Severe, recurrent in-stent carotid restenosis: endovascular approach, risk factors. Results from a prospective academic registry of 2637 consecutive carotid artery stenting procedures (TARGET-CAS)

Drug-Coated Balloons for Treatment of Internal Carotid Artery Restenosis After Stenting: A Single-Center Mid-Term Outcome Study

PURPOSE

Endovascular and surgical treatments of stenosis of the extracranial internal carotid artery (ICA) are common procedures, yet both introduce a risk of restenosis due to endothelial hyperplasia. Drug-coated balloons (DCBs) are designed to decrease neointimal hyperplasia, however rarely used in the neurovascular setting. This study retrospectively analyzes mid-term results of DCB-treated in-stent restenosis (ISR) of the ICA.

MATERIALS AND METHODS

The medical history, comorbidities, and periprocedural data of patients receiving DCB treatment for > 50% ISR of the ICA after carotid artery stenting were analyzed. Follow-up after DCB treatment was performed with Doppler ultrasound. Suspicious cases were checked with CT- or MR-angiography and-if there was agreement between the modalities-validated with digital subtraction angiography. Potential risk factors for restenosis and differences in outcomes after PTA with three types of DCB balloons were evaluated.

RESULTS

DCB treatment was performed in 109 cases, 0.9% of which involved in-hospital major stroke; no minor strokes occurred. A total of 17 patients (15.6%) had recurrent ISR after DCB treatment, after a mean time of 30.2 months (7-85 months). Tobacco use was significantly associated with a higher incidence of recurrent ISR.

CONCLUSION

DCB angioplasty for ISR is an effective treatment that may delay and decrease restenosis. Treating comorbidities and adopting lifestyle changes may additionally help prevent ISR.

Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes

INTRODUCTION

Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA).

EVIDENCE ACQUISITION

Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect.

EVIDENCE SYNTHESIS

Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery.

CONCLUSIONS

Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).

Cardiac microRNAs: diagnostic and therapeutic potential

MicroRNAs are small non-coding post-translational biomolecules which, when expressed, modify their target genes. It is estimated that microRNAs regulate production of approximately 60% of all human proteins and enzymes that are responsible for major physiological processes. In cardiovascular disease pathophysiology, there are several cells that produce microRNAs, including endothelial cells, vascular smooth muscle cells, macrophages, platelets, and cardiomyocytes. There is a constant crosstalk between microRNAs derived from various cell sources. Atherosclerosis initiation and progression are driven by many pro-inflammatory and pro-thrombotic microRNAs. Atherosclerotic plaque rupture is the leading cause of cardiovascular death resulting from acute coronary syndrome (ACS) and leads to cardiac remodeling and fibrosis following ACS. MicroRNAs are powerful modulators of plaque progression and transformation into a vulnerable state, which can eventually lead to plaque rupture. There is a growing body of evidence which demonstrates that following ACS, microRNAs might inhibit fibroblast proliferation and scarring, as well as harmful apoptosis of cardiomyocytes, and stimulate fibroblast reprogramming into induced cardiac progenitor cells. In this review, we focus on the role of cardiomyocyte-derived and cardiac fibroblast-derived microRNAs that are involved in the regulation of genes associated with cardiomyocyte and fibroblast function and in atherosclerosis-related cardiac ischemia. Understanding their mechanisms may lead to the development of microRNA cocktails that can potentially be used in regenerative cardiology.

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

BACKGROUND Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. MATERIAL AND METHODS We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. RESULTS Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% - endovascular, 6.7% - surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). CONCLUSIONS In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

Clinical Application of Serum microRNAs in Atherosclerotic Coronary Artery Disease

MicroRNAs (miRs) are promising diagnostic, prognostic and therapeutic biomolecules for atherosclerotic cardiovascular disease. Atherosclerotic occlusive disease concerns a large population of patients, carrying the highest incidence of fatal and non-fatal adverse events, such as myocardial infarction, ischemic stroke, and limb ischemia, worldwide. Consistently, miRs are involved in regulation and pathogenesis of atherosclerotic coronary artery disease (CAD), acute coronary syndromes (ACS), both with ST-segment (STEMI) and non-ST segment elevation myocardial infarctions (NSTEMI), as well as cardiac remodeling and fibrosis following ACS. However, the genetic and molecular mechanisms underlying adverse outcomes in CAD are multifactorial, and sometimes difficult to interpret for clinicians. Therefore, in the present review paper we have focused on the clinical meaning and the interpretation of various miRs findings, and their potential application in routine clinical practice.

Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study

INTRODUCTION

Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated.

AIM

To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS.

MATERIALS AND METHODS

In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months.

RESULTS

Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22).

CONCLUSIONS

MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

BACKGROUND

Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS.

METHODS

A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up.

RESULTS

There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04).

CONCLUSION

The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

Treatment of the Carotid In-stent Restenosis: A Systematic Review

Background and Purpose: In-stent restenosis (ISR) after carotid artery stent (CAS) is not uncommon. We aimed to evaluate therapeutic options for ISR after CAS. Methods: We searched PubMed and EMBASE until November 2, 2020 for studies including the treatment for ISR after CAS. Results: In total, 35 studies, covering 1,374 procedures in 1,359 patients, were included in this review. Most cases (66.3%) were treated with repeat CAS (rCAS), followed by percutaneous transluminal angioplasty (PTA) (17.5%), carotid endarterectomy (CEA) (14.3%), carotid artery bypass (1.5%), and external beam radiotherapy (0.4%). The rates of stroke & TIA within the postoperative period were similar in three groups (PTA 1.1%, rCAS 1.1%, CEA 1.5%). CEA (2.5%) was associated with a slightly higher rate of postoperative death than rCAS (0.7%, P = 0.046). Furthermore, the rate of long-term stroke & TIA in PTA was 5.7%, significantly higher than rCAS (1.8%, P = 0.036). PTA (27.8%) was also associated with a significantly higher recurrent restenosis rate than rCAS (8.2%, P = 0.002) and CEA (1.6%, P < 0.001). The long-term stroke & TIA and recurrent restenosis rates showed no significant difference between rCAS and CEA. Conclusions: rCAS is the most common treatment for ISR, with low postoperative risk and low long-term risk. CEA is an important alternative for rCAS. PTA may be less recommended due to the relatively high long-term risks of stroke & TIA and recurrent restenosis.

Long-term survival of carotid stenting patients with regard to single- or double-vessel carotid artery disease: a propensity score matching analysis

INTRODUCTION

There is lack of long-term data outside of controlled clinical trials in carotid artery stenting (CAS). In this study, we compared the short-term outcome, long-term survival, and rate of re-interventions for restenosis in patients after CAS, related to the extent of carotid atherosclerosis classified as single-vessel (unilateral) or double-vessel (bilateral) carotid artery disease.

MATERIAL AND METHODS

We retrospectively evaluated 599 patients with significant carotid artery stenosis, who underwent 763 CAS procedures, and used the propensity score to match 226 pairs (452 patients) in the single- or double-vessel carotid disease.

RESULTS

There was no significant difference in the occurrence of in-hospital major adverse events (3.5% vs. 3.1% of patients in the double-vessel carotid group vs. the single-vessel carotid group; p = 1) The mean follow-up was 6.1 ±4.0 years, and a total of 181 (40%) deaths occurred during 2759 patient-years, which translates into 7.8 and 5.3 deaths per 100 patient-years in the double-vessel carotid group and the single-vessel carotid group, respectively (p < 0.01). The survival in the double-vessel carotid group vs. the single-vessel carotid group at 10 years was 46% (95% CI: 38-54%) vs. 55% (95% CI: 47-63%) (p < 0.01). Twenty-four (11%) patients and 6 (3%) patients underwent re-interventions for restenosis in the double-vessel and the single-vessel carotid disease group, respectively (p < 0.01).

CONCLUSIONS

Patients with CAS and significant double-vessel carotid artery disease had similar peri-procedural risk, but had a worse long-term survival, and a higher rate of re-interventions for restenosis compared to the single-vessel carotid artery disease patients.

Carotid artery stenting with Roadsaver stent. Early and four-year results from a single-center registry

INTRODUCTION

Prevention of peri- and postprocedural complications is still a challenge in carotid artery stenting (CAS).

AIM

To assess immediate and long-term safety and effectiveness of CAS using the Roadsaver double-nitinol-layer-micromesh stent.

MATERIAL AND METHODS

Since 2014, 298 CAS procedures in 287 non-consecutive patients (203 men, mean age 70.5 ±8.6 years, 100% symptomatic/high risk lesions) have been performed using the Roadsaver stent and proximal (40%) or distal (60%) neuroprotection system. Clinical and neurological examinations as well as duplex ultrasound were completed before CAS, before discharge, at 1, 6 and 12 months, then annually.

RESULTS

All CAS procedures were successful. Carotid stenosis was reduced from 84.9 ±9.9% to 11.0 ±9.4% (p < 000.1). In hospital, 1 ipsilateral periprocedural major (0.3%) and 3 minor (1.34%) ischemic strokes occurred, 2 (0.7%) patients died due to a cerebral hemorrhage on day 9 and 21. Three (1.0%) additional ipsilateral minor strokes within 30 consecutive days occurred. Thus, 30-day complications were observed in 9 (3.0%) patients. Two minor strokes were associated with in-stent thrombosis (0.7%). The 4-year follow-up showed 82% overall survival (95% CI: 69-91%) with no significant difference between asymptomatic (77%) and symptomatic patients (97%; p = 0.076). The stroke-free survival was 89% (95% CI: 77-95%), 84% asymptomatic vs. 98% symptomatic (p = 0.187). Seven (2.3%) patients developed > 50% in-stent restenosis.

CONCLUSIONS

Carotid artery stenting using the Roadsaver stent for symptomatic patients and high risk lesions showed to be safe and effective, with a low complication rate and acceptable in-stent restenosis risk in 4-year follow-up.