Carotid Artery Stenosis: Medical Therapy, Surgery, and Stenting

Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.

Robotic-assisted carotid artery stenting with R-OneTM: Feasibility and safety assessment in patients with carotid web lesions

PurposeRobotic-assisted carotid artery stenting (CAS) procedures are on the rise and have demonstrated benefits compared to manual intervention. The R-OneTM robotic platform has demonstrated safety and efficacy for percutaneous coronary interventions, but its utility for procedures in the common carotid artery has not been thoroughly studied. This study aims to assess the feasibility and initial safety of the R-OneTM robotic platform for treating patients with carotid artery disease (CAD) presenting with carotid web-diaphragm lesions.MethodsThe prospective CArotid Robotic procedure Evaluation study included patients with CAD suitable for CAS. The primary endpoint was procedure technical success, defined as the absence of any unplanned manual assistance or conversion to manual CAS for procedural completion. Secondary endpoints included the absence of intra-procedural complications, primary operator radiation exposure, patient radiation exposure, procedure time, and contrast volume.ResultsA total of seven patients were enrolled (mean age: 49.57 ± 13.10 years; 5 females). Procedure technical success rate was 85.7% (6/7). The absence of intra-procedural complications rate was 100%. Mean overall procedure time was 41.71 ± 9.83 min, mean robotic procedure time was 15.86 ± 7.60 min, and mean CAS procedure time was 27.14 ± 8.71 min. The average patient radiation exposure dose was 135.50 ± 78.88 mGy. The mean overall procedure contrast volume was 68.14 ± 20.14 mL, and the mean robotic procedure contrast volume was 1.43 ± 3.78 mL.ConclusionCAS procedures using R-OneTM are feasible and safe with a good technical success rate without complications. To confirm these findings, larger multi-center trials with a diverse range of patients are necessary.

Investigation of retinal microcirculation alterations following carotid artery angioplasty and stenting using optical coherence tomography angiography

Background

Carotid artery stenosis (CAS) is a common vascular condition that can impair retinal and optic nerve blood supply, leading to ocular ischemic damage. Optical coherence tomography angiography (OCTA) provides a non-invasive method to evaluate retinal microcirculation and detect vascular changes in CAS patients.

Methods

This study utilized OCTA to evaluate changes in retinal microcirculation in CAS patients before and after carotid artery angioplasty and stenting. A 6 × 6 mm OCTA scan was performed to analyze deep retinal vascular complex (DVC) blood flow density, foveal avascular zone area (FAZA), foveal density within a 300 μm-wide ring surrounding the FAZ (FD-300), and radial peripapillary capillary vessel density (RPC-VD). Additionally, ultra-wide-field OCTA imaging (24 × 20 mm) was employed to comprehensively assess perfusion in both the posterior pole and peripheral retina.

Results

Following carotid artery angioplasty and stenting, significant improvements were observed in the ipsilateral eye, including increased macular blood flow density (p = 0.004), FD-300 (p = 0.031), RPC-VD (p = 0.028) and decreased FAZA (p = 0.018) in the deep retinal vascular layer, indicating enhanced retinal microcirculation. No statistically significant changes were found in the contralateral eye. In some cases, ultra-wide-field OCTA revealed a reduction in macular non-perfusion areas in the ipsilateral eye, alongside an increase in non-perfusion areas near the vascular arcades.

Conclusion

Carotid artery angioplasty and stenting effectively improves retinal microcirculation in CAS patients, as evidenced by increased blood flow density and reduced non-perfusion areas in the ipsilateral eye. OCTA is a valuable non-invasive tool for assessing retinal circulation dynamics, identifying microvascular abnormalities, and monitoring treatment efficacy in CAS patients.

Use of Double-Layer Carotid Stents Is Associated with Improved Patient Survival and Lower Neurological Complications: A Single-Center Retrospective Observational Study

Background/Objectives: Dual-layer stents (DLS) with micromesh technology may offer better protection from plaque protrusion compared to single-layer stents (SLS), but little data are available. The aim of this study is to compare clinical outcomes of elective carotid artery stenting for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. Methods: This study is a single-center retrospective cohort study and included patients who underwent elective CAS between December 2006 and September 2023. The final analysis included patient baseline characteristics, postoperative complications and patient outcomes. Results: A total of 573 patients underwent elective carotid artery stenting in the study period. Most of the 573 patients undergoing CAS were male (62.5%), and the median age of patients at the time of CAS was 70 years. Of the 573 eligible patients, 43.5% (n = 249) were asymptomatic and 56.4% (n = 323) were symptomatic. Analyzing neurological complications, it was found that the only factor that had a statistically significant effect was the type of stent used. Patients who had a carotid stenting procedure using a single-layer carotid stent had statistically significantly more periprocedural neurological complications (8.3% (n = 35)) than the double-mesh stent group (2% (n = 3)), mostly due to more transient ischemic attacks in the single-layer stent group (4% (n = 17)) compared to the double-mesh group (0.7% (n = 1)). Conclusions: The use of carotid double-layer stents is associated with a low rate of periprocedural and postprocedural events.

Carotid Endarterectomy Ameliorates Cognitive Impairment in Clinical and Experimental Unilateral Carotid Artery Stenosis

BACKGROUND

Carotid endarterectomy (CEA) is widely used to treat carotid artery stenosis (CAS). However, the effects of CEA on unilateral CAS-induced cognitive impairment and the underlying mechanism remain poorly understood.

METHODS AND RESULTS

Thirteen patients diagnosed with unilateral severe CAS underwent pre- and post-CEA assessments, including 18fluoro-2-deoxy-d-glucose positron emission tomography/magnetic resonance imaging, cognitive assessments, and routine blood tests before and after CEA. Unilateral carotid common artery occlusion and ligation release (reperfusion) surgeries were performed in mice to mimic CAS and CEA. Cognitive function, cerebral blood flow, and white matter damage were evaluated in mice using the Morris water maze test, Doppler flowmetry, laser-speckle imaging, diffusion tensor imaging, Luxol fast blue staining, transmission electron microscopy, and western blot assays post unilateral carotid common artery occlusion and reperfusion. Genomic sequencing of the white matter was performed to explore the potential underlying mechanism. CEA significantly enhanced the Montreal Cognitive Assessment scores in patients with CAS and preoperative cognitive impairment. Moreover, CEA led to notable improvements in cerebral blood flow, energy metabolism, and white matter integrity, while concurrently reducing blood inflammation. In the mouse model, reperfusion surgery alleviated cognitive deficits, increased cerebral blood flow, and alleviated white matter damage following unilateral carotid common artery occlusion. Furthermore, transcriptional surveys have revealed substantial alterations in the upregulation of Nrf2 signaling and metabolic pathways, coupled with the inhibition of neuroinflammation, cellular communication, and immune cell population signaling following reperfusion.

CONCLUSIONS

CEA ameliorated CAS-induced cognitive dysfunction by improving the cerebral functional structure. These beneficial effects may be attributed to their antioxidant and anti-inflammatory properties.

Osteoprotegerin as an Emerging Biomarker of Carotid Artery Stenosis? A Scoping Review with Meta-Analysis

Objective: In developed countries, stroke is the fifth cause of death, with a high mortality rate, and with recovery to normal neurological function in one-third of survivors. Atherosclerotic occlusive disease of the extracranial part of the internal carotid artery and related embolic complications are common preventable causes of ischemic stroke (IS), attributable to 7-18% of all first-time cases. Osteoprotegerin (OPG), a soluble member of the tumor necrosis factor receptor (TNFR) superfamily, is considered a modulator of vascular calcification linked to vascular smooth muscle cell proliferation and collagen production in atherosclerotic plaques. Therefore, OPG emerges as a potential biomarker (BM) of calcified carotid plaques and carotid artery stenosis (CAS). Methods: We performed a literature search of PubMed on OPG in CAS and atherosclerosis published until 2024. Results: Increased levels of serum OPG were reported in both patients with symptomatic and asymptomatic CAS, and higher values were observed in those with unstable atherosclerotic plaques. Notably, increased OPG levels were observed regardless of the location of atherosclerosis, including coronary and other peripheral arteries. In addition, chronic kidney disease, the most significant confounder disturbing the association between vascular damage and circulating OPG levels, decreases the usefulness of OPG as a BM in CAS. Conclusions: Osteoprotegerin may be considered an emerging BM of global rather than cerebrovascular atherosclerosis. Its diagnostic significance in identifying patients with asymptomatic CAS and their monitoring is limited.

Screening of potential regulatory genes in carotid atherosclerosis vascular immune microenvironment

BACKGROUND

Immune microenvironment is one of the essential characteristics of carotid atherosclerosis (CAS), which cannot be reversed by drug therapy alone. Thus, there is a pressing need to develop novel immunoregulatory strategies to delay this pathological process that drives cardiovascular-related diseases. This study aimed to detect changes in the immune microenvironment of vascular tissues at various stages of carotid atherosclerosis, as well as cluster and stratify vascular tissue samples based on the infiltration levels of immune cell subtypes to distinguish immune phenotypes and identify potential hub genes regulating the immune microenvironment of carotid atherosclerosis.

MATERIALS AND METHODS

RNA sequencing datasets for CAS vascular tissue and healthy vascular tissue (GSE43292 and GSE28829) were downloaded from the Gene Expression Omnibus (GEO) database. To begin, the immune cell subtype infiltration level of all samples in both GSE43292 and GSE28829 cohorts was assessed using the ssGSEA algorithm. Following this, consensus clustering was performed to stratify CAS samples into different clusters. Finally, hub genes were identified using the maximum neighborhood component algorithm based on the construction of interaction networks, and their diagnostic efficiency was evaluated.

RESULTS

Compared to the controls, a higher number of immune cell subtypes were enriched in CAS samples with higher immune scores in the GSE43292 cohort. Advanced CAS was characterized by high immune cell infiltration, whereas early CAS was characterized by low immune cell infiltration in the GSE28829 cohort. Moreover, CAS progression may be related to the immune response pathway. Biological processes associated with muscle cell development may impede the progression of CAS. Finally, the hub genes PTPRC, ACTN2, ACTC1, LDB3, MYOZ2, and TPM2 had satisfactory efficacy in the diagnosis and prediction of high and low immune cell infiltration in CAS and distinguishing between early and advanced CAS samples.

CONCLUSION

The enrichment of immune cells in vascular tissues is a primary factor driving pathological changes in CAS. Additionally, CAS progression may be related to the immune response pathway. Biological processes linked to muscle cell development may delay the progression of CAS. PTPRC, ACTN2, ACTC1, LDB3, MYOZ2, and TPM2 may regulate the immune microenvironment of CAS and participate in the occurrence and progression of the disease.

30-Day Risk Score for Mortality and Stroke in Patients with Carotid Artery Stenosis Using Artificial Intelligence Based Carotid Plaque Morphology

BACKGROUND

The gold standard for determining carotid artery stenosis intervention is based on a combination of percent stenosis and symptomatic status. Few studies have assessed plaque morphology as an additive tool for stroke prediction. Our goal was to create a predictive model and risk score for 30-day stroke and death inclusive of plaque morphology.

METHODS

Patients with a computed tomographic angiography head/neck between 2010 and 2021 at a single institution and a diagnosis of carotid artery stenosis were included in our analysis. Each computed tomography was used to create a three-dimensional image of carotid plaque based off image recognition software. A stepwise backward regression was used to select variables for inclusion in our prediction models. Model discrimination was assessed with area under the receiver operating characteristic curves (AUCs). Additionally, calibration was performed and the model with the least Akaike Information Criterion (AIC) was selected. The risk score was modeled from the Framingham Study. Primary outcome was mortality/stroke.

RESULTS

We created 3 models to predict mortality/stroke from 366 patients: model A using only clinical variables, model B using only plaque morphology and model C using both clinical and plaque morphology variables. Model A used age, sex, peripheral arterial disease, hyperlipidemia, body mass index (BMI), chronic obstructive pulmonary disease (COPD), and history of transient ischemia attack (TIA)/stroke and had an AUC of 0.737 and AIC of 285.4. Model B used perivascular adipose tissue (PVAT) volume, lumen area, calcified volume, and target lesion length and had an AUC of 0.644 and AIC of 304.8. Finally, model C combined both clinical and software variables of age, sex, matrix volume, history of TIA/stroke, BMI, PVAT, lipid rich necrotic core, COPD and hyperlipidemia and had an AUC of 0.759 and an AIC of 277.6. Model C was the most predictive because it had the highest AUC and lowest AIC.

CONCLUSIONS

Our study demonstrates that combining both clinical factors and plaque morphology creates the best predication of a patient's risk for all-cause mortality or stroke from carotid artery stenosis. Additionally, we found that for patients with even 3 points in our risk score model has a 20% chance of stroke/death. Further prospective studies are needed to validate our findings.

Predicting Major Adverse Carotid Cerebrovascular Events in Patients with Carotid Stenosis: Integrating a Panel of Plasma Protein Biomarkers and Clinical Features-A Pilot Study

Background: Carotid stenosis (CS) is an atherosclerotic disease of the carotid artery that can lead to devastating cardiovascular outcomes such as stroke, disability, and death. The currently available treatment for CS is medical management through risk reduction, including control of hypertension, diabetes, and/or hypercholesterolemia. Surgical interventions are currently suggested for patients with symptomatic disease with stenosis >50%, where patients have suffered from a carotid-related event such as a cerebrovascular accident, or asymptomatic disease with stenosis >60% if the long-term risk of death is <3%. There is a lack of current plasma protein biomarkers available to predict patients at risk of such adverse events. Methods: In this study, we investigated several growth factors and biomarkers of inflammation as potential biomarkers for adverse CS events such as stroke, need for surgical intervention, myocardial infarction, and cardiovascular-related death. In this pilot study, we use a support vector machine (SVM), random forest models, and the following four significantly elevated biomarkers: C-X-C Motif Chemokine Ligand 6 (CXCL6); Interleukin-2 (IL-2); Galectin-9; and angiopoietin-like protein (ANGPTL4). Results: Our SVM model best predicted carotid cerebrovascular events with an area under the curve (AUC) of >0.8 and an accuracy of 0.88, demonstrating strong prognostic capability. Conclusions: Our SVM model may be used for risk stratification of patients with CS to determine those who may benefit from surgical intervention.

Quantitative assessment of retinochoroidal microvasculature in patients with carotid artery stenosis using OCT angiography

PURPOSE

To investigate the alterations in retinochoroidal parameters measured by optical coherence tomography (OCT) and OCT angiography (OCTA) in patients with carotid artery stenosis (CAS) and assess their associations with digital subtraction angiography (DSA) data.

METHOD

This study enrolled patients diagnosed with CAS and age-matched healthy controls. Both groups underwent OCT and OCTA examinations. DSA and assessment of carotid artery stenosis were performed only in the CAS group. The study evaluated various retinochoroidal parameters from OCT and OCTA, including linear vessel density (LVD), foveal avascular zone (FAZ), choroidal thickness (ChT), and retinal nerve fiber layer (RNFL) thickness. DSA-derived measures included cervical segment (C1) diameter, cavernous segment (C4) diameter, stenosis percentage, ophthalmic artery (OA) filling time, C1-OA filling time, and residual stenosis.

RESULTS

A total of 42 eyes from 30 CAS patients and 60 eyes from 30 healthy controls were included. Patients with CAS displayed significantly decreased LVD compared to controls (p < 0.001). Additionally, the CAS group had thinner choroid and RNFL (p = 0.047 and p < 0.001, respectively). Macular LVD negatively correlated with both stenosis percentage and C1-OA filling time (p = 0.010 and p = 0.014, respectively). In patients who underwent carotid artery stenting, preoperative ChT significantly correlated with residual stenosis (Pearson r = -0.480, p = 0.020).

CONCLUSION

OCT and OCTA provide a quantitative assessment of retinochoroidal microstructural changes associated with CAS, suggesting potential for noninvasive evaluation of the disease. This might contribute to the prevention of irreversible ocular complications and early detection of CAS. Furthermore, ChT may not only aid in diagnosing CAS more reliably but also offer prognostic information.

Utility of the triglyceride-glucose index for predicting restenosis following revascularization surgery for extracranial carotid artery stenosis: A retrospective cohort study

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are effective interventions for treating extracranial carotid artery stenosis (ECAS), but long-term prognosis is limited by postoperative restenosis. Carotid restenosis is defined as carotid stenosis >50% by various examination methods in patients after carotid revascularization. This retrospective cohort study examined the value of the triglyceride-glucose (TyG) index for predicting vascular restenosis after carotid revascularization.

METHODS

A total of 830 patients receiving CEA (408 cases, 49.2%) or CAS (422 cases, 50.8%) were included in this study. Patients were stratified into three subgroups according to TyG index tertile (high, intermediate, and low), and predictive value for restenosis was evaluated by constructing multivariate Cox proportional hazard regression models.

RESULTS

Incidence of postoperative restenosis was significantly greater among patients with a high TyG index according to univariate analysis. Kaplan-Meier survival curve analysis revealed a progressive increase in restenosis prevalence with rising TyG index. Multivariate Cox regression models also identified TyG index as an independent predictor of restenosis, while receiver operating characteristic (ROC) curve analysis showed that TyG index predicted restenosis with moderate sensitivity (57.24%) and specificity (67.99%) (AUC: 0.619, 95% CI 0.585-0.652, z-statistic=4.745, p<0.001). Addition of the TyG index to an established risk factor model incrementally improved restenosis prediction (AUC: 0.684 (0.651-0.715) vs 0.661 (0.628-0.694), z-statistic =2.027, p = 0.043) with statistical differences.

CONCLUSION

The TyG index is positively correlated with vascular restenosis risk after revascularization, which can be used for incremental prediction and has certain predictive value.

Correlation between Morphological and Hemodynamic Parameters of Carotid Arteries and Cerebral Vasomotor Reactivity

The function of cerebral small vessels can be assessed using cerebral vasomotor reactivity (VMR). Our aim in this retrospective cross-sectional study was to investigate a correlation between carotid artery stenosis measured through ultrasonographic morphological and hemodynamic parameters and cerebral VMR. A total of 285 patients (125 males; mean age 54) were included. The breath-holding index (BHI) was used to evaluate cerebral VMR. Ultrasonographic carotid artery parameters were collected: the presence and characteristics of carotid plaques, the degree of carotid diameter stenosis, intima-media thickness (IMT), peak systolic velocity (PSV), and end diastolic velocity (EDV). Additionally, hemodynamic parameters of the middle cerebral artery (MCA) were evaluated, including the mean flow velocity (MFV) and pulsatility index (PI). The following was collected from patients' medical histories: age, gender, and vascular risk factors. A negative correlation between the BHI and age (r = -0.242, p < 0.01), BHI and the presence of carotid plaques, BHI and IMT (r = -0.203, p < 0.01), and BHI and the PI of MCA on both sides (r = -0.268, p < 0.01) was found. We found a positive correlation between the BHI in the left MCA and EDV in the left internal carotid artery (r = 0.121, p < 0.05). This study shows the correlation between cerebral VMR and carotid stenosis but indicates a higher influence of morphological parameters on VMR values.

The Atherogenic Index of Plasma Predicts Carotid in-Stent Restenosis: Development and Validation of a Nomogram

Purpose

To explore the predictive value of atherogenic index of plasma(AIP) for carotid in-stent restenosis(ISR).

Methods

Patients who underwent carotid artery stenting (CAS) in hospital from January 2016 to January 2021 were retrospectively enrolled. They were randomly divided into training and validation sets. Based on the results of carotid digital subtraction angiography (DSA) during the follow-up period, the patients were divided into ISR group and non-ISR group. The differences of AIP and lipid levels between the two groups were compared. The independent risk factors of ISR and the predictive value of AIP for ISR were analyzed. A nomogram was developed based on the independent risk factors, and the receiver operating characteristic (ROC) curve, the calibration curve and the decision curve analysis were conducted to assess the predictive ability and clinical practicability of the nomogram in both the training set and validation sets.

Results

A total of 361 patients were enrolled, including 98 in the ISR group and 263 in the non-ISR group. In the training set, AIP was significantly higher in the ISR group than in the non-ISR group (P < 0.05) and was independently associated with ISR (OR= 10.912, 95% CI: 2.520-47.248). When AIP was 0.10, it had the highest predictive value for ISR, with a sensitivity of 72. 1% and a specificity of 75.0%. Additionally, hypertension, residual stenosis, symptomatic stenosis and Hcy were also independent risk factors for ISR. The nomogram showed good discrimination performance and clinical practicability in both the training set (AUC = 0.827) and the validation set (AUC = 0.880).

Conclusion

AIP was an independent risk factor for ISR and was closely related to ISR. The nomogram developed by AIP and other variables had good predictive ability and clinical practicability for ISR.

Carotid endarterectomy for the management of carotid stenosis occurring concurrently with head and neck cancer

PURPOSE OF REVIEW

Currently, most patients with concurrent head and neck cancer (HNC) and carotid stenosis (CS) are treated disjointedly for their oncologic and vascular lesions. The purpose of this review is to evaluate literature exploring a novel approach to these cases that poses several advantages, in which carotid endarterectomy (CEA) is performed simultaneously with surgical resection of HNC.

RECENT FINDINGS

Carotid stenosis is a common comorbidity of patients presenting with head and neck cancer as these pathologies have overlapping risk factors. Adjuvant oncologic therapy such as radiation therapy to the site of the lesion is known to increase development or progression of carotid stenosis. Performing simultaneous surgical management of CS and HNC decreases total procedures for the patient, provides a less challenging surgical field, and eliminates prioritization of treatment initiation for one pathology over the other. There has been limited reporting of simultaneous CEA with oncologic resection of HNC in the literature. However, of the 21 cases reviewed here, no perioperative strokes were reported with only one perioperative death from myocardial infarction.

SUMMARY

Available literature supports that simultaneous CEA with oncologic resection of HNC is safe and may offer several advantages, although larger studies are required.

K, R.Ya. D, I.S. D, N.V. C. The course of arterial hypertension in patients with type 2 diabetes after surgical treatment of carotid artery stenotic lesions

Background. Arterial hypertension (AH) is the cause of 70–75 % of strokes. Atherosclerotic lesion of the carotid artery (CA) is a classic example of a vascular lesion in individuals with hypertension. The risk of stroke increases twice when hypertension and diabetes are combined. Carotid endarterectomy (CA), which has both a curative and preventive nature, is the main method of surgical treatment of CA stenoses. The purpose was to study the course of blood pressure in patients with type 2 diabetes and without it after CE. Materials and methods. 138 patients with arterial hypertension and CA stenosis were selected for the purpose of CE under local anesthesia. Patients were divided into two groups: 68 patients with type 2 diabetes (group I) and 70 patients without diabetes (group II). The median age of patients in group I was 64 [50–71] years, group II — 63.5 [47–68] years. Daily blood pressure monitoring (BPD) was performed 2 days before surgery (1 examination), 5–7 days after surgery (2 examinations) and 3–6 months after CE (3 examinations). The average indicators of systolic blood pressure (SBP) and diastolic blood pressure (DBP) per day, day, and night were evaluated; average pulse blood pressure (BP); variability of SBP and DBP per day, day, night. Results. Before the operation, group I, in contrast to group II, recorded significantly higher indicators: SATdb (p = 0.02), SATd (p = 0.03), SATn (p = 0.01), DBTn (p < 0, 05), PAT (p = 0.03), varDATdb (p = 0.03), varSATd (p = 0.03), varDATn (p = 0.04). During the second examination in group II, significantly more significant dynamics of DMAT indicators were noted: SATdb (p = 0.002), SATd (p = 0.02), DAPdb (p = 0.002), DAPd (p = 0.01), DAPn (p = 0.03), varSATn (p < 0.04), varDATn (p < 0.05), varSATdb (p = 0.0002), varDATdb (p = 0.0001). The dynamics of PAT and midnight SAT were insignificant. 3 months after KE, all mean values of SBP and DBP, as well as PAT, decreased significantly in patients of group II. The expressiveness of changes in SBP indicators during the day, day and night, as well as indicators of SBP variability in group II was more significant. During the third examination, the proportion of patients with a "dipper" circadian rhythm increased in the two groups (p < 0.05). In group II, the proportion of patients with an unfavorable type of daily profile "over-dipper" significantly decreased (p < 0.001), which did not occur in group I. Conclusions. Surgical treatment of carotid stenoses in patients with and without type 2 diabetes is associated with a decrease in blood pressure in the early postoperative period and is observed for several months after the operation.

Non-invasive Diagnosis and Postoperative Evaluation of Carotid Artery Stenosis by BSA-Gd2O3 Nanoparticles-Based Magnetic Resonance Angiography

Contrast-enhanced magnetic resonance angiography is a powerful and effective method to accurately diagnose carotid artery stenosis. Small molecular gadolinium (Gd)-based agents have reliable signal enhancement, but their short circulating time may result in a loss of image resolution due to insufficient vascular filling or contrast agent emptying. Here, we report an MRA imaging approach to diagnose carotid artery stenosis using long-circulating bovine serum albumin (BSA)-Gd2O3 nanoparticles (NPs). The BSA-Gd2O3 NPs synthesized by a simple biomineralization approach exhibit admirable monodispersity, uniform size, favorable aqueous solubility, good biocompatibility, and high relaxivity (14.86 mM-1 s-1 in water, 6.41 mM-1 s-1 in plasma). In vivo MRA imaging shows that outstanding vascular enhancement of BSA-Gd2O3 NPs (0.05 mmol Gd/kg, half the dose in the clinic) can be maintained for at least 2 h, much longer than Gd-DTPA. Vessels as small as 0.3 mm can be clearly observed in MRA images with high resolution. In a rat carotid artery stenosis model, the BSA-Gd2O3 NPs-based MRA enables the precise diagnosis of the severity and location and the therapeutic effect following the surgery of carotid artery stenosis, which provides a method for the theranostics of vascular diseases.

Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment

PURPOSE

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment.

MATERIALS AND METHODS

Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention.

RESULTS

A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group.

CONCLUSIONS

The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Long non-coding RNA RMST serves as a diagnostic biomarker in patients with carotid artery stenosis and predicts the occurrence of cerebral ischemic event: A retrospective study

OBJECTIVES

The purpose of this retrospective study is to explore the diagnostic and prognostic roles of serum RMST in carotid artery stenosis (CAS).

METHODS

Serum levels of RMST were detected in CAS patients, and the relationship between degree of carotid stenosis and RMST levels was analyzed. The ROC curve was drawn to evaluate RMST value in predicting the risk of CAS. Then, all CAS patients received a 5-year follow-up. K-M curve was used to analyze the significance of RMST on prognosis of CAS patients. Multi-factor cox logistic regression analysis was conducted to evaluate independent factors for outcome of CAS patients.

RESULTS

An increased RMST expression was certified in CAS patients when compared with healthy controls. The increase of serum RMST expression was related to high degree of carotid stenosis. In addition, serum RMST was a possible diagnosis and an independent influencing factor of prognosis in patients with CAS.

CONCLUSIONS

Raised serum RMST level was found in patients with CAS. Detecting RMST expression levels was of high value for predicting the occurrence and outcomes in CAS.

Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers

Endovascular carotid artery stenting (CAS) is a common treatment for carotid artery stenosis and stroke prevention. Previous studies have shown that high procedural volume centers are associated with improved patient outcomes. Unplanned 30-day readmissions, which are associated with significant expenses, are increasingly used as a metric of patient outcome. Despite prior studies evaluating associations between procedural volume and multiple outcomes, the association between very high CAS volume and short-term (30-day) readmission has not yet been evaluated in a large multicenter study. The National Readmissions Database (NRD) was analyzed retrospectively from 2010 to 2015 to evaluate the association between hospital procedural volume and patient outcomes in asymptomatic and symptomatic CAS patients. Very high volume centers (VHVC) were defined as the top 10% hospitals in terms of procedural volume, performing >= 79 procedures a year. Univariate and multivariate analyses of patient and hospital characteristics evaluated associations with short-term (30-day) readmissions (SR), long-term (90-day) readmissions (LR), index mortality, discharge disposition, major complications, and neurological complications. A total of 36,128 asymptomatic patients and 8,390 symptomatic patients who underwent CAS were identified. Asymptomatic CAS patients treated at VHVCs were associated with decreased likelihood of SR (OR 0.88, 95% CI 0.80-0.95, p = 0.003) and LR (OR 0.91, 95% CI 0.85-0.99, p = 0.037) compared to asymptomatic patients at non-VHVCs. There was no significant difference in SR or LR between symptomatic CAS patients treated at a VHVC vs. non-VHVC. Our findings provide additional evidence to support the role of experience in improved CAS treatment outcomes.

A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting

BACKGROUND

The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience.

OBJECTIVE

To assess outcomes of TF vs TR approach for CAS.

METHODS

This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study.

RESULTS

A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts.

CONCLUSION

The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.

Using eZIS of SPECT to evaluate the therapeutic effect of carotid endarterectomy

OBJECTIVE

Stroke is an acute cerebrovascular disease with high morbidity and mortality. The main causes of ischemic stroke include carotid artery stenosis, and carotid endarterectomy (CEA) can be used to improve the blood flow of the lesion site. Regional cerebral blood flow (rCBF) can be decreased by using single photon emission computed tomography (SPECT). The Easy Z-Score imaging system (eZIS) can display the changes of rCBF as Z-Score. The purpose of this study was to determine whether eZIS of SPECT can be used to evaluate the therapeutic effect of CEA in the treatment of carotid artery stenosis.

METHODS

In this study, subjects were divided into the surgery group and the control group. The surgery group included seven patients with unilateral or bilateral internal carotid artery stenosis who received CEA treatment, and the control group included 11 patients who only received conventional drug treatment but did not receive surgery. Cerebral perfusion imaging (CPI) was collected twice before and after the corresponding treatment (within 6 months). rCBF of the lesion site was measured and Z-score was calculated before and after treatment by the eZIS technique.

RESULTS

The postoperative Z-score of the surgery group was 0.54 ± 2.71 compared with that of the preoperative -1.34 ± 2.68 ( P  = 0.0034; t  = 4.687; df  = 6), while the z-score of the control group was -0.33 ± 2.58 compared with that of the pretreatment 1.84 ± 2.62 ( P  = 0.0010; t  = 4.618; df  = 10).

CONCLUSION

CEA can effectively improve the blood flow in the lesion area of patients with carotid artery stenosis. eZIS of SPECT can be used to evaluate the therapeutic effect of CEA on carotid artery stenosis visually.

Carotid Artery Disease in the Era of Biomarkers: A Pilot Study

The intima-media thickness (IMT) and its irregularities or ulcerations in the common carotid artery (CCA) are useful tools as sentinel biomarkers for the integrity of the cardiovascular system. Total homocysteine and lipoprotein levels are the most commonly used elements in cardiovascular risk stratification. Duplex ultrasound (DUS), associated with serum biomarkers, can be used simply to assess the degree of atherosclerotic disease and cardiovascular risk. This study highlights the role of different kinds of biomarkers, showing their usefulness and potentiality in multi-district atherosclerotic patients, especially for early diagnosis and therapy effectiveness monitoring. A retrospective analysis performed from September 2021 to August 2022, of patients with carotid artery disease, was performed. A total of 341 patients with a mean age of 53.8 years were included in the study. The outcomes showed an increased risk of stroke in patients with significative carotid artery disease, nonresponsive to therapy, monitored through a series of serum biomarkers (homocysteine, C-reactive protein, and oxidized LDL). In this reported experience, the systematic use of DUS in association with the multiple biomarkers approach was effective for the early identification of patients at higher risk of disease progression or inefficient therapy.

Bibliometric and visual analysis of cerebral revascularization from 1999 to 2022

Background

Cerebral revascularization is a neurosurgical procedure used to restore the cerebral collateral circulation channel. This study examines the countries, institutions, authors, journals, keywords, and references related to the disease in the field of cerebral revascularization from 1999 to 2022 from a bibliometrics perspective, evaluates the changes of knowledge structure clustering and identifies the new hot spots and new research directions in this field.

Methods

The Web of Science Core Collection (WOSCC) database and the PICOS retrieval method were used to conduct a comprehensive search for articles and reviews pertaining to cerebral revascularization. The final filtered data were bibliometrically and visually drawn using Microsoft office 365, CiteSpace (v.6.1.R2), and VOSviewer (v.1.6.18).

Results

From 1999 to 2022, a total of 854 articles pertaining to cerebral revascularization, which originated from 46 nations, 482 institutions, and 686 researchers, were extracted from the WOSCC database, and the number of publications in this field of study was rising. The United States held the highest proportion in the ranking analysis of countries, institutions, authors, and journals. By analyzing co-citations, the scientific organization of this field and the development status of frontier fields were realized. Cerebral revascularization, moyamoya disease, extracranial intracranial bypass, and occlusion are the current research focal points in the field of cerebral revascularization. Hyperperfusion and vascular disorder may also become a new study focus in this discipline in the near future.

Conclusion

Using the method of bibliometrics, this study analyzed and reviewed the articles in the field of cerebral revascularization, which enabled scholars to better comprehend the dynamic process in this field and provided a foundation for future in-depth research.

Deregulated Long Non-Coding RNA HCG11 in Cerebral Atherosclerosis Serves as a Biomarker to Predict the Risk of Cerebrovascular Events

Carotid artery stenosis (CAS) is one of the main risk factors of ischemic stroke (IS), which needs a screening and monitoring biomarker. The study focused on the clinical significance of long non-coding RNA (lncRNA) HCG11 in CAS patients aiming to identify a potential therapeutic target for CAS. Serum samples were collected from 70 CAS patients and 80 age- and gender-matched healthy people. HCG11 levels were measured via quantitative real-time PCR (qRT-PCR), and its significance in CAS identification and development prediction was also assessed. HCG11 was enriched in the serum of CAS patients, and serves as a possible biomarker for disease diagnosis with the area under the curve (AUC) of 0.930. Elevated expression of HCG11 was significantly correlated with hypertension, dyslipidemia, and degree of carotid stenosis. HCG11 was highly expressed in severe CAS cases compared to moderate ones, which was positively related to the disease severity. Cox regression analysis determined the close relationship of serum HCG11 with the occurrence of cerebral ischemia events. CAS patients with high HCG11 expression showed a high occurrence rate of cerebral ischemia events. The upregulation of HCG11 could serve as a potential diagnostic biomarker for CAS and is positively related to the disease severity. Serum HCG11 can independently predict the occurrence of following cerebral ischemia events.

Carotid endarterectomy versus carotid stenting for asymptomatic carotid stenosis: Evaluating the overlapping meta-analyses of randomized controlled trials

Background

Asymptomatic carotid stenosis is associated with increased risk of ischemic stroke. The management of asymptomatic carotid stenosis ranges from open surgical approaches, minimally invasive endovascular interventions, and medical therapeutics. However, the research synthesis comparing these interventions, as shown by the scattered and overlapping published meta-analysis, has been inconsistent and non-comprehensive.

Methods

Using previously-employed methods, we searched for and compared published meta-analyses comparing carotid endarterectomy and carotid stenting. A comprehensive search was conducted for all relevant studies published until November 13th, 2021, using the following databases: PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, OVID, and Google Scholar.

Results

Five meta-analysis studies were included in this review. In summary, clinical findings were: carotid endarterectomy reduced the rate of ischemic stroke and stroke-related mortality, but led to a higher rate of intraoperative cranial nerve injury. There was no significant difference between carotid endarterectomy and carotid stenting in ipsilateral stroke and myocardial infarction events.

Conclusions

The clinical findings favor the carotid endarterectomy over the carotid stenting in terms of stroke incidence (overall and minor events) and stroke-related mortality rates. However, the carotid stenting was superior to the carotid endarterectomy in the events of cranial nerve injury during the intervention.

Extracranial carotid plaque hemorrhage predicts ipsilateral stroke recurrence in patients with carotid atherosclerosis – a study based on high-resolution vessel wall imaging MRI

Background

Intraplaque hemorrhage (IPH) is a hallmark of carotid plaque vulnerability. We aim to investigate the association between IPH and recurrent ipsilateral ischemic stroke.

Methods

Patients with a recent stroke or transient ischemic attack (TIA) were prospectively recruited and underwent an ultrasonographic examination and carotid HR VWMRI on the side consistent with symptoms. Carotid plaque was defined as carotid intima-media-thickness (IMT) by ultrasound≥1.5 mm. IPH was determined that the ratio of the plaque signal intensity relative to that of adjacent muscle was > 1.5. All enrolled patients were clinically followed until an ipsilateral ischemic stroke, TIA, carotid endarterectomy (CEA)/carotid artery stenting (CAS), or death within 12 months. Univariate analysis was used to analyze the correlation between clinical characteristics and IPH. Kaplan-Meier survival analysis and a log-rank test were used to compare recurrence-free survival time between the IPH and non-IPH groups. Cox regression models evaluated IPH as the predictor of ipsilateral stroke recurrence.

Results

A total of 171 patients (mean age, 60.13 ± 10.04 years; 118 males) were included in the final analysis. Thirty-two patients (18.7%) showed carotid IPH. During the follow-up, patients with carotid IPH suffered 60.9% (14 of 23) of recurrent ipsilateral strokes and 60.0% (3 of 5) TIA. Multivariate Cox regression analysis proved IPH as a strong predictor of ipsilateral stroke; the adjusted hazard ratio (HR) was 6.64 (95% confidence interval [CI], 2.84–15.54, P < 0.001). Meanwhile, Cox regression analysis also proved that IPH could predict recurrent ischemic events; the adjusted HR was 8.08 (95% CI, 3.65–17.91, P < 0.001).

Conclusions

Carotid intraplaque hemorrhage is strongly associated with recurrent ischemic events and could predict recurrent ipsilateral stroke.

Persistent Hemodynamic Depression After Carotid Artery Stenting: A Review and Update

According to the American Heart Association, ischemic stroke is the second leading cause of death globally and is responsible for approximately 11% of deaths. Carotid endarterectomy (CEA) is the standard treatment for moderate or severe extracranial internal carotid artery (ICA) stenoses. With the development of materials and technology in neurointervention, the Centers for Medicare and Medicaid Services (CMS) have proposed that carotid artery stenting (CAS) can serve as an alternative treatment for CEA. As CAS is widely used worldwide, comorbidities, especially persistent hemodynamic depression (PHD) and stroke, have attracted public attention. In this review, we summarized the current advances in PHD after CAS. A better understanding of CAS-related PHD may inspire the design of potential prognostic and therapeutic tools.

α-Lipoic Acid-Plus Ameliorates Endothelial Injury by Inhibiting the Apoptosis Pathway Mediated by Intralysosomal Cathepsins in an In Vivo and In Vitro Endothelial Injury Model

α-Lipoic acid-plus (LAP), an amine derivative of α-lipoic acid, has been reported to protect cells from oxidative stress damage by reacting with lysosomal iron and is more powerful than desferrioxamine (DFO). However, the role of LAP in experimental carotid artery intimal injury (CAII) has not yet been well investigated. Therefore, we sought to uncover the role and potential endovascular protective mechanisms of LAP in endothelial injury. In vitro, oxyhemoglobin (OxyHb) stimulation of cultured human umbilical vein endothelial cells (HUVECs) simulated intimal injury. In vivo, balloon compression injury of the carotid artery was used to establish a rat CAII model. We found that the protein levels of cathepsin B/D, ferritin, transferrin receptor (TfR), cleaved caspase-3, and Bax increased in the injured endothelium and HUVECs but were rectified by DFO and LAP treatments, as revealed by western blotting and immunofluorescence staining. Additionally, DFO and LAP decreased oxidative stress levels and endothelial cell necrosis of the damaged endothelium. Moreover, DFO and LAP significantly ameliorated the increased oxidative stress, iron level, and lactic dehydrogenase activity of HUVECs and improved the reduced HUVEC viability induced by OxyHb. More importantly, DFO and LAP significantly reduced mitochondrial damage and were beneficial for maintaining lysosomal integrity, as indicated by acridine orange (AO), Lyso-Tracker Red, JC-1, and ATPB staining in HUVECs. Finally, LAP might offer more significant endovascular protective effects than DFO. Our data suggested that LAP exerted endovascular protective effects by inhibiting the apoptosis signaling pathway mediated by intralysosomal cathepsins by reacting with excessive iron in endothelial lysosomes after intimal injury.

Carotid Artery Stenting in Patients with Symptomatic and Asymptomatic Stenosis: In-Hospital Clinical Outcomes at a Single Neurovascular Center

Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications.

Efficacy and mechanism of stellate ganglion block in patients undergoing carotid endarterectomy

OBJECTIVES

Carotid endarterectomy (CEA) is an effective technique for carotid artery stenosis and has been widely used. Stellate ganglion block (SGB) has good effect on the treatment of both painful and non-painful diseases. To investigate the efficacy of SGB in terms of cerebral protection in patients undergoing CEA and to analyze its mechanism.

METHODS

In this retrospective analysis, 120 patients who underwent CEA were enrolled and divided into study group (SG) (60 cases, general anesthesia and SGB) and control group (CG) (60 cases, general anesthesia). The differences in hemodynamic indexes, middle cerebral artery (MCA) hemodynamic indexes, and endocrine-related indexes between the two groups at the baseline, after induction of anesthesia (induction), and skin incision (incision) were compared. The differences in neurological function and pain level between two groups 1 day pre-operatively (pre-op 1), 1 day postoperatively (POD 1), 2 day postoperatively (POD 2), and 7 day postoperatively (POD 7) were also evaluated. Perioperative adverse events and intraoperative anesthetics dosage were compared between two groups.

RESULTS

The systolic blood pressure, diastolic blood pressure, mean pulse pressure difference, and heart rate of SG at incision were lower than those of the CG (p < 0.05); Vs, Vd, and Vm of MCA were significantly higher in the SG than in CG at induction and incision (p < 0.05). Cortisol and aldosterone levels were lower and potassium and insulin levels were higher in the SG than in CG at induction and incision (p < 0.05); At pre-op 1, POD 1, POD 2, and POD 7, the VAS scores of patients in the SG were significantly lower than those in CG at POD 1, POD 2, and POD 7 (p < 0.05). The patients in SG showed decreased incidence of perioperative adverse events compared with the CG (p < 0.05); The consumption of anesthetics in the SG was lower than that in CG (p < 0.05).

CONCLUSION

SGB in patients undergoing CEA treatment can improve perioperative cerebral blood supply and reduce the consumption of anesthetics and the incidence of perioperative adverse events, which is safe and feasible as a cerebral protection measure. Meanwhile, SGB may also help stabilize patients' perioperative hemodynamic indexes, but the result still needs to be supported by further large sample data.

The clinical application of a scoring protocol to select endarterectomy or stenting for carotid artery stenosis

Previously we described the protocol-based decision for choosing the proper surgical treatment option for carotid stenosis. The objective of this study is to describe our experiences of using this scoring protocol in the selection of endarterectomy or stenting for carotid stenosis. Between October 2014 and March 2018, the scoring protocol was applied to a total of 105 consecutive patients. Eighty (76.2%) patients had symptomatic stenosis ≥ 50%, and 25 (23.8%) patients had asymptomatic stenosis ≥ 80%. We also speculated about how effectively the protocol worked in the real clinical setting. Stenting was performed in 73 patients and endarterectomy in 32 patients. Overall, 98 (93.3%) patients were treated according to the protocol, while the protocol was violated in seven (6.7%) patients. Sixty-one (58.1%) patients received treatments that were decided by the protocol. There were 37 (35.2%) patients who had the same score for both treatment options. Among these patients, 28 patients underwent stenting and nine patients underwent endarterectomy. In the stenting cases, 90.4% of the patients followed the protocol and violations occurred in 9.6%. In the endarterectomy cases, all of the patients followed the protocol. Overall, one patient had a procedure-related complication without morbidity. During the 12-month follow-ups, there were no restenoses or major strokes. Minor strokes were diagnosed in three (2.8%) patients. In patients with carotid artery stenosis, stenting and endarterectomy should be considered simultaneously together, not against each other. Our scoring protocol can be used to weigh these options and applied in clinical practice.

A Meta-Analysis of Using Protamine for Reducing the Risk of Hemorrhage During Carotid Recanalization: Direct Comparisons of Post-operative Complications

Background: Protamine can decrease the risk of hemorrhage during carotid recanalization. However, it may cause severe side effects. There is no consensus on the safety and efficacy of protamine during surgery. Thus, we conduct a comprehensive review and meta-analysis to compare the differences between the protamine and the no-protamine group.

Method: We systematically obtained literature from Medline, Google Scholar, Cochrane Library, and PubMed electronic databases. All four databases were scanned from 1937 when protamine was first adopted as a heparin antagonist until February 2021. The reference lists of identified studies were manually checked to determine other eligible studies that qualify. The articles were included in this meta-analysis as long as they met the criteria of PICOS; conference or commentary articles, letters, case report or series, and animal observation were excluded from this study. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool are used to assess the risk of bias of each included observational study and RCT, respectively. Stata version 12.0 statistical software (StataCorp LP, College Station, Texas) was adopted as statistical software. When I2 &lt; 50%, we consider that the data have no obvious heterogeneity, and we conduct a meta-analysis using the fixed-effect model. Otherwise, the random-effect model was performed.

Result: A total of 11 studies, consisting of 94,618 participants, are included in this study. Our analysis found that the rate of wound hematoma had a significant difference among protamine and no-protamine patients (OR = 0.268, 95% CI = 0.093 to 0.774, p = 0.015). Furthermore, the incidence of hematoma requiring re-operation (0.7%) was significantly lower than that of patients without protamine (1.8%). However, there was no significant difference in the incidence of stroke, wound hematoma with hypertension, transient ischemic attacks (TIA), myocardial infarction (MI), and death.

Conclusion: Among included participants undergoing recanalization, the use of protamine is effective in reducing hematoma without increasing the risk of having other complications. Besides, more evidence-based performance is needed to supplement this opinion due to inherent limitations.

Atherosclerosis and Atrial Fibrillation: Double Trouble

PURPOSE OF REVIEW

This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis.

RECENT FINDINGS

MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.

Extracranial Carotid Plaque Hemorrhage Is Independently Associated With Poor 3-month Functional Outcome After Acute Ischemic Stroke-A Prospective Cohort Study

Background and Purpose: Carotid plaque hemorrhage (IPH) is a critical plaque vulnerable feature. We aim to elucidate the association between symptomatic extracranial carotid atherosclerotic IPH and poor 3-month functional outcome after acute ischemic stroke by high-resolution vessel wall MRI (HRVMRI).

Methods: We prospectively studied consecutive patients with a recent stroke or transient ischemic attack (TIA) of carotid atherosclerotic origin. All patients underwent a High-Resolution (HR) VWMRI scan of ipsilateral extracranial carotid within 1 week after admission. The patients recruited were interviewed by telephone after 3 months after stroke onset. The primary outcome was a 3-month functional prognosis of stroke, expressed as a modified Rankin Scale (mRS) score. A poor prognosis was defined as a 3-month modified Rankin Scale (mRS) score ≥ of 3. Univariate analysis was used to analyze the correlation between risk factors and IPH. The relation between IPH and 3-month functional outcome was analyzed by Logistic regression analysis.

Results: A total of 156 patients (mean age, 61.18 ± 10.12 years; 108 males) were included in the final analysis. There were significant differences in the age, gender, smoking history, national institutes of health stroke scale (NIHSS) on admission, and diastolic blood pressure (DBP) on admission between the IPH group and the non-IPH group (all p < 0.05). During the follow-up, 32 patients (20.5%) had a poor functional outcome. According to the prognosis analysis of poor functional recovery, there was a significant difference between the two groups [36.7 vs. 16.7%; unadjusted odds ratio (OR), 2.32, 95% confidence interval (CI), 1.12–4.81, p = 0.024). Even after adjusting for confounding factors [such as age, gender, smoking history, National Institutes of Health Stroke Scale (NIHSS) on admission, DBP on admission, stenosis rate of carotid artery (CA), calcification, loose matrix, lipo-rich necrotic core (LRNC), and statins accepted at 3 months], IPH was still a strong predictor of poor 3-month outcome, and the adjusted OR was 3.66 (95% CI 1.68–7.94, p = 0.001).

Conclusions: Extracranial carotid IPH is significantly associated with poor 3-month outcome after acute ischemic stroke and can predict the poor 3-month functional prognosis.

Intracranial atherosclerotic disease and acute ischaemic stroke: A review of diagnosis and management

Intracranial atherosclerotic disease is highly prevalent and a common cause of ischaemic stroke globally. With the increasing use of endovascular treatment for acute stroke management, computed tomography and magnetic resonance imaging have become an essential part of patient selection. In this review, we present the typical imaging findings of intracranial atherosclerosis and an overview of management as relevant to diagnostic and interventional radiologists.

[Optical coherence tomography angiography and cardiovascular diseases. An overview of the current knowledge]

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death worldwide. The observability of retinal vessel changes in the context of CVD by funduscopy has been known for a long time. Optical coherence tomography angiography (OCTA) is a novel technique for noninvasive detailed imaging and quantification of the retinal microcirculation. The OCTA enables the visualization of vascular changes in a simple and well-reproducible way. Its applications are not limited to the field of ophthalmology. In recent years, several experimental and clinical studies have been published on vascular changes detectable with OCTA in CVD. This review summarizes the most important findings of these studies.

METHODS

This work is based on a comprehensive review of the literature and on the presentation of own data.

RESULTS

Nowadays, OCTA studies are available for many diseases of the cardiovascular spectrum. This indicates that systemic vascular diseases are associated with changes in the retinal microcirculation. These changes can be visualized and reproducibly quantified with OCTA. In many diseases subclinical changes, which are detectable by OCTA, occur before the underlying disease causes otherwise measurable changes or noticeable symptoms for the patient.

CONCLUSION

The OCTA is a promising imaging method in the context of CVD in both scientific and clinical applications. It can be used for the diagnostics and quantification of retinal vascular changes. Further studies will show whether OCTA can be of assistance in the estimation of individual systemic cardiovascular risk profiles.

MicroRNA-375-3p is implicated in carotid artery stenosis by promoting the cell proliferation and migration of vascular smooth muscle cells

Background

Atherosclerosis is the main cause of carotid artery stenosis (CAS) which mostly occurs in the elderly. In this paper, the expression level of miR-375-3p in asymptomatic CAS patients and its diagnostic value for asymptomatic CAS were investigated, and the effects of miR-375-3p on the cell proliferation and migration of vascular smooth muscle cells (VSMCs) was further explored.

Methods

98 healthy subjects and 101 asymptomatic CAS patients were participated in this study. qRT-PCR was used to measure the expression level of serum miR-375-3p, and the ROC curve was established to evaluate the predictive value of miR-375-3p for asymptomatic CAS. After transfection with miR-375-3p mimic or inhibitor in vitro, cell proliferation and migration were detected by CCK-8 assay, colony formation assay, and Transwell assay, respectively. The levels of TNF-α, IL-1β, IL-6 were detected by ELISA. Western blot was used to detect the protein expression of XIAP. Finally, luciferase reporter gene assay was applied to assess the interaction of miR-375-3p with target genes.

Results

The expression level of serum miR-375-3p in asymptomatic CAS patients was significantly higher than that in healthy controls, and the AUC value of ROC curve was 0.888. The sensitivity and specificity were 80.2 and 86.7%, respectively, indicating that miR-375-3p had high diagnostic value for asymptomatic CAS. In vitro cell experiments showed that up-regulation of miR-375-3p significantly promoted the proliferation and migration of VSMCs, and also promoted the generation of inflammatory factors and phenotypic transformation of VSMCs. Luciferase reporter gene assay confirmed that XIAP was a target gene of miR-375-3p and was negatively regulated by miR-375-3p.

Conclusions

In this study, miR-375-3p may have a clinical diagnostic value for asymptomatic CAS patients which need further validation. Increased miR-375-3p levels in CAS may be associated with increased proliferation and migration of VSMCs via downregulation of the apoptosis inducing gene XIAP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02326-6.

Multi-omics approaches for revealing the complexity of cardiovascular disease

The development and progression of cardiovascular disease (CVD) can mainly be attributed to the narrowing of blood vessels caused by atherosclerosis and thrombosis, which induces organ damage that will result in end-organ dysfunction characterized by events such as myocardial infarction or stroke. It is also essential to consider other contributory factors to CVD, including cardiac remodelling caused by cardiomyopathies and co-morbidities with other diseases such as chronic kidney disease. Besides, there is a growing amount of evidence linking the gut microbiota to CVD through several metabolic pathways. Hence, it is of utmost importance to decipher the underlying molecular mechanisms associated with these disease states to elucidate the development and progression of CVD. A wide array of systems biology approaches incorporating multi-omics data have emerged as an invaluable tool in establishing alterations in specific cell types and identifying modifications in signalling events that promote disease development. Here, we review recent studies that apply multi-omics approaches to further understand the underlying causes of CVD and provide possible treatment strategies by identifying novel drug targets and biomarkers. We also discuss very recent advances in gut microbiota research with an emphasis on how diet and microbial composition can impact the development of CVD. Finally, we present various biological network analyses and other independent studies that have been employed for providing mechanistic explanation and developing treatment strategies for end-stage CVD, namely myocardial infarction and stroke.

Urinary Proteomics Identifying Novel Biomarkers for the Diagnosis and Phenotyping of Carotid Artery Stenosis

Background: Carotid artery stenosis (CAS) is caused by the formation of atherosclerotic plaques inside the arterial wall and accounts for 20–30% of all strokes. The development of an early, noninvasive diagnostic method and the identification of high-risk patients for ischemic stroke is essential to the management of CAS in clinical practice.

Methods: We used the data-independent acquisition (DIA) technique to conduct a urinary proteomic study in patients with CAS and healthy controls. We identified the potential diagnosis and risk stratification biomarkers of CAS. And Ingenuity pathway analysis was used for functional annotation of differentially expressed proteins (DEPs). Furthermore, receiver operating characteristic (ROC) analysis was performed to evaluate the diagnostic values of DEPs.

Results: A total of 194 DEPs were identified between CAS patients and healthy controls by DIA quantification. The bioinformatics analysis showed that these DEPs were correlated with the pathogenesis of CAS. We further identified 32 DEPs in symptomatic CAS compared to asymptomatic CAS, and biological function analysis revealed that these proteins are mainly related to immune/inflammatory pathways. Finally, a biomarker panel of six proteins (ACP2, PLD3, HLA-C, GGH, CALML3, and IL2RB) exhibited potential diagnostic value in CAS and good discriminative power for differentiating symptomatic and asymptomatic CAS with high sensitivity and specificity.

Conclusions: Our study identified novel potential urinary biomarkers for noninvasive early screening and risk stratification of CAS.

Silent brain infarcts and white matter lesions in patients with asymptomatic carotid stenosis

The association of carotid atherosclerosis with silent brain infarcts (SBIs) and white matter lesions (WMLs) currently remains unknown. This study aims to compare SBIs, deep white matter lesions (DWMLs), and periventricular white matter lesions (PWMLs) in ipsilateral and contralateral hemispheres to internal carotid artery (ICA) stenosis, and investigate their association with stenosis grade in patients with asymptomatic ≥ 50% unilateral extracranial ICA stenosis. Patients without previous history of stroke and/or transient ischemic attack who had ≥ 50% stenosis in unilateral ICA on carotid color Doppler ultrasound were enrolled in the study. Patient demographics, vascular risk factors and ICA stenosis grades; number, location, and size of SBIs, DWMLs, and PWMLs in ICA territory were evaluated in both hemispheres using magnetic resonance imaging of the brain. Of the 69 patients, 53 had 50-69% (76.8%) and 16 had ≥ 70% (23.2%) unilateral ICA stenosis. There was no statistically significant difference in SBIs between ipsilateral and contralateral hemispheres to ≥ 50% ICA stenosis. Comparison of ICA stenoses as 50-69% and ≥ 70% revealed a greater number of patients with SBI in ipsilateral hemisphere to ≥ 70% stenosis compared to contralateral (p = 0.025). The number of SBIs was also higher in ipsilateral hemisphere to ≥ 70% stenosis compared to contralateral (p = 0.022). While DWMLs and PWMLs did not differ between hemispheres, frequency of Fazekas grade 1 DWMLs was lower in ipsilateral hemisphere to either 50-69% or ≥ 70% ICA stenosis compared to contralateral (p = 0.035 and p = 0.025, respectively). Results of the present study indicate that stenosis grade may be relevant in the association between asymptomatic carotid stenosis and SBIs, and ≥ 70% stenosis may pose a risk of SBI development.

Shear-Wave Elastography Enables Identification of Unstable Carotid Plaque

Shear-wave elastography (SWE) is a novel ultrasound technique for quantifying tissue elasticity. The aim of this study was to identify differences in atherosclerotic plaque elasticity measured using SWE among individuals with symptomatic, asymptomatic progressive and asymptomatic stable carotid plaques. Consecutive patients from the Atherosclerotic Plaque Characteristics Associated with a Progression Rate of the Plaque and a Risk of Stroke in Patients with the Carotid Bifurcation Plaque Study were screened for this research. Neurosonography examination of carotid arteries was performed to identify plaque stenosis of ≥50% using B-mode ultrasound and SWE imaging to measure the mean, maximal and minimal elasticity. The set consisted of 97 participants-74 with asymptomatic stable stenosis, 12 with asymptomatic progressive stenosis and 11 with symptomatic stenosis. The mean elasticity in the asymptomatic stable plaque group was significantly higher than in the asymptomatic progressive (52.2 vs. 30.4 kPa; p < 0.001) and symptomatic (52.2 vs. 36.4 kPa; p = 0.033) plaque groups. No significant differences were found between asymptomatic progressive and symptomatic (p > 0.1) plaque groups. Asymptomatic stable, asymptomatic progressive and symptomatic plaques did not differ in echogenicity, calcifications, homogeneity, occurrence of ulcerated surface, or intra-plaque hemorrhage (p > 0.05 in all cases). SWE was a helpful modality for differentiating between stable and unstable atherosclerotic plaques in carotid arteries.

Frailty Measurement and Implications for Cerebrovascular Disease Management in a Veteran Based Population

BACKGROUND

Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains difficult and variable. The Risk Analysis Index (RAI) is a validated medical record-based assessment of frailty that has been used to predict clinical outcomes for patients undergoing surgical procedures including CEA. We applied RAI to a veteran population following CEA for asymptomatic cerebrovascular disease and examined the factors related to post-operative morbidity and mortality.

METHODS

After obtaining IRB approval, Veteran Affairs Surgical Quality Improvement Program data was queried for CEA procedures from 2002 to 2015 for ICD-9 codes indicating asymptomatic patients. RAI was then calculated based on Veteran Affairs Surgical Quality Improvement Program variable medical record extraction. Three groupings of patients were undertaken including non-frail (RAI < 30), frail (RAI 30-34) and very frail (RAI ≥ 35). Chi squared and ANOVA were used to assess cohort differences. Binary logistic regression was used to evaluate predictors of post-operative stroke, myocardial infarction (MI), any complication, and death.

RESULTS

Between 2002 and 2015, 37,873 asymptomatic patients underwent CEA. Over 98% (37,266) of the patients were male with an average age of 68.3 ± 8.55 years. The cohorts contained 82.8% (n = 31,362), 12.4% (n = 4,678), and 4.8% (n = 1,833) for the non-frail, frail and very frail groups respectively. Frailty was associated with increased rates of post-operative stroke, MI, any complication, death, and longer hospital length of stay (P< 0.001). Operative time did not significantly differ between the groups. Increasing frailty was associated with having one or more complications (OR 1.69, 95% CI 1.50-1.90 for frail and OR 2.79, 95% CI 2.41-3.24 for very frail, (P< 0.001), post-operative stroke in frail (OR 1.33 95% CI 1.06-1.67) and very frail (OR 1.57 1 95% CI 1.14-2.16) patients, and MI in both frail (OR 1.68, CI 1.17-2.43) and very frail (OR 3.73, CI 2.52-5.51) patients. Frailty was also significantly associated with death with in very frail patients (OR 4.14, 95% CI 3.00-5.71, P< 0.001).

CONCLUSION

Increasing frailty as determined by RAI was associated with worse post-operative outcomes in asymptomatic patients undergoing CEA. Higher RAI score cohorts were associated with higher rates of postoperative stroke, MI, complications, and death. We recommend the use of this frailty index as a screening tool to guide risk discussions with asymptomatic patients undergoing CEA.

Platelet-Derived Extracellular Vesicles Increase Col8a1 Secretion and Vascular Stiffness in Intimal Injury

The arterial mechanical microenvironment, including stiffness, is a crucial pathophysiological feature of vascular remodeling, such as neointimal hyperplasia after carotid endarterectomy and balloon dilatation surgeries. In this study, we examined changes in neointimal stiffness in a Sprague-Dawley rat carotid artery intimal injury model and revealed that extracellular matrix (ECM) secretion and vascular stiffness were increased. Once the endothelial layer is damaged in vivo, activated platelets adhere to the intima and may secrete platelet-derived extracellular vesicles (pEVs) and communicate with vascular smooth muscle cells (VSMCs). In vitro, pEVs stimulated VSMCs to promote collagen secretion and cell adhesion. MRNA sequencing analysis of a carotid artery intimal injury model showed that ECM factors, including col8a1, col8a2, col12a1, and elastin, were upregulated. Subsequently, ingenuity pathway analysis (IPA) was used to examine the possible signaling pathways involved in the formation of ECM, of which the Akt pathway played a central role. In vitro, pEVs activated Akt signaling through the PIP₃ pathway and induced the production of Col8a1. MicroRNA (miR) sequencing of pEVs released from activated platelets revealed that 14 of the top 30 miRs in pEVs targeted PTEN, which could promote the activation of the Akt pathway. Further research showed that the most abundant miR targeting PTEN was miR-92a-3p, which promoted Col8a1 expression. Interestingly, knockdown of Col8a1 expression in vivo abrogated the increase in carotid artery stiffness and simultaneously increased the degree of neointimal hyperplasia. Our results revealed that pEVs may deliver miR-92a-3p to VSMCs to induce the production and secretion of Col8a1 via the PTEN/PIP3/Akt pathway, subsequently increasing vascular stiffness. Therefore, pEVs and key molecules may be potential therapeutic targets for treating neointimal hyperplasia.

Potential Role of Melatonin as an Adjuvant for Atherosclerotic Carotid Arterial Stenosis

Carotid artery stenosis (CAS) is an atherosclerotic disease characterized by a narrowing of the artery lumen and a high risk of ischemic stroke. Risk factors of atherosclerosis, including smoking, hypertension, hyperglycemia, hyperlipidemia, aging, and disrupted circadian rhythm, may potentiate atherosclerosis in the carotid artery and further reduce the arterial lumen. Ischemic stroke due to severe CAS and cerebral ischemic/reperfusion (I/R) injury after the revascularization of CAS also adversely affect clinical outcomes. Melatonin is a pluripotent agent with potent anti-inflammatory, anti-oxidative, and neuroprotective properties. Although there is a shortage of direct clinical evidence demonstrating the benefits of melatonin in CAS patients, previous studies have shown that melatonin may be beneficial for patients with CAS in terms of reducing endothelial damage, stabilizing arterial plaque, mitigating the harm from CAS-related ischemic stroke and cerebral I/R injury, and alleviating the adverse effects of the related risk factors. Additional pre-clinical and clinical are required to confirm this speculation.

Circulating miR-27b as a Biomarker of the Development and Progression of Carotid Artery Stenosis

OBJECTIVE

A close relationship of microRNAs (miRNAs) with various human diseases has been widely reported, including cardiovascular disease. The current study attempted to examine the abnormal expression of miR-27b in asymptomatic carotid artery stenosis (ACAS), its diagnostic value and predictive value for the development of ACAS were also assessed.

METHODS

Clinical serum samples were collected from both ACAS patients and healthy individuals, and levels of miR-27b in the clinical samples were detected using Real-time quantitative PCR. Cerebral ischemia events (CIEs) of patients during the 5-year follow-up were collected. The diagnostic and predictive values of serum miR-27b was assessed via plotting Receiver operating characteristic (ROC) and Kaplan-Meier curves. Multivariate cox regression analysis was performed for clinical independent index analysis.

RESULTS

ACAS patients had higher levels of miR-27b than the healthy subjects. There were close association of serum miR-27b levels with total cholesterol (TC) level, absence of hypertension and degree of carotid stenosis. High levels of miR-27b could differentiate ACAS cases from healthy subjects, and predicted the high incidence of CIEs. MiR-27b could be used as an independent predictor of cerebrovascular events via multiple Cox regression analysis (P = .031).

CONCLUSION

The high level of miR-27b can predict the occurrence of ACAS, and is closely related to the subsequent occurrence of CIEs. The present results provide evidence for circulating miR-27b as a diagnostic and prognostic marker in patients with ACAS.

Perioperative outcomes for carotid revascularization on asymptomatic dialysis-dependent patients meet Society for Vascular Society guidelines

OBJECTIVE

The current Society for Vascular Surgery practice guidelines recommend carotid revascularization for asymptomatic disease in patients with at least a 3-year life expectancy and stenosis >60% when the expected perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who require dialysis would not meet the perioperative stroke and death thresholds nor the long-term survival benchmarks to justify carotid surgery. To determine whether carotid surgery for patients requiring dialysis is appropriate, the present study compared the perioperative outcomes after carotid revascularization for dialysis-dependent patients relative to nondialysis patients in a contemporary, national cohort.

METHODS

The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who undergone carotid endarterectomy or carotid artery stenting for asymptomatic carotid disease from 2011 to 2018. The cohort was categorized as requiring or not requiring dialysis. The primary 30-day outcomes included mortality and the composite of stroke/death and stroke/death/myocardial infarction (MI). Univariate analyses were performed using the Fisher exact test and Wilcoxon rank sum test. Multivariable analyses were used to assess the independent associations of the estimated glomerular filtration rate and dialysis dependence with the stroke/death rate.

RESULTS

A total of 17,579 patients met the inclusion criteria. Of these patients, 226 (1.3%) required dialysis at revascularization. No difference was found in the degree of severe stenosis (80%-99%) demonstrated by 69% of the dialysis cohort and 72% of the nondialysis cohort (P = .9). Of the dialysis and nondialysis cohorts, 5% and 3.6% underwent carotid artery stenting (P = .3). The dialysis-dependent patients were younger (68 vs 71 years; P < .001) and were more likely to have insulin-dependent diabetes (47% vs 12%; P < .001), congestive heart failure (8.4% vs 1.4%; P < .001), and severe chronic obstructive pulmonary disease (15% vs 10%; P = .03). In the dialysis and nondialysis cohort, 2 (0.9%) and 88 (0.5%) patients died (P = .3); 4 (1.8%) and 247 (1.4%) experienced strokes (P = .6); and 3 (1.3%) and 185 (1.1%) patients experienced MI (P = .5), respectively. The composite outcomes of stroke/death and stroke/death/MI was 2.2% (n = 5) and 1.8% (n = 319; P = .6) and 3.5% (n = 8) and 2.8% (n = 479; P = .4) in the dialysis and nondialysis cohorts, respectively. After multivariable analysis, neither the estimated glomerular filtration rate (adjusted odds ratio, 1.0; 95% confidence interval, 1.00-1.01; P = .26) nor dialysis dependence (adjusted odds ratio, 0.21; 95% confidence interval, 0.03-1.57; P = .13) was independently associated with the composite outcome of stroke/death.

CONCLUSIONS

The 30-day carotid revascularization outcomes for asymptomatic disease in dialysis-dependent patients met the Society for Vascular Surgery guidelines in this national cohort and might be better than previously surmised. Hence, vascular surgeons could consider carotid revascularization for select dialysis-dependent patients with the appropriate expected longevity and perioperative risk.

Carotid endarterectomy should be performed early or delayed in patients with symptomatic carotid stenosis?

BACKGROUND

To date, the literature directly comparing early carotid endarterectomy (CEA) and delayed CEA in patients with symptomatic carotid stenosis (CS) is limited. We aimed to evaluate the efficacy and safety of early CEA and delayed CEA in patients with symptomatic CS by performing a meta-analysis.

MATERIAL AND METHOD

The PubMed, Cochrane Library (last searched in May 2020) and relevant websites such as Web of Science and EMBASE (1990 to May 2020) were searched. All meta-analyses of eligible results were conducted using the STATA version 12.0 (Stata Corporation, College Station, Texas, USA).

RESULTS

A total of 7 articles were included in the study hailing from the New Scotland, Chicago, Sweden, UK, Italy, and France. In this study, the early CEA meant that the procedure was performed within the first 14 days or first 30 days. And the delayed CEA meant the procedure was performed more than 14 days or 30 days after the symptom occurrence. Referring to the latter early CEA group and delayed CEA group, there were three publications. The results illustrated that the early CEA group was not associated with a higher incidence of stroke (OR = 0.77, 95 % CI: 0.273-2.170; P = 0.620). And no statistic difference was found on the incidence of postoperative 30-day mortality and stroke or mortality. Meanwhile, referring to the former early CEA group and delayed CEA group, there were six articles. The results demonstrated that the early CEA group was associated with a higher rate of postoperative 30-day mortality (RD = 0.010, 95 % CI: 0.002 to 0.019; P = 0.022).

CONCLUSION

The meta-analysis of these related studies suggests that, compared to the delayed CEA group, the early CEA performed in patients with the acute post stroke phase resulted in a higher risk of postoperative mortality. Therefore, the delayed CEA was safer than early CEA for patients with symptomatic CS.