Endovascular Management of Post-Irradiated Carotid Blowout Syndrome in Patients with Lower Neck Cancers

OBJECTIVE

Lower neck cancers (LNCs) include specific tumour types and have some different vascular supply or collaterals from other head and neck cancers. This prospective study evaluated the outcome of endovascular management of post-irradiated carotid blowout syndrome (PCBS) in patients with LNC by comparing reconstructive management (RE) and deconstructive management (DE).

METHODS

This was a single centre, prospective cohort study. Patients with LNC complicated by PCBS between 2015 and 2021 were enrolled for RE or DE. RE was performed by stent graft placement covering the pathological lesion and preventive external carotid artery (ECA) embolisation without balloon test occlusion (BTO). DE was performed after successful BTO by permanent coil or adhesive agent embolisation of the internal carotid artery (ICA) and ECA to common carotid artery, or ICA occlusion alone if the pathological lesion was ICA only. Cross occlusion included the proximal and distal ends of the pathological lesion in all patients. Re-bleeding events, haemostatic period, and neurological complications were evaluated.

RESULTS

Fifty-nine patients (mean age 58.5 years; 56 male) were enrolled, including 28 patients undergoing RE and 31 patients undergoing DE. Three patients originally grouped to DE were transferred to RE owing to failed BTO. The results of RE vs. DE were as follows: rebleeding events, 13/28 (46%) vs. 10/31 (32%) (p = .27); haemostatic period, 9.4 ± 14.0 months vs. 14.2 ± 27.8 months (p = .59); neurological complication, 4/28 (14%) vs. 5/31 (16%) (p = .84); and survival time, 11.8 ± 14.6 months vs. 15.1 ± 27.5 months (p = .61).

CONCLUSION

No difference in rebleeding risk or neurological complications was observed between the DE and RE groups. RE could be used as a potential routine treatment for PCBS in patients with LNC.

Tophi and carotid atherosclerosis in gout patients: Role of insulin resistance

BACKGROUND AND AIM

Gout and cardiovascular disease are closely related, but the mechanism linking them is still unknown. Gout may affect the insulin signaling pathway inducing insulin resistance (IR). The study aims to evaluate the association between tophi and carotid atherosclerosis, considering the potential role of IR.

METHODS AND RESULTS

A total of 595 patients with gout aged 18 to 80 were enrolled in this study. Carotid intima-media thickness, plaques and tophi were evaluated by B-mode ultrasonography. IR was assessed by the HOMA index (hepatic IR) and Gutt index (peripheral IR). Multivariable logistic regression and interaction analysis were used to examine the association between tophi and IR and its impact on carotid atherosclerosis. Among these participants, the average age was 55.4 (±12.54) years, and 94.6 % were male. Tophi were associated with increased odds of carotid atherosclerosis and burden after adjustment for confounders (P < 0.05). Tophi and IR synergically interacted for inducing carotid atherosclerosis. The interaction between peripheral IR with tophi was more pronounced than hepatic IR with tophi.

CONCLUSIONS

Tophi were independently associated with carotid atherosclerosis risk. IR mediated a significant amount of the effect of tophi on the development of carotid atherosclerosis. Peripheral IR probably plays a more important role than hepatic IR does.

Relationships of serum FGF23 and α-klotho with atherosclerosis in patients with type 2 diabetes mellitus

BACKGROUND

Compelling evidence suggests that calcium/phosphorus homeostasis-related parameters may be linked to diabetes mellitus and cardiovascular events. However, few studies have investigated the association of fibroblast growth factor 23 (FGF23), α-klotho and FGF23/α-klotho ratio with atherosclerosis in patients with type 2 diabetes mellitus (T2DM).

OBJECTIVE

This study was designed to evaluate whether FGF23, α-klotho and FGF23/α-klotho ratio are associated with T2DM and further to explore the relationships between these three factors and atherosclerosis in Chinese patients with T2DM.

METHODS

Serum FGF23 and α-klotho levels were measured via an enzyme-linked immunosorbent assay (ELISA) kit, and the carotid intima-media thickness (CIMT) was assessed via high-resolution color Doppler ultrasonography. The associations of serum FGF23, α-klotho and FGF23/α-klotho ratio with atherosclerosis in T2DM patients were evaluated using multivariable logistic regression models.

RESULTS

This cross-sectional study involved 403 subjects (207 with T2DM and 196 without T2DM), 41.7% of the patients had atherosclerosis, and 67.2% of the carotid intima were thickened to a thickness greater than 0.9 mm. Compared with those in the lowest tertile, higher tertiles of FGF23 levels and FGF23/α-klotho ratio were positively associated with T2DM after adjusting for covariates, and serum α-klotho concentration was inversely correlated with T2DM (all P values < 0.01). Moreover, elevated serum FGF23 levels and FGF23/α-klotho ratio were positively associated with CIMT and carotid atherosclerosis in T2DM patients (all P values < 0.01). Further spline analysis similarly revealed linear dose‒response relationship (all P values < 0.01). And there was still significant differences in CIMT and carotid atherosclerosis between the highest group of α-klotho and the reference group in T2DM patients (P values = 0.05).

CONCLUSIONS

T2DM was positively linearly related to serum FGF23 concentration and FGF23/α-klotho ratio, and negatively correlated with serum α-klotho concentration. Furthermore, both FGF23 and FGF23/α-klotho ratio were positively correlated with CIMT and atherosclerosis in T2DM patients, while α-klotho was inversely correlated with both CIMT and atherosclerosis, although the associations were not completely significant. Prospective exploration and potential mechanisms underlying these associations remain to be further elucidated.

Microplastics and Nanoplastics in Atheromas and Cardiovascular Events

BACKGROUND

Microplastics and nanoplastics (MNPs) are emerging as a potential risk factor for cardiovascular disease in preclinical studies. Direct evidence that this risk extends to humans is lacking.

METHODS

We conducted a prospective, multicenter, observational study involving patients who were undergoing carotid endarterectomy for asymptomatic carotid artery disease. The excised carotid plaque specimens were analyzed for the presence of MNPs with the use of pyrolysis-gas chromatography-mass spectrometry, stable isotope analysis, and electron microscopy. Inflammatory biomarkers were assessed with enzyme-linked immunosorbent assay and immunohistochemical assay. The primary end point was a composite of myocardial infarction, stroke, or death from any cause among patients who had evidence of MNPs in plaque as compared with patients with plaque that showed no evidence of MNPs.

RESULTS

A total of 304 patients were enrolled in the study, and 257 completed a mean (±SD) follow-up of 33.7±6.9 months. Polyethylene was detected in carotid artery plaque of 150 patients (58.4%), with a mean level of 21.7±24.5 μg per milligram of plaque; 31 patients (12.1%) also had measurable amounts of polyvinyl chloride, with a mean level of 5.2±2.4 μg per milligram of plaque. Electron microscopy revealed visible, jagged-edged foreign particles among plaque macrophages and scattered in the external debris. Radiographic examination showed that some of these particles included chlorine. Patients in whom MNPs were detected within the atheroma were at higher risk for a primary end-point event than those in whom these substances were not detected (hazard ratio, 4.53; 95% confidence interval, 2.00 to 10.27; P<0.001).

CONCLUSIONS

In this study, patients with carotid artery plaque in which MNPs were detected had a higher risk of a composite of myocardial infarction, stroke, or death from any cause at 34 months of follow-up than those in whom MNPs were not detected. (Funded by Programmi di Ricerca Scientifica di Rilevante Interesse Nazionale and others; ClinicalTrials.gov number, NCT05900947.).

Adherence to an energy-restricted Mediterranean diet is associated with the presence and burden of carotid atherosclerosis in people with type 1 diabetes

AIMS

People with type 1 diabetes (T1D) have an increased risk of cardiovascular disease (CVD). The Mediterranean diet is associated with reduced CVD; however, the evidence in T1D is scarce. We aimed to analyse the relationships between adherence to the energy-restricted Mediterranean diet (erMEDd) and carotid atherosclerosis.

MATERIALS AND METHODS

We included children with T1D without CVD, with ≥1 of the following: age ≥40 years, diabetic kidney disease, or ≥10 years of disease duration with another risk factor. Plaque presence (intima-media thickness ≥1.5 mm) was determined by ultrasonography. The PREDIMED-Plus 17-item questionnaire (PP-17) was used to assess adherence to the erMEDd.

RESULTS

Four hundred one individuals were included (48% males, age 48.3 ± 11 years, diabetes duration 26.8 ± 11.4 years). Those harbouring plaques (42%) showed lower adherence to the erMEDd (PP-17: 8.9 ± 2.3 of a maximum of 17 vs. 9.8 ± 2.5, p < 0.001). Greater adherence to the erMEDd was correlated with an overall better metabolic profile. After adjusting for multiple confounders, adherence to the erMEDd was independently associated with carotid atherosclerosis (OR 0.86 [0.77-0.95] for plaque presence and OR 0.85 [0.75-0.97] for ≥2 plaques). The consumption of fruit and nuts and preference of white over red meat was higher in individuals without atherosclerosis (p < 0.05). Fruit and nut consumption was associated with lower plaque prevalence in the fully adjusted models (OR 0.38 [0.19-0.73] and 0.51 [0.29-0.93]).

CONCLUSIONS

Greater adherence to the erMEDd is associated with less carotid atherosclerosis in children with T1D at high risk of CVD. Strategies to improve and implement healthy dietary patterns in this population should be encouraged.

Complication of head and neck cancer: Carotid blowout syndrome

Carotid blowout syndrome (CBS) is an uncommon but potentially life-threatening condition characterized by the spontaneous or traumatic rupture of the carotid artery in the neck. Oftentimes, CBS is due a loss of structural arterial integrity from local radiotherapy or surgical procedures. A vast majority of patients who develop CBS also have a previous diagnosis of head and neck cancer. Due to the specific patient population who develop CBS and its life-threatening nature, CBS should be a part of emergency physicians differential for those who present with a chronic neck wound or neurological symptoms in those with a previous head and neck cancer diagnosis. In this case report, a patient with a history of squamous cell carcinoma of the oropharynx who was treated with chemoradiation therapy, presented to the emergency department with spontaneous bleeding from an existing chronic wound on the left lateral neck. Conservative measures were taken including wound dressing, and the patient was discharged to see dermatology for biopsy of a suspected cancerous lesion. Once the chronic lesion was biopsied, the patient had to be immediately rushed to the operating room due to a brisk pulsatile bleeding from puncturing the carotid artery. Proper wound packing and an ultrasound of the neck for a proper diagnosis may have prevented the need for surgical intervention in this case. Although CBS is not common, complications can lead to death as seen in this case. Timely recognition and proper interventions are critical for preventing potentially fatal outcomes in those with CBS.

Metabolically healthy obesity, transition from metabolic healthy to unhealthy status, and carotid atherosclerosis

BACKGROUND

Evidence of the effects of metabolically healthy obesity (MHO) on atherosclerosis is limited; the transition effects of metabolic health and obesity phenotypes have been ignored. We examined the association between metabolic health and the transition to atherosclerosis risk across body mass index (BMI) categories in a community population.

METHODS

This cross-sectional study was based on a national representative survey that included 50,885 community participants aged ≥40 years. It was conducted from 01 December 2017 to 31 December 2020, in 13 urban and 13 rural regions across Hunan China. Metabolic health was defined as meeting less than three abnormalities in blood pressure, glucose, high-density lipoprotein cholesterol, triglycerides, or waist circumference. The participants were cross-classified at baseline based on their metabolic health and obesity. In addition, the relationship between atherosclerosis and transitions in metabolic health status based on 4733 participants from baseline to the second survey after 2 years was considered. The relationship between metabolic health status and the risk of transition to Carotid atherosclerosis (CA) was assessed using logistic regression and Cox proportional hazards regression analyses.

RESULTS

In this study, the mean age of the participants was 60.7 years (standard deviation [SD], 10.91), 53.0% were female, and 51.2% had CA. As compared with metabolically healthy normal weight (MHN), those with MHO phenotype (odd ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.21), metabolically unhealthy normal weight (OR 1.27, 95% CI 1.19-1.35), metabolically unhealthy overweight (OR 1.41, 95% CI 1.33-1.48), and metabolically unhealthy obese (OR 1.54, 95% CI 1.44-1.64) had higher risk for CA. However, during the follow-up of 2 years, almost 33% of the participants transitioned to a metabolically unhealthy status. As compared with stable healthy normal weight, transition from metabolically healthy to unhealthy status (hazard ratios [HR] 1.21, 95% [CI] 1.02-1.43) and stable metabolically unhealthy overweight or obesity (MUOO) (HR 1.32, 95% CI 1.17-1.48) were associated with higher risk of CA.

CONCLUSIONS

In the community population, obesity remains a risk factor for CA despite metabolic health. However, the risks were highest for metabolically unhealthy status across all BMI categories. A large proportion of metabolically healthy overweight or participants with obesity converts to an unhealthy phenotype over time, which is associated with an increased risk of CA.

Carotid intima layer thickness but not intima-media thickness is related to coronary artery calcification in type 2 diabetes individuals: Results from the Brazilian diabetes study

BACKGROUND AND AIMS

Carotid intima-media thickness (cIMT) is inconsistent in predicting cardiovascular risk. This may stem from the variability of the media thickness (cM) outweighing the intimal thickness (cIT) as the sign of atherosclerosis. Thus, we evaluated in type 2 diabetes (T2D) individuals, the association between carotid measures and coronary artery calcification (CAC).

METHODS AND RESULTS

Association between the presence of CAC and cIT, cM, and cIMT were examined on 224 individuals. Logistic binary regression was used to assess CAC predictors. The Akaike information criterion (AIC) and log-likelihood test (LLT) were used to assess differences among univariate models. The cIT (0.335 mm vs 0.363 mm; p = 0.001) and cIMT (0.715 vs 0.730; p = 0.019), but not cM (0.386 mm vs 0,393 mm; p = 0.089) were higher among individuals with CAC. In unadjusted analysis, cIT (273;-134; p = 0.001) showed greater relationship with CAC, when compared to cIMT (279;-137; p = 0.022) and cM (281;-139; p = 0.112) based on the AIC and LLT, respectively. In multivariate logistic regression, CAC was related to carotid plaque (OR): 1.91, 95% confidence interval (CI):1.08, 3.38; p = 0.027), and high-cIT (OR: 2.70, 95%CI:1.51, 4.84; p = 0.001), but not to high-cIMT (OR:1.70, 95%CI:0.96, 3.00; p = 0.067) nor high-cM (OR:1.33, 95%CI:0.76, 2.34; p = 0.322).

CONCLUSION

In T2D individuals, cIT is a better predictor of CAC than cIMT; cM is not associated with CAC.

The association between metabolic dysfunction-associated steatotic liver disease, cardiovascular and cerebrovascular diseases and the thickness of carotid plaque

BACKGROUND

The relationship between metabolic dysfunction-associated steatotic liver disease (MASLD) and atherosclerosis has been controversial, which has become a hit of recent research. The study aimed to explore the association between MASLD, cardiovascular and cerebrovascular diseases (CCVD), and the thickness of carotid plaque which was assessed by ultrasound.

METHODS

From September 2018 to June 2019, 3543 patients were enrolled. We asked participants to complete questionnaires to obtain information. All patients underwent liver ultrasound and bilateral carotid ultrasound to obtain carotid intima-media thickness (IMT) and maximum carotid plaque thickness (CPT). Hepatic steatosis was quantified during examination according to Hamaguchi's ultrasonographic score, from 0 to 6 points. A score < 2 was defined as without fatty liver, and a score ≥ 2 was defined as fatty liver. Information about blood lipids was collected based on the medical records.

RESULTS

We found common risk factors for CCVD events, MASLD, and atherosclerosis. There was a significant correlation between MASLD and carotid plaque, but not with CPT. No association was found between MASLD and CCVD events. CPT and IMT were thicker in CCVD patients than in non-CCVD patients. No significant difference was found between IMT and CPT in MASLD patients and non-MASLD patients. CCVD was independently and consistently associated with higher IMT, and free fatty acid (FFA).

CONCLUSIONS

According to our results, we recommend carotid ultrasound examination of the patients when FFA is increased, regardless of the presence of risk factors and MASLD. Due to the distribution of CPT of both CCVD and MASLD patients in the CPT 2-4 mm group, contrast-enhanced ultrasound is necessary to assess the vulnerability of the plaque when CPT ≥ 2 mm. Timely treatment of vulnerable plaques may reduce the incidence of future CCVD events.

Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience

To explore the treatments for and manifestations of carotid blowout syndrome (CBS) and to further explore the critical role of high-flow bypass combined with parent artery isolation. The clinical data of nine patients with radiotherapy-related CBS who were admitted to our hospital from March 2020 to March 2023 were retrospectively analyzed. Relevant literature was reviewed. From March 2020 to March 2023, nine CBS patients were admitted to Tianjin Huanhu Hospital, including eight males and one female. Digital subtraction angiography was performed for all the patients; all the pseudoaneurysms were located at the petrous segment of the internal carotid artery. A balloon occlusion test was performed on four patients, which was tolerated by all patients. CT and MRI scans showed seven cases of osteonecrosis combined with infection and two cases of tumor recurrence. Emergency permanent parent artery occlusion was performed on six patients, aneurysm embolization was completed in one case, covered stent implantation was performed in one patient, and three cases were treated by cerebral bypass surgery (including two patients with failed interventional treatment). Rebleeding was found in two patients, and no rebleeding was found in the bypass group. Paralysis was found in three patients, and asymptomatic cerebral infarction without permanent neurologic impairment was found in three patients. Two patients died due to tumor progression. Emergency occlusion surgery is lifesaving in the acute phase of CBS. Endovascular therapy cannot prevent the progression of pseudoaneurysms or lower the recurrence rate of bleeding events. High-flow bypass combined with parent artery isolation is a safe and effective method that may facilitate further surgical treatment. Further research is warranted.

Prevalence and factors associated with carotid atherosclerosis in a Malagasy population with Type 2 diabetes mellitus: A cross-sectional retrospective study

AIM

Our study aims to determine the prevalence and factors associated with carotid atherosclerosis in Malagasy Type 2 diabetes mellitus (T2DM).

METHODS

This was a cross-sectional retrospective study, carried out over a period of 30 months. The diagnosis of carotid atherosclerosis is established by the presence of a carotid plaque increased carotid intima-media thickness ≥1.1 mm on Doppler ultrasound.

RESULTS

We included 132 T2DM. The prevalence of carotid atherosclerosis was 63.6% (38.6% carotid plaque and 25% intima-media thickening). After univariate analysis, the factors associated with carotid atherosclerosis were age ≥70 years (3.28 [1.18-10, 62]), previous intake of oral antidiabetics (0.33 [0.14-0.73]), insulin (0.28 [0.11-0.66]) and angiotensin receptor blocker (0.45 [0.20-0.98]), and current smoking (5.93 [1.64-32.6]). After adjustment for age and gender, previous intake of oral antidiabetics (0.29 [0.13-0.64]), insulin (0.27 [0.12-0.61]) and angiotensin receptor blocker (0.40 [0.19-0.86]), and current smoking (5.98 [1.61-22.1]) were associated with carotid atherosclerosis.

CONCLUSION

Smoking cessation, education on therapeutic compliance and comprehensive management of all cardiovascular risk factors and T2DM are therefore essential in order to reduce the occurrence of carotid atherosclerosis.

Perirenal fat thickness as a superior obesity-related marker of subclinical carotid atherosclerosis in type 2 diabetes mellitus

Objective

Emerging evidence highlighted that perirenal adipose tissue might regulate the cardiovascular and metabolism system through several pathways. This study aimed to assess the association between perirenal fat thickness (PrFT) and subclinical carotid atherosclerosis (SCCA) in type 2 diabetes mellitus (T2DM).

Method

A total of 670 participants with complete data were included in this study. The trained reviewer collected demographic and anthropometric information. Laboratory assessments were determined by standard methods. PrFT and SCCA were evaluated by computed tomography and ultrasound. Binomial logistic regression analysis was conducted to assess the association between PrFT and SCCA. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the identifying value of PrFT for SCCA.

Results

Overall, the prevalence of SCCA was 61.8% in T2DM. PrFT was significantly increased in the SCCA group. Growing trends were observed in the prevalence of hypertension, carotid intima-media thickness (cIMT) > 1, plaque, and SCCA across the PrFT quartiles. Spearman correlation analysis revealed that PrFT was positively associated with cIMT (r = 0.401, p < 0.001). This correlation remained significant after adjustment for visceral fat area (VFA), subcutaneous fat area (SFA), and traditional metabolic risk factors (β = 0.184, p < 0.001). Meanwhile, PrFT was independently correlated with plaque, cIMT > 1 mm, and SCCA. The ORs (95% CI) were 1.072 (1.014-1.135), 1.319 (1.195-1.455), and 1.216 (1.119-1.322). Furthermore, PrFT remained correlated considerably with SCCA in subgroup analysis after stratification for age, sex, smoking, hypertension, and body mass index. From the ROC curve analysis, the AUCs (95% CI) of PrFT, VFA, and SFA identifying SCCA were 0.794 (0.760-0.828), 0.760 (0.724-0.796), and 0.697 (0.656-0.737), respectively. The AUC of PrFT was significantly higher than VFA (p = 0.028) and SFA (p < 0.001). The optimal cutoff values of PrFT were 14.0 mm, with a sensitivity of 66.7% and a specificity of 76.2%.

Conclusion

PrFT was independently associated with cIMT, plaque, cIMT > 1 mm, and SCCA as a superior obesity-related marker of SCCA in T2DM.

Clinical trial registration

Clinical Trials.Gov, identifier ChiCTR2100052032.

Deconstructive vs. reconstructive endovascular treatment paradigms in acute carotid blowout

BACKGROUND

Carotid Blowout (CBO), a neuro-oncological emergency characterized by the rupture of the carotid artery, has been predominantly reported in patients with head and neck cancer who have undergone radiation therapy. In this study, our objective is to share our experience with deconstructive and reconstructive endovascular treatments for CBO.

METHODS

This study includes 17 patients who experienced intractable acute CBO, presenting with ear, oral, or nasal bleeding, between 2003 and 2022. We employed deconstructive embolization using vascular plugs, expanding hydrogel coils, glue, and balloons. If vascular anatomy and pathology permitted, we opted for reconstructive treatment using a covered stent. All patients underwent clini-cal follow-up visits, and we used the modified Rankin Scale to evaluate the clinical success of the procedures. We compared outcomes in terms of complications between the deconstructive and reconstructive treatment methods using the Chi-square test.

RESULTS

The patient cohort had an age range of 20-64 years (mean 50.9), including three females (18%) and 14 males (82%). We conducted 15 endovascular procedures on 14 patients during 19 angiography sessions. All 15 treatments achieved immediate hemo-stasis, resulting in complete technical success (p=1.0). Six patients (35%) underwent reconstructive treatments with covered stents in the internal carotid artery, while nine patients (65%) underwent deconstructive embolization in either the external or internal carotid artery. We found no significant association between the treatment paradigms (deconstructive vs. reconstructive) and the development of complications using a Chi-square test of independence X² (2, n=15)=0.07, p=0.79.

CONCLUSION

Recent advancements in endovascular treatments have shown promising results in managing life-threatening acute CBO cases. Our study found no significant difference in outcomes between deconstructive and reconstructive endovascular paradigms in such patients. However, it is important to note that the available data, including ours, is heterogeneous and scarce, necessitating higher levels of evidence to draw more definitive conclusions.

Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement

Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.

Circulating interleukin-6 and cardiovascular disease risk in patients with rheumatoid arthritis with low disease activity due to active therapy

OBJECTIVES

Interleukin-6 (IL-6) has been implicated in the pathophysiology of rheumatoid arthritis (RA) and in the development of atherosclerosis in the general population. In the present work we aimed to study if IL-6 serum levels have an influence on factors associated with cardiovascular (CV) disease in a cohort of Spanish patients with RA.

METHODS

Cross-sectional study that encompassed 407 patients with RA. Serum IL-6 levels were assessed. Multivariable analysis was performed to examine the relationship of IL-6 to subclinical carotid atherosclerosis and classic CV risk factors, including a comprehensive lipid molecule profile and indices of insulin resistance and beta-cell function.

RESULTS

Circulating levels of IL-6 showed a correlation with acute phase reactants, disease activity, and other features of RA. However, classic CV risk factors, lipid profile and indices of insulin resistance, as well as subclinical carotid atherosclerosis, were not associated with serum IL-6 levels.

CONCLUSIONS

Although a direct association between IL-6 levels and traditional CV risk factors and subclinical carotid atherosclerosis was not observed, circulating IL-6 was associated with disease activity and acute-phase reactants, which have been associated with an increased risk of CV in these patients.

Total carotene plasma concentrations are inversely associated with atherosclerotic plaque burden: A post-hoc analysis of the DIABIMCAP cohort

BACKGROUND AND AIMS

Atherosclerosis is the major risk factor for cardiovascular disease (CVD), the first cause of death worldwide. Chronic low-grade inflammation and a sustained oxidative milieu are causatively related to atherosclerosis onset and progression, and therefore, dietary patterns rich in bioactive compounds with anti-inflammatory and antioxidant activities might likely contribute to revert or slowing the progression of atherosclerosis. The aim of this study is to analyse the association between fruit and vegetables intake, quantitatively measured through carotene plasma concentrations, and atherosclerotic burden, as a surrogate biomarker of CVD, in free-living subjects from the DIABIMCAP cohort study.

METHODS

The 204 participants of the DIABIMCAP Study cohort (Carotid Atherosclerosis in Newly Diagnosed Type 2 Diabetic Individuals, ClinicalTrials.gov Identifier: NCT01898572), were included in this cross-sectional study. Total, α-, and β-carotenes were quantified by HPLC-MS/MS. Lipoprotein analysis in serum was performed by 2D- 1H NMR- DOSY, and atherosclerosis and intima media thickness (IMT) were measured through standardized bilateral carotid artery ultrasound imaging.

RESULTS

Subjects with atherosclerosis (n = 134) had lower levels of large HDL particles than subjects without atherosclerosis. Positive associations were found between α-carotene and both large and medium HDL particles, and inverse associations were found between β- and total carotene, and VLDL and its medium/small particles. Subjects with atherosclerosis presented significantly lower plasma concentrations of total carotene compared with subjects without atherosclerosis. Plasma concentrations of carotene decreased as the number of atherosclerotic plaques increased, although after multivariate adjustment, the inverse association between β- and total carotene with plaque burden remained significant only in women.

CONCLUSIONS

A diet rich in fruit and vegetables results in higher plasmatic carotene concentrations, which are associated with a lesser atherosclerotic plaque burden.

Associations of alcohol intake with subclinical carotid atherosclerosis in 22,000 Chinese adults

BACKGROUND AND AIMS

We investigated the causal relevance of alcohol intake with measures of carotid artery thickness and atherosclerosis in Chinese adults.

METHODS

The study included 22,384 adults from the China Kadoorie Biobank, with self-reported alcohol use at baseline and resurvey, carotid artery ultrasound measurements, and genotyping data for ALDH2-rs671 and ADH1B-rs1229984. Associations of carotid intima media thickness (cIMT), any carotid plaque, and total plaque burden (derived from plaque number and size) with self-reported (conventional analyses) and genotype-predicted mean alcohol intake (Mendelian randomization) were assessed using linear and logistic regression models.

RESULTS

Overall 34.2% men and 2.1% women drank alcohol regularly at baseline. Mean cIMT was 0.70 mm in men and 0.64 mm in women, with 39.1% and 26.5% having carotid plaque, respectively. Among men, cIMT was not associated with self-reported or genotype-predicted mean alcohol intake. The risk of plaque increased significantly with self-reported intake among current drinkers (odds ratio 1.42 [95% CI 1.14-1.76] per 280 g/week), with directionally consistent findings with genotype-predicted mean intake (1.21 [0.99-1.49]). Higher alcohol intake was significantly associated with higher carotid plaque burden in both conventional (0.19 [0.10-0.28] mm higher per 280 g/week) and genetic analyses (0.09 [0.02-0.17]). Genetic findings in women suggested the association of genotype-predicted alcohol with carotid plaque burden in men was likely to due to alcohol itself, rather than pleiotropic genotypic effects.

CONCLUSIONS

Higher alcohol intake was associated with a higher carotid plaque burden, but not with cIMT, providing support for a potential causal association of alcohol intake with carotid atherosclerosis.

Childhood Dyslipidemia and Carotid Atherosclerotic Plaque in Adulthood: The Cardiovascular Risk in Young Finns Study

Background Childhood exposure to dyslipidemia is associated with adult atherosclerosis, but it is unclear whether the long-term risk associated with dyslipidemia is attenuated on its resolution by adulthood. We aimed to address this question by examining the links between childhood and adult dyslipidemia on carotid atherosclerotic plaques in adulthood. Methods and Results The Cardiovascular Risk in Young Finns Study is a prospective follow-up of children that began in 1980. Since then, follow-up studies have been conducted regularly. In 2001 and 2007, carotid ultrasounds were performed on 2643 participants at the mean age of 36 years to identify carotid plaques and plaque areas. For childhood lipids, we exploited several risk factor measurements to determine the individual cumulative burden for each lipid during childhood. Participants were categorized into the following 4 groups based on their childhood and adult dyslipidemia status: no dyslipidemia (reference), incident, resolved, and persistent. Among individuals with carotid plaque, linear regression models were used to study the association of serum lipids with plaque area. The prevalence of plaque was 3.3% (N=88). In models adjusted for age, sex, and nonlipid cardiovascular risk factors, the relative risk for carotid plaque was 2.34 (95% CI, 0.91-6.00) for incident adult dyslipidemia, 3.00 (95% CI, 1.42-6.34) for dyslipidemia resolved by adulthood, and 5.23 (95% CI, 2.57-10.66) for persistent dyslipidemia. Carotid plaque area correlated with childhood total, low-density lipoprotein, and non-high-density lipoprotein cholesterol levels. Conclusions Childhood dyslipidemia, even if resolved by adulthood, is a risk factor for adult carotid plaque. Furthermore, among individuals with carotid plaque, childhood lipids associate with plaque size. These findings highlight the importance of primordial prevention of dyslipidemia in childhood to reduce atherosclerosis development.

Metabolic dysfunction-associated fatty liver disease increased the risk of subclinical carotid atherosclerosis in China

Background and aims

Metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed to substitute NAFLD in 2020. This new term highlights the systematic metabolic disturbances that accompany fatty liver. We evaluated the correlations between MAFLD and subclinical carotid atherosclerosis (SCA) based on a nationwide health examination population in China.

Methods

We performed a nationwide cross-sectional population and a Beijing retrospective cohort from 2009 to 2017. SCA was defined as elevated carotid intima-media thickness. The multivariable logistic and Cox models were used to analyze the association between MAFLD and SCA.

Results

153,482 participants were included in the cross-sectional study. MAFLD was significantly associated with SCA in fully adjusted models, with an odds ratio of 1.66; 95% confidence interval (CI): 1.62-1.70. This association was consistent in the cohort, with a hazard ratio (HR) of 1.31. The association between baseline MAFLD and incident SCA increased with hepatic steatosis severity. Subgroup analysis showed an interaction between age and MAFLD, with a higher risk in younger groups (HR:1.67, 95% CI: 1.17-2.40).

Conclusion

In this large cross-section and cohort study, MAFLD was significantly associated with the presence and development of SCA. Further, the risk was higher among MAFLD individuals with high hepatic steatosis index and young adults.

Relationship between circulating adipokines and cholesterol efflux in subjects with severe carotid atherosclerosis

AIMS

Cholesterol efflux capacity (CEC) as a measure of high-density lipoprotein functionality is independently and inversely associated with increased risk of cardiovascular events and mortality, and advanced plaque morphology. Adipokines, adipose tissue-derived factors, can influence systemic lipoprotein metabolism, and participate in the regulation of vascular function and inflammation. We aimed to investigate the association between CEC and circulating adipokine levels (anti-inflammatory adiponectin, and pro-inflammatory chemerin and resistin) in subjects with severe carotid atherosclerotic disease and evaluate its impact on post-surgical outcomes.

METHODS AND RESULTS

This is a cross-sectional study with a 5-year follow-up component. Consecutive patients with severe carotid atherosclerosis scheduled for a carotid endarterectomy were recruited from hospital-based centres in Montreal, Canada (n = 285). Fasting blood samples were collected pre-operatively and used to measure plasma total and high-molecular weight (HMW) adiponectin, chemerin, and resistin, and to perform cholesterol efflux assays in J774 macrophage-like cells. Five-year post-surgery outcomes were obtained through medical chart review. Subjects had a mean age of 70.1 ± 9.4, were 67.0 % male, had various comorbidities (hypercholesterolemia [85.3 %], hypertension [83.5 %], type 2 diabetes [34.5 %], coronary artery disease [38.6 %]), and previously experienced cerebrovascular symptomatology (77.9 %). CEC was independently and positively associated with total and HMW adiponectin levels (ß [95 % confidence interval]; 0.216 [0.134-0.298] and 0.107 [0.037-0.176], respectively) but not with chemerin or resistin. Total adiponectin had the greatest association accounting for 8.3 % of the variance in CEC. Interaction regression models demonstrated a significant interaction between adiponectin and chemerin in increasing CEC. Notably, with each unit increase in CEC there was a 93.9 % decrease in the odds of having an ischemic cerebrovascular event 5 years post-surgery (0.061 [0.007-0.561]).

CONCLUSIONS

Our findings demonstrated circulating adiponectin to have a strong association with increased CEC in subjects with severe carotid atherosclerosis and high CEC to be associated with more favourable post-surgical outcomes. These findings reflect the importance of adipose tissue health in influencing CEC levels and atherosclerotic cardiovascular disease risk.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS

OBJECTIVES

Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS.

METHODS

A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected.

RESULTS

A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality.

CONCLUSIONS

Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:576-587, 2023.

Combined effects of hypertension, hyperlipidemia, and diabetes mellitus on the presence and severity of carotid atherosclerosis in community-dwelling elders: A community-based study

BACKGROUND

Hypertension, hyperlipidemia, and diabetes mellitus (DM) are common cardiovascular disease (CVD) comorbidities and well-known major determinants of atherosclerosis. However, their combined effects and relative contributions have not been well explored. This study aimed to characterize the characteristics of carotid atherosclerosis and dissect the relative effects of these common CVD comorbidities on the presence and severity of carotid atherosclerosis in community-dwelling elderly individuals.

METHODS

We enrolled 817 elders from communities in northern Taiwan. We evaluated their cardiovascular risk profiles and scanned their extracranial carotid arteries using high-resolution ultrasonography systems.

RESULTS

The prevalence rates for hypertension, hyperlipidemia, and DM were 45.4%, 37.1%, and 16.8%, respectively. Sixty-two (7.6%) and 188 (23.0%) elderly had all three and two of these common CVD comorbidities, respectively. The prevalent rates of carotid plaque and moderate-to-severe atherosclerosis were 62.9% and 35.5%, respectively. The percentages of one or more common CVD comorbidities in elders with carotid plaque and moderate-to-severe atherosclerosis were 78.2% and 83.1%, respectively. Multivariate analyses showed that the number of common CVD comorbidities was the most predictive determinant. Multivariable-adjusted odds ratios (ORs) per comorbidity for the presence of carotid plaque and advanced carotid atherosclerosis were 1.52 (95% CI, 1.28-1.81) and 1.57 (95% CI, 1.28-1.93), respectively. Models containing hypertension and DM were the second most predictive. Combinatory analyses showed distinct relationship patterns between carotid atherosclerosis and hypertension, hyperlipidemia, and DM. Hypertension was significantly correlated with higher ORs for the presence of carotid plaque and advanced carotid atherosclerosis but not for hyperlipidemia.

CONCLUSION

Carotid plaques are highly prevalent in community-dwelling elders. The number of common CVD comorbidities was the most predictive determinant of carotid plaques and advanced carotid atherosclerosis. Our results indicate that to reduce the impact of atherosclerotic diseases, blood pressure controls precede the control of blood lipids and glucose in the community-dwelling elders.