Histological analysis of extracranial carotid artery aneurysms

Introduction

Extracranial carotid artery aneurysms (ECAA) are rare but may be accompanied with significant morbidity. Previous studies mostly focused on diagnostic imaging and treatment. In contrast, the pathophysiological mechanisms and natural course of ECAA are largely unknown. Understanding the pathophysiological background may add to prediction of risk for adverse outcome and need for surgical exclusion. The aim of this study was to investigate the histopathological characteristics of ECAA in patients who underwent complete surgical ECAA resection.

Material and Methods

From March 2004 till June 2013, 13 patients were treated with open ECAA repair. During surgery the aneurysm sac was resected and processed for standardized histological analysis. Sections were stained with routine hematoxylin and eosin and special stains to detect elastin, collagen, different types of inflammatory cells, vascular smooth muscle cells and endothelial cells.

Results

Histopathological characterization revealed two distinct categories: dissection (abrupt interruption of the media; n = 3) and degeneration (general loss of elastin fibers in the media; n = 10). In the degenerative samples the elastin fibers in the media were fragmented and were partly absent. Inflammatory cells were observed in the vessel wall of the aneurysms.

Conclusion

Histological analysis in this small sample size revealed dissection and degeneration as the two distinct underlying mechanisms in ECAA formation.

HMG-coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials

BACKGROUND

Statins increase the risk of new-onset type 2 diabetes mellitus. We aimed to assess whether this increase in risk is a consequence of inhibition of 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the intended drug target.

METHODS

We used single nucleotide polymorphisms in the HMGCR gene, rs17238484 (for the main analysis) and rs12916 (for a subsidiary analysis) as proxies for HMGCR inhibition by statins. We examined associations of these variants with plasma lipid, glucose, and insulin concentrations; bodyweight; waist circumference; and prevalent and incident type 2 diabetes. Study-specific effect estimates per copy of each LDL-lowering allele were pooled by meta-analysis. These findings were compared with a meta-analysis of new-onset type 2 diabetes and bodyweight change data from randomised trials of statin drugs. The effects of statins in each randomised trial were assessed using meta-analysis.

FINDINGS

Data were available for up to 223 463 individuals from 43 genetic studies. Each additional rs17238484-G allele was associated with a mean 0·06 mmol/L (95% CI 0·05-0·07) lower LDL cholesterol and higher body weight (0·30 kg, 0·18-0·43), waist circumference (0·32 cm, 0·16-0·47), plasma insulin concentration (1·62%, 0·53-2·72), and plasma glucose concentration (0·23%, 0·02-0·44). The rs12916 SNP had similar effects on LDL cholesterol, bodyweight, and waist circumference. The rs17238484-G allele seemed to be associated with higher risk of type 2 diabetes (odds ratio [OR] per allele 1·02, 95% CI 1·00-1·05); the rs12916-T allele association was consistent (1·06, 1·03-1·09). In 129 170 individuals in randomised trials, statins lowered LDL cholesterol by 0·92 mmol/L (95% CI 0·18-1·67) at 1-year of follow-up, increased bodyweight by 0·24 kg (95% CI 0·10-0·38 in all trials; 0·33 kg, 95% CI 0·24-0·42 in placebo or standard care controlled trials and -0·15 kg, 95% CI -0·39 to 0·08 in intensive-dose vs moderate-dose trials) at a mean of 4·2 years (range 1·9-6·7) of follow-up, and increased the odds of new-onset type 2 diabetes (OR 1·12, 95% CI 1·06-1·18 in all trials; 1·11, 95% CI 1·03-1·20 in placebo or standard care controlled trials and 1·12, 95% CI 1·04-1·22 in intensive-dose vs moderate dose trials).

INTERPRETATION

The increased risk of type 2 diabetes noted with statins is at least partially explained by HMGCR inhibition.

FUNDING

The funding sources are cited at the end of the paper.

Symptomatic carotid atherosclerotic disease: correlations between plaque composition and ipsilateral stroke risk

BACKGROUND AND PURPOSE

For symptomatic patients with carotid artery stenosis, the risk benefit for surgical intervention may vary among patient groups. Various modalities of plaque imaging have been promoted as potential tools for additional risk stratification, particularly in patients with moderate stenosis. However, it remains uncertain to what extent carotid plaque components predict risk of future ipsilateral ischemic stroke.

METHODS

In 2 large atherosclerotic carotid plaque biobank studies, we related histological characteristics of 1640 carotid plaques with a validated risk model for the prediction of individual 1- and 5-year stroke risk.

RESULTS

No significant heterogeneity between the studies was found. Predicted 5-year stroke risk (top versus bottom quartile) was related to plaque thrombus (odds ratio, 1.42; 95% confidence interval, 1.11-1.89; P=0.02), fibrous content (0.65; 0.49-0.87; P=0.004), macrophage infiltration (1.41; 1.05-1.90; P=0.02), high microvessel density (1.49; 1.05-2.11; P=0.03), and overall plaque instability (1.40; 1.05-1.87; P=0.02). This association was not observed for cap thickness, calcification, intraplaque hemorrhage, or lymphocyte infiltration. Plaques removed within 30 days of most recent symptomatic event were most strongly correlated with predicted stroke risk.

CONCLUSIONS

Features of the vulnerable carotid plaque, including plaque thrombus, low fibrous content, macrophage infiltration, and microvessel density, correlate with predicted stroke risk. This study provides a basis for plaque imaging studies focused on stroke risk stratification.

High reproducibility of histological characterization by whole virtual slide quantification; an example using carotid plaque specimens

Objective

Tissue biobanks are an important source for discovery and validation studies aiming for new proteins that are causally related with disease development. There is an increasing demand for accurate and reproducible histological characterization, especially for subsequent analysis and interpretation of data in association studies. We assessed reproducibility of one semiquantative and two quantitative methods for histological tissue characterization. We introduce a new automated method for whole digital slide quantification. Carotid atherosclerotic plaques were used to test reproducibility.

Methods

50 atherosclerotic plaques that were obtained during carotid endarterectomy were analysed. For the semiquantitative analysis, 6 different plaque characteristics were scored in categories by two independent observers, and Cohen's κ was used to test intra- and interobserver reproducibility. The computer-aided method (assessed by two independent observers) and automated method were tested on CD68 (for macrophages) and α smooth muscle actin (for smooth muscle cells) stainings. Agreement for these two methods (done on a continuous scale) was assessed by intraclass correlation coefficients (ICCs).

Results

For the semiquantitative analysis, κ values ranged from 0.55 to 0.69 for interobserver variability, and were slightly higher for intraobserver reproducibility in both observers. The computer-aided method yielded intra- and interobserver ICCs between 0.6 and 0.9. The new automated method performed most optimal regarding reproducibility, with ICCs ranging from 0.92 to 0.97.

Conclusions

The analysis of performance of three methods for histological slide characterization on carotid atherosclerotic plaques showed high precision and agreement in repeated measurements for the automated method for whole digital slide quantification. We suggest that this method can fulfill the need for reproducible histological quantification.

Modest utility of quantitative measures in (18)F-fluorodeoxyglucose positron emission tomography scanning for the diagnosis of aortic prosthetic graft infection

BACKGROUND

The clinical dilemma in suspected aortic graft infection (AGI) is how to noninvasively obtain a reliable proof of infection. In addition to confirming the presence of infection, obtaining information regarding the extent of infection to select a proper strategy for reoperation is also necessary. Therefore, developing a more reliable noninvasive physiologic approach to detect infected prostheses is required. (18)F-fluorodeoxyglucose positron emission tomography scanning ((18)F-FDG PET) has been suggested to have a pivotal role in the detection of AGI. In this study, we assessed the contribution of two (semi) quantitative parameters-maximal standardized uptake value (SUVmax) and tissue-to-background ratio (TBR)-and of two visual parameters-fluorodeoxyglucose (FDG) distribution patterns and visual grading scale-in the final confirmation of the diagnosis of AGI.

METHODS

Patients with a central aortic prosthetic graft and symptoms clinically suggestive of AGI were gathered from a prospectively maintained database. Included were those who underwent (18)F-FDG PET scanning combined with computed tomography angiography and in whom periprosthetic samples were taken at some stage in the diagnostic process. AGI was considered proven in case of a positive culture and compared with a group with negative cultures. Positive predictive values (PPVs) and negative predictive values (NPVs) were calculated. Receiver operating characteristics curves were used to assess the ability of SUVmax and TBR to identify the presence and absence of AGI (ie, accuracy).

RESULTS

In 37 of 77 patients with suspected AGI, (18)FDG-PET and perigraft material for culturing was obtained. The tissue culture was positive in 21 of these 37 patients (56.7%). Mean ± standard deviation SUVmax for proven infection was 8.1 ± 3.7 (range, 3.6-18.5) and TBR was 5.9 ± 2.7 (range, 1.7-13.0). The area under the curve for SUVmax was 0.78 (95% confidence interval, 0.63-0.93). A cutoff value of 8 yielded a PPV of 80% and a NPV of 54%. The area under the curve for TBR was 0.70 (95% confidence interval, 0.52-0.87). A cutoff value of 6 yielded a PPV of 73% and NPV of 52%. The PPVs for the visual grading scale and (18)F-FDG distribution patterns were 75% and 61%, respectively; the NPVs were 77% and 67%, respectively.

CONCLUSIONS

Our study, performed in a small sample of patients suspected of AGI, showed that the diagnostic abilities of quantitative and visual (18)F-FDG PET parameters are modest.

The impact of female sex on long-term survival of patients with severe atherosclerosis undergoing endarterectomy

OBJECTIVES

Long-term age- and sex-specific mortality data in patients undergoing carotid endarterectomy (CEA) and iliac/femoral endarterectomy (FEA) are scarce. We examined long-term mortality in these patient groups, stratified by age and sex.

METHODS

Between 2002 and 2012, 1771 patients (1200 men, 571 women) treated by CEA, and 685 patients (495 men, 190 women) who underwent FEA, were included and linked to the national mortality registry of the Netherlands. Absolute mortality risks during follow-up were analyzed by life-table and Kaplan Meier survival analyses in two age groups and stratified by sex, and compared to a matched sample from the general population. In addition, multivariable Cox regression analyses were performed.

RESULTS

After CEA, with a median follow-up duration of 4.3 years (interquartile range 2.0-7.1), 298 all-cause deaths had occurred in men (25%) and 105 (18%) in women. As in the general population, cumulative survival after CEA was significantly better in women compared to men (P = 0.002) and absolute CEA-associated mortality risk in women was similar to that of the general population. For FEA patients, mortality risk was worse than for CEA patients and the general population in both sexes and surprisingly, female sex did not have a favorable effect on survival. Following FEA, 130 men (26%) and 51 women (27%) died after a median follow-up time of 3.0 years (interquartile range 1.5-5.9). Stratifying by age, and adjusting for cardiovascular risk factors did not change these trends.

CONCLUSIONS

Long-term mortality after CEA is higher in men than in women, and in women mortality risk is similar to the general population. After FEA, the benefit of women as seen after CEA is lost.

7.0 T MRI detection of cerebral microinfarcts in patients with a symptomatic high-grade carotid artery stenosis

In the current study, the presence of cerebral cortical microinfarcts (CMIs) was evaluated in a series of 21 patients with a symptomatic high-grade >50% stenosis of the carotid artery. A T2-weighted fluid-attenuated inversion recovery sequence and a T1-weighted turbo field echo sequence of the brain were obtained at 7.0 Tesla magnetic resonance imaging. Primary study endpoint was the number of CMIs and macroinfarcts. In total, 53 cerebral infarcts (35 macroinfarcts; 18 CMIs) were found ipsilateral to the symptomatic carotid artery, in 14 patients (67%). In four of these patients, both CMIs and macroinfarcts were visible. In the contralateral hemisphere, seven infarcts (five macroinfarcts and two CMIs) were found in five patients (24%). In the ipsilateral hemispheres, the number of CMIs and macroinfarcts were significantly correlated (P=0.02). Unpaired comparison of medians showed that the number of CMIs in the ipsilateral hemisphere was significantly higher than the number of CMIs in the contralateral hemisphere (P=0.04). No significant correlation was found between stenosis grade and the number of any infarct. The current study shows that in symptomatic patients with significant extracranial carotid artery stenosis, CMIs are part of the total cerebrovascular burden and these CMIs prevail with a similar pattern as observed macroinfarcts.

Increased platelet reactivity is associated with circulating platelet-monocyte complexes and macrophages in human atherosclerotic plaques

OBJECTIVE

Platelet reactivity, platelet binding to monocytes and monocyte infiltration play a detrimental role in atherosclerotic plaque progression. We investigated whether platelet reactivity was associated with levels of circulating platelet-monocyte complexes (PMCs) and macrophages in human atherosclerotic carotid plaques.

METHODS

Platelet reactivity was determined by measuring platelet P-selectin expression after platelet stimulation with increasing concentrations of adenosine diphosphate (ADP), in two independent cohorts: the Circulating Cells cohort (n = 244) and the Athero-Express cohort (n = 91). Levels of PMCs were assessed by flow cytometry in blood samples of patients who were scheduled for percutaneous coronary intervention (Circulating Cells cohort). Monocyte infiltration was semi-quantitatively determined by histological examination of atherosclerotic carotid plaques collected during carotid endarterectomy (Athero-Express cohort).

RESULTS

We found increased platelet reactivity in patients with high PMCs as compared to patients with low PMCs (median (interquartile range): 4153 (1585-11267) area under the curve (AUC) vs. 9633 (3580-21565) AUC, P<0.001). Also, we observed increased platelet reactivity in patients with high macrophage levels in atherosclerotic plaques as compared to patients with low macrophage levels in atherosclerotic plaques (mean ± SD; 8969 ± 3485 AUC vs. 7020 ± 3442 AUC, P = 0.02). All associations remained significant after adjustment for age, sex and use of drugs against platelet activation.

CONCLUSION

Platelet reactivity towards ADP is associated with levels of PMCs and macrophages in human atherosclerotic carotid plaques.

Prediction of asymptomatic carotid artery stenosis in the general population: identification of high-risk groups

BACKGROUND AND PURPOSE

Because of a low prevalence of severe carotid stenosis in the general population, screening for presence of asymptomatic carotid artery stenosis (ACAS) is not warranted. Possibly, for certain subgroups, screening is worthwhile. The present study aims to develop prediction rules for the presence of ACAS (>50% and >70%).

METHODS

Individual participant data from 4 population-based cohort studies (Malmö Diet and Cancer Study, Tromsø Study, Carotid Atherosclerosis Progression Study, and Cardiovascular Health Study; totaling 23 706 participants) were pooled. Multivariable logistic regression was performed to determine which variables predict presence of ACAS (>50% and >70%). Calibration and discrimination of the models were assessed, and bootstrapping was used to correct for overfitting.

RESULTS

Age, sex, history of vascular disease, systolic and diastolic blood pressure, total cholesterol/high-density lipoprotein ratio, diabetes mellitus, and current smoking were predictors of stenosis (>50% and >70%). The calibration of the model was good confirmed by a nonsignificant Hosmer and Lemeshow test for moderate (P=0.59) and severe stenosis (P=0.07). The models discriminated well between participants with and without stenosis, with an area under the receiver operating characteristic curve corrected for over optimism of 0.82 (95% confidence interval, 0.80-0.84) for moderate stenosis and of 0.87 (95% confidence interval, 0.85-0.90) for severe stenosis. The regression coefficients of the predictors were converted into a score chart to facilitate practical application.

CONCLUSIONS

A clinical prediction rule was developed that allows identification of subgroups with high prevalence of moderate (>50%) and severe (>70%) ACAS. When confirmed in comparable cohorts, application of the prediction rule may lead to a reduction in the number needed to screen for ACAS.

Ipsilateral foetal-type posterior cerebral artery is associated with cognitive decline after carotid revascularisation

Background

Stenosis of the internal carotid artery has been associated with cognitive impairment and decline. However, studies testing the effect of carotid revascularisation on cognition have had conflicting results. This may in part be explained by variation in the flow territory of the carotid artery. In 12 to 36% of the patients, the posterior cerebral artery is mainly or exclusively supplied by the internal carotid artery via a foetal-type posterior cerebral artery. In these patients, ipsilateral carotid artery stenosis is likely to result in a larger area with hypoperfusion than in case of a normal posterior cerebral artery. Patients with a foetal-type posterior cerebral artery could therefore benefit more from revascularisation. We compared the effects of carotid revascularisation on cognition between patients with a foetal-type and those with a normal posterior cerebral artery.

Methods

Patients with symptomatic internal carotid artery stenosis ≥ 50%, enrolled in the International Carotid Stenting Study (ICSS) at a single centre, underwent detailed neuropsychological examinations before and 6 months after revascularisation. Cognitive test results were standardized into z-scores, from which a cognitive sumscore was calculated. The primary outcome was the change in cognitive sumscore between baseline and follow-up. Changes in cognitive sumscore were compared between patients with an ipsilateral foetal-type and those with a normal posterior cerebral artery, as assessed with CT or MR angiography.

Results

Of 145 patients enrolled in ICSS at the centre during the study period, 98 had both angiography at baseline and neuropsychological examination at baseline and at 6-months follow-up. The cognitive sum score decreased by 0.28 (95% confidence interval, 0.10 to 0.45) in 13 patients with an ipsilateral foetal-type posterior cerebral artery and by 0.07 (95% CI, 0.002 to 0.15) in 85 patients with a normal posterior cerebral artery (mean difference, -0.20; 95% CI, -0.40 to -0.01). This did not change essentially after adjustment for baseline factors.

Conclusion

An ipsilateral foetal-type posterior cerebral artery appears to increase cognitive decline after carotid revascularisation. Our findings have to be reproduced in an independent study before further implications can be made.

Time-dependent changes in atherosclerotic plaque composition in patients undergoing carotid surgery

BACKGROUND

Time-dependent trends in the incidence of cardiovascular disease have been reported in high-income countries. Because atherosclerosis underlies the majority of cardiovascular diseases, we investigated temporal changes in the composition of atherosclerotic plaques removed from patients undergoing carotid endarterectomy.

METHODS AND RESULTS

The Athero-Express study is an ongoing, longitudinal, vascular biobank study that includes the collection of atherosclerotic plaques of patients undergoing primary carotid endarterectomy in the province of Utrecht from 2002 to 2011. Histopathologic features of plaques of 1583 patients were analyzed in intervals of 2 years. The analysis included quantification of collagen, calcifications, lipid cores, plaque thrombosis, macrophages, smooth muscle cells, and microvessels. Large atheroma, plaque thrombosis, macrophages, and calcifications were less frequently observed over time, with adjusted odds ratios of 0.72 (95% confidence interval, 0.650-0.789), 0.62 (95% confidence interval, 0.569-0.679), 0.87 (95% confidence interval, 0.800-0.940), and 0.75 (95% confidence interval, 0.692-0.816) per 2-year increase in time, respectively. These changes in plaque characteristics were consistently observed in patient subgroups presenting with stroke, transient ischemic attack, ocular symptoms, and asymptomatic patients. Concomitantly, risk factor management and secondary prevention strategies among vascular patients scheduled for carotid endarterectomy significantly improved over the past decade.

CONCLUSIONS

In conclusion, over the past decade, atherosclerotic plaques harvested during carotid endarterectomy show a time-dependent change in plaque composition characterized by a decrease in features currently believed to be causal for plaque instability. This appears to go hand in hand with improvements in risk factor management.

Parental history and the risk of subsequent vascular events in patients with clinically manifest vascular disease: the effects of sex of the parent and vascular disease location

BACKGROUND

Parental history of cardiovascular disease is a risk factor for first vascular events. It is unknown whether this also holds for subsequent events in patients with vascular disease. Also, the role of the location of parental vascular disease and the sex of the affected parent is unidentified.

METHODS

In a cohort of 4529 patients with symptomatic vascular disease enrolled in the Second Manifestations of Arterial Disease (SMART) Study, the relation between parental cardiovascular history under the age of sixty, sex of the parent, location of parental vascular disease (heart, brain, lower extremities) and subsequent myocardial infarction (MI), stroke, vascular death and peripheral artery disease (PAD) was determined by Cox-proportional hazard analyses.

RESULTS

During a median follow-up of 4.9 years (interquartile range 2.5-7.0), MI was experienced by 220 patients, stroke by 112, PAD by 297, whereas 371 patients died. A positive parental history of cardiovascular disease, without knowledge of vascular disease location and sex of that particular parent, was not associated with subsequent events (HR1.0; 95%CI 0.8-1.3). For specific types of parental history regarding sex and vascular location, having a father with a history of PAD was related to an increased risk of incident PAD (HR3.1; 95%CI 2.1-4.6).

CONCLUSIONS

A positive parental history of cardiovascular disease without information about vascular disease location and sex does not increase the risk of recurrent vascular events in patients with symptomatic vascular disease. Vascular patients with a father with PAD have an increased risk of subsequent peripheral artery disease compared with vascular patients without such a family history.

Circulating immunoglobulins are not associated with intraplaque mast cell number and other vulnerable plaque characteristics in patients with carotid artery stenosis

Background

Recently, we have shown that intraplaque mast cell numbers are associated with atherosclerotic plaque vulnerability and with future cardiovascular events, which renders inhibition of mast cell activation of interest for future therapeutic interventions. However, the endogenous triggers that activate mast cells during the progression and destabilization of atherosclerotic lesions remain unidentified. Mast cells can be activated by immunoglobulins and in the present study, we aimed to establish whether specific immunoglobulins in plasma of patients scheduled for carotid endarterectomy were related to (activated) intraplaque mast cell numbers and plasma tryptase levels. In addition, the levels were related to other vulnerable plaque characteristics and baseline clinical data.

Methods and Results

OxLDL-IgG, total IgG and total IgE levels were measured in 135 patients who underwent carotid endarterectomy. No associations were observed between the tested plasma immunoglobulin levels and total mast cell numbers in atherosclerotic plaques. Furthermore, no associations were found between IgG levels and the following plaque characteristics: lipid core size, degree of calcification, number of macrophages or smooth muscle cells, amount of collagen and number of microvessels. Interestingly, statin use was negatively associated with plasma IgE and oxLDL-IgG levels.

Conclusions

In patients suffering from carotid artery disease, total IgE, total IgG and oxLDL-IgG levels do not associate with plaque mast cell numbers or other vulnerable plaque histopathological characteristics. This study thus does not provide evidence that the immunoglobulins tested in our cohort play a role in intraplaque mast cell activation or grade of atherosclerosis.

LDL-c-linked SNPs are associated with LDL-c and myocardial infarction despite lipid-lowering therapy in patients with established vascular disease

BACKGROUND

Several single-nucleotide polymorphisms (SNPs) are associated with both plasma low-density lipoprotein cholesterol (LDL-c) level and coronary artery disease in the general population. It is unclear whether these associations also apply to patients with vascular disease and whether the associations are independent of lipid-lowering therapy.

DESIGN

Single-nucleotide polymorphisms associated with plasma LDL-c and vascular risk in the general population (rs11206510 (PCSK9), rs1122608 (LDLR), rs579459 (ABO) and rs599839 (SORT1)) were genotyped in a prospective cohort study of 5482 patients with vascular disease. We determined the association between LDL-c-associated alleles and plasma LDL-c levels and the risk of new vascular events.

RESULTS

All tested SNPs were associated with LDL-c plasma levels with a magnitude between +0·06 (95% CI 0·02-0·10) mM and +0·14 (95% CI 0·09-0·18) mM per LDL-c-increasing allele. The associations were independent of the use of lipid-lowering medication, except for rs579459, for which the association was not present in patients using lipid-lowering medication. In patients with 7-8 risk alleles for these SNPs, 59% of the patients treated with lipid-lowering medication did not reach the LDL-c target of <2·5 mM compared with 45% in patients with 3 or fewer risk alleles. LDL-c-increasing alleles were not associated with increased risk of vascular events in patients not using lipid-lowering medication (HRs: 1·01; 95% CI: 0·93-1·09). In patients using lipid-lowering medication, the risk of myocardial infarction increased with 14% (HRs: 1·14; 95% CI: 1·01-1·28) per allele.

CONCLUSIONS

In patients with established vascular disease, the studied SNPs increase LDL-c plasma levels. LDL-c-increasing alleles may be associated with increased risk of myocardial infarction in patients treated with lipid-lowering medication, but not in patients not treated with lipid-lowering medication.

Posterior transverse plication of the internal carotid artery to correct for kinking

BACKGROUND

The occasional need for shortening of the internal carotid artery (ICA) following carotid endarterectomy (CEA) to correct for kinking is still controversial. Although several technical options have been suggested, the impact on perioperative outcome remains unclear, and long-term clinical follow-up is lacking. Shortening by resection has a theoretical risk for a twisted anastomosis and subsequent ICA thrombosis. Posterior transverse plication (PTP) offers an alternative shortening technique without the need for a new anastomosis. We aimed to assess the safety and patency of CEA with concomitant PTP. Secondly, we aimed to provide an overview of different technical modalities for shortening of the carotid artery in current literature.

METHODS

Within the time frame of 2000 through 2011, 29 patients (mean age, 73.4 years) undergoing CEA with additional PTP of the ICA and standardized patchplasty were retrospectively identified. Patient characteristics, surgical procedural details, and both short- (<30 days) and long- (>30 days) term clinical and duplex ultrasound follow-up were retrieved. Restenosis was defined as ≥50% stenosis on duplex ultrasound. In addition, a literature search was performed on different techniques for ICA shortening.

RESULTS

Thirty-day outcome revealed no deaths or strokes. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. During follow-up (mean, 34.3 months; range, 3-125 months), one patient (4%) died of a noncardiovascular cause. Three patients (11%) developed ipsilateral neurological symptoms (1 stroke, 2 transient ischemic attacks) after 5, 19, and 66 months follow-up, respectively. Of these, two patients (7%) had restenosis at the site of PTP. Asymptomatic restenosis occurred in one other patient (4%) after 16 months.

CONCLUSIONS

Although the indications for additional shortening procedures following CEA need to be defined, in this small series, PTP as an additional shortening procedure of the ICA following CEA seems feasible and safe with no additional periprocedural risk for narrowing at the plicature or thrombosis of the endarterectomy plane. However, restenosis at the plicature may hamper the long term benefit of carotid reconstruction.

Extracellular vesicle-derived CD14 is independently associated with the extent of cardiovascular disease burden in patients with manifest vascular disease

BACKGROUND

In patients with established cardiovascular disease, high levels of the extracellular vesicle (EV)-derived proteins cystatin C, CD14, and α2-antiplasmin predict recurrent cardiovascular events. We examined whether these proteins are associated with the extent of vascular disease.

METHODS

In 1062 patients from the SMART (Secondary Manifestations in ARTerial disease) study, EVs were isolated from plasma at baseline. Cystatin C, CD14, and α2-antiplasmin were measured in these vesicles using a multiplex assay. The extent of vascular disease burden was determined by a sum score that incorporates history and current presence of clinically manifest coronary, cerebrovascular, peripheral arterial, and abdominal aneurysm disease, and parameters of atherosclerosis that were assessed during the SMART screening protocol (ankle-brachial index, common carotid intima-media thickness, carotid stenosis, and aorta diameter). The relation between EV protein levels and extent of vascular disease was evaluated using ordinal multivariable regression models.

RESULTS

EV-derived CD14 was significantly associated with the number of affected vascular territories (OR 2.4, 95% CI 1.4-4.1) as represented by the sum score, independently of cardiovascular risk factors. Cystatin C and α2-antiplasmin EV levels did not show an independent association with vascular disease extent. When investigating parameters of the sum score separately, we did not observe a strong association between any of the EV-derived proteins and the markers of atherosclerosis.

CONCLUSIONS

EV-derived CD14 levels are strongly correlated to the extent of vascular disease, but not specifically to markers that reflect atherosclerosis burden, in patients with manifest cardiovascular disease.