Prevalence of Significant Asymptomatic Carotid Artery Disease in Patients with Peripheral Vascular Disease: A Meta-Analysis

Prevalence of extracranial carotid artery disease in symptomatic peripheral artery disease and implications for long-term outcome

BACKGROUND

Patients with peripheral artery disease (PAD) still experience excessive rates of fatal cardiovascular events. In this context, the relevance of co-existing extracranial carotid artery disease (ECAD) on outcome in patients with PAD is unclear. Thus, this study elucidates long-term outcome effects of the presence of both atherosclerotic entities for further risk stratification.

MATERIALS AND METHODS

A total of 669 patients from the Lip-LEAD study with symptomatic PAD (Fontaine stage 2-4) were evaluated for ECAD (internal carotid artery stenosis >50%) with ultrasonography within 6 months after endovascular repair for PAD. Outcome was assessed with a long-term follow-up period with a maximum of 10 years.

RESULTS

Patients presenting with ECAD (n = 245, 36.7%) exhibited worse hemodynamic parameters of PAD than those without (ankle-brachial index (ABI). (0.53 (0.37-0.68) vs. 0.57 (0.47-0.68), p = 0.009; toe-brachial index (TBI) (0.50 (0.36-0.63) vs. 0.55 (0.42-0.70), p = 0.005). Significant correlations between grade of carotid stenosis and ABI as well as TBI were present (r=-0.190, p < 0.001; r=-0.219, p < 0.001). Cox-regression analyses revealed worse outcome in patients with ECAD for both all-cause and cardiovascular (CV)-mortality after multivariable adjustment for traditional CV risk-factors [1.48 (2.02-2.17); 2.10 (1.19-3.69)].

CONCLUSION

Patients with additional ECAD to symptomatic PAD exhibited an unfavourable long-term outcome in comparison to those without. The results suggest that the additional presence of ECAD highlights a highly vulnerable cohort of patients with symptomatic PAD at risk for further fatal CV events and thus should be considered for further diagnostic evaluation and stronger risk modification initiatives.

The diagnosis and treatment of asymptomatic and symptomatic patients with carotid artery stenosis

Carotid artery atherosclerotic stenosis is an important annual cause of stroke in the United States. Moreover, the incidence of carotid artery stenosis is significantly increasing due to the widespread popularity of high fat and high salt diets, sedentary lifestyles, and the increasing age of the population. Of major importance to cardiovascular specialists is the fact that individuals with atherosclerotic carotid artery stenosis can have a prevalence of atherosclerotic coronary artery disease as high as 50 to 75%. Vascular screening for carotid artery stenosis with Doppler ultrasound should be considered for all symptomatic patients with possible carotid stenosis and also considered for asymptomatic patients with (1) symptomatic peripheral arterial disease, coronary artery disease, or atherosclerotic aortic aneurysm or, (2) multiple atherosclerotic risk factors. Carotid artery atherosclerotic plaques that are at high risk for rupture and thrombosis or cerebral embolization are characterized by large lipid cores, intraplaque hemorrhage, thin fibrous caps less than 165 μms that are infiltrated by macrophages and T cells or have surface ulcer(s) or fissures. Carotid artery plaque rupture with cerebral embolism can cause a stroke, transient ischemic attacks (TIA), or ipsilateral blindness (amaurosis fugax). Medical treatment based on the recommendations of the American and European Societies for Vascular Surgery and the American Heart Association for symptomatic patients with carotid stenosis and also asymptomatic patients with high risk carotid stenosis plaques include antiplatelet drugs, antihypertensive drugs for hypertension control and lipid lowering drugs. Management strategies and decisions about carotid revascularization in asymptomatic patients with high risk carotid stenosis should involve a multidisciplinary team and shared decision-making is recommended. The 30 day and five to 10 year outcomes in asymptomatic carotid stenosis patients who have undergone carotid endarterectomy, carotid stenting and/or optimal medical therapy are summarized from the Veterans Administration Cooperative Study, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trials. The current Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) should help to resolve the debate regarding carotid artery revascularization versus primary medical treatment in asymptomatic patients with >70% carotid artery stenosis. Symptomatic patients who present within 4.5 hours of stroke onset require evaluation for acute intravenous pharmacologic thrombolysis and patients who present with large vessel occlusion within 24 hours of symptom onset should be considered for mechanical thrombectomy to reduce the neurologic deficit. Patients with carotid artery stenosis who present with a history of cerebral infarct in the preceding six months due to cerebral embolism require medical treatment and evaluation by a multidisciplinary team for carotid revascularization in order to prevent future strokes or TIAs. The outcomes of the North American Symptomatic Carotid Endarterectomy Trial, Carotid Revascularization Endarterectomy Versus Stent Trial, Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial, and the Safety and Efficacy Study for Reverse Flow Used during Carotid Artery Stenting Procedure trials for symptomatic patients with carotid stenosis are reviewed. A synopsis of treatment guidelines for symptomatic and asymptomatic carotid stenosis patients from the American and European Societies of Vascular Surgery and the American Heart Association/American Stroke Association are presented. Each patient with carotid artery stenosis must be carefully evaluated to determine the best treatment based on the clinical presentation, the imaging and laboratory diagnostic information, the treatment guidelines, and the patient needs and preferences as well as the patient's social and cultural factors.

Superficial femoral artery disease as a cardiovascular prognostic predictor in aortoiliac revascularization-A cohort study

IntroductionAortoiliac disease is a severe manifestation of peripheral artery disease (PAD) that reduces blood flow to the lower limbs, leading to significant morbidity and mortality. Patients with AID frequently present lesions in other arterial territories, particularly in the superficial femoral artery (SFA), which may lead to more challenging and higher risk outcomes in patients. This study aims to evaluate the prognostic value for major adverse cardiovascular events (MACE) of SFA disease in patients undergoing aortoiliac revascularization.MethodsThis prospective cohort study included all consecutive patients who underwent elective aortoiliac revascularization between January 2013 and September 2022 at both a central and a district hospital, representing two healthcare facilities within the Portuguese Health System. Only patients with aortoiliac Transatlantic Inter-Society Consensus (TASC) II type D lesions were included, excluding those with aortoiliac aneurysmal disease. Moreover, patients with severe multivessel disease in other arterial areas, apart from the aortoiliac artery and SFA, were excluded. Patient demographics, clinical characteristics, and procedural details were collected. Outcomes were assessed in the first 30 days post-procedure and during long-term follow-up. Statistical analyses included Kaplan-Meier survival curves and multivariate Cox regression.ResultsA total of 133 patients were included, with a mean age of 62.3 ± 9.23 years; 94.0% were male, and a median follow-up of 61 [IQR: 55.0-67.0] months. SFA disease was present in 60.9% of patients and was associated with hypertension (p = .025), coronary artery disease (p = .005), congestive heart failure (p = .020), and age (p = .008). Patients with SFA disease had a lower 30-day ankle-brachial index (ABI) (p < .001), smaller post-surgery ABI variation (p = .003), longer hospital stays (p = .005), and higher rates of major adverse limb event (MALE) (p = .007). Survival analysis demonstrated increased long-term MALE, MACE, and all-cause mortality in patients with SFA disease. Multivariable analysis confirmed SFA disease as a significant predictor of all-cause mortality (HR = 2.046 [1.042-4.443] p = .048) and suggested a trend towards increased risk of MACE (HR = 1.542, [0.866-3.101], p = .075).ConclusionThis study identifies SFA disease as a critical prognostic marker for adverse cardiovascular outcomes in patients undergoing aortoiliac revascularization. Further research with larger sample sizes and longer follow-up periods is warranted to validate these findings and improve patient management strategies.

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.

One Puncture, Two Solutions: Simultaneous Carotid and Iliac Artery Stenting

An 81-year-old man with asymptomatic severe carotid artery stenosis and symptomatic iliac artery stenosis underwent simultaneous carotid artery stenting (CAS) and iliac artery percutaneous transluminal angioplasty and stenting. The procedure involved transfemoral access, balloon angioplasty, and stenting of the right iliac artery, followed by CAS of the right carotid artery. Similar procedures were performed later on the left iliac and carotid arteries. The patient was discharged with no neurological deficits and remained asymptomatic at a six-month follow-up. Simultaneous CAS and iliac artery stenting were feasible and effective in patients with concurrent severe carotid and iliac artery stenosis, providing a comprehensive revascularization strategy for patients with complex atherosclerotic disease.

Rapid Carotid Screening by Duplex: A Prospective Single Centre Assessment

OBJECTIVE

A novel carotid quick scan (CQS) protocol was developed to rapidly screen for carotid atherosclerosis greater than 50% stenosis in a vascular outpatient setting. This study assessed accuracy and time saved.

MATERIAL & METHODS

The CQS was developed by consensus agreement between vascular surgeons and accredited clinical vascular scientists through a modified Delphi technique. The protocol comprised a rapid B-mode then colour flow transverse sweep of the common and internal carotid arteries, with internal carotid artery velocity assessment. One hundred outpatients attending with peripheral artery disease or abdominal aortic aneurysm were recruited. CQS sensitivity, specificity and accuracy was assessed against a conventional full carotid duplex study, performed to UK and ESVS guidelines.

RESULTS

Twenty four percent of patients (n = 100) had >50% carotid NASCET stenosis. CQS achieved an excellent accuracy of 96.5% in detecting >50% stenosis when compared to full duplex; Cohen's ƙ = .88, (95%CI .79-.97; P < .001), sensitivity 91.4%, specificity 97.6%, positive predictive value (PPV) 88.9% and negative predictive value (NPV) 98.2%. Median (IQR) time to complete the CQS was 13 sec (±12) per side, compared to 151 sec (±78) per side for the full carotid duplex. In the presence of >50% carotid disease, median CQS time was 25 sec (±31) per side compared to 214 (±104) by full scan.

CONCLUSION

CQS as a carotid screening tool is rapid, accurate and acceptable to the population and workforce. It would be simple to roll out in all vascular laboratories to reduce the time and cost burden of excluding significant carotid disease in any group.

12-Month Outcomes of Carotid Artery Stenting With CGuard MicroNET-Covered Stent: A Single-Center Study in 113 Patients

Dual layer mesh stents constitute a novel treatment option for patients who undergo carotid artery stenting (CAS). The aim of this prospective study is to report 12 month outcomes of patients who underwent CAS with CGuard (Inspire MD, Tel Aviv, Israel) microNET self-expanding stent with embolic protection system in a tertiary center from October 2018 to March 2022. Primary endpoints included in-stent restenosis >70% verified by ultrasound (DUS), ipsilateral transient ischemic attack (TIA), and stroke at 12 months. Secondary endpoints included cardiovascular-related mortality (stroke, myocardial infarction, heart failure) and all-cause mortality during follow-up. One hundred thirteen patients were included in the study (male 72.5%), symptomatic 47.8%. Median follow-up was 25 months (2-48). By 12 months, there was one in-stent occlusion that manifested as stroke (1/113, 0.8%) but no other forms of in-stent restenosis. Two patients experienced contralateral TIA (1.7%). CVRM was 3.5% (4 MI) and all-cause mortality was 6% at follow-up. This prospective study shows that CAS with CGuard MicroNET-covered stent is safe with minimal neurological adverse events at 12 months follow-up. Larger, and longer-term studies are necessary to define CGuard long-term safety and protection against carotid-related stroke.

Patients with Polyvascular Disease: A Very High-risk Group

Polyvascular disease (PolyvascDis) with atherosclerosis occurring in >2 vascular beds (coronary, carotid, aortic, visceral and/or peripheral arteries) is encountered in 15-30% of patients who experience greater rates of major adverse cardiovascular (CV) events. Every patient with multiple CV risk factors or presenting with CV disease in one arterial bed should be assessed for PolyvascDis clinically and noninvasively prior to invasive angiography. Peripheral arterial disease (PAD) can be readily diagnosed in routine practice by measuring the ankle-brachial index. Carotid disease can be diagnosed by duplex ultrasound showing % stenosis and/or presence of plaques. Coronary artery disease (CAD) can be screened by determining coronary artery calcium score using coronary computed tomography angiography; further, non-invasive testing includes exercise stress and/or myocardial perfusion imaging or dobutamine stress test, prior to coronary angiography. Abdominal ultrasound can reveal an abdominal aortic aneurysm. Computed tomography angiography will be needed in patients with suspected mesenteric ischemia to assess the mesenteric arteries. Patients with the acute coronary syndrome and concomitant other arterial diseases have more extensive CAD and poorer CV outcomes. Similarly, PolyvascDis in patients with carotid disease and/or other PAD is independently associated with an increased risk for all-cause and CV mortality during long-term follow-up. Treatment of patients with PolyvascDis should include aggressive management of all modifiable risk factors by lifestyle changes and drug therapy, with particular attention to patients who are commonly undertreated, such as those with PAD. Revascularization should be reserved for symptomatic vascular beds, using the least aggressive strategy in a multidisciplinary vascular team approach.

Detection of asymptomatic carotid stenosis in patients with lower-extremity arterial disease: development and external validations of a risk score

BACKGROUND

Recommendations for screening patients with lower-extremity arterial disease (LEAD) to detect asymptomatic carotid stenosis (ACS) are conflicting. Prediction models might identify patients at high risk of ACS, possibly allowing targeted screening to improve preventive therapy and compliance.

METHODS

A systematic search for prediction models for at least 50 per cent ACS in patients with LEAD was conducted. A prediction model in screened patients from the USA with an ankle : brachial pressure index of 0.9 or less was subsequently developed, and assessed for discrimination and calibration. External validation was performed in two independent cohorts, from the UK and the Netherlands.

RESULTS

After screening 4907 studies, no previously published prediction models were found. For development of a new model, data for 112 117 patients were used, of whom 6354 (5.7 per cent) had at least 50 per cent ACS and 2801 (2.5 per cent) had at least 70 per cent ACS. Age, sex, smoking status, history of hypercholesterolaemia, stroke/transient ischaemic attack, coronary heart disease and measured systolic BP were predictors of ACS. The model discrimination had an area under the receiver operating characteristic (AUROC) curve of 0.71 (95 per cent c.i. 0.71 to 0.72) for at least 50 per cent ACS and 0.73 (0.72 to 0.73) for at least 70 per cent ACS. Screening the 20 per cent of patients at greatest risk detected 12.4 per cent with at least 50 per cent ACS (number needed to screen (NNS) 8] and 5.8 per cent with at least 70 per cent ACS (NNS 17). This yielded 44.2 and 46.9 per cent of patients with at least 50 and 70 per cent ACS respectively. External validation showed reliable discrimination and adequate calibration.

CONCLUSION

The present risk score can predict significant ACS in patients with LEAD. This approach may inform targeted screening of high-risk individuals to enhance the detection of ACS.

Features of Antithrombotic Therapy in Patients with Multifocal Arterial Disease

Multifocal arterial injury is common in patients with atherosclerotic cardiovascular diseases and is associated with increased risk of cardiovascular complications and death. Administration of more intensive antithrombotic therapy, particularly combinations of acetylsalicylic acid and a "vascular" dose of rivaroxaban, in patients with multifocal arterial injury is characterized by a beneficial ratio of efficiency and safety due to a pronounced decrease in the risk of cardiovascular complications. Detection of peripheral artery diseases in patients with ischemic heart disease and atherosclerotic cerebrovascular pathology makes it possible to improve the risk stratification, optimize the diagnostic tactics and clarify indications for more intensive antithrombotic therapy.

Clinical situations requiring radial or brachial access during carotid artery stenting

Introduction

Radial or brachial access may be preferred in the case of severe peripheral artery disease (PAD) or difficult aortic arch anatomy during carotid artery stenting (CAS).

Aim

To evaluate the clinical conditions indicating potential benefit from non-femoral access as well as feasibility and safety of transradial/transbrachial access (TRA/TBA) as an alternative approach for CAS.

Material and methods

Since 2013, 67 patients (mean age: 70 years old, 44 men, 42% symptomatic) were selected for CAS with the TRA/TBA approach. The composite endpoint was stroke/death/myocardial infarction within 30 days of the procedure and compared to the propensity score matched transfemoral approach (TFA) group. Clinical (including neurological) examination and Doppler ultrasonography were performed before the procedure, at discharge and at 30 days.

Results

CAS with TRA/TBA was successful in 63/67 patients. Transfemoral access was not feasible due to PAD in 35 (52.2%) patients, bovine arch in 10 (14.9%), obesity (BMI > 35 kg/m²) in 9 (13.4%), severe degenerative disease of the spine in 7 (10.5%), arch type III in 5 (7.5%) and excessive subclavian stent protrusion in 1 (1.5%) patient. Mean NASCET carotid artery stenosis was reduced from 81% to 9% (p < 0.001). The composite endpoint occurred in 3 (4.8%) cases and it was not statistically significantly different from the matched TFA group (6.3%; p = 0.697). No access site complications requiring surgical intervention or blood transfusion developed.

Conclusions

Transradial and transbrachial CAS may be an effective and safe procedure, and it may constitute a viable alternative to the femoral approach in patients with severe PAD, difficult aortic arch anatomy or obesity.

Should we screen patients for carotid artery disease before lung cancer resection?

Background

Postoperative stroke is a rare complication after lung cancer surgery but has a high mortality rate. No strategy has been recommended to detect carotid artery disease preoperatively in lung cancer patients. The main objective of this study was to evaluate whether a routine carotid duplex ultrasound (DUS) altered the preoperative management of these patients.

Methods

We performed a single-centre, retrospective study of all patients referred for lung cancer resection over a two-year period and reviewed the available carotid DUS results. We quantified the number of carotid artery disease diagnosis, the severity of the disease according to DUS results, and the number of treatments initiated preoperatively. We examined relationships between cardiovascular history and preoperative carotid artery disease diagnosis.

Results

Among the 398 consecutive lung surgery patients, 6% had a preoperative history of stroke or transient ischemic attack, and one developed a postoperative stroke, of cardioembolic origin. Three hundred and seven patients (77%) had preoperative carotid DUS. Carotid DUS results elicited anti-platelet therapy initiation or endarterectomy before lung resection in 7 out of these 307 patients (2.3%). One hundred and seventy-one carotid DUS were retrospectively reviewed by an expert, who diagnosed carotid stenosis >50% and occlusion in 2.3% and 1.2% of patients, respectively. Abnormal carotid DUS was associated with history of lower extremity artery disease (P<0.001), diabetes mellitus (P<0.05) and dyslipidemia (P<0.05).

Conclusions

This retrospective observational study showed that routine preoperative carotid DUS led to few carotid stenosis detection and few perioperative management alterations. Carotid artery disease diagnosis was associated with cardiovascular history and risk factors. Future studies should examine how to select patients who will benefit from a preoperative carotid DUS.

Prevalence of Lower Extremity Arterial Disease as Measured by Low Ankle-Brachial Index in Patients with Acute Cerebral Ischemic Events

BACKGROUND

Low ankle-brachial index (ABI) of ≤0.9 is diagnostic of lower extremity arterial disease (LEAD). It is also a strong marker of generalized atherosclerosis. The objective of this study was to assess the prevalence of low ABI in patients with acute cerebral ischemic events (ACIE): ischemic stroke (IS) or transient ischemic attack (TIA).

METHODS

We compared 150 inpatients with ACIE to 50 inpatient controls and assessed risk factors, ABI measurements, and Duplex ultrasound of the cervical vessels.

RESULTS

Low ABI was seen in 69 patients (46%) in the ACIE group and in 8 (16%) in the control group; p < 0.01. The mean and median ABI values in the ACIE group were 0.88 (SD = 0.22) and 0.91 (0.24-1.33), which were significantly lower than in the control group: 1.04 (SD = 0.16) and 1.0 (0.66-1.36); p < 0.0001, respectively. Coronary artery disease, carotid stenosis of ≥50% and smoking were risk factors, which were associated with significantly lower ABI in the study group; the ABI with risk factors vs. without was 0.85 vs. 0.92 (coronary artery disease); p < 0.05, 0.7 vs. 0.92; (carotid stenosis) p < 0.001 and 0.83 vs. 0.98; (smoking) p < 0.001, respectively.

CONCLUSION

Our study demonstrated that patients with ACIE have significantly higher involvement of another vascular bed as LEAD. Coronary artery disease, carotid stenosis ≥50% and smoking were main risk factors associated with coexistence of LEAD and ACIE.

Extended duration therapy regimens based on Pegylated interferon for chronic hepatitis B patients focusing on hepatitis B surface antigen loss: A systematic review and meta-analysis

AIMS

Hepatitis B surface antigen (HBsAg) loss is associated with disease control and improvement of prognosis. Therefore, it is regarded as the optimal treatment endpoint for chronic hepatitis B (CHB) patients. Pegylated interferon (PegIFN)-based extended therapy regimens was assessed in several studies. In order to summarize a conclusion on the HBsAg loss rate and safety in this regimen, a systematic review and meta-analysis was performed.

METHODS

Studies on Hepatitis B and PegIFN were searched thoroughly in Pubmed, EMBASE, and the Cochrane Library from inception to November 18, 2019. The primary endpoint of this study was the HBsAg loss rate at the end of the extended duration therapy. The secondary endpoint was safety. All analyses were performed by using the R3.6.1 version Software. Quality assessment of RCTs was carried out by using Review manager 5.3.

RESULTS

A total of nine studies, including 545 CHB patients met the inclusion criteria. The pooled HBsAg loss rate after PegIFN-based extended duration therapy was 11% (95% CI: 0.05-0.19), I² = 82%, P < 0.01(Q test). The extended duration therapy regimen was safe and tolerable. Subgroup analysis showed HBsAg loss rates were 14% (95% CI: 0.04-0.29) and 10% (95% CI: 0.02-0.20) respectively for HBeAg positive and HBeAg negative patients (P = 0.52). HBsAg loss rates were 11%(95%CI:0.03-0.22)and 12%(95%CI:0.04-0.24)respectively for PegIFN monotherapy and PegIFN with Nucleos(t)ide analogs (NAs) therapy (P = 0.84). HBsAg loss rates were 25% (95% CI: 0.19-0.31) and 8% (95% CI: 0.03-0.15) respectively for the advantageous group and non-advantageous group (P = 0.001).

CONCLUSIONS

For CHB patients, extended duration of PegIFNα-based treatment for more than 48 weeks is likely to improve HBsAg clearance rate. Specially, the advantageous group will benefit a lot. In addition, the extended duration therapy regimen is safe and tolerable.

Atherosclerotic Extension of Carotid Arteries: An Insertion in Clinical Practice

INTRODUCTION

Atherosclerotic disease is a diffuse disease that is strongly associated with age, risk factors, and variable progression. The anatomical prevalence of atheromas does not always follow, a sequence by sectors, and in many cases are concomitant.

OBJECTIVES

This study is aimed at studying atherosclerosis in the arterial territories of the carotid and lower limbs, in order to correlate their extension as a form of primary prevention.

METHODS

Participating patients with the main risk factors for atherosclerotic disease were composed of two groups: one with chronic peripheral obstructive arterial disease (PAD) and another without PAD. After performing carotid ultrasound Doppler (USD) of all patients, the occasional prevalence of the disease was evaluated. We performed by statistical tests the correlation between the findings in these patients and the risk factors. Obtaining n from 226 patients, in which 116 patients are from the PAD group and 110 patients are from the group without PAD.

RESULTS

Our findings add up to 8.8% for lesions over 50% in patients with PAD, with 6.2% over 70% meeting the few published scientific findings. In this study, the correlation was evaluated between carotid stenosis and PAD, in which we observed a positive association. We observed in the studies that the prevalence of moderate and severe carotid stenosis was similar to patients with coronary artery disease (CAD). There are a number of nonclassical risk factors that we do not evaluate, but even studying the traditional ones, we find that they are less than 27% dependent.

CONCLUSION

Therefore, our study proposes an improvement in the clinical approach of patients with PAD for both the carotid and coronary territory, not using only 2 factors traditional risk factors, for the extension study and to consider the PAD that has 10% dependence alone, as effect and projection of the carotid atherosclerotic plaque.

Carotid, Vertebral, and Brachiocephalic Interventions

Carotid atherosclerosis most frequently manifests in the proximal internal carotid artery and the common carotid artery bifurcations. Subclavian artery atherosclerosis affects the proximal segments with a relatively higher incidence on the left and becomes clinically important in the presence of vertebrobasilar insufficiency or coronary steal. Atherosclerosis of the vertebral artery can lead to posterior circulation stroke. The authors review the major trials on carotid carotid, brachiocephalic and vertebral artery stenosis along with the various available diagnostic and interventional techniques.

Relationship between symptomatic lower limb peripheral artery disease and calcified carotid artery plaque detected on panoramic images of neurologically asymptomatic males

OBJECTIVE

Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD.

METHODS

Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of ≤ 0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05.

RESULTS

Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects.

CONCLUSION

We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.

Association between carotid artery stenosis and peripheral artery disease: Evaluation by screening carotid ultrasonography (cross-sectional study)

We aimed to investigate the association between carotid artery stenosis and peripheral artery disease (PAD) by screening carotid ultrasonography (CUS).From January 2012 to December 2015, 231 consecutive patients who had undergone preoperative CUS for PAD were included in this study. A radiologist assessed the degree of internal carotid artery (ICA) stenosis by using the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Severe (>70%) ICA stenosis was evaluated based on the type of vascular surgery, PAD lesion, and ankle-brachial index (ABI). Data were analyzed using multiple logistic regression analysis and the χ test.Among 231 PAD patients, multilevel lesions revealed significantly higher incidence of severe ICA stenosis than iliac and infrainguinal lesion (22.5% vs 9.4% vs 8%: P = .016). Age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.12: P = .035), chronic kidney disease (CKD, OR: 6.19, 95% CI: 2.04-45.04: P = .013), and cerebral vascular disease (CVD, OR: 4.08, 95% CI: 1.13-16.46: P = .037) were significant risk factors of severe ICA stenosis in multivariate analysis. Prevalence of severe ICA stenosis according to ABI in PAD was not significant.Preoperative screening by CUS provides valuable information onasymptomatic carotid artery stenosis (ACAS) that can identify severe ACAS patients who are at high risk of stroke and to consider more intensive management of carotid disease in PAD patients. CUS can be a useful noninvasive preoperative screening imaging tool for PAD patients with multilevel lesions, aged > 65 years old, with CKD and CVD.

Cost-effectiveness of magnetic resonance carotid plaque imaging for primary stroke prevention in Canada

OBJECTIVE

Magnetic resonance of the carotid arteries provides important insight into plaque composition and vulnerability in addition to the traditional measure of stenosis. The purpose of this study was to evaluate the cost-effectiveness of MR imaging as a first-line modality to assess carotid disease and guide management for high-risk patients with <50% stenosis.

METHODS

Using TreeAge Pro, a cost-effectiveness simulation was conducted comparing two strategies: (a) standard of care first-line carotid duplex ultrasound (DUS) with regular follow-up, vs (b) first-line MR assessment of stenosis and intraplaque haemorrhage (MRIPH) in which patients with IPH received annual DUS surveillance and immediate carotid endarterectomy in case of plaque progression.

RESULTS

For patients aged 70 years old, using a first-line MRIPH strategy resulted in a 16.8% relative risk reduction in strokes compared to DUS (0.080 vs 0.097 strokes per patient per lifetime), and an increased quality-adjusted-life years (12.23 vs 12.20) at an increased cost of $897.33 over a patient's lifetime ($5784.53 vs $4887.20 average total cost per patient per lifetime). The incremental cost-effectiveness ratio was $29,744 per quality-adjusted-life years. MRIPH remained cost-effective below a willingness-to-pay threshold of $50,000 for 91.8% of sensitivity analyses.

CONCLUSION

MRIPH was found to be a cost-effective first-line tool to identify asymptomatic patients at high risk for stroke requiring annual surveillance and prompt management. Advances in Knowledge: Using MR imaging as a fist-line method to detect the presence of IPH provides clinically useful and cost-effective information that allows for enhanced risk evaluation and primary stroke prevention.

The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

Plaque Imaging to Decide on Optimal Treatment: Medical Versus Carotid Endarterectomy Versus Carotid Artery Stenting

Many of the current guidelines for the management of carotid atherosclerosis are based on clinical trial findings published more than 2 decades ago. The lack of plaque information in clinical decision making represents a major shortcoming and highlights the need for contemporary trials based on characteristics of the atherosclerotic lesion itself, rather than luminal stenosis alone. This article summarizes the major dilemmas clinicians face in current practice, and discusses the rationale and evidence that plaque imaging may help to address these challenges and optimize the clinical management of carotid artery disease in the future.

Impact of Real-World Adherence with Best Medical Treatment on Cost-Effectiveness of Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis

BACKGROUND

To present a model of decision and cost-effectiveness analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy (CEA) and the rate of preventable future events and the impact of real-world adherence of best medical treatment (BMT) on cost-effectiveness of both therapeutic options.

METHODS

We used data from the current literature to define values for a base case and perform a sensitivity analysis. The primary end point was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either prophylactic CEA or adherent and nonadherent best medical treatment, respectively.

RESULTS

The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is 44 days over the course of 5 years in case of nonadherent best medical treatment. Over a 5-year time horizon, prophylactic CEA would be cost-effective in 50.8% of bootstrap replicates and nonpersistent BMT might be economically dominant in 11.1%. The probability that CEA would be cost-effective at a willingness-to-pay (WTP) threshold of Euro 50,000/quality-adjusted life year gained was 71.8%. In 17.9% prophylactic CEA would be more costly and effective than persistent BMT, but its incremental cost-effectiveness ratio was greater than the WTP, so persistent BMT would be optimal.

CONCLUSIONS

In this model, in case of real-world drug adherence, it was likely that a strategy of early endarterectomy might be a cost-effective or even the dominant therapeutic option in comparison with a strategy of medical therapy alone (deferred surgery). If background any-territory stroke rates on contemporary medical therapy would fall substantially below 0.7%, surgery would cease to be cost-effective.

Pathophysiology and Medical Treatment of Carotid Artery Stenosis

Stroke is the third leading cause of mortality. Approximately 80 to 85% strokes are ischemic due to carotid artery stenosis (CAS). The prevalence of significant CAS is 7% in women and 9% in men. Severe asymptomatic CAS varies from 0 to 3.1%. Prevalence of symptomatic CAS is high in patients with peripheral arterial disease. CAS is due to atherosclerosis, the major risk factors for which include dyslipidemia, hypertension, diabetes, obesity, cigarette smoking, advanced glycation end products (AGEs) and its receptors (RAGE, soluble RAGE [sRAGE]), lack of exercise and C-reactive protein (CRP). This article discusses the basic mechanism of atherosclerosis and the mechanisms by which these risk factors induce atherosclerosis. The role of AGEs and its receptors in the development and progression of CAS has been discussed in detail. Lifestyle changes and medical treatment of CAS such as lifestyle changes, lipid-lowering agents, antihypertensive agents, antidiabetic drugs, anti-AGE therapy, measures to elevate soluble receptors of AGE (sRAGE, esRAGE). CRP-lowering agents have been discussed in detail. The drugs especially lipid-lowering agents, and antihypertensive and antidiabetic drugs suppress, regress, and slow the progression of CAS. The possible role of lowering the levels of AGEs and raising the levels of sRAGE in the treatment of CAS has been proposed. Lifestyle changes besides medical treatment have been stressed. Lifestyle changes and medical treatment not only would slow the progression of CAS but would also regress the CAS.

Medical and Revascularization Therapies for Asymptomatic Carotid Stenosis

Asymptomatic internal carotid artery stenosis increases with age and is more common in men. Carotid endarterectomy and stenting have reduced stroke rates in patients with asymptomatic carotid stenosis in clinical trials. A variety of risk stratification methods are available for selection of patients with carotid stenosis for revascularization. In the past decade, there is increasing evidence that the rate of stroke declined with the use of aggressive multi-modal medical therapy. These developments have led to new clinical trials to compare revascularization versus aggressive medical therapy in patients with asymptomatic carotid stenosis.

[Occlusion of the aorta and iliac arteries]

Occlusion of the aorta and the iliac arteries leads to an insufficient perfusion of the legs and the genital and gluteal region. The occurring symptoms may be variable, mainly depending on the collateralization network of the internal iliac artery (IIA) circulation. Various differential diagnoses need to be excluded. Invasive therapy is almost always inevitable if an aortoiliac stenosis is established. With good patency rates and low mortality rates the indications for reconstructive procedures are liberally interpreted; therefore, invasive therapy can be performed in the early stages of claudication in certain situations. Due to lower invasiveness and therefore lower risk of complications while showing comparable long-term patency rates, endovascular treatment is the preferred first line therapy for the majority of occlusions. Because aortoiliac occlusion processes also affect patients who are actively involved in a professional career, the indications for invasive therapy can be attained even in Fontaine stage IIa.

Co-existence of carotid artery disease, renal artery stenosis, and lower extremity peripheral arterial disease in patients with coronary artery disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis5

Background

The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST).

Methods

This was a cost–utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates.

Results

The ICER was £ 7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £ 20 000 and £ 30 000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £ 3254, and that for men aged 75 years or above was £ 71 699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective.

Conclusion

In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £ 20 000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective.

A high prevalence of carotid artery stenosis in male patients older than 65 years, irrespective of presenting clinical manifestation of atherosclerotic diseases

This study investigated the prevalence of carotid artery stenosis (CS) and the association with various risk factors in male patients (>65 years) diagnosed with cardiovascular diseases. Duplex sonography of the carotid arteries was performed in 434 of 473 eligible patients of whom 118 (27.8%) patients had significant CS ≥50%. The prevalence and severity of CS did not differ between patients who presented with neurological symptoms or acute coronary syndrome/peripheral artery disease (30.8% vs 25.9%, respectively). Among patients with CS, a higher rate of current smoking, a higher systolic blood pressure, and a lower glomerular filtration rate were observed compared with patients without CS. A history of coronary artery bypass graft was a significant predictor of the presence of CS (P = .003, odds ratio [OR] = 2.70 [1.40-5.19]). The prevalence of CS in elderly males with manifest atherosclerotic disease is high, irrespective of presenting clinical manifestation.

Prevalence of significant carotid artery stenosis in Iranian patients with peripheral arterial disease

BACKGROUND

Generalized screening for carotid artery stenosis with carotid duplex ultrasonography in patients with peripheral arterial disease is controversial.

OBJECTIVES

The aim of the present study was to determine the prevalence of significant internal carotid artery (ICA) stenosis in a group of Iranian patients with peripheral arterial disease.

METHODS

We prospectively screened 120 patients with a known diagnosis of peripheral vascular disease for carotid artery stenosis. Based on the angiographic assessment of abdominal aorta and arteries of the lower extremities, patients with stenosis greater than 70% in the lower extremity arteries were included. A group of healthy individuals aged ≥ 50 years was recruited as a control. Risk factors for atherosclerosis including smoking, diabetes mellitus, hyperlipidemia, ischemic heart disease, and cerebrovascular disease were recorded. Common carotid arteries (CCAs) and the origins of the internal and external arteries were scanned with B-mode ultrasonography. Significant ICA stenosis, > 70% ICA stenosis but less than near occlusion of the ICA, was diagnosed when the ICA/CCA peak systolic velocity ratio was ≥ 3.5.

RESULTS

Ninety-five patients, with a mean age of 58.52 ± 11.04 years, were studied. Twenty-five patients had a history of smoking, six patients had a history of coronary artery disease, six patients had hypertension, and ten patients had diabetes mellitus. Significant ICA stenosis was present in four patients (4.2%) with peripheral arterial disease in one healthy individual (1%) of the control group (P > 0.05). In terms of the risk factors for atherosclerosis, no statistically significant relationship was found between individual atherosclerotic risk factors and significant ICA stenosis (P > 0.05).

CONCLUSION

The prevalence of significant ICA stenosis in Iranian patients with peripheral arterial disease is low. In addition, there is no relationship between individual atherosclerotic risk factors and significant ICA stenosis.

Patient preference survey in the management of asymptomatic carotid stenosis

OBJECTIVES

Carotid stenosis accounts for 20% of ischemic strokes and can be managed with pharmacotherapy alone or in conjunction with carotid endarterectomy or stenting. The management of asymptomatic carotid stenosis is controversial amongst physicians. The aim of this study was to explore patient preferences for the potential management options using a standardized scenario to minimize clinician bias. These data will then be used to facilitate comparison with existing published data on physicians' preferences in the management of asymptomatic carotid stenosis.

METHODS

A patient information booklet and questionnaire was developed, validated, and distributed to patients who were identified as candidates for carotid screening duplex based on the presence of peripheral arterial, coronary, or aneurismal disease. Patients were asked to imagine their duplex revealed a 70% unilateral carotid stenosis. Five-year stroke or death risks of 11% were quoted for best medical therapy. The perioperative stroke or death rates quoted were 3% for endarterectomy and 3% to 5% for stenting, based on best current evidence. No physician interaction was allowed to minimize clinician bias. Responses for treatment preference and reasoning were analyzed using appropriate statistical methods. Results from this survey were then compared with a previously published poll of physician preference.

RESULTS

One hundred two questionnaires were analyzed with a 94% response rate: 48% chose pharmacotherapy alone, 30% selected carotid endarterectomy, and 22% opted for stenting. The preference for pharmacotherapy alone over either intervention, and for endarterectomy, over stenting was consistent in subgroup analyses by age, gender, prior stroke, family history of stroke, and smoking status.

CONCLUSION

In this scenario, patients were split equally between medical and surgical treatment of asymptomatic carotid stenosis. This was identical to a recent poll of physicians. Tools for risk assessment and the results of the SPACE2, ACST2, and ACT1 trials would benefit patients and physicians making this important treatment decision.

Prevalence of asymptomatic critical carotid artery stenosis in Korean patients with chronic atherosclerotic lower extremity ischemia: is a screening carotid duplex ultrasonography worthwhile?

This study aimed to investigate prevalence of asymptomatic carotid artery stenosis (ACAS) in Korean patients with peripheral arterial disease (PAD) and identify predictive factors of ACAS in patients with PAD. Between 1994 and 2008, 546 patients who underwent bypass surgery due to PAD were identified in a single tertiary teaching hospital. Of those, 409 patients underwent preoperative screening carotid duplex ultrasonography (CDUS). Patients who had an episode of cerebrovascular event or previous carotid artery intervention were excluded and then a retrospective analysis was made of 340 patients. The degree of internal carotid artery (ICA) stenosis was determined by the criteria of Society of Radiologists in Ultrasound Consensus Conference. To determine the risk factors of ACAS, demographic, coexisting medical condition and lesion characteristics were tested with binary logistic regression model. The prevalence of > or = 70% ICA stenosis was 14%. ICA occlusion was detected in 7.1%. Multivariate analysis revealed age > 65 yr (OR: 2.610, 95% CI: 1.197-5.691) and coronary artery disease (CAD, OR: 2.333, 95% CI: 1.169-4.657) are predictive factors of > or = 70% stenosis. A PAD patient who needs revascularization, particularly, > 65 yr or has a concomitant CAD, can be a good candidate of screening CDUS.