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

Disability and associated outcomes among patients suffering periprocedural strokes after carotid artery stenting

OBJECTIVE

Perioperative stroke after carotid artery stenting (CAS) is rare. However, the degree of disability and long-term effects from a postoperative stroke remain unclear. Our goal was to assess the degree of disability from a stroke after transcarotid artery revascularization (TCAR) and transfemoral CAS (TFCAS) for asymptomatic carotid artery disease, and the associated 1-year impact on subsequent neurological events and mortality.

METHODS

The Vascular Quality Initiative CAS registry (2016-2023) was queried for CAS performed for asymptomatic disease. Patients with a postoperative stroke had their disability stratified by modified Rankin score of 0 to 1 (mild), 2 to 3 (moderate), 4 to 5 (severe), and 6 (deceased). Postoperative stroke-related disability based on modified Rankin scale for those recorded at discharge and its association with long-term outcomes were analyzed.

RESULTS

There were 23,435 TCAR and 7487 TFCAS procedures performed for asymptomatic disease. Among TCAR patients, the periprocedural stroke and stroke/death rates were 0.80% and 1.03%, respectively, with disability distributed as 33.6% mild, 31.0% moderate, 28.9% severe, and 7.5% deceased. Among TFCAS patients, the periprocedural stroke and stroke/death rates were 0.92% and 1.19%, respectively, with disability distributed as 37.7% mild, 31.0% moderate, 27.5% severe, and 2.9% deceased. Multivariable analysis demonstrated that severe early postoperative disability was associated with increased 1-year mortality (hazard ratio [HR], 11.04; 95% confidence interval [CI], 6.9-17.7; P = .001) and increased subsequent neurological event/death (HR, 10.82; 95% CI, 6.93-16.9; P = .001). Patients with a stroke after TFCAS had a higher risk of 1-year mortality (HR, 1.27; 95% CI, 1.10, 1.47; P = .001) and neurological event/death (HR, 1.27; 95% CI, 1.11-1.45; P < .001), as compared with patients with a stroke after TCAR. Among patients who undergo a CAS procedure for asymptomatic disease, hypertension was associated with a higher likelihood of developing severe disability (odds ratio [OR], 4.2; 95% CI, 1.03-17.32; P = .045), whereas preoperative aspirin (OR, 0.51; 95% CI, 0.30-0.87; P = .01) or P2Y12 inhibitor use (OR, 0.45; 95% CI, 0.27-0.74; P = .11) was associated with a lower likelihood of developing a severe disability.

CONCLUSIONS

The majority of patients who undergo TCAR and TFCAS for asymptomatic carotid artery disease who suffered a periprocedural stroke had substantial disability. Patients with strokes from TFCAS have worse 1-year outcomes as compared with patients with stroke after TCAR. These findings should help to guide patient-provider discussions regarding the surgical management of asymptomatic carotid stenosis and the risks of CAS interventions, as well as aid in the prognostication of postoperative stroke.

Outcomes of redo vs primary carotid endarterectomy in the transcarotid artery revascularization era

OBJECTIVE

Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the United States Food and Drug Administration in 2015.

METHODS

All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

RESULTS

Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the Vascular Quality Initiative decreased from 2.3% to 1.0% as endovascular methods became more available (P < .001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) despite an improvement in the death rate (P = .009). From 2003 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.14-2.73; P = .007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

CONCLUSIONS

The proportion of rCEAs done yearly in the United States has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within Society for Vascular Surgery guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.

Utilization of coronary artery bypass grafting with combined or staged carotid revascularization in a national sample

BACKGROUND

Strategies to treat co-prevalent carotid and coronary artery disease include carotid endarterectomy (CEA) or stenting (CAS) with coronary artery bypass graft (CABG). There is uncertainty with respect to treatment utilization frequency. The objective of this study is to describe trends in the volume of CABGs performed concurrently with staged or combined CEA/CAS spanning a two-decade period and identify factors associated with utilization.

METHODS

A nationally representative cohort was developed using National Inpatient Sample data from 1998 to 2020, identifying patients who underwent concurrent CABG and carotid revascularization. We included patients who underwent either CABG/CEA or CABG/CAS. Sample-weighted volumes of both staged (CABG+CEA/CAS during the same admission) and combined (both procedures on the same day) strategies were used to describe trends. Poisson regression models were used to identify factors predicting increased procedure volume. Interactions between strategy and procedure year, and facility CABG volume and strategy were tested.

RESULTS

We analyzed 12,260 patients who underwent CABG with concurrent carotid revascularization, of whom 9702 (79.1%) were staged and 2558 (20.9%) were combined. In both the staged and combined groups, a significantly greater frequency of patients underwent CEA compared with CAS (97.5% and 91.7%, respectively; P < .001). In the multivariable model and as time progressed, concurrent volume decreased by 7% per year-a decrease observed across both staged and combined operations. Concurrent procedure volume significantly increased in urban relative to rural hospitals, with urban teaching hospitals reporting higher volume (urban nonteaching hospitals [incident rate ratio = 2.06, 95% confidence interval: 1.87, 2.27]; urban teaching hospitals [incident rate ratio = 3.01, 95% confidence interval: 2.73, 3.32]). Interactions between strategy, procedure year, and facility CABG volume were not statistically significant.

CONCLUSIONS

In a recent 20-year period, utilization of concurrent CABG/CEA and CABG/CAS operations decreased significantly, independent of timing strategy (either staged or combined). Resource allocation and guideline planning should consider the relative frequency of these operations.

Moderate-to-Severe Preoperative Anemia is Associated with Increased Postoperative Myocardial Infarction and Mortality in Patients Undergoing Transcarotid Artery Revascularization

BACKGROUND

While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR.

METHODS

A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes.

RESULTS

Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]).

CONCLUSION

In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.

Meta-Analysis Investigating the Association Between the Degree of Chronic Kidney Disease and Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Carotid Artery Stenosis

OBJECTIVE

Chronic Kidney Disease (CKD) has been identified as an important risk factor for perioperative morbidity and mortality. Carotid endarterectomy (CEA) is recommended to reduce the risk of stroke for >80% carotid stenosis in asymptomatic patients and carotid stenosis of >50% in symptomatic patients. This meta-analysis aims to investigate the association of CKD with the 30-day outcomes after CEA.

METHODS

The review protocol for the current study is registered on the Open Science Framework (OSF) database. Using PubMed and Scopus databases, a systematic literature review was performed in English, querying papers published up to April 2024. The review was designed to include published observational studies investigating the association of CKD with postoperative outcomes of CEA, including mortality and stroke within 30 days. CKD was defined as having an eGFR <60 mL/min/1.73 m2, while an eGFR ≥60 mL/min/1.73 m2 was defined as normal kidney function. Pooled odds ratios (ORs) for the overall mortality was computed using the confidence interval of 95%. The heterogeneity among the included studies was calculated by Q-metric and quantified using Higgins I2 statistics.

RESULTS

32,505 patients were represented in the eight studies published from 2008 to 2021. Of the patients undergoing CEA, 17,891 (55%) patients had CKD with varying levels of eGFR, and 14,614 (45%) did not. Pooled OR revealed an increased risk of 30-day mortality (OR, 1.72; 95% CI, 1.40-2.11) and stroke (OR, 1.27; 95% CI, 1.08-1.50) among patients in the CKD group. Similar results with higher mortality (OR, 2.21; 95% CI, 1.26-3.86), stroke (OR, 2.19; 95% CI, 0.94-5.07), and composite of mortality or stroke (OR, 2.52; 95% CI, 1.31-4.84) were observed in CKD patients undergoing CEA for symptomatic Carotid artery stenosis (CAS). For asymptomatic CAS patients and comorbid CKD, this risk prevailed with a higher risk of mortality (OR, 1.96; 95% CI, 1.10-3.48), stroke (OR, 3.21; 95% CI, 1.46-7.07), and composite of mortality or stroke (OR, 2.20; 95% CI, 1.37-3.54) was observed. A reduction in eGFR and increased severity in CKD was associated with a greater risk of adverse outcomes.

CONCLUSION

CKD patients undergoing CEA are at a high risk of increased mortality, stroke, or a composite of the two within the first 30 days after the procedure. This risk increases with the severity of the CKD, as highlighted by lower renal function defined by low eGFR. Primary outcomes did not seem to differ among symptomatic versus asymptomatic CAS patients. These patients may warrant more aggressive postoperative management, especially within the first 30 days post-CEA.

Systematic Review of Biomechanical Forces Associated with Carotid Plaque Disruption and Stroke

OBJECTIVE

Carotid plaque disruption with release of atheroembolic debris and consequent brain infarction is the primary mechanism for brain injury in patients with carotid stenosis. Disease severity is traditionally quantified by the degree of stenosis, though it is not an accurate marker of stroke-risk. It has been proposed that biomechanical forces acting on a carotid plaque may render it vulnerable to rupture by causing adverse remodeling of its morphology, or by direct disruption. We conducted a systematic review to assess the forces acting on carotid plaques and their relationship to adverse plaque outcomes.

METHODS

A literature search for studies reporting measurements of flow-related biomechanical forces acting on carotid atherosclerotic plaques was conducted using PubMed, Embase and Web of Science. Studies were included if they reported on human carotid plaques, used patient-specific geometry, measured forces on or in the atherosclerotic lesions, and reported on carotid plaque-related adverse outcomes.

RESULTS

Of 5,635 manuscripts screened, 154 met eligibility criteria. Forces were computed using patient-specific arterial geometry derived from multiple imaging modalities, mainly magnetic resonance imaging (58.4%) and ultrasonography (25.3%). Methodologies used to quantify the forces included computational fluid dynamics (31.8%), finite element analysis (10.4%), fluid-structure interaction models (27.3%), in-vivo measurements (29.9%), or in-vitro assessments (0.6%). Wall shear stress (WSS) and plaque wall stress (PWS) were the most frequently measured forces, in 72.1% and 45.5% of studies respectively. Principal PWS (n=15 studies) and WSS (n=21 studies) were elevated in patients with adverse outcomes. PWS levels of >160 kPa had a sensitivity of >80% and specificity of >75% in identifying patients with adverse events. Increasing PWS was associated with subsequent ischemic cerebrovascular events (HR=12.98 per 1 kPa increase, p=0.02). WSS levels of >50 dyn/cm2 had a sensitivity of 100% and specificity of 67% in differentiating patients with adverse events (plaque rupture, cerebral infarction, stroke, or transient ischemic attack) compared to those without.

CONCLUSIONS

There is heterogeneity in sample size, study design, imaging protocols, image-processing methodology, forces assessed, and adverse carotid plaque-related outcomes measured in the literature. Despite these limitations, increasing PWS and WSS were consistently associated with adverse plaque outcomes, and predicted adverse outcomes with moderate to high degrees of sensitivity and specificity. Since the information available is heterogenous, these relationships need to be confirmed in larger prospective studies.

Outcomes and Insights from a Decade of Transcarotid Artery Revascularization in Community Practice

OBJECTIVE

Transcarotid arterial revascularization (TCAR) with flow reversal is a well-established minimally invasive alternative to carotid endarterectomy. Our multicenter, private practice is an early adopter and has performed TCARs in the community since 2013. We report our real-world experience after performing 650 TCARs over ten years in the community.

METHODS

655 TCAR procedures were performed on 588 patients between 2013-2024. A retrospective chart review was performed on these procedures. The cohort included nine vascular surgeons across ten hospitals. All procedures used the enroute transcarotid neuroprotection system (NPS), which uses common carotid access and high-rate flow reversal as embolic protection during stenting. The primary endpoints for this study are 30-day rates of stroke and myocardial infarction (MI). Secondary endpoints included operative time, cranial nerve injury, neck hematoma requiring evacuation, arterial dissection, and death.

RESULTS

655 TCAR procedures were performed on 588 unique patients. 403 (61.52%) of patients were asymptomatic at the time of surgery. The median patient age was 73 (67-79) years. Patient medical history, surgical history, pre- and post-dilation balloon sizes, stent sizes, operative time, flow-reversal time, contrast volume, reoperation status, discharge statin, and anticoagulation therapies are listed and summarized in the tables below. Eleven patients suffered a perioperative stroke (1.68%) within 30 days of the operations, and ten (1.53%) suffered a stroke after thirty days but within one year of the operation. MI occurred in one patient (0.15%) within 30 days and six (0.91%) within one year. Cranial nerve injury occurred in 10 (1.52%) patients, defined as either dysphagia (n=1) or hoarseness (n=9). Neck hematoma with evacuation occurred in 10 patients (1.53%). An arterial dissection transpired in a single patient (0.15%).

CONCLUSIONS

Over the last decade, TCAR has emerged as an effective and efficient first-line therapy for treating suitable patients with carotid artery stenosis regularly in less than 1 hour of operative time. Early adoption and integration of this technology into practice have yielded excellent patient outcomes, matching or surpassing those reported in the literature for the gold standard, CEA.

Matrix Metalloproteinase-9 and Postoperative Outcomes in Carotid Endarterectomy: A Systematic Review

Background/Objectives: Carotid endarterectomy (CEA) is the treatment of choice for severe symptomatic and asymptomatic carotid artery stenosis. Nonetheless, it carries risks and several complications, including stroke and death. Previous studies have indicated that elevated matrix metalloproteinase-9 (MMP-9) levels may serve as biomarkers for adverse outcomes after CEA. This systematic review investigates the association between plasma MMP-9 levels and adverse cardiovascular outcomes following CEA. Methods: PubMed/MedLine, Scopus and Web of Science were searched for studies assessing the relationship between plasma MMP-9 levels and postoperative outcomes after CEA. Assessment of studies' quality was performed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for observational cohorts and cross-sectional studies. Results: Five studies were included (n = 891 participants). All five were retrospective cohort studies. MMP-9 was significantly higher in patients who presented with a combination of amaurosis fugax, central retinal artery occlusion, TIA and minor/major stroke at follow-up. However, individual outcomes like TIA or stroke did not consistently correlate with MMP-9 levels. Additionally, increased MMP-9 levels were also associated with cognitive dysfunction post CEA. Conclusions: Despite the potential of MMP-9 levels to serve as a biomarker for predicting postoperative cerebrovascular complications, this review presents limitations, including a high risk of bias in included studies and variability in methodologies. There is a need for further research with larger cohorts to validate these findings and improve risk stratification and management strategies for patients undergoing CEA.

Urgent Carotid Artery Revascularization Fraught with Higher Rates of Neurovascular Events in Symptomatic Carotid Artery Stenosis

BACKGROUND

Symptomatic carotid artery stenosis requires timely intervention to reduce risk of recurrent stroke. However, the optimal timing of revascularization remains debated. This study evaluates outcomes in patients undergoing urgent (<48 hr), early (3-14 days), or delayed (>14 days) carotid artery revascularization.

METHODS

This retrospective cohort study included 186 interventions in symptomatic patients categorized by timing of intervention defined as urgent (<48 hr from symptom onset, n = 47), early (3-14 days, n = 90), and delayed (>14 days, n = 49). Baseline characteristics, procedural details, and outcomes were analyzed. Outcome measures included perioperative stroke, transient ischemic attack (TIA), myocardial infarction, and mortality at 30 days and on follow-up.

RESULTS

The cohort's mean age was 71.3 ± 9.6 years, with no difference among groups, and with a balanced sex distribution (P = 0.75). Comorbidities included hypertension, hyperlipidemia, and chronic kidney disease, which were similar across groups (P > 0.05). National Institutes of Health stroke scale on admission was significantly different between groups (urgent: 4.7 ± 4.6; early: 8.2 ± 8.1; delayed: 4.0 ± 5.2; P = 0.01). The level of disability measured through the modified Rankin scale at discharge demonstrated no significant difference between groups (urgent: 0.9 ± 1.3; early: 1.1 ± 1.3; delayed: 0.5 ± 1.0; P = 0.09). At 30 days, ipsilateral strokes/TIA occurred in 3 (6.4%) patients in the urgent group, and none in either the early group or delayed group (P = 0.02). Thirty-day mortality was observed in 2 (4.3%) patients in the urgent group and 1 (1.1%) in the early group (P = 0.23). The 30-day composite of stroke, TIA, myocardial infarction, or death was significantly higher in the urgent group (urgent: 8.5%, early: 1.1%, delayed: 0.0%; P = 0.02). At a mean follow-up of 14.6 ± 16.9 months, ipsilateral stroke rates were similar across groups (urgent: 4.3%, early: 5.6%, delayed: 4.1%; P = 1.00). All-cause mortality at follow-up occurred in 21.3% of urgent, 10.0% of early, and 10.2% of delayed patients (P = 0.17). Restenosis and reintervention rates at follow-up were significantly higher in the urgent (10.6%) and delayed (14.3%) groups than the early group (2.2%; P = 0.01).

CONCLUSION

Urgent carotid revascularization is associated with higher perioperative stroke/TIA rate than early and delayed interventions. Mid-term outcomes were comparable across groups. Restenosis and reintervention rates were higher in the urgent and delayed groups than the early intervention group.

A Computational Model-Based Study on Trans-Stenotic Pressure Ratio of Carotid Artery Stenosis and Its Predictive Value for Cerebral Ischemia

Trans-stenotic pressure ratio (herein denoted by dpPR) has been proposed as a complementary index to stenosis rate (SR) for assessing the functional severity of carotid artery stenosis (CAS); however, it remains unclear how well dpPR can indicate cerebral ischemia. In this study, a physiology-based computational model of the cerebral circulation was developed to yield a tool for generating large-scale in silico data to characterize the changes of the dpPR of the left internal CAS in response to variations in SR and various anatomical/pathophysiological factors that represent inter-patient differences. In addition, a cerebral ischemia index (CII) was defined to evaluate the predictive value of dpPR for cerebral ischemia. Results showed that dpPR was affected by many factors unrelated to the severity of stenosis, such as the anatomical structure and geometrical size of cerebral arteries, mean systemic arterial blood pressure (MAP), flow autoregulation function of cerebral microcirculation (quantified by CFAI), and coexisting contralateral CAS. In comparison with SR, dpPR exhibited a stronger correlation with CII. In particular, the relationship between dpPR and CII was found to be describable by a mathematical function if MAP and CFAI were fixed. The findings not only deepen our understanding of the physiological implications of dpPR but also provide valuable theoretical insights to guide the application of dpPR in clinical practice.

Editor's Choice - Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines for Vascular Surgery: A Systematic Review

OBJECTIVE

Clinical practice guideline recommendations are often informed by systematic reviews. This review aimed to appraise the reporting and methodological quality of systematic reviews informing clinical practice recommendations relevant to vascular surgery.

DATA SOURCES

MEDLINE and Embase.

METHODS

MEDLINE and Embase were searched from 1 January 2021 to 5 May 2023 for clinical practice guidelines relevant to vascular surgery. Guidelines were then screened for systematic reviews informing recommendations. The reporting and methodological quality of these systematic reviews were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) 2017 tool. Pearson correlation and multiple regression analyses were performed to determine associations between these scores and extracted study characteristics.

RESULTS

Eleven clinical practice guidelines were obtained, containing 1 783 references informing guideline recommendations. From these, 215 systematic reviews were included for synthesis. PRISMA item completeness ranged 14 - 100%, with a mean of 63% across reviews. AMSTAR 2 item completeness ranged 2 - 95%, with a mean of 50%. Pearson correlation highlighted a statistically significant association between a review's PRISMA and AMSTAR 2 score (r = 0.85, p < .001). A more recent publication year was associated with a statistically significant increase in both scores (PRISMA coefficient 1.28, p < .001; and AMSTAR 2 coefficient 1.31, p < .001). Similarly, the presence of funding in a systematic review was shown to be statistically significantly associated with an increase in both PRISMA and AMSTAR 2 scores (coefficient 4.93, p = .024; and coefficient 6.07, p = .019, respectively).

CONCLUSION

Systematic reviews informing clinical practice guidelines relevant to vascular surgery were of moderate quality at best. Organisations producing clinical practice guidelines should consider funding systematic reviews to improve the quality of their recommendations.

Thirty-day stroke/mortality of carotid revascularization in asymptomatic patients with newly diagnosed and/or decompensated heart failure exceeds the Society for Vascular Society guideline risks

BACKGROUND

According to the latest Society for Vascular Surgery guidelines, carotid revascularization for asymptomatic individuals should be offered if the perioperative stroke/death rate does not exceed 3%. Heart failure (HF) has been associated with reduced survival rates following carotid revascularization, which may significantly impact the risk-benefit decision of treating asymptomatic patients with HF. This study aimed to evaluate the 30-day postoperative risks in asymptomatic patients with newly diagnosed and/or decompensated HF undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS).

METHODS

Asymptomatic patients who underwent CEA and CAS were identified in the American College of Surgeons-National Surgery Quality Improvement Program targeted databases from 2011 through 2023. HF was defined as newly diagnosed HF and/or an acute exacerbation of chronic HF within 30 days of the surgery. A 1:3 propensity-score matching was used to balance preoperative differences between patients with and without HF. Patients who underwent CEA and CAS were analyzed separately. Thirty-day postoperative outcomes were examined.

RESULTS

There were 23,274 patients who underwent CEA, where 601 (2.58%) had HF, who were matched to 1803 non-HF patients. Among 1361 patients who underwent CAS, 87 (6.38%) had HF and were matched to 222 non-HF counterparts. Patients with HF had a much higher comorbidity burden. After CEA, patients with HF had higher risks of stroke/mortality (4.83% vs 2.55%; P = .01), cardiac (6.66% vs 3.38%; P < .01), pulmonary (4.49% vs 2.44%; P = .02), and renal complications (1.66% vs 0.44%; P = .01), as well as sepsis (1.50% vs 0.44%; P = .02), distal embolization (0.50% vs 0.00%; P = .02), unplanned operation (5.99% vs 3.49%; P = .01), prolonged hospital stay (P < .01), and 30-day readmission (13.14% vs 8.65%; P < .01). After CAS, patients with HF had similarly high risks of stroke/mortality (5.75% vs 3.60%; P = .53).

CONCLUSIONS

For newly diagnosed and/or decompensated patients with HF and asymptomatic carotid stenosis, the 30-day postoperative stroke/mortality risks after both CEA and CAS greatly exceed the Society for Vascular Surgery guideline recommendations. Coupled with the substantially higher risk of other major complications, the decision to pursue surgical revascularization in asymptomatic patients with HF should be approached with extreme caution, and conservative management may be prioritized.

Cumulative Risks for Reoperation Due to Bleeding After Carotid Endarterectomy and The Associated Clinical Impact of Bleeding Events

OBJECTIVE

The purpose of this study was to identify all preoperative and intraoperative variables in the Vascular Quality Initiative (VQI) carotid endarterectomy (CEA) module that have a statistically significant association with reoperation for bleeding. A weighted risk score was developed and validated to predict this event, with assessment of its impact on 30-day mortality and other adverse perioperative events.

METHODS

The VQI CEA module was queried between January 2003 and October 2023. Overall, 192,547 CEA procedures met study inclusion. An internal VQI validation cohort was created with the same exclusion criteria utilizing CEA performed between November 2023 and October 2024 over which time period 17,449 procedures met inclusion criteria.

RESULTS

The following variables had a statistically significant multivariable association (P<.05) with reoperation for bleeding after CEA : Black race (adjusted odds ratio (aOR) 1.53); BMI <20 kg/m2 (aOR 1.40); hypertension (aOR 1.19); history of CAD revascularization (aOR 1.16); CHF (aOR 1.37); COPD (aOR 1.19); dual antiplatelet at time of surgery (aOR 1.51); on anticoagulation baseline (aOR 1.23); preoperative Rankin score 2 or higher (aOR 1.41); urgent/emergent CEA (aOR 1.36); eversion CEA technique (aOR 1.33); surgeon selection for drain placement (aOR 1.17); and, lack of protamine utilization intraoperatively (aOR 2.08). The following variables had a significant (P<.05) protective effect versus reoperation for bleeding after CEA : female sex (aOR .84); BMI>35 kg/m2; and active smoking status (aOR 0.85). Patients with risk scores of zero or less had an only .006% risk of return to the operating room for bleeding. There was significant elevation in risk for return to the operating room for bleeding with escalating risk sores. Patients with risk scores 11 and higher had an absolute reoperation for bleeding event rate of 3.6% which was a total event rate 600 times higher than individuals with scores of 0 or less and 3.6 times as high as individuals with scores as high as 5. The internal VQI validation cohort experienced the event of return to the operating room for bleeding at very similar rates to the primary study source cohort with no statistically significant difference at any of the risk score points indicating consistency for the risk score. Patients who experienced return to the operating room for bleeding after CEA experienced a statistically significant increased rate of : 30 day mortality (OR 1.59); cranial nerve injury (OR 2.03); perioperative neurological event (OR 5.80); myocardial infarction (MI) (OR 6.56); cardiac dysrhythmia (OR 4.20); perioperative congestive heart failure (CHF) (OR 5.26); and skin-soft tissue infection (SSI) postoperatively (OR 12.61) with P<.001 for all.

CONCLUSIONS

A validated quantitative risk score has been developed to predict reoperation for bleeding after carotid endarterectomy (CEA). The most impactful variables, which are also largely modifiable, include intraoperative protamine utilization and avoidance of dual antiplatelet therapy. Patients who experience reoperation for bleeding after CEA experience significantly higher rates of 30-day mortality, MI, CHF, cranial nerve injury, SSI, and adverse perioperative neurological events.

Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy

BACKGROUND

This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals.

MATERIALS AND METHODS

This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180-15, 14-8, 7-3, 2-0 days or 'in-hospital index event'. In-hospital delay was divided into: 0-1, 2-3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR).

RESULTS

Prehospital delay was 0-2 days in 34.9%, 3-14 days in 29.5% and >14 days in 18.6%. Higher age (β=-1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=-4.41, p<0.001; stroke: β=-6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2-3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk.

CONCLUSIONS

This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2-3 days) were associated with increased risk of perioperative stroke or death.

Long-Term Performance and Safety of the Self-Expandable Carotid Stent MER: 5-Year Outcomes from the OCEANUS Study, with Subgroup Analysis Based on Predilatation Before Carotid Artery Stenting

Background: Carotid artery stenting (CAS) with neuroprotection is a widely used treatment for carotid artery stenosis. This study aimed to evaluate the long-term outcomes of CAS using the MER stent (Balton, Poland) and various neuroprotection devices, with subgroup analysis based on predilatation. Methods: A prospective analysis was conducted on patients treated with CAS at four high-volume centers in Poland between October 2016 and May 2017. Patients were stratified into two groups based on whether predilatation was performed. Procedural and clinical outcomes, including major adverse events (MAEs) defined as all-cause death, stroke, and myocardial infarction (MI), were evaluated at 30 days and 5 years post-procedure. Kaplan-Meier analysis and Cox regression models were used to assess event-free survival and predictors of MAEs. Results: The study population consisted of 100 patients (males: 61%) with a mean age of 68 years. Dyslipidemia (84.4% vs. 60.0%, p = 0.007) and smoking (67.3% vs. 44.4%, p = 0.022) differed significantly between the predilatation and non-predilatation groups. The procedural success rate (<30% residual stenosis) was 97%. At 5 years, the overall restenosis rate was 7%, and target vessel revascularization was required in 3% of patients. The cumulative mortality rate was 15%, and two strokes (2%) were recorded. Multivariable regression identified prior CABG as an independent predictor of MAEs (HR 3.5, 95% CI 1.14-10.83, p = 0.03). Conclusions: CAS with the MER stent demonstrated high procedural success and favorable long-term outcomes. Predilatation did not impact outcomes. Neuroprotection was effective in all cases, with no device-related complications reported.

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

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

Asymptomatic Carotid Artery Stenosis, Cognitive Function, and the Impact of Carotid Revascularization: A Narrative Review

BACKGROUND

The association between asymptomatic carotid artery stenosis and impaired cognition, and the cognitive changes after revascularization remain active areas of interest in the field of carotid disease. This narrative review focuses on the association between carotid artery atherosclerosis and impaired cognitive function, proposed mechanisms, and the effects of carotid revascularization on cognition.

METHODS

A critical review of the literature to identify studies evaluating carotid artery stenosis, cognition, and carotid revascularization was performed using PubMed to query the MEDLINE database through March 2023.

RESULTS

Many studies demonstrate a link between carotid disease and cognitive impairment but direct evidence is lacking. Revascularization may offer cognitive benefits but the effect is likely subtle and affected by the choice of revascularization procedure.

CONCLUSIONS

Integrating cognitive outcomes into ongoing randomized controlled trials such as the nested CREST-H arm of the CREST-2 trial hold promise for offering new insight into the role of carotid artery stenosis and carotid revascularization on cognition.

Local Anesthesia and Enhanced Recovery after Transcarotid Artery Revascularization

BACKGROUND

Transcarotid artery revascularization (TCAR) is a minimally invasive surgical treatment for carotid artery stenosis. This study describes a 10-year institutional experience of TCAR and the concurrent development of enhanced recovery protocols.

METHODS

Standardized practices were implemented at a single institution for patients undergoing TCAR. This included protocolized preoperative imaging and medical optimization, intraoperative workflow, and postoperative care. Additionally, vascular anesthesiology protocols were established for managing local and general anesthesia. A retrospective review of patients undergoing TCAR was subsequently conducted. Data on patient demographics, procedural details, and outcomes were analyzed from a prospectively maintained institutional database.

RESULTS

Across 321 patients, the median hospital stay after TCAR was 1.0 days with low-postoperative complications, most notably a 1.9% perioperative stroke-death rate.

CONCLUSION

Multidisciplinary collaboration is necessary to develop sustainable and effective enhanced recovery protocols. Implementation of these care pathways can improve patient outcomes and efficiency of care.

Timing of Intervention in Symptomatic Carotid Artery Stenosis

Symptomatic carotid artery stenosis is defined as an acute neurologic deficit (transient ischemic attack or stroke) occurring in the last 6 months, that is, ipsilateral to an extracranial carotid artery with at least 50% stenosis. Previous studies have identified the benefit of surgical intervention on symptomatic carotid stenosis, but the ideal timing is less clear. The timing of intervention must balance the risk of perioperative stroke and death (higher during the hyperacute period within 48 hr) and the risk of recurrent stroke while waiting to intervene, particularly if delayed beyond 14 days. Several factors such as acuity of neurologic deficit, degree of stenosis, or contralateral occlusion, and other comorbidities, may contribute to the risk of perioperative stroke or death when intervening within the acute period. The Society for Vascular Surgery recommends carotid endarterectomy as the intervention for symptomatic carotid artery stenosis, but recent studies have shown that transcarotid revascularization may also have similar outcomes.

Avoiding Complications with Transcarotid Artery Revascularization

BACKGROUND

Transcarotid artery revascularization (TCAR) for carotid artery stenting offers an innovative method for treating carotid artery occlusive disease. This technique utilizes the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, CA) to temporarily reverse flow in the carotid artery prior to crossing or treating the carotid lesion, reducing the perioperative risk of stroke. This review aims to summarize possible complications associated with the procedure and offer suggestions to address or avoid these issues in practice.

METHODS

A review of the available scientific literature was performed via PubMed database queries. Our institutional experience with TCAR was reviewed from a prospectively maintained database. Outcomes assessed included perioperative complications and overall rates of re-stenosis after TCAR.

RESULTS

Potential complications of TCAR were identified and summarized. These are organized based on preoperative, intraoperative, or postoperative timing of the potential complication. Our group's real-world outcomes of 273 patients undergoing TCAR with median (interquartile range) follow up of 17.4 (4.4 -38.7) months, including safety and restenosis data, are presented.

CONCLUSIONS

Herein we summarize the available literature regarding potential complications that may be encountered when performing TCAR. Safe and effective clinical outcomes, comparable to those of published clinical trial data, can be successfully achieved in the real-world setting.

The elevated stroke and death rates among asymptomatic patients undergoing carotid stenting in the Pacific Northwest are associated with high-risk patient selection

OBJECTIVE

Current guidelines recommend treatment of patients with asymptomatic carotid stenosis when stroke/death rates less than 3% can be achieved. However, in the Pacific Northwest region of the Vascular Quality Initiative, elevated stroke/death rates have been reported. This study aims to characterize regional and center-specific outcomes for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) and investigate potential underlying drivers.

METHODS

A retrospective review of asymptomatic patients undergoing TCAR and TF-CAS in the Vascular Quality Initiative for the Pacific Northwest region from 2016 to 2022 was performed. The primary outcome was the composite of stroke or death within 30 days of index hospitalization. Overall regional outcomes and center-specific outcomes were assessed. A high stroke/death rate was defined as greater than 3%. Demographics, comorbidities, and operative risk factors were then compared between centers with high and low stroke/death rates.

RESULTS

A total of 1154 asymptomatic patients across 27 centers underwent carotid stenting in the Pacific Northwest from 2016 to 2022, of which 886 (76.8%) underwent TCAR and 268 (23.2%) underwent TF-CAS. The overall stroke/death rates were 2.5% and 3.0% for TCAR and TF-CAS, respectively. Among centers with stroke/death rates above 3%, for both TCAR and TF-CAS, all were in the top one-half of centers by volume. When patients undergoing TCAR were assessed, those treated at centers with high stroke/death rate underwent revascularization at higher volume centers (12 vs 7 cases per year; P = .03), which treated fewer patients with >80% stenosis (42.1% vs 52.2%; P < .01) and more patients with high-risk anatomy (42.3% vs 35.3%; P = .01), and high-risk physiology as defined by an American Society of Anesthesiologists (ASA) class of 4 or 5 (25.5% vs 17.5%; P < .01). Among patients undergoing TF-CAS, those treated at centers with a high stroke/death rate were more likely to have high-risk anatomy (63.5% vs 48.6%; P = .03), and high-risk physiology as defined by an ASA class of 4 or 5 (23.5% vs 10.4%; P < .01).

CONCLUSIONS

High stroke/death rates in the Pacific Northwest appear to be driven by the selection of high-risk patients with less than 80% stenosis. Decreasing the frequency of carotid revascularization in asymptomatic patients with very high physiologic risk including those with ASA class 4 and those with less than 80% stenosis may offer the opportunity for improved outcomes.

Concomitant Carotid and Coronary Artery Disease Management: A Review of the Literature

This review examines current evidence regarding management of patients with both coronary and carotid artery disease. It highlights the elevated stroke risk after surgery for this cohort and scrutinizes approaches to minimize this risk. Various revascularization methods are outlined, including carotid endarterectomy (CEA), carotid artery stenting (CAS), and staged versus simultaneous surgical approaches. The importance of judiciously screening coronary artery bypass grafting (CABG) candidates for carotid stenosis is emphasized, suggesting risk factor-based targeted screening is noninferior to indiscriminate screening. Efficacy comparisons are made between revascularization strategies such as staged versus synchronous CEA/CABG, CAS, and hybrid techniques. Controversies surrounding necessity and optimal timing of carotid revascularization in asymptomatic patients are addressed, indicating a need for rigorous randomized controlled trials to establish definitive treatment algorithms.

Carotid Disease and Management

Carotid artery stenosis is a leading cause of stroke, and 25% of patients experience a recurrent stroke within 5 years. Early detection and treatment are important to reduce the risk of stroke. Optimal medical therapy should be ensured among these patients regardless of symptom status. Carotid artery revascularization with carotid endarterectomy or carotid artery stenting (CAS) should be considered among patients with symptomatic carotid stenosis, or among patients with severe asymptomatic carotid artery stenosis. Refined procedural techniques, improvement in stent design, and use of embolic protection devices have enhanced the efficacy of CAS while reducing the risk of procedural complications.

Risk score for two-year mortality following carotid endarterectomy performed for symptomatic stenosis

OBJECTIVE

The purpose of this study is to identify variables at the time of clinical presentation that place patients at higher risk for mortality following carotid endarterectomy (CEA) for symptomatic lesions. Further, this study will create a risk score for mortality within 2 years following CEA for symptomatic stenosis to help tailor future postoperative and long-term management by identifying patients who require heightened vigilance in postoperative care to facilitate survival.

METHODS

The Vascular Quality Initiative CEA module was queried for procedures performed for symptomatic (within 180 days) carotid bifurcation stenosis. After exclusions, 24,713 met study inclusion. Univariable analysis for the binary outcome of mortality within 2 years of surgery was performed with χ2 testing for categorical variables and Student t-test for ordinal variables. Multivariable binary logistic regression was then performed utilizing variables that achieved univariable significance (P < .05) for the outcome. Variables with a multivariable P value ≤ .05 were included in the risk score and weighted based on their respective regression beta-coefficient in a point scale. Variables with a beta-coefficient of less than .25 were assigned 1 point, and then a point was added for each rise in beta-coefficient at .25 intervals. The risk score was then tested utilizing 20,668 patients deemed to be of acceptable surgical risk who underwent carotid stenting for symptomatic disease in the Vascular Quality Initiative.

RESULTS

Variables that achieved multivariable significance (P<.05) towards the outcome of mortality within 2 years of symptomatic CEA that were included in the risk score were: home status within the top 20% of area deprivation index (most disadvantaged) (adjusted odds ratio [aOR], 1.20); female sex (aOR, 1.157); body mass index <20 kg/m2 (aOR, 1.49); any history of tobacco smoking (aOR, 1.39); coronary artery disease (aOR, 1.47); history of congestive heart failure (aOR, 1.47); chronic obstructive pulmonary disease (aOR, 1.45); baseline renal insufficiency (aOR, 1.46); end-stage renal disease dialysis status at presentation (aOR, 2.38); American Society of Anesthesiology class 4 operative risk designation (aOR, 1.33); diabetes mellitus (aOR, 1.16); anemia (aOR, 2.09); history of peripheral artery intervention (aOR, 1.20); history of major lower extremity amputation (aOR, 1.93); prior CEA or carotid stenting (aOR, 1.32); escalating preoperative modified Rankin score (aOR, 4.46); and escalating age (aOR, 1.04/year). A steep escalation was noted from 2-year mortality rates of <4% for patients with risk scores of ≤4 to >35% for patients with scores of ≥17. Hosmer and Lemeshow goodness of fit testing for the multivariable regression analysis revealed an overall accuracy of 93.1% for the model, with 99.9% accuracy in predicting survival. Model testing in the symptomatic carotid stenting cohort revealed excellent correlation with no statistical difference in the mortality rate at 16 of the 19 risk score data points and a near identical mortality escalation pattern with rising risk score. When applied to the validation cohort, the risk score had an area under the receiver operating characteristic curve of 0.70 and a Hosmer-Lemeshow overall accuracy of 91.3%.

CONCLUSIONS

A risk score with quality accuracy in determining 2-year survival after CEA performed for symptomatic stenosis has been developed. Severity of preoperative stroke, dialysis status, baseline anemia, advancing age, low body weight, and cardiopulmonary comorbidities are the most deleterious variables negatively impacting survival. The score has utility in patient shared decision-making and expectation counseling.

Effectiveness of Transcarotid vs Transfemoral Carotid Stenting for Stroke Prevention

Importance

The effectiveness of surgical transcarotid artery revascularization (TCAR) compared with percutaneous transfemoral carotid artery stenting (TF-CAS) for stroke prevention beyond the periprocedural period is poorly quantified.

Objective

To compare the risk of stroke after TCAR vs TF-CAS.

Design, Setting, and Participants

This retrospective cohort study used data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data that captures clinical, procedural, and outcome data on patients who underwent carotid stenting. Patients who underwent TCAR or TF-CAS between October 1, 2016, and December 31, 2019, and were captured in the VISION database were included. Data were analyzed between January and June 2024.

Exposure

Type of carotid stenting (TCAR vs TF-CAS).

Main Outcomes and Measures

The primary outcomes were any stroke, including both periprocedural and during follow-up, defined using a validated claims code list, and death. Asymptomatic and symptomatic patients were analyzed separately. Kaplan-Meier analysis was used to calculate the cumulative incidence of the outcomes, and a multivariable Cox proportional hazards model was used to determine hazard ratios (HRs).

Results

There were 5798 asymptomatic patients (mean [SD] age, 74.6 [7.7] years; 3631 male [62.6%]; 3482 underwent TCAR; 2316 underwent TF-CAS) and 4721 symptomatic patients (mean [SD] age, 74.2 [8.3] years; 2969 male [62.9%]; 2377 underwent TCAR; 2344 underwent TF-CAS) who underwent carotid stenting. Patients who underwent TCAR were older, more likely to be female, and less likely to have had a prior ipsilateral carotid revascularization procedure. Among asymptomatic patients, the Kaplan-Meier 3-year risk of stroke was lower after TCAR (5.1%; 95% CI, 3.0%-7.1%) than TF-CAS (9.2%; 95% CI, 7.7%-10.7%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 22.6% (95% CI, 18.8%-26.3%), compared with 31.4% (95% CI, 28.3%-34.3%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR of stroke after TF-CAS among asymptomatic patients was 1.69 (95% CI, 1.25-2.28; P < .001). Among patients with symptomatic carotid stenosis, the 3-year stroke risk was also lower for TCAR (16.6%; 95% CI, 12.1%-20.9%) than for TF-CAS (20.9%; 95% CI, 17.5%-24.1%) (log-rank P < .001). The composite 3-year stroke or death risk after TCAR was 35.9% (95% CI, 30.1%-41.2%), compared with 41.5% (95% CI, 37.6%-45.1%) after TF-CAS (log-rank P < .001). Compared with TCAR, the adjusted HR for stroke after TF-CAS among symptomatic patients was 1.42 (95% CI, 1.17-1.73; P < .001). Sensitivity analyses yielded similar results.

Conclusions and Relevance

In this comparative effectiveness study, TCAR was associated with a lower risk of stroke than TF-CAS. This finding was consistent in both asymptomatic and symptomatic patients and durable over a 3-year interval. These findings can inform procedure choices for patients considering carotid artery stenting.

Best Medical Therapy for Asymptomatic Carotid Stenosis: Imminent or Ineffective?

Carotid artery disease accounts for approximately 20% of all ischemic strokes, a major cause of morbidity, and the fifth leading cause of death in the United States. Landmark trials in the 1990s, such as Asymptomatic Carotid Atherosclerosis Study and Asymptomatic Carotid Surgery Trial, establish carotid endarterectomy (CEA) plus best medical therapy (BMT) as the standard of care for patients with asymptomatic carotid stenosis over 60%. However, advances in medical therapy and the emergence of carotid artery stenting (CAS) have prompted a reevaluation of treatment efficacy. Recent studies have questioned the superiority of CEA over BMT alone in reducing stroke risk, suggesting no significant difference in outcomes with contemporary medical management. In addition, analysis from the U. S. Department of Veterans Affairs indicated minimal net benefit of CEA over BMT when accounting for all-cause mortality. Comparative studies have found no significant difference in long-term stroke-free survival between CEA and CAS. However, procedural risks vary, with higher myocardial infarction rates associated with CEA and higher stroke rates with CAS. Identifying high-risk plaques and patient-specific risk factors remains crucial. Meta-analyses have highlighted features such as neovascularization and lipid rich cores as predictors of stenosis progression and ischemic events. Ongoing research, particularly the CREST-2 trial, aims to provide clear guidance on the optimal treatment of asymptomatic carotid stenosis. This trial emphasizes stringent adherence to modern BMT protocols and includes comprehensive lifestyle modification programs. The evolving landscape of medical and surgical interventions necessitates continuous evaluation to optimize treatment strategies for asymptomatic carotid stenosis, which is the impetus for this review. Future findings from ongoing trials are expected to refine current guidelines and improve patient outcomes.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization.

METHODS

We conducted a retrospective review of the Society of Vascular Surgery Vascular Quality Initiative database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into 4 groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA; 2) patients who had a prior unilateral CAS followed by a contralateral CEA; 3) patients had a prior unilateral CAS followed by a contralateral CAS; and 4) patients had a prior unilateral CEA followed by a contralateral CAS. Univariate analysis (Pearson χ2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality.

RESULTS

A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the prior unilateral CAS followed by a contralateral CAS group, patients who underwent CEA followed by contralateral CAS (prior unilateral CEA followed by a contralateral CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P = 0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (odds ratio [OR] 0.42; 95% confidence interval 0.29-0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% confidence interval 0.49-0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for prior unilateral CEA followed by a contralateral CEA and prior unilateral CEA followed by a contralateral CAS groups.

CONCLUSIONS

Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

Association of same-day antiplatelet loading and outcomes after transcarotid artery revascularization

OBJECTIVE

Prior studies have emphasized the importance of compliance with preoperative dual antiplatelet therapy (DAPT) in patients undergoing transcarotid artery revascularization (TCAR). This investigation examines differences in perioperative outcomes after TCAR in those receiving a loading dose of antiplatelet medications on the day of the procedure vs those already maintained on DAPT.

METHODS

Consecutive TCAR procedures from the Vascular Quality Initiative (2016-2022) were identified. Patients were divided into (1) those on preoperative DAPT (aspirin and P2YI2 antagonist) taken at least within 36 hours of the procedure (61.9%); (2) those on at least one antiplatelet medication who received a supplemental dose of another antiplatelet within 4 hours before the procedure (AP + loading, 37.1%); and (3) patients receiving only a loading dose (of aspirin or P2Y12 antagonist) without prior use of antiplatelet therapy (1%). In-hospital and 30-day outcomes were compared between the three groups using univariable and multivariable analyses.

RESULTS

A total of 22,310 patients were on DAPT; 13,392 were on at least one antiplatelet and received a supplemental dose (AP + loading) and 361 patients received a loading dose on the day of the intervention. On univariable analysis, there was no significant difference in in-hospital or 30-day outcomes between the three groups, except for an increased rate of in-hospital stent thrombosis/occlusion in patients loaded with antiplatelet medications on the day of TCAR (n = 2 [0.6%]), compared with those maintained on DAPT (n = 23 [0.1%]) and patients in the AP + loading group (n = 26 [0.2%]) (P = .01). After adjusting for baseline differences between the three groups, no significant association was observed between the groups and in-hospital stroke/death or bleeding complications. However, compared with patients maintained on DAPT, patients receiving antiplatelet loading had higher odds of stent thrombosis/occlusion (odds ratio, 1.92; 95% confidence interval, 1.08-3.4; P = .03). Among patients in the AP + loading group, those maintained on aspirin preoperatively and receiving another antiplatelet loading on the day of the intervention were more likely to have stent thrombosis.

CONCLUSIONS

This study demonstrates that administering loading or supplemental doses of antiplatelet medication(s) to rapidly achieve therapeutic levels on the day of TCAR is not associated with higher rates of in-hospital stroke or bleeding complications. However, an increase in stent thrombosis or occlusion was noted in patients receiving a loading dose or supplementation of antiplatelet medications and warrants further investigation. In elective cases, it might be safer to delay intervention until patients receive adequate DAPT regimen, especially if patients are not maintained on P2Y12 inhibitors preoperatively.

Recurrent carotid artery stenosis successfully and safely treated with drug-coated balloon angioplasty under flow reversal

Carotid artery restenosis after index carotid artery revascularization reduces its stroke prevention benefit. A 73-year-old woman presented with recurrent right carotid artery restenosis following two carotid endarterectomies with patch angioplasty and in-sent restenosis after subsequent transcarotid artery revascularization. We performed in-stent paclitaxel-coated balloon angioplasty under flow reversal with resolution of the lesion on imaging and improvement in symptoms. Patient remains asymptomatic with no evidence of restenosis 16 months after treatment.

Comparison of restenosis and reintervention rates in closed cell stents compared to open cell stents after carotid artery stenting

OBJECTIVE

The aim of this study was to compare short- and mid-term outcomes after carotid artery stenting (CAS) related to stent configuration.

METHODS

This is a retrospective study of all CAS including transcarotid and transfemoral approaches, performed at our institution from 2015 to 2024. Groups were identified according to the stent used at the index procedure by open-cell stents (OCS) and closed-cell stents (CCS). Subgroup analysis by symptomatic status was also performed. Stroke, myocardial infarction (MI), and death were analyzed, including those occurring within 30 days of procedure and on last follow-up (14.5 ± 15.1 months). Restenosis and need for reintervention were also assessed.

RESULTS

Two hundred forty-six patients were included in our study cohort, with 128 OCS (Enroute stent [Silkroad Medical], 76; Protégé stent [Medtronic], 34; Precise stent [Cordis], 15; Acculink stent [Abbott], 3), and 118 CCS (Wallstent [Boston Scientific], 118). Baseline characteristics and comorbidities of the overall cohort showed differences in body mass index (CCS: 28.57 ± 6.19 kg/m2, OCS: 29.79 ± 5.98 kg/m2; P = .018) and symptomatic status (CCS: 78; 66.1%, OCS: 34; 26.6%; P < .001). In subgroup analysis within symptomatic and asymptomatic patients, these differences did not persist. Of note, in symptomatic patients, a higher rate of diabetics received CCS (33.3%) compared with OCS (14.7%; P = .043). Composite outcomes of stroke, MI, and death were no different at 30 days and on mid-term follow-up (14.5 ± 15.1 months). Only MI at follow-up in the overall cohort was significantly higher in the OCS group (4.7%) compared with CCS (0%; P = .03); however, this difference did not persist in subgroup analysis among symptomatic and asymptomatic patients. Restenosis (CCS: 16; 13.6%, OCS: 2; 1.6%; P < .001) and reinterventions (CCS: 13; 11%, OCS: 0; 0%; P < .001) were higher in the CCS group. Furthermore, this difference persisted for both outcomes in symptomatic and asymptomatic subgroup analysis. Multivariate analysis showed increased risk for restenosis in CCS (adjusted hazard ratio, 10.28; 95% confidence interval, 2.25-47.09; P = .003).

CONCLUSIONS

No difference in short- and mid-term outcomes was present in either CCS or OCS regarding stroke, MI, or death. On mid-term follow-up, CCS patients had a higher rate of restenosis and reintervention, and this difference persisted in both symptomatic and asymptomatic subgroups.

Lipidomic Expression Analysis in Carotid Atherosclerotic Disease: A Systematic Review

BACKGROUND

Lipids are key molecules for atherosclerosis, with tight regulation mechanisms, making them potential biomarkers for disease-specific diagnostics and therapeutics. Therefore, we aim to perform a systematic literature review on lipidomic analysis in serum/plasma and plaque samples of patients with carotid atherosclerosis.

METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on the lipidomic profile in serum/plasma and carotid artery plaques from patients with significant carotid disease by degree of stenosis in preoperative imaging and clinical presentation (symptomatic, asymptomatic, and radiation-induced carotid disease). Main outcome was the differential lipidomic expression of serum/plasma, and plaque lipids of patients with carotid artery atherosclerosis. Studies were screened using the Newcastle-Ottawa Scale to determine the quality of the design and content of the selected manuscripts.

RESULTS

We included fourteen studies, from which ten included plaque analysis. The lipidomic analysis revealed that sterols and hydroxycholesterols were consistently found in both blood and plaque across studies. Triacylglycerols were present in both sample types, with specific forms linked to radiation-induced carotid artery disease. Symptomatic patients exhibited esterified hydroxyeicosatetraenoic acids and arachidonic acid precursors exclusively in plaque with an inflammatory profile of the disease. In contrast, docosahexaenoic acid and eicosapentaenoic acid were associated with plaque stability. Diabetics showed nonesterified fatty acids and specific phospholipids only in plaque, indicating localized lipid changes. Other pathways relevant to disease progression include the sphingolipids and ceramide pathways with inflammatory profiling.

CONCLUSION

Lipidomic provides an innovative approach to stratify carotid atherosclerotic disease. Integrating lipidomic data with other -omics approaches may further enhance our understanding of disease mechanisms and aid in the development of precision medicine approaches, specifically in those patients at risk for early carotid atherosclerotic disease.

Ischemia targeted coronary revascularization improves 5-year survival following carotid endarterectomy

OBJECTIVES

Long-term survival after carotid endarterectomy (CEA) is limited by adverse cardiac events with 5% annual mortality. We sought to determine whether diagnosis of silent coronary ischemia together with elective ischemia-targeted coronary revascularization can reduce death and myocardial infarction (MI) and improve long-term survival of patients after CEA.

METHODS

Observational cohort study of patients with no cardiac history or coronary symptoms undergoing elective CEA. Patients enrolled in a prospective study of preoperative cardiac evaluation using coronary computed tomography-derived fractional flow reserve (FFRCT) to detect silent (asymptomatic) coronary ischemia together with elective postoperative ischemia-targeted coronary revascularization were compared with matched controls with standard preoperative cardiac evaluation and no elective coronary revascularization. Lesion-specific coronary ischemia was defined as an FFRCT of ≤0.80 distal to >30% stenosis with severe ischemia defined as an FFRCT of ≤0.75. End points included all-cause death, cardiac death, MI, stroke, and major adverse cardiovascular events (MACE) (defined as cardiovascular death, MI, or stroke) during 5 years of follow-up.

RESULTS

FFRCT (n = 100) and control (n = 100) cohorts were well-matched with no significant differences in age, gender, comorbidities, or indications for CEA. Asymptomatic lesion-specific coronary ischemia (FFRCT of ≤0.80) was present in 57% of FFRCT patients, with severe ischemia in 44% and left main ischemia in 7%; 43% had no coronary ischemia (FFRCT of >0.80). The status of coronary ischemia was unknown in the controls. CEA was performed successfully in both cohorts with no deaths or neurological events, and all patients received optimal postoperative medical therapy. Elective ischemia-targeted coronary revascularization was performed in 33% of FFRCT patients within 3 months of CEA. Controls had no elective coronary revascularization. During 5 years of follow-up, compared with controls, the FFRCT group had fewer all-cause deaths (11% vs 24%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.17-0.77; P = .016); fewer cardiac deaths (3% vs 13%; HR, 0.15; 95% CI, 0.03-0.69; P = .009); fewer MIs (3% vs 21%; HR, 0.07; 95% CI, 0.02-0.31; P < .001), and fewer MACEs (10% vs 33%; HR, 0.21; 95% CI, 0.10-0.44; P < .001) with no differences in stroke. There were no cardiac deaths or MIs among patients with no coronary ischemia (FFRCT of >0.80). Annual mortality in FFRCT was 2.2% per year compared with 4.8% per year in controls.

CONCLUSIONS

Diagnosis of silent coronary ischemia together with elective ischemia-targeted coronary revascularization after CEA decrease the 5-year risk of all-cause death, cardiac death, MI, and MACE by >50% and improved survival (89%) compared with patients receiving standard cardiac evaluation and care (76%).

Higher long-term mortality in patients with positive preoperative stress test undergoing elective carotid revascularization with carotid endarterectomy compared to transfemoral carotid artery stenting or transcarotid revascularization

OBJECTIVE

This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR).

METHODS

Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database who underwent elective carotid revascularization from 2016 to 2020 were included. Patients were analyzed by group based on whether they underwent cardiac stress testing within 2 years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or myocardial infarction [MI]). Outcomes of interest were postoperative MI/neurological events, 90-day readmission rates, and long-term mortality.

RESULTS

We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, and 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). Although comorbidities were significantly higher among patients undergoing CEA with a preoperative stress test compared with those without stress testing, the overall prevalence of comorbidities was higher among patients undergoing TF-CAS or TCAR, irrespective of preoperative stress test status. Compared with patients with a negative stress test, patients with a positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day readmission rates (CEA 19.6% vs 15.8% [P = .003]; CAS 33.3% vs 18.6% [P < .001]; TCAR 25% vs 17.5% [P = .04]). No group demonstrated a difference in the incidence of in-hospital postoperative neurological events or congestive heart failure, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital postoperative MI (1.7% vs 0.6%; P < .001). In 3-year follow-up, those with a positive compared with negative stress test were more likely to undergo coronary artery bypass graft/percutaneous coronary intervention in the CEA (adjusted hazard ratio [HR], 1.87 [95% confidence interval (CI), 1.42-2.27]; P < .0001) and CAS groups (adjusted HR, 3.89 [95% CI, 1.77-8.57]; P < .01), but not the TCAR cohort. Notably, those undergoing CEA with a positive compared with negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR, 1.28 [95% CI, 1.03-1.58]; P = .03) at 3 years. Conversely, those patients with a negative stress test compared with no stress test undergoing CEA experienced a 14% decrease in mortality at 3 years (adjusted HR, 0.86 [95% CI, 0.76-0.98]; P = .02); this mortality difference was not observed in similar stress test cohorts undergoing TF-CAS or TCAR.

CONCLUSIONS

Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be offered optimal medical management and/or stenting preferentially.

Medicare Patients with Symptomatic Carotid Disease Requiring Carotid Revascularization are Likely to Have Delayed Access: An Analysis of a Multicenter Surgical Data

BACKGROUND

The Society for Vascular Surgery guidelines recommend carotid revascularization within 14 days of symptom onset for neurologically stable stroke patients. However, in the United States, insurance status may affect surgical timing, although large-scale studies are lacking. Using the Vascular Quality Initiative database, we evaluated the impact of insurance status on surgical wait times for patients with symptomatic carotid disease.

METHODS

Symptomatic patients undergoing carotid revascularization from 2010 to 2022 with Modified Rankin score <2 were included. The primary outcome was time from symptom onset to intervention, with patients divided into timely or late cohort (LC) intervention groups (> 14 days). Categorical variables were compared using Chi-square test, and 1-way analysis of variance was used for continuous variables. Multivariable logistic regression assessed the association between insurance status and surgical wait time, adjusting for confounders.

RESULTS

There were 11,973 timely cohort and 21,253 LC patients. LC patients were older, less likely to undergo carotid endarterectomy, and more likely to have elective procedures. After adjusting for confounders, Medicare Advantage (adjusted odds ratio [aOR] 0.89, 95% confidence interval [CI] 0.80-0.99, P = 0.03), Commercial (aOR 0.84, 95% CI 0.78-0.90, P < 0.001), Military/Veterans Affairs (aOR 0.67, 95% CI 0.54-0.84, P < 0.001), and Self-Pay (aOR 0.54, 95% CI 0.45-0.65, P < 0.001) had lower odds of delayed carotid endarterectomy/carotid artery stenting compared to Medicare. Medicaid patients had similar odds to Medicare. Non-US insurance had higher odds (aOR 1.48, 95% CI 1.13-1.95, P = 0.005) compared to Medicare.

CONCLUSIONS

Medicare, Medicaid, and non-US insurance patients were more likely to experience surgical delays compared to those with Commercial, Military/Veterans Affairs, and Self-Pay coverage. Further research is needed to explore the causes and impacts of these delays.

Intraplaque Hemorrhage and Plaque Ulceration Are More Likely in Patients with Symptomatic Mild-to-Moderate Carotid Artery Stenosis than in Symptomatic and Asymptomatic High-Grade Stenosis: A Retrospective Cohort Study

BACKGROUND

To compare a cohort of symptomatic patients with mild-to-moderate (<70%) carotid artery stenosis (CAS) with those patients with high-grade (≥70%) CAS (symptomatic and asymptomatic) to assess for markers that places them at a higher risk for stroke.

METHODS

A propensity score-matched cohort study design for all patients who underwent carotid revascularization between 2015 and 2024 was utilized to compare the high-grade (≥70%) symptomatic and asymptomatic carotid stenosis groups against the mild to moderate (<70%) symptomatic carotid stenosis group. Matched variables included age, sex, and atrial fibrillation. Vulnerable plaque was defined as the presence of intraplaque hemorrhage, ulceration, lipid necrotic core, and inflammation on cross-sectional imaging. Images assessed included computed tomography angiography and magnetic resonance angiography with vessel wall imaging. Odds ratios (ORs) were then calculated to assess for risk of vulnerable features present on cross-sectional imaging before carotid intervention.

RESULTS

There were 58 patients in each cohort matched and analyzed. In our cohort of interest, there were fewer patients with diabetes and higher proportion of hyperlipidemia compared to those patients who were symptomatic with ≥70% CAS. Further, there were fewer patients with diabetes and none on dialysis compared to our asymptomatic high-grade stenosis group. The OR of presenting with vulnerable features in our mild-to-moderate stenosis symptomatic group was 5.85 (95% confidence interval (CI) 1.74-19.60, P = 0.002) compared to the high-grade asymptomatic stenosis patients and 7.52 (95% CI 3.22-17.66, P < 0.001) compared to the high-grade symptomatic stenosis patients. Additionally, the symptomatic <70% stenosis group had higher odds of intraplaque hemorrhage (OR 4.91, 95% CI 1.80-13.78, P < 0.001) and ulcerated plaque (OR 8.93, 95% CI 2.47-32.82, P < 0.001) compared to the asymptomatic ≥70% group, as well as increased odds of intraplaque hemorrhage (OR 4.14, 95% CI 1.59-10.74, P = 0.002) and ulcerated plaque (OR 5.16, 95% CI 1.77-15.03, P = 0.001) compared to the symptomatic ≥70% group. Composite outcomes of stroke, myocardial infarction, and death were no different in 30-day and mid-term follow-up.

CONCLUSION

High-risk plaque features on cross-sectional imaging studies may justify a short-term more aggressive medical management and/or early intervention in patients with mild-to-moderate CAS, even when luminal narrowing alone would not typically warrant such measures. As such, use of advanced imaging to assess for plaque characteristics may allow for improved risk stratification and guide earlier management of this patient population.

Preoperative smoking cessation improves carotid endarterectomy outcomes in asymptomatic carotid stenosis patients

OBJECTIVE

Smoking cessation has been suggested as having the potential to improve the outcomes of carotid endarterectomy (CEA) and mitigate the risk of long-term stroke in patients with asymptomatic carotid stenosis (ACS). This study aims to compare the perioperative and long-term outcomes of CEA in patients with ACS across different smoking status groups.

METHODS

All patients receiving an elective CEA for ACS between 2013 and 2023 were identified in the Vascular Quality Initiative (VQI). Patients with an ipsilateral carotid stenosis <70% and those receiving a concomitant coronary artery bypass graft were excluded. Patients were then classified according to their smoking status: never smokers, former smokers (defined as those who have stopped smoking more than 30 days prior to their operation), and current smokers. Patient characteristics and outcomes were compared using the χ2 or Fischer exact test as appropriate for categorical variables and the analysis of variance or Kruskal-Wallis test as appropriate for continuous variables. Cox regression analysis was used to study the association between smoking status and the primary outcomes of long-term stroke and major adverse cardiac events (MACE) defined as the composite outcome of stroke, myocardial infarction, and/or mortality.

RESULTS

A total of 77,664 patients received a CEA for ACS, of which 19,416 patients (25%) were never smokers, 39,374 patients (51%) were former smokers, and 18,874 patients (24%) were current smokers. Patients in the three groups had similar rates of perioperative stroke (P = .79), myocardial infarction (P = .07), mortality (P = .23), and MACE (P = .17). At 18-month follow-up, former and never smokers had similar rates of stroke (former 0.9% vs never 0.8%; P = .92), with former smokers exhibiting a lower stroke risk than current smokers (former 0.9% vs current 1.5%; P = .001). At 18 months, former smokers had a significantly lower rate of MACE compared with current smokers (former 11.8% vs current 13.2%; P = .03), but a higher rate compared with never smokers (former 11.8% vs never 8.7%; P < .001). On multivariate Cox regression analysis, compared with current smokers, former smokers were independently associated with a lower risk of stroke (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.53-0.87; P = .002), mortality (HR, 0.79; 95% CI, 0.74-0.84; P < .001), and MACE (HR, 0.77; 95% CI, 0.70-0.83; P < .001). No difference in long-term stroke risk was observed between former and never smokers (HR, 1.06; 95% CI, 0.82-1.38; P = .65).

CONCLUSIONS

This study demonstrates that preoperative smoking cessation in patients with ACS significantly reduces the risk of stroke, mortality, and MACE following CEA compared with continued smoking, aligning their outcomes more closely with those of never smokers. Optimizing patients with ACS prior to surgery should include smoking cessation counseling. Vascular surgeons play a critical role in encouraging smoking cessation, as their guidance can significantly improve patient outcomes following CEA.

Optimal Duration of Dual Antiplatelet Therapy After Carotid Artery Stenting: A Nationwide Cohort Study

BACKGROUND

Carotid artery stenting (CAS) is an alternative treatment for patients with carotid artery stenosis who are not eligible for carotid endarterectomy. Dual antiplatelet therapy (DAPT) after CAS aims to prevent ischemic stroke. However, its optimal duration remains unclear. We aimed to determine the optimal duration of DAPT by identifying the differences in clinical events that occur depending on the DAPT maintenance period.

METHODS

Data were obtained from the nationwide database of the Korean Health Insurance Review and Assessment Service between 2007 and 2019. Patients who received CAS, as identified by procedure codes, were divided into 2 groups according to the duration of DAPT (aspirin and clopidogrel): those who maintained DAPT for at least 90 days but for <6 months (short-DAPT group) and those who maintained it for longer (long-DAPT group). The primary outcome was a composite of ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage within 12 months of switching to single antiplatelet therapy. Statistical analyses used inverse probability of treatment weighting to balance baseline characteristics, with Cox regression and Fine and Gray competing risk models used to assess outcomes.

RESULTS

Of the 12 034 patients who underwent CAS, 2529 and 9505 were assigned to the short-DAPT and long-DAPT groups, respectively. In the short-DAPT group, ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage occurred in 41 (1.6%), 22 (0.9%), and 4 (0.2%) patients, respectively. In the long-DAPT group, ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage occurred in 108 (1.1%), 87 (0.9%), and 4 (0.04%) patients, respectively. The primary outcome did not differ significantly between the groups (2.5% versus 2.1%; adjusted hazard ratio of long-DAPT to short-DAPT, 0.869 [95% CI, 0.652-1.158]; P=0.337).

CONCLUSIONS

Short-duration DAPT can be recommended, as it does not differ from long-duration DAPT in terms of clinical efficacy and adverse events after CAS.

Neuro-ophthalmic outcomes after carotid intervention for ocular symptoms

BACKGROUND

The long-term neuro-ophthalmic outcomes after carotid intervention in patients presenting with preoperative visual symptoms vary widely based on the underlying etiology of retinal ischemia and are not well understood.

METHODS

We performed a retrospective review of consecutive patients presenting with retinal ischemia who subsequently underwent carotid intervention from January 2018 to December 2022. Patients were classified into three groups (group I: amaurosis fugax/vascular transient monocular vision loss, group II: ocular ischemic syndrome [OIS], and group III: central/branch retinal artery occlusion). Clinical details and the nature of visual symptoms were recorded. Outcomes analyzed were ipsilateral symptom recurrence, visual improvement, stroke rate, and survival.

RESULTS

A total of 90 patients were included in this study (70 male, aged 75 ± 9 years): 31 patients (34%) in group I (amaurosis fugax), 7 patients (8%) in group II (OIS), and 52 patients (58%) in group III central/branch retinal artery occlusion. Atherosclerotic risk factors were similar across groups with similar preoperative antiplatelet and statin use. Interventions performed were carotid endarterectomy in 64 (71%), transfemoral carotid artery stenting in 21 (23%), transcarotid artery revascularization in 4 (4%), and carotid artery bypass in 1 patient (1%). The median follow-up was 38.5 months (range: 0-207 months). There was no recurrence of transient or permanent retinal ischemic events in any patient in group I. In group II, 5 of 7 patients presenting with transient symptoms of OIS showed resolution of symptoms and ocular signs. Two patients presenting with permanent vision loss in group II had no improvement but no worsening symptoms, and visual decline was reported in two patients in group III. Ipsilateral stroke rate was 2% at 5 years for the entire group. Survival was 93% and 82% at 1 and 5 years, respectively, with no difference between groups (P < .05). There was one postoperative death from ischemic stroke secondary to stent thrombosis within 30 days (group III), with no long-term mortality from cerebrovascular disease in the rest of the cohort.

CONCLUSIONS

Neuro-ophthalmic outcomes after carotid intervention for visual symptoms are favorable with low symptomatic recurrence after both carotid endarterectomy and carotid artery stenting. Intervention for OIS when detected early (with transient symptoms) is associated with resolution of symptoms and prevention of permanent visual loss.

Long-term Impact of Carotid Endarterectomy on Choroidal and Choriocapillaris Perfusion: The INFLATE Study

Purpose

When performed for clinically significant carotid artery stenosis (CAS), the long-term impact of carotid endarterectomy (CEA) on choroidal and choriocapillaris (CC) circulation was studied using swept-source OCT angiography.

Design

Prospective observational study.

Participants

Patients with clinically significant CAS undergoing unilateral CEA.

Methods

Swept-source OCT angiography scans were performed on both eyes at baseline (before CEA), within 1 week post-CEA (short-term follow-up [FU]), and ≥30 days post-CEA (long-term FU). Using validated algorithms, we measured mean choroidal thickness (MCT), choroidal vascularity index (CVI), choroidal vessel volume (CVV), CC flow deficit percentage (CC FD%), and CC thickness within the 5-mm circle centered on the fovea for both the eye ipsilateral to CEA (surgical side) and the contralateral eye (nonsurgical side). Multivariable regression analysis was conducted to evaluate the impact of baseline demographic and clinical factors on the changes in choroidal and CC parameters.

Main Outcome Measures

Both the short- and long-term changes in MCT, CVI, CVV, CC FD%, and CC thickness.

Results

The study included 58 eyes from 29 patients. Significant short-term improvements in MCT (P < 0.001) and CC thickness (P = 0.006) were observed post-CEA on the surgical side. Long-term FU showed sustained increases in MCT compared with baseline (P = 0.02), while CC thickness was not significantly different from baseline (P = 0.10). The CVI did not change significantly from baseline at either short-term (P = 0.45) or long-term (P = 0.22) FU on the surgical side. While CVV demonstrated a short-term rise immediately post-CEA (P < 0.001), the difference was not statistically significant at the long-term evaluation (P = 0.06). No significant improvement in CC FD% from baseline was observed at any visit post-CEA (short-term P = 0.81, long-term P = 0.91). The nonsurgical side only showed a significant reduction in CVI at the long-term FU visit compared with before CEA (P = 0.01). Clinical variables such as age, degree of stenosis, diabetes, hypertension, and smoking status did not greatly impact the outcomes.

Conclusions

Unilateral CEA demonstrated a sustained increase in MCT, suggesting persistent improvements in choroidal perfusion in the ipsilateral eye.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The value of contrast-enhanced ultrasound in assessing carotid plaque vulnerability and predicting stroke risk

The presence of vulnerable carotid plaques plays a critical role in ischemic stroke pathogenesis, with intraplaque neovascularization (IPN) serving as a key indicator of plaque instability. Contrast-enhanced ultrasound (CEUS) provides a comprehensive evaluation of both plaque surface morphology and microvascular features. This study assesses the utility of CEUS in identifying vulnerable carotid plaques, quantifying IPN, and predicting stroke risk. The study involved 91 patients with carotid stenosis who underwent carotid endarterectomy (CEA). Preoperative assessments included CEUS and high-resolution magnetic resonance imaging (HR-MRI). Following surgery, plaque samples were collected and subjected to pathological analysis. CEUS offered comprehensive morphological insights, categorizing plaques by the direction of diffusion into inside-out and non-inside-out types. Neovascularization was semi-quantitatively evaluated using CEUS. HR-MRI and pathological assessments identified the composition and vulnerability of plaques. Microvessel density (MVD), microvessel area (MVA), and microvessel ratio (MVR) in plaque sections were quantified using high-power microscopy. Among the 91 subjects, 53 had a history of symptomatic stroke, while 38 had experienced asymptomatic stroke events. The analysis identified a significant association between symptomatic stroke events and fibrous cap rupture (FCR), as indicated by CEUS (P = 0.032), contrast agent diffusion within the plaque (P = 0.002), and a semi-quantitative grade 3 neovascularization (P = 0.007). Regression analysis further established CEUS grade 3 as an independent predictor of symptomatic stroke events (OR = 3.39, 95% CI: 1.25-9.19). CEUS showed comparable sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in identifying vulnerable plaques when compared to HR-MRI, with slightly superior values for CEUS; however, the differences did not reach statistical significance (P = 0.503). Plaques demonstrating inside-out contrast agent diffusion had a markedly higher incidence of FCR and intraplaque hemorrhage (IPH) than those without such diffusion (P < 0.001). A positive correlation existed between the CEUS grade and both MVD and MVR (P < 0.001), but no significant relationship was observed with MVA (P = 0.221). Additionally, a significant association was found between the CEUS grade and IPH (P = 0.008). In summary, this study emphasizes the utility of CEUS in identifying vulnerable carotid plaques and evaluating neovascularization, both of which correlate with stroke risk. Notably, a CEUS grade 3 score may serve as an independent predictor of symptomatic stroke. This evidence supports the potential of CEUS as an effective, non-invasive method for assessing carotid plaque instability and identifying individuals at elevated risk for stroke.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

CAS-OPCABG vs OPCABG-alone in patients with asymptomatic carotid Stenosis: Multi-center experience

Objective

The objective was to evaluate the relationship between carotid stenting and off-pump coronary artery grafting (CAS-OPCABG) and OPCABG only in patients with asymptomatic severe carotid stenosis.

Methods

This study retrospectively included 669 patients with asymptomatic severe carotid artery stenosis who underwent OPCABG at multiple centers. After propensity score matching for baseline characteristics, the study compared two groups of patients with clinical data, early and midterm death, stroke, and myocardial infarction (MI).

Results

After matching, there was no significant difference between two groups at baseline. The rates of early stroke, midterm stroke, and intensive care unit (ICU) stay were significantly lower in the CAS OPCABG group, yet the use of the internal mammary artery (IMA) was comparatively lower. Kaplan-Meier analysis revealed that there was no significant difference in midterm mortality between two groups. In the bilateral asymptomatic carotid stenosis subgroup, the early stroke rate was significantly lower after CAS-OPCABG, but there was no significant difference in the unilateral carotid stenosis subgroup. Multivariate logistic regression analysis identified previous atrial fibrillation, previous stroke, aortic atherosclerosis, bilateral carotid stenosis and the use of an intra-aortic balloon pump (IABP) as significant risk factors for early postoperative stroke, CAS emerged as a protective factor. Use of IMA was found to be a protective factor against postoperative mortality.

Conclusions

CAS-OPCABG is an efficacious and safe approach for the treatment of asymptomatic severe carotid artery stenosis, effectively decreasing the incidence of postoperative stroke.

Generative artificial intelligence chatbots may provide appropriate informational responses to common vascular surgery questions by patients

OBJECTIVES

Generative artificial intelligence (AI) has emerged as a promising tool to engage with patients. The objective of this study was to assess the quality of AI responses to common patient questions regarding vascular surgery disease processes.

METHODS

OpenAI's ChatGPT-3.5 and Google Bard were queried with 24 mock patient questions spanning seven vascular surgery disease domains. Six experienced vascular surgery faculty at a tertiary academic center independently graded AI responses on their accuracy (rated 1-4 from completely inaccurate to completely accurate), completeness (rated 1-4 from totally incomplete to totally complete), and appropriateness (binary). Responses were also evaluated with three readability scales.

RESULTS

ChatGPT responses were rated, on average, more accurate than Bard responses (3.08 ± 0.33 vs 2.82 ± 0.40, p < .01). ChatGPT responses were scored, on average, more complete than Bard responses (2.98 ± 0.34 vs 2.62 ± 0.36, p < .01). Most ChatGPT responses (75.0%, n = 18) and almost half of Bard responses (45.8%, n = 11) were unanimously deemed appropriate. Almost one-third of Bard responses (29.2%, n = 7) were deemed inappropriate by at least two reviewers (29.2%), and two Bard responses (8.4%) were considered inappropriate by the majority. The mean Flesch Reading Ease, Flesch-Kincaid Grade Level, and Gunning Fog Index of ChatGPT responses were 29.4 ± 10.8, 14.5 ± 2.2, and 17.7 ± 3.1, respectively, indicating that responses were readable with a post-secondary education. Bard's mean readability scores were 58.9 ± 10.5, 8.2 ± 1.7, and 11.0 ± 2.0, respectively, indicating that responses were readable with a high-school education (p < .0001 for three metrics). ChatGPT's mean response length (332 ± 79 words) was higher than Bard's mean response length (183 ± 53 words, p < .001). There was no difference in the accuracy, completeness, readability, or response length of ChatGPT or Bard between disease domains (p > .05 for all analyses).

CONCLUSIONS

AI offers a novel means of educating patients that avoids the inundation of information from "Dr Google" and the time barriers of physician-patient encounters. ChatGPT provides largely valid, though imperfect, responses to myriad patient questions at the expense of readability. While Bard responses are more readable and concise, their quality is poorer. Further research is warranted to better understand failure points for large language models in vascular surgery patient education.

[What is new in the management of peripheral arterial occlusive disease and diseases of the aorta? : Highlights of the ESC guidelines 2024]

The European Society of Cardiology (ESC) guidelines on peripheral arterial disease (PAD) and diseases of the aorta published in September 2024 for the first time combine recommendations for both diseases in a joint guideline document. The consolidation of PAD and aorta guidelines follows a holistic approach, which underlines the entirety of the arterial vascular system. This aim is underlined by a specifically introduced recommendation to take the entirety of the circulatory system into account in patients with vascular diseases. The focus in the current ESC guideline document is on a multidisciplinary, patient-centered management of PAD and diseases of the aorta, whereby the prevention and follow-up of patients after therapeutic interventions are emphasized. In PAD the document highlights exercise training and the procedure for patients with chronic wounds as well as risk stratification and hereditary diseases of the aorta.

Outcome of primary closure following carotid endarterectomy with a novel technique: An 8-year multicenter cohort study

This study evaluated the safety and efficacy of a novel primary closure technique in carotid endarterectomy compared with traditional methods. Conducted over 8 years at three university hospitals, this study included 184 patients. Early complications (8.7%) included hematoma, transient ischemic attack, myocardial infarction, stroke, and death. Late complications involved myocardial infarction, death, transient ischemic attack, stroke, and reintervention. The 1-year follow-up showed a significant (>70%) restenosis rate of only 1.9%. The novel technique in carotid endarterectomy seems to be a safe and effective alternative to patch angioplasty, offering advantages for selected patients. Further studies are required.

Using machine learning to predict outcomes following transcarotid artery revascularization

Transcarotid artery revascularization (TCAR) is a relatively new and technically challenging procedure that carries a non-negligible risk of complications. Risk prediction tools may help guide clinical decision-making but remain limited. We developed machine learning (ML) algorithms that predict 1-year outcomes following TCAR. The Vascular Quality Initiative (VQI) database was used to identify patients who underwent TCAR between 2016 and 2023. We identified 115 features from the index hospitalization (82 pre-operative [demographic/clinical], 14 intra-operative [procedural], and 19 post-operative [in-hospital course/complications]). The primary outcome was 1-year post-procedural stroke or death. The data was divided into training (70%) and test (30%) sets. Six ML models were trained using pre-operative features with tenfold cross-validation. Overall, 38,325 patients were included (mean age 73.1 [SD 9.0] years, 14,248 [37.2%] female) and 2,672 (7.0%) developed 1-year stroke or death. The best pre-operative prediction model was XGBoost, achieving an AUROC of 0.91 (95% CI 0.90-0.92). In comparison, logistic regression had an AUROC of 0.68 (95% CI 0.66-0.70). The XGBoost model maintained excellent performance at the intra- and post-operative stages, with AUROC's (95% CI's) of 0.92 (0.91-0.93) and 0.94 (0.93-0.95), respectively. Our ML algorithm has potential for important utility in guiding peri-operative risk-mitigation strategies to prevent adverse outcomes following TCAR.

Carotid artery stenosis and ischemic cerebrovascular events after radiotherapy in patients with head and neck cancer

Radiotherapy is the main treatment for patients with head and neck cancer (HNC) and is associated with an increased risk of ischemic cerebrovascular events (ICVE). The purpose of this cross-sectional study was to determine the incidence of ICVE and carotid artery stenosis (CAS) in patients with HNC who receive radiotherapy and the risk factors for CAS. We enrolled 907 patients with HNC who underwent radiotherapy between February 2011 and June 2022 and obtained information on their clinical and tumor characteristics and their treatment from the clinical records. Data on risk factors for atherosclerosis, medications used, and radiotherapy were also collected. The patients were followed through to the end of 2023 unless they died or were lost to follow-up. The overall incidence of ICVE was 1.98%, with a cumulative incidence of 1.65% over 5 years. In patients who did not have a preexisting carotid artery lesion, the cumulative incidence of significant CAS was 1.3% at 12 months, 2.2% at 24 months, and 2.5% at 36 months post-radiotherapy. The most important risk factors for new CAS were age >65 years (aHR = 2.60, p = 0.008, 95% confidence Interval: 1.28-5.30), laryngeal cancer (aHR = 2.36, p<0.017, 95% confidence Interval: 1.01-5.55), and total plaque score (aHR = 1.38, p<0.001, 95% confidence Interval: 1.23-1.56). There was a significant increase in stenosis, plaque score, and wall thickness in all areas in the carotid artery (p<0.001). The incidence of ICVE and the cumulative incidence of CAS was found to be lower in the Thai population than in other populations. The main risk factors for new CAS were age >65 years, laryngeal cancer, and total plaque score. Changes in the carotid artery were detected early and affected all areas in the artery. Patients with HNC treated by radiotherapy should be assessed for risk factors for CAS and undergo vascular surveillance during follow-up.

Immunoglobulin G N-glycan markers of mild cognitive impairment in a Chinese population with cerebrovascular stenosis: A case-control study

BACKGROUND

Immunoglobulin G (IgG) N-glycans have been shown to regulate the inflammatory response in the context of disease. In recent years, it has been found to be associated with several neurodegenerative disorders. In this study, we examined the relationship between IgG N-glycans and mild cognitive impairment (MCI) in a high-risk population for MCI, specifically patients with cerebrovascular stenosis.

METHODS

In a case-control study, we investigated IgG N-glycans and cytokines in MCI and non-MCI patients in a population with cerebrovascular stenosis. A multifactorial logistic regression analysis was employed to investigate the potential association between IgG N-glycoprotein and MCI, with familial error rates being corrected for using the Benjamin-Hochberg method. To construct discriminatory models, logistic stepwise regression was employed and evaluated for their diagnostic efficacy.

RESULTS

A statistically significant difference was found in eight of the IgG-GPs between the two groups. Three IgG-GPs were correlated with MCI, with an overall false discovery rate <0.05. Specifically, IgG-GP7 (non-sialylated glycan) was positively correlated with MCI, while IgG-GP14 (digalactosylated glycans) and IgG-GP18 (bis-sialylated glycan) were negatively correlated with MCI. The model constructed by combining IgG N-glycans (IgG-GP7, IgG-GP14, IgG-GP18) and cytokines (IL-1β, IL-10, BDNF and VEGF) demonstrated the highest diagnostic efficacy [AUC: 0.939, 95 % CI: (0.910-0.967)].

DISCUSSION

In the present study, we observed that agalactosylation and no-sialylation play a role in the progression of MCI by influencing the pro-inflammatory impact of IgG. The integration of IgG N-glycan and cytokines into a discriminative model demonstrated strong diagnostic efficacy, suggesting its potential use as a screening tool for early prediction of MCI in patients with cerebrovascular stenosis.