Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis

OBJECTIVE

The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS.

METHODS

A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS.

RESULTS

BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking.

CONCLUSIONS

The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.

Pseudoaneurysm temporary embolization as a new method for the management of catheter-related complication

A new minimally invasive method for the management of catheter-related pseudoaneurysms (PSAs) using percutaneous temporary guidewire embolization (TGE) is presented. We performed percutaneous insertion of a flexible 0.018-in. guidewire into the PSA cavity under ultrasound guidance. Once thrombosis of the PSA cavity was achieved, the guidewire was removed. In all seven cases, TGE was technically feasible and achieved complete thrombosis of the PSA. The time required for PSA thrombosis from insertion to removal of the guidewire ranged from 5 to 40 minutes. TGE is a highly effective, safe, and minimally invasive treatment of PSA.

Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

OBJECTIVE

To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients.

METHODS

Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines.

RESULTS

Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation.

CONCLUSION

Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

[Resuscitative endovascular balloon occlusion of the aorta in haemodynamically unstable patients with bleeding (webinar review)]

This article reviews a webinar of the European Society for Vascular Surgery and the Endovascular Trauma and Resuscitation Management Society, dedicated to using endovascular balloon occlusion of the aorta in haemodynamically unstable patients, briefly covering the main conclusions of the reports and underlining prospects of this method. Possibilities of using aortic balloon occlusion arise interest of various-specialty medical experts, and the number of scientific works in this field has increasingly been growing, thus explaining the need for measures and studies on the subject concerned.

[Modern strategy to improve remote results of surgical treatment of peripheral artery disease]

Treatment of patients presenting with peripheral artery disease requires a comprehensive approach: correction of risk factors, drug therapy and, if necessary, an endovascular/hybrid/open intervention. Reconstructive operation may effectively improve a patient's quality of life in intermittent claudication, save the limb and life in case of severe ischaemia. Discussed in the article are advantages and disadvantages of various types of surgical interventions for peripheral artery disease, the concept PLAN (Patient risk, Limb severity, and ANatomic complexity) and the new Global Anatomic Staging System (GLASS). Good remote results may be ensured by adequate medicamentous therapy. Variations of antithrombotic therapy are versatile and debatable. Long-term dual antithrombotic or systemic anticoagulant therapy with administration of vitamin K antagonists are not indicated for peripheral artery disease. In this connection, the findings of the COMPASS and VOYAGER PAD studies are analysed. The VOYAGER PAD trial showed that in patients with peripheral artery disease who underwent revascularization of lower limbs, the addition of rivaroxaban at a dose of 2.5 mg twice daily to aspirin decreased the risk of lower-extremity unfavourable ischaemic events and major adverse cardiovascular events by 15%. The obtained findings open new possibilities of conservative therapy having a significant role in decreasing the risk for development of limb-threatening conditions.

[Antithrombotic therapy in patients with peripheral artery diseases]

Complications of cardiovascular diseases whose substrate is atherothrombosis continue to occupy leading positions in the structure of mortality worldwide. Peripheral artery diseases (PAD), in particular, are characterized by an especially unfavourable life prognosis for patients with cardiovascular diseases. In order to decrease the risks of ischaemic complications in patients with PAD, various approaches to antithrombotic therapy have over the last two decades been studied, with the resulting standard of therapy continuing to be acetylsalicylic acid. Even more difficult today is the task of selecting antithrombotic therapy in patients having endured revascularization.

[The modern principles of management of intermittent claudication]

Number of patients with peripheral arterial disease, despite various national public health programs, remains high and has no steady downward trend over the past few decades. Despite recent advances in drug therapy, сonservative approach in the management of peripheral arterial disease is often neglected by vascular surgeons. However, vast majority of patients with intermittent claudication, who receive comprehensive conservative treatment, including risk factor modification, exercise and drug therapy, may get significant improvement in quality of life by partial or complete relief of symptoms related to the disease. Patients strictly adhering to medical recommendations has favorable prognosis and progression of disease to the stage of critical limb ischemia is very unlikely. Noncompliant patients and those who continue smoking in particular, often experience progression of symptoms related to the disease. That may result in the need for surgical intervention aiming to prevent or delay the onset of critical limb ischemia.

[Stagewise treatment of a patient with multifocal atherosclerosis, limb ischaemia, and surgical infection]

The authors share herein their experience in successful treatment of a male patient with multifocal atherosclerosis and lower-limb critical ischaemia complicated by erysipelas.

THE AIM OF THE WORK

to show not only efficacy of iloprost (Ilomedin) used as conservative treatment in patients presenting with critical ischaemia and surgical infection in both pre- and postoperative periods in order to save the limb, but also the possibility of postponing reconstructive intervention, improving the patient's quality of life during this period, as well as shortening the duration of the postoperative period, and also to demonstrate both immediate outcomes of endovascular repair of an abdominal aortic aneurysm and remote results of comprehensive treatment for disseminated multifocal atherosclerosis with severe accompanying pathology.

[Optimization of the technique of the vascular anastomosis formation in reconstructive surgery of lower extremity arteries]

In reconstructive surgery of arteries of the femoro-popliteal-tibial segment the leading role belongs to autovenous bypass surgery. The standard kind of vascular bypass applied during this procedure is bypass "autovein end to the artery side" using the "parachute technique". The classical method means constant help of an assistant, certain inconvenience associated with inadequate fixation and positioning the autovein end, it also does not exclude risk of traumatism of the bypass posterior wall. The article presents an optimized variant of the technique of forming the "autovein end to the artery side" bypass using improved surgical instruments: atraumatic pincers and retractor and a proposed for the first time vascular dilatator.