Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis

Contemporary carotid artery stenting practices and peri-procedural outcomes in different European countries: ROADSAVER study multicentric insights

BACKGROUND

Regional variations in patient selection and procedural techniques for carotid artery stenting have been well documented. However, their impact on procedural outcomes, especially with the use of dual-layer micromesh stents, is not fully understood.

METHODS

This prospective, multi-center observational study included 1965 patients with asymptomatic or symptomatic carotid artery stenosis treated with the Roadsaver dual-layer micromesh stent. The primary outcome measure was the 30-day rate of major adverse events, defined as any death or stroke occurring within 30 days post-procedure. This sub-analysis compared patient characteristics and procedural techniques across 13 participating countries and investigated differences in outcomes via logistic regression modelling.

RESULTS

Patient demographics, comorbidities, and symptom presentation varied widely among countries. Similarly, the frequency of use of duplex ultrasound and diffusion-weighted magnetic resonance imaging at baseline and 30-day follow-up differed. Procedural approaches also varied, with differences in femoral access site selection (18.2% to 100.0%), use of embolic protection devices (0.0% to 100.0%), pre-dilatation (4.3% to 46.7%) and post-dilatation (66.7% to 100.0%). Although 30-day major adverse event rates differed across the compared countries, after adjusting for post-dilatation balloon pressure (categorized as no post-dilatation vs. ≤ 11atm vs. > 11atm), and the number of enrolled patients per study site, the difference became statistically non-significant.

CONCLUSION

Our study reveals variability in patient selection, procedural carotid stenting practices and clinical outcomes across European countries. The differences in 30-day any death or stroke rates between countries may be attributed to differing post-dilatation practices and the number of enrolled patients per study site.

LEVEL OF EVIDENCE

Level 3, observational study.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03504228.

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.

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.

Photon-Counting CT: Technology, Current and Potential Future Clinical Applications, and Overview of Approved Systems and Those in Various Stages of Research and Development

Photon-counting CT (PCCT) has emerged as a transformative technology, with the potential to herald a new era of clinical capabilities. This review provides an overview of the current status and potential future developments of PCCT, including basic physics principles and technical implementation by different vendors, with special attention to applications that have not, to date, been emphasized in the literature. The technologic underpinnings that distinguish PCCT scanners from traditional energy-integrating detector (EID) CT scanners with dual-energy capability are discussed. The inherent challenges of PCCT and the innovative breakthroughs that have enabled key PCCT features, such as enhanced image resolution, material discrimination, and radiation dose efficiency, are reviewed. Two categories of clinical applications are considered: (a) applications that are possible with current-generation EID CT but may be improved with the higher spatial, temporal, and contrast resolution of PCCT (eg, CT angiographic vasculitis imaging with high spatial, contrast, and temporal resolution and ultra-high-spatial-resolution "opportunistic" osseous imaging) and (b) potential future applications that are not currently feasible with EID CT but that may become possible and practical with PCCT (eg, reduced need for serial follow-up imaging with advanced CT or MRI because of more complete, definitive imaging evaluation with PCCT at first presentation).

One year outcomes following of carotid endarterectomy in different age groups: Russian multicenter study

Introduction

This is a retrospective analysis of the results of carotid endarterectomy (CEA) in different age groups.

Methods

This cohort, comparative, retrospective, open-label study for the period from 2008 to 2020 included 7248 patients with hemodynamically significant stenoses of the internal carotid artery (ICA), who underwent CEA. According to the classification of the World Health Organization, patients were divided into groups depending on age: up to 44 years-young age (n = 84); 45-60 years-middle age (n = 1635); 61-75-elderly age (n = 4817); over 75 years-senile age (n = 712).

Results

In terms of the frequency of hospital complications, the group of patients over 75 years of age experienced the largest number of cardiovascular events. One year after surgery, there were no significant differences in the incidence of complications between groups: death (group 1, 1.2%; group 2, 0.5%; group 3, 0.4%; group 4, 1%; p = 0.14), myocardial infarction (group 1, 1.2%; group 2, 0.3%; group 3, 0.14%; group 4, 0.3%; p = 0.12), stroke (group 1, 0%; group 2, 0.3%; group 3, 0.1%; group 4, 0.4%; p = 0.32).

Conclusion

The largest number of adverse cardiovascular events after CEA are observed among patients over 75 years of age, which is due to the high frequency of multivessel coronary lesions, atrial fibrillation, and the severity of the comorbidities. One year after surgery, there were no significant differences in the incidence of complications between groups.

Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis

This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.