Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary

The Impact of age and outcomes of high-risk patients on carotid revascularization

OBJECTIVES

To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups.

METHODS

We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs).

RESULTS

A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group (n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922-10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391-11.155; p < 0.001) was also higher for CAS than CEA. In the age <75 subgroup of the Hr group (n = 428), CAS was associated with higher 30-day stroke/death (OR, 14.089; 95% CI, 1.314-151.036; p = 0.029). In the age ≥75 subgroup of the Hr (n = 139), there was no difference in 30-day stroke/death between CEA and CAS. In the age <75 subgroup of the Nr group (n = 1318), 30-day stroke/death (OR, 6.300; 95% CI, 2.797-14.193; p < 0.001) was higher in CAS. In the age ≥75 subgroup of the Nr group (n = 460), 30-day stroke/death (OR, 6.468; 95% CI, 1.862-22.471; p = 0.003) was higher in CAS.

CONCLUSIONS

In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.

Transcarotid arterial revascularization is feasible and safe with concomitant inferior vena cava occlusion

Transcarotid artery revascularization (TCAR) has risen as a promising minimally invasive intervention for high-risk patients with favorable anatomy. TCAR's noninferiority to carotid endarterectomy regarding stroke is reliant on its flow reversal technology and lack of aortic arch manipulation. We present the case of a 79-year-old man with a chronically occluded inferior vena cava who safely underwent staged bilateral TCAR for bilateral high-grade carotid artery stenosis. Although chronic inferior vena cava occlusion alters flow mechanics, we suspect that any pressure gradient facilitating retrograde flow from the carotid artery to the femoral vein provides neuroprotective benefits.

Classification and management strategy of spontaneous carotid artery dissection

OBJECTIVE

Spontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance.

METHODS

This is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs.

RESULTS

A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%).

CONCLUSIONS

This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.

Outcomes of carotid endarterectomy in octogenarians compared to their younger counterparts: a retrospective observational study

Purpose

This study was performed to analyze the association between age and outcomes of carotid endarterectomy (CEA) by comparing postoperative outcomes between octogenarians and younger patients.

Methods

From November 1994 to December 2022, 1,585 internal carotid arteries of 1,434 patients were enrolled. Patients were stratified into 2 groups: octogenarians (≥80 years old) and non-octogenarians (<80 years old). Primary endpoints were early (≤30 days) outcomes of ipsilateral stroke, any stroke, myocardial infarction, death, and major adverse cardiovascular events (MACE). We also compared overall any stroke and death between the 2 groups.

Results

One of 132 octogenarians (0.8%) and 17 of 1,453 non-octogenarians (1.1%) experienced ipsilateral stroke within 30 days. Thirty-day MACE occurred in 4 of 132 octogenarians (3%) and 44 of 1,453 non-octogenarians (3%). There were no significant differences in any early (≤30 days) outcomes. Symptomatic status was associated with increased 30-day MACE (odds ratio [OR], 2.610; 95% confidence interval [CI], 1.450-4.696; P = 0.003) and 30-day any stroke (OR, 3.999; 95% CI, 1.627-9.828; P = 0.003). Symptomatic status was also associated with overall any stroke (hazard ratio [HR], 2.885; 95% CI, 1.865-4.463; P < 0.001), but age of ≥80 years was not associated with 30-day MACE, 30-day any stroke, or overall stroke. Age of ≥80 years was only associated with overall survival (HR, 2.644; 95% CI, 1.967-3.555; P < 0.001).

Conclusion

CEA would be a safe and effective treatment for octogenarians with low 30-day complications and long-term stroke rates, comparable with that of younger counterparts. Advanced age is not a contraindication for CEA.

Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is currently performed by multiple surgical specialties. The impact of surgical specialty and operative volume on post-CEA outcomes has been well described. However, it is unclear whether trainees of different surgical specialties have similar quality of operative training.

METHODS

Data from Accreditation Council for Graduate Medical Education annual reports were collected and compared between graduating vascular surgery (VS) residents, VS fellows, and neurological surgery (NS) residents. Only cases reported as chief/senior/lead resident, surgeon junior, or surgeon fellow were included in analysis. Linear regression analysis was utilized to evaluate trends in case-mix and volume.

RESULTS

From 2013 to 2022, total CEA case volume was higher among VS residents and fellows, compared to NS residents (52.8 ± 0.8 vs. 44.3 ± 1.4 vs. 12.9 ± 0.6, P < 0.0001). Additionally, VS residents and fellows performed other carotid operations including transfemoral or transcarotid artery stenting (11.1 ± 0.9 vs. 11.2 ± 0.8 vs. 0), carotid body tumor resection (0.7 ± 0.1 vs. 0.7 ± 0.0 vs. 0), and extracranial cervical bypass (6.7 ± 0.3 vs. 6.3 ± 0.3 vs. 0) that were not reported by the NS resident cohort (P < 0.0001 each). On linear regression analysis, total CEA procedures did not change for VS residents (R2 = 0.03, P = 0.62), decreased for VS fellows (-1.29 cases/yr, R2 = 0.75, P < 0.0001), and decreased among NS residents (-0.41 cases/yr, R2 = 0.44, P = 0.01) over the study period.

CONCLUSIONS

Although residents of multiple surgical specialties are trained in CEA, vascular training offers significantly greater numbers and diversity of extracranial carotid cases. It also appears that CEA volume is decreasing among neurosurgical trainees. In light of recent reports on the volume-outcome effect in carotid surgery, these data may have implications for future practice patterns in the domain of extracranial carotid artery disease.

Surveillance duplex ultrasound prompted interventions after carotid endarterectomy

OBJECTIVE

Current societal guidelines recommend duplex ultrasound (DUS) surveillance beyond 30 days after carotid endarterectomy (CEA) for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate duration of this surveillance has not yet been identified, and the rate at which DUS surveillance prompts intervention is unknown. Multiple calls for decreasing health care spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance DUS on the ipsilateral or contralateral carotid artery after CEA and determine the value of continued surveillance by determining the rate of DUS-prompted intervention.

METHODS

A single-center, retrospective chart review of all patients older than 18 years who had undergone CEA from August 2009 to July 2022 was performed. Patients with at least one postoperative duplex in our Intersocietal Accreditation Council-accredited ultrasound lab were included. Exclusion criteria were patients with incomplete medical charts or patients who underwent a concomitant procedure. The primary end point was return to the operating room for subsequent intervention based on abnormal surveillance DUS findings. Secondary end points were the number of postoperative surveillance duplexes, duration of surveillance, and incidence of perioperative stroke. The study participant data were queried for patients who had a diagnosis of stroke that occurred following their procedure.

RESULTS

A total 767 patients, accounting for 771 procedures, were included in this study, which resulted in 2145 ultrasound scans. A total of 40 (5.2%) patients required 44 subsequent interventions that were prompted by DUS surveillance scans. The average number of ultrasound scans per patient was 2.8 (range: 0-14), and the average duration of surveillance was 26.4 months (range: 0-155 months). Of the 767 patients, 669 (87.2%) had a unilateral CEA. A total of 62 of 767 (8.1%) patients had planned endarterectomies on the contralateral side based on initial imaging, not prompted by interval DUS surveillance scans. Of 767 patients, 28 (3.7%) patients who underwent CEA had a subsequent procedure for progression of contralateral disease, which was prompted by duplex surveillance scans. The average duration between index CEA and intervention on contralateral carotid was 29.57 months (range: 3-81 months). A total of 11 patients, accounting for 12 procedures, underwent a subsequent procedure for restenosis of their ipsilateral carotid, prompted by duplex surveillance scans. The average duration between index CEA and reintervention on the ipsilateral carotid was 17.9 months (range: 4-70 months). Three of 767 (0.4%) patients in total were identified as having a perioperative stroke.

CONCLUSIONS

The overall rate of ipsilateral reintervention after CEA is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest that regular duplex surveillance after CEA is warranted for patients with at least moderate contralateral disease; however, the yield is low for ipsilateral restenosis after 36 months based on this single institution study. Further study is needed to better delineate which patients need follow-up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease.

Mobile Atheroma in the Left Internal Carotid Artery: A Case of Impending Doom!

A 69-year-old male presented for evaluation of a carotid bruit. Carotid ultrasound demonstrated the unique finding of a large, highly mobile atheroma in the proximal left internal carotid artery. The presence of a mobile atheroma confers an even higher risk of stroke, so this presentation posed a dilemma in terms of endovascular versus open surgical management strategies. In patients with carotid artery disease, the risk of stroke is related to plaque rupture and distal embolization. The patient underwent successful carotid stenting without periprocedural complications. Our case reports the unusual occurrence of a highly mobile atheroma as the initial presentation of carotid artery disease treated safely with percutaneous carotid artery stenting.

Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network

Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.

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.

Current Biomarkers for Carotid Artery Stenosis: A Comprehensive Review of the Literature

Carotid artery stenosis (CAS), an atherosclerotic disease of the carotid artery, is one of the leading causes of transient ischemic attacks (TIA) and cerebrovascular attacks (CVA). The atherogenic process of CAS affects a wide range of physiological processes, such as inflammation, endothelial cell function, smooth muscle cell migration and many more. The current gold-standard test for CAS is Doppler ultrasound; however, there is yet to be determined a strong, clinically validated biomarker in the blood that can diagnose patients with CAS and/or predict adverse outcomes in such patients. In this comprehensive literature review, we evaluated all of the current research on plasma and serum proteins that are current contenders for biomarkers for CAS. In this literature review, 36 proteins found as potential biomarkers for CAS were categorized in to the following nine categories based on protein function: (1) Inflammation and Immunity, (2) Lipid Metabolism, (3) Haemostasis, (4) Cardiovascular Markers, (5) Markers of Kidney Function, (6) Bone Health, (7) Cellular Structure, (8) Growth Factors, and (9) Hormones. This literature review is the most up-to-date and current comprehensive review of research on biomarkers of CAS, and the only review that demonstrated the several pathways that contribute to the initiation and progression of the disease. With this review, future studies can determine if any new markers, or a panel of the proteins explored in this study, may be contenders as diagnostic or prognostic markers for CAS.

Insurance status is associated with urgent carotid endarterectomy and worse postoperative outcomes

OBJECTIVE

Underinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes.

METHODS

We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes.

RESULTS

A total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1).

CONCLUSIONS

Medicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.

The role of patch closure in current-day carotid endarterectomy

BACKGROUND

It has long been debated whether it is preferable to perform conventional carotid endarterectomy (CEA) with or without patch closure. Although most contemporary surgeons patch, many still do not. Recent small studies have surfaced implying patching is unnecessary. The objective of our analysis was to determine the difference in short- and long-term outcomes according to patch use in a large modern, cross-specialty database.

METHODS

Analyzing more than 118,000 records from the Vascular Quality Initiative, multimodel inference was used to evaluate the effect of patch use on important outcomes of conventional CEA. The composite short-term outcome included any ipsilateral neurological event, return to the operating room for a neurological event, and an increase in the Rankin score postoperatively. Late composite outcome incorporated restenosis as well as early and late ipsilateral neurological events.

RESULTS

Patch use for conventional CEA closure was found to be a strong predictor of both early and late outcomes, as evidenced by its Akaike importance weight of 0.99. Examining predischarge events, patch closure is associated with a decrease in major negative events (odds ratio, 0.5; 95% confidence interval, 0.4-0.6). For long-term events, such closure offers a decrease in untoward outcome (odds ratio, 0.8; 95% confidence interval, 0.7-0.9).

CONCLUSIONS

Analysis in a large current-day database suggests that patch closure of conventional CEA effects superior short- and long-term outcomes.

Aspirin Resistance in Vascular Disease: A Review Highlighting the Critical Need for Improved Point-of-Care Testing and Personalized Therapy

Aspirin resistance describes a phenomenon where patients receiving aspirin therapy do not respond favorably to treatment, and is categorized by continued incidence of adverse cardiovascular events and/or the lack of reduced platelet reactivity. Studies demonstrate that one in four patients with vascular disease are resistant to aspirin therapy, placing them at an almost four-fold increased risk of major adverse limb and adverse cardiovascular events. Despite the increased cardiovascular risk incurred by aspirin resistant patients, strategies to diagnose or overcome this resistance are yet to be clinically validated and integrated. Currently, five unique laboratory assays have shown promise for aspirin resistance testing: Light transmission aggregometry, Platelet Function Analyzer-100, Thromboelastography, Verify Now, and Platelet Works. Newer antiplatelet therapies such as Plavix and Ticagrelor have been tested as an alternative to overcome aspirin resistance (used both in combination with aspirin and alone) but have not proven to be superior to aspirin alone. A recent breakthrough discovery has demonstrated that rivaroxaban, an anticoagulant which functions by inhibiting active Factor X when taken in combination with aspirin, improves outcomes in patients with vascular disease. Current studies are determining how this new regime may benefit those who are considered aspirin resistant.

Transcarotid Artery Revascularization: Is It Better than Carotid Endarterectomy?

Transcarotid artery revascularization (TCAR) is a novel carotid stenting method that avoids the manipulation of the aortic arch and uses a flow-reversal neuroprotection system that effectively reduces the risk of embolic events during carotid intervention. Studies have shown a lower risk of stroke or death compared with the transfemoral carotid stenting approach, and an equivalent risk of stroke or death compared with traditional carotid endarterectomy. TCAR has added benefits of lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared with endarterectomy. TCAR has become widely adopted by vascular surgeons in the United States for the treatment of patients with high-risk medical comorbidities and those with challenging surgical anatomy.

Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments

BACKGROUND

Carotid artery stenosis is an important cause of stroke and transient ischemic attack. Correctly and rapidly identifying patients with symptomatic carotid artery stenosis is essential for adequate treatment with early cerebral revascularization. Doubts about the diagnostic value regarding the accuracy of duplex ultrasound (DUS) and the possibility of using DUS as the single diagnostic test before carotid revascularization are still debated.

OBJECTIVES

To estimate the accuracy of DUS in individuals with symptomatic carotid stenosis verified by either digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA).

SEARCH METHODS

We searched CRDTAS, CENTRAL, MEDLINE (Ovid), Embase (Ovid), ISI Web of Science, HTA, DARE, and LILACS up to 15 February 2021. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data.

SELECTION CRITERIA

We included studies assessing DUS accuracy against an acceptable reference standard (DSA, MRA, or CTA) in symptomatic patients. We considered the classification of carotid stenosis with DUS defined with validated duplex velocity criteria, and the NASCET criteria for carotid stenosis measures on DSA, MRA, and CTA. We excluded studies that included < 70% of symptomatic patients; the time between the index test and the reference standard was longer than four weeks or not described, or that presented no objective criteria to estimate carotid stenosis.

DATA COLLECTION AND ANALYSIS

The review authors independently screened articles, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain list. We extracted data with an effort to complete a 2 × 2 table (true positives, true negatives, false positives, and false negatives) for each of the different categories of carotid stenosis and reference standards. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where meta-analysis was possible, we used a bivariate meta-analysis model.

MAIN RESULTS

We identified 25,087 unique studies, of which 22 were deemed eligible for inclusion (4957 carotid arteries). The risk of bias varied considerably across the studies, and studies were generally of moderate to low quality. We narratively described the results without meta-analysis in seven studies in which the criteria used to determine stenosis were too different from the duplex velocity criteria proposed in our protocol or studies that provided insufficient data to complete a 2 × 2 table for at least in one category of stenosis. Nine studies (2770 carotid arteries) presented DUS versus DSA results for 70% to 99% carotid artery stenosis, and two (685 carotid arteries) presented results from DUS versus CTA in this category. Seven studies presented results for occlusion with DSA as the reference standard and three with CTA as the reference standard. Five studies compared DUS versus DSA for 50% to 99% carotid artery stenosis. Only one study presented results from 50% to 69% carotid artery stenosis. For DUS versus DSA, for < 50% carotid artery stenosis, the summary sensitivity was 0.63 (95% confidence interval [CI] 0.48 to 0.76) and the summary specificity was 0.99 (95% CI 0.96 to 0.99); for the 50% to 69% range, only one study was included and meta-analysis not performed; for the 50% to 99% range, the summary sensitivity was 0.97 (95% CI 0.95 to 0.98) and the summary specificity was 0.70 (95% CI 0.67 to 0.73); for the 70% to 99% range, the summary sensitivity was 0.85 (95% CI 0.77 to 0.91) and the summary specificity was 0.98 (95% CI 0.74 to 0.90); for occlusion, the summary sensitivity was 0.91 (95% CI 0.81 to 0.97) and the summary specificity was 0.95 (95% CI 0.76 to 0.99). For sensitivity analyses, excluding studies in which participants were selected based on the presence of occlusion on DUS had an impact on specificity: 0.98 (95% CI 0.97 to 0.99). For DUS versus CTA, we found two studies in the range of 70% to 99%; the sensitivity varied from 0.57 to 0.94 and the specificity varied from 0.87 to 0.98. For occlusion, the summary sensitivity was 0.95 (95% CI 0.80 to 0.99) and the summary specificity was 0.91 (95% CI 0.09 to 0.99). For DUS versus MRA, there was one study with results for 50% to 99% carotid artery stenosis, with a sensitivity of 0.88 (95% CI 0.70 to 0.98) and specificity of 0.60 (95% CI 0.15 to 0.95); in the 70% to 99% range, two studies were included, with sensitivity that varied from 0.54 to 0.99 and specificity that varied from 0.78 to 0.89. We could perform only a few of the proposed sensitivity analyses because of the small number of studies included.

AUTHORS' CONCLUSIONS

This review provides evidence that the diagnostic accuracy of DUS is high, especially at discriminating between the presence or absence of significant carotid artery stenosis (< 50% or 50% to 99%). This evidence, plus its less invasive nature, supports the early use of DUS for the detection of carotid artery stenosis. The accuracy for 70% to 99% carotid artery stenosis and occlusion is high. Clinicians should exercise caution when using DUS as the single preoperative diagnostic method, and the limitations should be considered. There was little evidence of the accuracy of DUS when compared with CTA or MRA. The results of this review should be interpreted with caution because they are based on studies of low methodological quality, mainly due to the patient selection method. Methodological problems in participant inclusion criteria from the studies discussed above apparently influenced an overestimated estimate of prevalence values. Most of the studies included failed to precisely describe inclusion criteria and previous testing. Future diagnostic accuracy studies should include direct comparisons of the various modalities of diagnostic tests (mainly DUS, CTA, and MRA) for carotid artery stenosis since DSA is no longer considered to be the best method for diagnosing carotid stenosis and less invasive tests are now used as reference standards in clinical practice. Also, for future studies, the participant inclusion criteria require careful attention.

Outcomes of Early Trans-Carotid Artery Revascularization Versus Carotid Endarterectomy after Acute Neurologic Events

OBJECTIVE

Carotid revascularization within 14 days of a neurologic event is recommended by society guidelines. Transcarotid artery revascularization (TCAR) carries the lowest overall stroke rate for any carotid artery stenting technique; however, outcomes of TCAR within 14 days of a neurologic event have not been directly compared to carotid endarterectomy (CEA).

METHODS

We compared 30-day outcomes of symptomatic patients undergoing TCAR and CEA within 14 days of stroke or transient ischemic attack (TIA) from January 2016 to February 2020 using the Society for Vascular Surgery Vascular Quality Initiative (VQI) carotid artery stenting and CEA databases. Propensity score matching was used to adjust for patient risk factors. The primary outcome was a composite of postoperative ipsilateral stroke, death, and myocardial infarction (MI).

RESULTS

A total of 1,281 symptomatic patients underwent TCAR and 13,429 patients underwent CEA within 14 days of a neurologic event. After 1:1 propensity matching, 728 matched pairs were included for analysis. The primary composite outcome of stroke, death, or MI was more frequent in the TCAR group (4.7% vs. 2.6%, p= 0.04). This was driven by a higher rate of post-operative ipsilateral stroke in the TCAR group (3.8% vs. 1.8%, p=0.005). There was no difference between TCAR and CEA in terms of death (0.7% vs. 0.8%, p= 0.8) or MI (0.8% vs. 1%, p= 0.7). Although TCAR procedures were shorter (69 minutes IQR 53-85 vs. 120 minutes IQR 93-150, p<0.001) and post procedure length of stay was similar (2 days, p= 0.3) compared to CEA, TCAR patients were more likely to be discharged to a facility other than home (26% vs. 19%, p<0.01). Performing TCAR within 48 hours of a stroke was an independent predictor of post-operative stoke or TIA (OR 5.4 95% CI 1.8-16). This increased risk of post-operative stroke or TIA was not seen when performing TCAR within 48 hours of a TIA.

CONCLUSION

TCAR within 14 days of a neurologic event results in higher ipsilateral post-operative stroke rates when compared to CEA, especially when performed within 48 hours of a stroke.

Short-term outcomes of transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients: data from a multicentric prospective registry in Brazil

BACKGROUND

Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Since their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy.

OBJECTIVE

The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry.

METHODS

Prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in five public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events - MACE). The registration of the study was made at clinicaltrials.gov NCT02538276.

RESULTS

From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TR-CAS: 0.66% x CEA: 0.66%, P=0.99), stroke (TF-CAS: 4.61% x CEA: 4.46%, P=0.99), and MI (TF-CAS: 0.66% x CEA: 0%, P=0.403) was similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% x CEA: 4.46%, P=0.633).

CONCLUSIONS

Data from a prospective registry of five Brazilian university hospitals showed that transfemoral carotid artery stenting and carotid endarterectomy in symptomatic patients had similar 30-day perioperative rates of death, stroke, and myocardial infarction and their combination.

Ocular Ischemic Syndrome and Its Related Experimental Models

Ocular ischemic syndrome (OIS) is one of the severe ocular disorders occurring from stenosis or occlusion of the carotid arteries. As the ophthalmic artery is derived from the branch of the carotid artery, stenosis or occlusion of the carotid arteries could induce chronic ocular hypoperfusion, finally leading to the development of OIS. To date, the pathophysiology of OIS is still not clearly unraveled. To better explore the pathophysiology of OIS, several experimental models have been developed in rats and mice. Surgical occlusion or stenosis of common carotid arteries or internal carotid arteries was conducted bilaterally or unilaterally for model development. In this regard, final ischemic outcomes in the eye varied depending on the surgical procedure, even though similar findings on ocular hypoperfusion could be observed. In the current review, we provide an overview of the pathophysiology of OIS from various experimental models, as well as several clinical cases. Moreover, we cover the status of current therapies for OIS along with promising preclinical treatments with recent advances. Our review will enable more comprehensive therapeutic approaches to prevent the development and/or progression of OIS.

Management of combined oral antithrombotic therapy by an Antithrombotic Stewardship Program: a prospective study

AIMS

Antithrombotic management initiatives could prevent inappropriate prescribing and improve patient outcomes especially in patients on combined antithrombotic therapy. To investigate this, a multidisciplinary antithrombotic stewardship program (ASP) was implemented in our hospital. The primary aim of this study was to determine the efficacy of this ASP by assessing the number of patients on combined antithrombotic therapy for whom one or more interventions were needed.

METHODS

A prospective cohort study in a large teaching hospital was conducted. Hospitalized patients were included who received combined antithrombotic therapy in which an oral anticoagulant was combined with one (double therapy) or two (triple therapy) platelet aggregation inhibitors. The ASP proactively evaluated the appropriateness of this combined antithrombotic therapy. If needed, ASP improved the concerned therapy. Each improvement measurement recommended by the ASP was counted as one intervention.

RESULTS

A total of 460 patients were included over a period of 12 months. 251 (54.6%) patients required at least one intervention from the ASP. The most common interventions were: 1) to define and document the maximum duration of the combined antithrombotic therapy needed instead of lifetime use of the combination (65.5%), 2) to discontinue antithrombotic therapy as the proper indication was lacking (19.4%), and 3) to adjust the dosage (8.1%).

CONCLUSION

An intervention was needed in more than half of the patients on combined antithrombotic therapy. Implementation of an dedicated ASP evaluating combined antithrombotic therapy improves the use and safety of antithrombotic medication.

Efficacy and safety of perioperative dual antiplatelet therapy with ticagrelor versus clopidogrel in carotid artery stenting

BACKGROUND

Clopidogrel resistance is associated with increased periprocedural neurologic events after carotid artery stenting (CAS). Ticagrelor offers an improved resistance profile; however, its bleeding risk has not been assessed with CAS. Therefore, we examined the efficacy and safety of perioperative dual antiplatelet therapy with aspirin/ticagrelor vs aspirin/clopidogrel in patients undergoing transfemoral carotid artery stenting (tfCAS) or transcarotid artery revascularization (TCAR).

METHODS

We identified all patients who underwent tfCAS or TCAR in the Vascular Quality Initiative registry from January 2016 to March 2021. We stratified patients by procedure and assessed outcomes using 1:3 propensity score-matched cohorts of patients who received perioperative aspirin/ticagrelor vs aspirin/clopidogrel. The primary efficacy outcome was a composite endpoint of in-hospital stroke/death, and the primary safety outcome was access-related bleeding. As a secondary analysis, we assessed these outcomes after stratifying each cohort by intraoperative protamine use.

RESULTS

Among 17,731 tfCAS patients, 593 (3.3%) received aspirin/ticagrelor and 11,404 (64%) received aspirin/clopidogrel. For the 2065 matched patients, no significant differences were found in the composite endpoint of stroke/death (aspirin/ticagrelor, 4.1%; vs aspirin/clopidogrel, 2.6%; relative risk [RR],1.5; 95% confidence interval [CI], 0.88-2.7) or in the individual endpoints of stroke (2.9% vs 1.8%; RR, 1.6; 95% CI, 0.87-3.0) or death (1.7% vs 1.1%; RR, 1.6; 95% CI, 0.71-3.5). However, aspirin/ticagrelor was associated with a higher risk of bleeding (5.8% vs 2.8%; RR, 2.0; 95% CI, 1.2-3.2). In a subgroup analysis of 297 tfCAS patients (14%) who received intraoperative protamine, no differences remained in stroke/death (1.5% vs 3.9%; RR, 0.38; 95% CI, 0.05-3.0), and there was no longer a difference in bleeding (3.0% vs 2.6%; RR, 1.1; 95% CI, 0.24-5.5). Among 17,946 TCAR patients, 453 (2.5%) received aspirin/ticagrelor and 13,696 (76%) received aspirin/clopidogrel. For the 1618 matched patients, no differences were found in stroke/death (0.7% vs 1.4%; RR, 0.53; 95% CI, 0.16-1.8), stroke (0.2% vs 1.2%; RR, 0.20; 95% CI, 0.03-1.5), death (0.5% vs 0.2%; RR, 3.0; 95% CI, 0.42-21), or bleeding (1.2% vs 1.6%; RR, 0.75; 95% CI, 0.28-2.0). For the 1429 TCAR patients (88%) who received protamine, no differences were found in stroke/death (0.8% vs 1.2%; RR, 0.68; 95% CI, 0.20-2.4) or bleeding (0.6% vs 1.4%; RR, 0.39; 95% CI, 0.09-1.7).

CONCLUSIONS

Compared with aspirin/clopidogrel, aspirin/ticagrelor was associated with a potentially lower risk of stroke/death and bleeding complications after CAS in cases in which protamine was used but a higher risk of these outcomes in the absence of protamine. Given our limited sample size, our analysis should be repeated when more patients are available for study. However, our findings suggest that aspirin/ticagrelor could be a reasonable alternative to aspirin/clopidogrel for both tfCAS and TCAR when protamine is used.

Endarterectomy for symptomatic non-stenotic carotids: a systematic review and descriptive analysis

OBJECTIVE

To systematically analyse prior reports of carotid endarterectomy (CEA) performed in cases of ≤50% carotid stenosis in order to understand patient tolerance and potential benefit.

METHODS

A systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English-language search was performed of online databases using librarian-selected search terms. Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis. Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal (≤50%) luminal stenosis with reported outcomes were included.

RESULTS

Six studies (which included our institutional series) with a total of 143 patients met the inclusion criteria. The weighted mean age at the time of CEA was 72.3 years; 113 (79.0%) were male. 55.8% of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy. Two patients out of 129 with available perioperative data (1.6%) had perioperative MRI findings of acute ischaemic stroke, both within the hemisphere contralateral to the side of CEA. Of the 138 patients with available follow-up (mean, 36 months), none had recurrent ipsilateral ischaemic events.

CONCLUSIONS

Endarterectomy for symptomatic carotid disease causing ≤50% stenosis may be a potentially beneficial strategy to prevent stroke recurrence. Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.

Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis

PURPOSE

Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis.

METHODS

All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization.

RESULTS

One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1-141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years.

CONCLUSION

This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.

Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP

BACKGROUND

Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis.

STUDY DESIGN

All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics.

RESULTS

Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients.

CONCLUSIONS

Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.

Clopidogrel Versus Ticagrelor for Antiplatelet Therapy in Transcarotid Artery Revascularization (TCAR) in the Society for Vascular Surgery Vascular Quality Initiative

OBJECTIVE

Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44-66% of patients taking clopidogrel, high on-treatment platelet reactivity (HTPR) may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers.

METHODS

Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients.

RESULTS

A total of 11973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 426 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66% [P = <.001]), particularly unstable angina or MI within 6 months (3% vs 9% [P = <.001]), and more likely to have insulin-dependent diabetes mellitus (14% vs 19% [P = <.001]). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5% [P = .14], 2.4% vs 1.4% [P = .18], and 1.9% vs 1.6% [P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant.

CONCLUSIONS

Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.

Importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease

Stroke is a leading cause of death and disability worldwide. Women are disproportionately affected by stroke, exhibiting higher mortality and disability rates post-stroke than men. Clinical stroke research has historically included mostly men and studies were not properly designed to perform sex- and gender-based analyses, leading to under-appreciation of differences between men and women in stroke presentation, outcomes, and response to treatment. Reasons for these differences are likely multifactorial; some are due to gender-related factors (i.e. decreased social support, lack of stroke awareness), yet others result from biological differences between sexes. Unlike men, women often present with 'atypical' stroke symptoms. Lack of awareness of 'atypical' presentation has led to delays in hospital arrival, diagnosis, and treatment of women. Differences also extend to carotid atherosclerotic disease, a cause of stroke, where plaques isolated from women are undeniably different in morphology/composition compared to men. As a result, women may require different treatment than men, as evidenced by the fact that they derive less benefit from carotid revascularization than men but more benefit from medical management. Despite this, women are less likely than men to receive medical therapy for cardiovascular risk factor management. This review focuses on the importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease, summarizing the current evidence with respect to (i) stroke incidence, mortality, awareness, and outcomes, (ii) carotid plaque prevalence, morphology and composition, and gene connectivity, (iii) the role of sex hormones and sex chromosomes in atherosclerosis and ischaemic stroke risk, and (iv) carotid disease management.

Controversies in Vascular Surgery

There have been significant advances in vascular surgery in recent years. These advances include procedural techniques, choice of procedure, and application of nonoperative management. Endovascular techniques have expanded greatly over the past decade. As a result, for many clinical scenarios there is more than 1 option for management, which has given rise to controversies in the choice of best management. This article reviews current controversies in the management of carotid artery disease, abdominal aortic aneurysms, acute deep venous thrombosis, and inferior vena cava filter placement.

CT angiographic biomarkers help identify vulnerable carotid artery plaque

OBJECTIVE

Current risk assessment for patients with carotid atherosclerosis relies primarily on measuring the degree of stenosis. More reliable risk-stratification could improve patient selection for targeted treatment. We developed and validated a model to predict major adverse neurological events (MANE; stroke, transient ischemic attack, and amaurosis fugax) incorporating a combination of plaque morphology, patient demographics, and patient clinical information.

METHODS

We enrolled 221 patients with asymptomatic carotid stenosis of any severity who had CT angiography at baseline and at least 6 months later. Images were analyzed for carotid plaque morphology (plaque geometry and tissue composition). Data were partitioned (training and validation cohorts). 190 patients had complete records and were advanced to analysis. The training cohort was used to develop the best model for predicting MANE, incorporating patient and plaque features. First, single-variable correlation and unsupervised clustering were performed. Next, several multi-variable models were implemented for the response variable of MANE. The best model was selected by optimizing area under the receiver operating characteristic curve (AUC, ROC) and Kappa. The model was validated on the sequestered data to demonstrate generalizability.

RESULTS

Sixty-two patients suffered a MANE on follow-up. Unsupervised clustering of patient and plaque features identified single-variable predictors of MANE. Multi-variable predictive modeling showed that a combination of plaque features at baseline (matrix, intra-plaque hemorrhage (IPH), wall thickness, plaque burden) with clinical features (age, BMI, lipid levels) best predicted MANE (AUC 0.79), while percent diameter stenosis performed worst (AUC 0.55). The strongest single variable in discriminating between patients with and without events was IPH, and the most predictive model was produced when IPH was considered together with wall remodeling. The selected model also performed well on the validation dataset (AUC of 0.64) and maintained superiority over percent diameter stenosis (AUC of 0.49).

CONCLUSIONS

A composite of plaque geometry, plaque tissue composition, patient demographics, and clinical information predicts MANE better than the traditionally utilized degree of stenosis alone in carotid atherosclerosis. Implementing this predictive model in the clinical setting can help identify patients at high-risk for major adverse neurological events.

Technical aspects and operative nuances using a high-definition 4K-3-dimensional exoscope for carotid endarterectomy surgery

PURPOSE

Carotid endarterectomy (CEA) is effective in treating carotid artery stenosis to prevent stroke. Historically, this operation has been performed utilizing loupe magnification with or without the operating microscope (OM). However, there remains a need for continued improvement in operative visualization and surgical ergonomics. Recently, newly developed digital 'exoscope' has provided the surgeon with unique lighting and magnification as well as improvements in surgical ergonomics and working angle. We sought to review our cumulative experience using a novel 4K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for CEA surgery.

METHODS

All CEA surgery cases at our institution between 2013 and 2019 using the 4K-HD 3D EX were reviewed. Operative parameters, patient outcome and operator's assessment of the EX compared to OM-assisted cases was conducted.

RESULTS

28 patients were treated, 10 of which were operated using the EX. All procedures were performed without perioperative complications, or significant differences in operative parameters (blood loss <20 cm3 and 164 ± 49.5 minutes) compared to OM-assisted cases. Operators reported improved level of comfort performing 'high' bifurcation surgery and improved visualization and posture during inspection of the distal ICA lumen as primary advantages of EX-assisted CEA over OM-assisted CEA.

CONCLUSIONS

The ORBEYE EX, albeit a learning curve necessitating a short period of the OR team, provided safety and outcome comparable to OM-assisted surgery. Potential advantages noted were improved visualization and ergonomics specifically for when extreme working angles were required. Our experience suggests that the exoscope may become a valuable alternative to standard magnification tools in CEA surgery.

Carotid artery stenting in patients with chronic internal carotid artery occlusion

BACKGROUND

The risk of ischemic stroke in patients with chronic total occlusion (CTO) of the internal carotid artery (ICA) on best medical treatment has been estimated to be 5.5% per year. The purpose of this study was to assess early and mid-term outcome of patients who underwent an attempt at transfemoral carotid artery stenting (CAS) for CTO of the ICA.

METHODS

Clinical data of symptomatic patients who underwent attempt at CAS for CTO of the ICA between January 1, 2010 and July 1, 2020 were retrospectively reviewed. Clinical success, perioperative and mid-term stroke and death rates were recorded. Descriptive statistics were used.

RESULTS

There were 27 patients, 14 females, 13 males, with a mean age of 66.8 years, range: 57 to 79. All patients had symptoms within 6 months prior to the procedure. 16 had ipsilateral stroke at a mean of 2.8 months, ranges: 1.5-4 months, two had transient ischemic attack (TIA), at 1 week and at 6 months, one had amaurosis fugax at one week, two had chronic ocular ischemia and six had chronic cerebral hypoperfusion. Technical success was 52% (14/27). One patient developed a minor reversible stroke (1/27, 3.7%) there was no early death, for an overall 30-day stroke and death rate of 3.7% (1/27). Two patients had perioperative TIAs. Among 14 patients with successful CAS (group A) one had minor, reversible ipsilateral stroke during a follow-up of 29 months (range: 4-112), two had contralateral stroke. There was no death. One patient developed asymptomatic stent occlusion, three had asymptomatic in-stent restenosis >50%, two had reinterventions. Among patients with unsuccessful attempt at CAS (group B), 31% (4/13) had stroke at 4, 10, 14 and 22 months, respectively. One stroke patient died at 10 months.

CONCLUSIONS

Transfemoral CAS of symptomatic patients with CTO of the ICA was feasible in half of the patients, with no mortality or major stroke, for an overall early stroke/death rate of 3.7%. Since one third of the patients with unsuccessful stenting developed stroke during follow-up, further studies to investigate the safety, efficacy and durability of CAS for CTO of the ICA are needed.

A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery

The management of patients with symptomatic chronic total occlusion (CTO) of the internal carotid artery (ICA) is controversial. The aim of this systematic review was to investigate patient selection, technical success, early and late outcome of endovascular treatment for CTO of the ICA. PubMed/Medline and EMBASE databases were searched until January 2, 2020 for studies on endovascular treatment for CTO of the ICA. A descriptive analysis of demographic, clinical and anatomic data, endovascular technique, perioperative and late outcomes was performed. A total of 1,222 articles were screened, 8 retrospective or prospective cohort studies were reviewed; 276 patients, 18.9% females, mean age: 64.3 years, underwent attempt at endovascular treatment of 278 lesions. Two hundred and thirteen patients (77.2%) had neurological symptoms; the others had evidence of ipsilateral cerebral hypoperfusion. Two hundred and thirty-eight lesions (91.2%) were treated >30 days after diagnosis of occlusion. Technical success was 66.9%. Perioperative mortality was 1.64% (4/243), early stroke rate was 3.3%. Follow-up averaged 23.4 months (range, 0.25–84 months), late mortality was 1.89% (5/265), stroke rate was 3.4% (9/265). Stroke rate was similar after successful stenting (3.57%, 4/112) vs. failed stenting (3.61%, 2/61; P=1.00), stroke/death rates were also similar after successful stenting (5.36%, 6/112) than after failed stenting (3.28%, 2/61; P=0.71). Endovascular treatment of CTO of the ICA in eight cohort studies was safe and feasible with a technical success of 67% and a low rate of early and late neurological complications. Pooled data in this review failed to confirm the benefit of successful stenting on stroke and mortality, but some of the included studies suggest benefit and some also supported improvement in neurocognitive function after successful stenting. Prospective randomized trials to investigate the benefit of endovascular treatment in addition to best medical therapy for symptomatic CTO of the ICA are urgently needed.

Intraoperative completion studies in carotid endarterectomy: systematic review and meta-analysis of techniques and outcomes

Background

Declining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes.

Methods

A PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I² values were assessed to quantify study heterogeneities.

Results

Identification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36–0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70–0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43–0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74–0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033–0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07–1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76–0.91) and IDUS (RR 0.86; 95% CI, 0.76–0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association.

Conclusions

This study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.

Plateletworks® as a Point-of-Care Test for ASA Non-Sensitivity

Aspirin (ASA) therapy is proven to be effective in preventing adverse cardiovascular events; however, up to 30% of patients are non-sensitive to their prescribed ASA dosage. In this pilot study, we demonstrated, for the first time, how ASA non-sensitivity can be diagnosed using Plateletworks®, a point-of-care platelet function test. Patients prescribed 81 mg of ASA were recruited in a series of two successive phases-a discovery phase and a validation phase. In the discovery phase, a total of 60 patients were recruited to establish a cut-off point (COP) for ASA non-sensitivity using Plateletworks®. Each sample was simultaneously cross-referenced with a light transmission aggregometer (LTA). Our findings demonstrated that >52% maximal platelet aggregation using Plateletworks® had a sensitivity, specificity, and likelihood ratio of 80%, 70%, and 2.67, respectively, in predicting ASA non-sensitivity. This COP was validated in a secondary cohort of 40 patients prescribed 81 mg of ASA using Plateletworks® and LTA. Our data demonstrated that our established COP had a 91% sensitivity and 69% specificity in identifying ASA non-sensitivity using Plateletworks®. In summary, Plateletworks® is a point-of-care platelet function test that can appropriately diagnose ASA non-sensitive patients with a sensitivity exceeding 80%.

Vascular emergencies in neuro-ophthalmology

The cerebral vascularization is assured by the 2 internal carotids and 2 vertebral arteries, and the Willis circle.

Carotid artery obstruction is the most common abnormality associated with ocular ischemic syndrome. Obstruction may be due to atheromatous plaque, external compression, arteritis, or dissection of the artery. An atheromatous lesion of the carotid artery is the most frequent lesion responsible for ocular ischemic syndrome. The signs and symptoms of ocular ischemic syndrome are associated with severe hypoperfusion of the eye. Inflammatory lesions of the carotid artery are responsible for decreased flow in the carotid system. Other vascular emergencies are carotid artery dissection, Horton arteritis, aneurysms and carotid-cavernous fistula.

The most common ocular signs and symptoms are transient monocular blindness, persistent monocular blindness, ocular ischemia, Claude Bernard Horner syndrome and oculomotor palsies.

The carotid pathology can be a life-threatening pathology and it is important to recognize all these signs and symptoms. A multi-specialty approach will prevent misdiagnosis and lead to a better patient management.

Abbreviations: OIS = ocular ischemic syndrome, TMB = transient monocular blindness, TIA = transient ischemic attack, ESR = erythrocyte sedimentation rate, CRP = C reactive protein, NVE = neovascularization elsewhere in the retina, NVD = neovascularization on the disc, AION A = anterior ischemic arteritic optic neuropathy, CBH = Claude Bernard Horner syndrome, MRI = magnetic resonance imaging

Roadmap Consensus on Carotid Artery Plaque Imaging and Impact on Therapy Strategies and Guidelines: An International, Multispecialty, Expert Review and Position Statement

Current guidelines for primary and secondary prevention of stroke in patients with carotid atherosclerosis are based on the quantification of the degree of stenosis and symptom status. Recent publications have demonstrated that plaque morphology and composition, independent of the degree of stenosis, are important in the risk stratification of carotid atherosclerotic disease. This finding raises the question as to whether current guidelines are adequate or if they should be updated with new evidence, including imaging for plaque phenotyping, risk stratification, and clinical decision-making in addition to the degree of stenosis. To further this discussion, this roadmap consensus article defines the limits of luminal imaging and highlights the current evidence supporting the role of plaque imaging. Furthermore, we identify gaps in current knowledge and suggest steps to generate high-quality evidence, to add relevant information to guidelines currently based on the quantification of stenosis.

Unintentional guideline deviations in hospitalized patients with two or more antithrombotic agents: an intervention study

Purpose

Treatment schedules for antithrombotic therapy are complex, and there is a risk of inappropriate prescribing or continuation of antithrombotic therapy beyond the intended period of time. The primary aim of this study was to determine the frequency of unintentional guideline deviations in hospitalized patients. Secondary aims were to determine whether the frequency of unintentional guideline deviations decreased after intervention by a pharmacist, to determine the acceptance rate of the interventions and to determine the type of interventions.

Methods

We performed a non-controlled prospective intervention study in three teaching hospitals in the Netherlands. We examined whether hospitalized patients who used the combination of an anticoagulant plus at least one other antithrombotic agent had an unintentional guideline deviation. In these cases, the hospital pharmacist contacted the physician to assess whether this deviation was intentional. If the deviation was unintentional, a recommendation was provided how to adjust the antithrombotic regimen according to guideline recommendations.

Results

Of the 988 included patients, 407 patients had an unintentional guideline deviation (41.2%). After intervention, this was reduced to 22 patients (2.2%) (p < 0.001). The acceptance rate of the interventions was 96.6%. The most frequently performed interventions were discontinuation of an low molecular weight heparin in combination with a direct oral anticoagulant and discontinuation of an antiplatelet agent when there was no indication for the combination of an antiplatelet agent and an anticoagulant.

Conclusion

A significant number of hospitalized patients who used an anticoagulant plus one other antithrombotic agent had an unintentional guideline deviation. Intervention by a pharmacist decreased unintentional guideline deviations.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03185-y.

SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.

Arterial stiffness as an ultrasound biomarker of radiation-induced carotid artery disease

Background: Radiation-induced carotid artery disease (RICAD) is an important issue in head and neck cancer (HNC) survivors after radiotherapy (RT). The risk of cerebrovascular disease in these patients is doubled. The aim of this study was to assess the effect of RT on carotid artery stiffness in HNC patients. Patients and methods: Conventional arterial stiffness parameters were measured in a total of 50 HNC survivors treated with RT for at least 5 years and compared to 50 unirradiated HNC patients. Elastic modulus (Ep) and Beta stiffness index (β) were measured in proximal, mid and distal common carotid artery (CCA). Results: The mean age of the subjects was 68±9 years (range: 44-84) in the irradiated group and 67±10 years (range: 45-85) in the control group. The RT group was treated with a mean radiation exposure of 60.3±6.7 Gy (range: 44-72) in the neck. Carotid stiffness parameters showed significant group differences: Ep in the RT group was 2.329±1.222 vs 1.742±828 in the non-RT group (p=0.006) and β index in the RT group was 23±11 vs 15±8 in the non-RT group (p<0.001). Radiation-induced carotid stiffness was quantified and cervical exposure to RT increased Ep in 575 kPa (p=0.014) and β in 7 units (p<0.003). Conclusions: Ep and β index could be suitable ultrasound biomarkers of radiation-induced atherosclerosis in HNC survivors. Further prospective studies are needed to feature RICD in this setting.

Editor's Choice - Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data

OBJECTIVE

This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS.

METHODS

The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated.

RESULTS

A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS.

CONCLUSION

Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.

Failed carotid artery stenting followed by successful surgical intervention: Case report

A 56-year-old female patient with significant carotid stenoses with circumferential plaques, causing localized vascular narrowing, was inappropriately indicated for carotid artery stenting. After placement of a distal embolic protection device in the left internal carotid artery, a stent was inserted; however, it could not be fully deployed due to the rigid, severely calcified vascular walls. The various endovascular attempts to recapture the protection device were futile and, eventually, led to fracture of the guidewire of the device and it remained entrapped together with the stent. Emergency carotid arteriotomy with extirpation of the stent and embolic protection device via carotid thromboendarterectomy was performed. In conclusion, the proper patient selection for carotid artery stenting is of utmost importance.

Quantitative Optical Coherence Tomography Angiography Detects Retinal Perfusion Changes in Carotid Artery Stenosis

Background

Carotid artery stenosis (CAS) is a multifaceted disease characterized by possible ocular involvement. Treatment with carotid endarterectomy helps to restore cerebral perfusion, which may prevent ocular and cerebral complications. The main aim was to assess retinal and choroidal vascular perfusion changes before and after endarterectomy in patients affected by CAS.

Methods

The design of the study was prospective and observational, including patients affected by CAS and healthy controls. The follow-up was 3 months. We performed quantitative optical coherence tomography (OCT) angiography (OCTA) analyses of retinal perfusion changes, before and after endarterectomy. The main outcome measures were the quantitative changes of choroidal thickness (CT), retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL); vessel density (VD); and vessel tortuosity (VT) OCTA metrics were also measured.

Results

Sixty eyes of 30 patients affected by CAS and 30 eyes of 30 controls were included. We separately considered the ipsilateral eyes to CAS, the contralateral eyes to CAS, and the healthy eyes. Visual symptoms were absent in all the patients. RNFL and GCL resulted similar between patients and controls (p > 0.05). CT was significantly thinner in ipsilateral eyes than controls (p < 0.01), and it resulted unchanged after surgery (p > 0.05). VD resulted significantly altered only in some plexa of the ipsilateral eyes (p < 0.01), whereas VT disclosed decreased values of the entire retinal vascular network, both in ipsilateral and contralateral eyes (p < 0.05). Endarterectomy was followed by statistically significant improvement of retinal perfusion (p < 0.05).

Conclusion

Optical coherence tomography angiography can noninvasively detect postendarterectomy retinal perfusion improvements in CAS patients with baseline diabetes and hypertension as a systemic risk factor.

Impact of Chronic Kidney Disease Under Nephrology Care on Outcomes of Carotid Endarterectomy

OBJECTIVE

This study aimed to investigate the impact of chronic kidney disease (CKD) and the delivery of nephrology care on outcomes of carotid endarterectomy (CEA).

METHODS

This was a single centre, retrospective observational study. Between January 2007 and December 2014, 675 CEAs performed on 613 patients were stratified by pre-operative estimated glomerular filtration rate (eGFR) values (CKD [eGFR < 60 mL/min/1.73m²] and non-CKD [eGFR ≥ 60 mL/min/1.73m²] groups) for retrospective analysis. The study outcomes included the occurrence of major adverse cardiovascular events (MACEs), defined as fatal or non-fatal stroke, myocardial infarction, or all cause mortality, during the peri-operative period and within four years after CEA.

RESULTS

The CKD group consisted of 112 CEAs (16.6%), and the non-CKD group consisted of 563 CEAs (83.4%). The MACE incidence was higher among patients with CKD compared with non-CKD patients during the peri-operative period (4.5% vs. 1.8%; p = .086) and within four years after CEA (17.9% vs. 11.5%; p = .066), with a non-statistically significant trend. In a subgroup analysis of patients with CKD under nephrology care (63/112, 56.3%; with better controlled risk factors and tighter medical surveillance by a nephrologist), patients with CKD without nephrology care (49/112, 43.8%), and non-CKD patients, the risk of both peri-operative (4.1% vs. 0.4%; p = .037) and four year post-operative (20.4% vs. 7.3%; p = .004) all cause mortality was statistically significantly higher among patients with CKD without nephrology care compared with non-CKD patients. However, there were no statistically significant differences between patients with CKD who received nephrology care and non-CKD patients in peri-operative and four year post-operative MACE occurrence, both in terms of the composite MACE outcome and the individual MACE components.

CONCLUSION

Despite the higher risk of peri-operative and four year MACE after CEA among patients with CKD, and the statistically significantly higher peri-operative and four year post-operative all cause mortality rates among patients with CKD without nephrology care, patients with CKD under nephrology care had similar outcomes to non-CKD patients.

Neurovascular disease, diagnosis, and therapy: Cervical and intracranial atherosclerosis, vasculitis, and vasculopathy

Stroke is a leading cause of death, disability, and financial burden in the United States. Perhaps more than any other disease process, the rapidity with which the diagnosis and treatment of stroke are successfully achieved is paramount to the reduction of its associated morbidity and mortality. Steno-occlusive intracranial vascular disease, the most notorious culprit of cerebral ischemia and/or hemorrhage, traces its etiology to native and embolic atherosclerosis as well as various forms of vascular inflammation, insult, and dysfunction. Distinguishing between these causes is a critical first step in the diagnosis and treatment of a patient presenting with cerebrovascular compromise. In this chapter, we delineate the clinical and imaging features of cervical and intracranial atherosclerosis, vasculitis, and vasculopathy, along with the evidence behind the treatments which comprise their current-day standard of care. The modern imaging armamentarium is diverse and complex, with contrast-enhanced and non-contrast MR angiography, CT angiography, digital subtraction angiography, and ultrasound; each playing an important role in providing rapid insight into the patient's disease process. Understanding these imaging techniques and their application in the acute setting is critical for the provider caring for stroke patients.

Duplex ultrasound findings and clinical outcomes of carotid restenosis after carotid endarterectomy

This study aimed to describe the duplex ultrasound (DUS) findings associated with carotid restenosis after carotid endarterectomy (CEA) and to determine whether carotid restenosis is associated with the clinical outcomes of CEA. Between January 2007 and December 2016, a total of 660 consecutive patients who underwent 717 CEAs were followed up at our hospital with DUS surveillance for at least 3 years after CEA. These patients were analyzed retrospectively for this study. Following CEA, restenosis was defined as the development of ≥50% stenosis, diagnosed on the basis of DUS findings of the luminal narrowing and velocity criteria. The study outcomes were defined as restenosis of the ipsilateral carotid artery after CEA and late (>30days) fatal or nonfatal stroke ipsilateral to the carotid restenosis. During the median follow-up period of 74 months, the restenosis incidence was 2.8% (20/717), and there were 2 strokes (2/20, 10%) ipsilateral to the restenosis after CEA; reintervention was performed for 11 patients with carotid restenosis (55%). Within 2 years after CEA, restenosis was identified in 9 cases (45%, 9/20), and 8 reinterventions (72.7%, 8/11) were performed. According to DUS findings, the morphologic characteristics of carotid restenosis were different from the preoperative plaque morphology. Among the 20 carotid restenosis cases, we observed the following DUS patterns: homogenous isoechoic restenosis (n = 14, 70%), homogenous hypoechoic (n = 2, 10%), isoechoic with hypoechoic surface (n = 3, 15%), and hypoechoic with isoechoic surface (n = 1, 5%). Although 9 carotid restenosis patients received prophylactic reintervention to mitigate the progression of restenosis, the 2 symptomatic restenosis patients had isoechoic lesions with hypoechoic surfaces on DUS. On Kaplan-Meier survival analyses, in terms of stroke-free survival rates, there was a higher risk of stroke among patients with carotid restenosis compared with patients without restenosis, with a non-significant trend (P = 0.051). In conclusion, most carotid restenoses were identified within 2 years after CEA, and there was a non-significant trend toward a higher risk of stroke among patients with carotid restenosis.

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.

Chronic total occlusion and spontaneous recanalization of the internal carotid artery: Natural history and management strategy

OBJECTIVES

Spontaneous recanalization of a chronic total occlusion of the extra-cranial internal carotid artery is an under-reported clinical entity. This paper reviews the different etiologies of internal carotid artery occlusion, its natural course, as well as the significance and our recommendations for the management of spontaneous internal carotid artery recanalization.

METHODS

A review of literature on etiology, diagnosis, and treatment of internal carotid artery occlusion and recanalization was conducted. PubMed database was searched using the terms "internal carotid occlusion" and "recanalization". Articles were reviewed and studies involving the management of internal carotid artery occlusion and spontaneous recanalization were included. We subsequently developed a management algorithm for chronic total occlusion of the internal carotid artery and spontaneous recanalization of such lesions based on the available evidence.

RESULTS

Common etiologies of chronic total occlusion of the internal carotid artery include carotid atherosclerotic disease, cardioembolic, and carotid dissection. Progression of an asymptomatic to symptomatic occlusion is estimated at 2-8% annually. Well-compensated patients can be asymptomatic. In others, clinical symptoms range from ipsilateral or global hypoperfusion to embolic stroke in some cases of spontaneous recanalization. Spontaneous recanalization occurs in 2.3-10.3% of patients but rarely results in a cerebrovascular event.

CONCLUSIONS

Progression of an asymptomatic chronic total occlusion of the internal carotid artery to symptomatic is infrequent. The management algorithm of chronic total occlusion of the internal carotid artery and spontaneous recanalization of the internal carotid artery must be tailored to the patient based on symptoms, etiology of the lesion, imaging findings, surgical risk, and reliability for follow-up.

Outcomes of Transcarotid Artery Revascularization and Carotid Endarterectomy at a Single Institution

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are accepted revascularization modalities to treat carotid artery stenosis. Higher incidences of perioperative adverse neurological events and death have been reported in patients with transfemoral CAS. Transcarotid artery revascularization (TCAR) is a newer operative technique that involves direct transcervical carotid access, mitigating aortic arch manipulation and minimizing the risk of embolic stroke via cerebral blood flow reversal. Perioperative stroke, myocardial infarction (MI), and death rates have been shown to be similar between TCAR and CEA, with TCAR having fewer complications. The objective of this study was to ascertain the safety and viability of TCAR by evaluating perioperative outcomes. We hypothesized that patients undergoing TCAR and CEA have equivalent outcomes.

METHODS

We performed a single-institution retrospective review of a prospectively maintained Vascular Quality Initiative database on patients who underwent TCAR or CEA between 2012 and 2019. A total of 66 TCAR cases from February 2018 to December 2019 and 501 CEA cases from January 2012 to December 2019 were reviewed. Preoperative, intraoperative, and postoperative characteristics as well as perioperative outcomes were captured for the statistical analyses.

RESULTS

From 2012 to 2019, 567 patients underwent TCAR or CEA. Patients who underwent TCAR were found to have higher rates of comorbidities compared with CEA. There were no procedure-related strokes in patients who underwent TCAR. There was no statistically significant difference between TCAR and CEA procedure-related strokes (0% vs. 1.0%, P = 0.42). There were 5 CEA procedure-related strokes because of technical problems resulting in thrombosis of the target vessels. Three patients who underwent CEA had strokes unrelated to the operations. Overall, there were no perioperative deaths, MI, cranial nerve injury (CNI), or hematoma in patients who underwent TCAR. There were no complications of surgical site infection, pseudoaneurysm, or arteriovenous fistula among patients who underwent TCAR or CEA.

CONCLUSIONS

This single-center retrospective analysis of TCAR and CEA for the treatment of carotid artery disease suggests TCAR can result in equivalent perioperative procedure-related stroke as CEA as well as equivalent incidence of perioperative complications including MI, CNI, hematoma, and death in selected patients or patients with proper anatomy. TCAR may be considered a safe, feasible carotid revascularization option for carotid artery stenosis.