with restenosis to promote VSMC proliferation. In contrast, BMP receptor II (BMPR2), an inhibitor of VSMC proliferation is downregulated in carotid restenosis. We further found that BMPR2 downregulation is mediated by miR-17-92 cluster, which is transcriptionally regulated by Smad3. Thus, Smad3 upregulation and Smad3/miR-17-92 cluster-dependent BMPR2 downregulation are likely to promote VSMC proliferation and restenosis. Taken together, our results may provide novel clues for early diagnosis of carotid restenosis and developing new therapeutic strategy.