Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association

Measuring pulsatile cortical blood flow and volume during carotid endarterectomy

Carotid endarterectomy (CEA) involves removal of plaque in the carotid artery to reduce the risk of stroke and improve cerebral perfusion. This study aimed to investigate the utility of assessing pulsatile blood volume and flow during CEA. Using a combined near-infrared spectroscopy/diffuse correlation spectroscopy instrument, pulsatile hemodynamics were assessed in 12 patients undergoing CEA. Alterations to pulsatile amplitude, pulse transit time, and beat morphology were observed in measurements ipsilateral to the surgical side. The additional information provided through analysis of pulsatile hemodynamic signals has the potential to enable the discovery of non-invasive biomarkers related to cortical perfusion.

Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting

OBJECTIVE

It is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort.

METHODS

Data were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events.

RESULTS

A total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001).

CONCLUSIONS

Patients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

Midterm outcomes of simultaneous carotid revascularization combined with coronary artery bypass grafting

BACKGROUND

Simultaneous carotid endarterectomy (CEA) combined with coronary artery bypass grafting (CABG) has been widely used in patients with coronary heart disease complicated with severe carotid stenosis to reduce the risk of stroke and death. Carotid artery stenting (CAS) has been proven to be an alternative to CEA in recent years. We investigated the early and mid-term outcomes of simultaneous CEA or CAS combined with CABG in these patients.

METHODS

From January 2011 to January 2021, 88 patients who underwent simultaneous carotid revascularization combined with CABG under the same anesthesia in Beijing Anzhen Hospital were retrospectively analyzed, and this study included 25 patients who underwent CAS-CABG and 63 patients who underwent CEA-CABG. The main outcomes included all-cause death, stroke, myocardial infarction and combined adverse events. The main outcomes of the two groups were compared at 30 days after the operation and the mid-term follow-up. Univariate and multivariate Cox proportional hazards regression analyses were performed to determine the independent risk factors affecting mid-term mortality.

RESULTS

Within 30 days after the operation, there was no significant difference in combined adverse events between the two groups (P = 0.88). During the median follow-up period of 6.69 years (IQR, 5.82-7.57 years), 9 patients (14.30%) in the combined CEA-CABG group died, while 1 patient (4.00%) in the combined CAS-CABG group died. There were no significant differences in mid-term death (P = 0.20), stroke (P = 0.78), myocardial infarction (P = 0.88), or combined adverse events (P = 0.62) between the two groups. Univariate and multivariate Cox proportional hazards regression showed that NYHA grade IV (HR 5.01, 95% CI 1.16-21.64, P = 0.03) and previous myocardial infarction (HR 5.43, 95% CI 1.01-29.29, p = 0.04) were independent risk factors for mid-term mortality. We also found that combined CEA-CABG surgery may be associated with a higher risk of death (HR, 13.15; 95% CI 1.10-157.69, p = 0.04).

CONCLUSIONS

Combined CAS-CABG is a safe and effective treatment for patients with coronary heart disease complicated with severe carotid stenosis. NYHA grade IV and previous MI were independent risk factors for mid-term mortality.

A systematic review and meta-analysis of combined carotid endarterectomy with ipsilateral proximal intervention (hybrid approach) for tandem carotid artery lesions

OBJECTIVE

The safety and effectiveness of using the hybrid approach to treat tandem carotid lesions is controversial, and the clinical significance of the technical variants on the perioperative outcomes has not been evaluated. The present meta-analysis was performed to evaluate the technique, safety, effectiveness, and long-term outcomes of the hybrid approach.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched to identify studies from January 1, 1996 to January 11, 2020. The baseline patient characteristics, comorbidities, procedural details, and perioperative and long-term outcomes were collected and analyzed. A pooled overall survival curve was drawn. Univariate analysis was performed to compare the perioperative stroke risk between subgroups.

RESULTS

Overall, 275 patients (mean age, 66.94 years) from 15 studies were included. All the patients had presented with tandem stenosis of ≥50%, and 67.2% were symptomatic. The overall technical success rate was 99.8% (95% confidence interval [CI], 98.0%-100.0%). The pooled perioperative complications rates were as follows: death, 1.5% (95% CI, 0.0%-2.9%); stroke, 2.6% (95% CI, 0.7%-4.4%); combined stroke/death, 3.3% (95% CI, 1.2%-5.4%); and myocardial infarction, 3.2% (95% CI, 0.7%-9.1%). The overall primary patency rates were 99.2% (95% CI, 96.0%-100.0%) and 88.2% (95% CI, 78.8%-95.4%) at 1 and 2 years, respectively. Reintervention was performed in 6.6% of the patients (95% CI, 3.0%-11.2%). The pooled overall survival rates were 89.9% (95% CI, 83.7%-96.7%), 83.7% (95% CI, 75.9%-92.2%), and 75.9% (95% CI, 66.5%-86.7%) at 1, 3, and 5 years, respectively. Operations in which carotid endarterectomy was performed first carried a significantly greater risk of perioperative stroke compared with those in which proximal intervention had been performed first (5.7% vs 0.0%; P = .01). No difference was found in perioperative stroke risk between the subgroups of baseline symptomatic status (asymptomatic, 5.1%; symptomatic, 1.9%; P = .32), preoperative antiplatelet therapy (dual, 3.6%; single, 5.8%; P = .79), and carotid clamping during intervention (clamping, 2.8%; unclamping, 6.3%; P = .40).

CONCLUSIONS

For patients with a presumed high risk of neurologic events because of carotid tandem lesions, the hybrid approach could be considered a reasonable option with high technical success and acceptable perioperative and long-term results. Performing carotid artery stenting before carotid endarterectomy and administering perioperative dual antiplatelet therapy should be considered to promote technical success and better outcomes. Prospective and randomized controlled studies are needed to confirm the results and provide recommendations on patient selection for the hybrid approach.

Perioperative Stroke

PURPOSE OF REVIEW

This review overviews perioperative stroke as it pertains to specific surgical procedures.

RECENT FINDINGS

As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.

Is Peripheral Artery Disease an Independent Predictor of Isolated Coronary Artery Bypass Outcome?

AIM

The aim was to use a propensity score-based analysis to determine the impact of peripheral artery disease (PAD) on early outcomes after coronary artery bypass surgery grafting (CABG) in patients with PAD.

METHOD

We conducted a multicentre retrospective analysis of 11,311 consecutive patients who underwent CABG between 1997 and 2017. Patients with previous or concomitant vascular surgery were excluded. The main endpoints were death, stroke, and limb ischaemia requiring percutaneous or surgical revascularisation. Subgroup analyses were performed to test the interaction of PAD with concomitant factors.

RESULTS

There was no difference in mortality in patients with and without PAD (p=0.06 and p=0.179, respectively). Patients with PAD had a greater incidence of stroke (p=0.04), acute kidney disease (p=0.003), and limb ischaemia requiring interventions (p<0.001) than those without PAD. The use of off-pump or no-touch aortic techniques did not influence the effect of PAD on the outcomes. Early mortality rate increased in patients with PAD when associated with long cardiopulmonary bypass, cross-clamp times (both p<0.001), and postoperative low cardiac output (p=0.01).

CONCLUSIONS

The presence of PAD is associated, independently of other factors, with greater incidence of stroke, acute kidney disease, and limb ischaemia following CABG, irrespective of the technique employed. Operative mortality was greater in patients with PAD only when associated with long cardiopulmonary bypass and aortic cross-clamp times, and low cardiac output.

Combined spatiotemporal and frequency-dependent shear wave elastography enables detection of vulnerable carotid plaques as validated by MRI

Fatal cerebrovascular events are often caused by rupture of atherosclerotic plaques. However, rupture-prone plaques are often distinguished by their internal composition rather than degree of luminal narrowing, and conventional imaging techniques might thus fail to detect such culprit lesions. In this feasibility study, we investigate the potential of ultrasound shear wave elastography (SWE) to detect vulnerable carotid plaques, evaluating group velocity and frequency-dependent phase velocities as novel biomarkers for plaque vulnerability. In total, 27 carotid plaques from 20 patients were scanned by ultrasound SWE and magnetic resonance imaging (MRI). SWE output was quantified as group velocity and frequency-dependent phase velocities, respectively, with results correlated to intraplaque constituents identified by MRI. Overall, vulnerable lesions graded as American Heart Association (AHA) type VI showed significantly higher group and phase velocity compared to any other AHA type. A selection of correlations with intraplaque components could also be identified with group and phase velocity (lipid-rich necrotic core content, fibrous cap structure, intraplaque hemorrhage), complementing the clinical lesion classification. In conclusion, we demonstrate the ability to detect vulnerable carotid plaques using combined SWE, with group velocity and frequency-dependent phase velocity providing potentially complementary information on plaque characteristics. With such, the method represents a promising non-invasive approach for refined atherosclerotic risk prediction.

The SAPPHIRE criteria, history of myocardial infarction and diabetes predict adverse outcomes following carotid endarterectomy similar to stenting

Aims

Identifying factors associated with worse outcome following carotid endarterectomy (CEA) is important to improve prevention of major adverse cardiovascular and cerebrovascular events (MACCE), yet rarely used for registries. We intended to identify predictors of MACCE following CEA as recently analysed for stenting.

Methods and results

Patients undergoing CEA at 2 centers over 13 years were entered into a database. Baseline clinical characteristics, procedural factors and a panel of clinical and lesion-related high-risk features (SHR) and exclusion criteria (SE), empirically compiled for stratification in the SAPPHIRE trial, were differentially analysed using Cox regressions. The analysis included 748 operations; 262 (35%) asymptomatic, 208 (28%) with previous strokes, and 278 (37%) with transient ischemic attacks (TIA). The overall 30-day MACCE rate was 6.7%, 5.0% in asymptomatic and 7.6% in symptomatic patients. Previous MI (HR 2.045, p = 0.022), diabetes (HR 2.111, p = 0.011) and symptomatic patients (HR 2.045, p = 0.044) were independently associated with MACCE. SE patients (n = 81) had a MACCE rate of 13.6%; the MACCE rate of the remainder dropped to 5.8% (4.7% in asymptomatic and 6.5% in symptomatic patients). Hazard ratio for SHR patients was 2.069 (CI 1.087–3.941) and 2.389 for SE (CI 1.223–4.666), each compared to all patients with lower risk and adjusted for symptomatic status. Among SHR and SE criteria NYHA 3–4, contralateral occlusions and intraluminal thrombus were significant determinants and MI < 4 weeks before CEA showed a strong trend (p = 0.05).

Conclusion

Patients identified by SHR and SE criteria, prior MI and diabetes warrant increased attention to prevent MACCE following CEA.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01546-3) contains supplementary material, which is available to authorized users.

Biomarker Profiling of Neurovascular Diseases in Patients with Stage 5 Chronic Kidney Disease

Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk of developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD) are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Eleven plasma biomarker levels in patients with CKD5D (n = 97) and healthy controls (n = 17-50) were measured using sandwich enzyme-linked immunosorbent assay (ELISA) method. Of the 97 patients with CKD5D, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Elevations in NACHT, LRR, and PYD domains-containing protein 3 (NALP3) levels in patients with CKD5D (+)CCAD (1.80 ± 0.11 ng/mL) compared to patients with (−)CCAD (1.55 ± 0.08 ng/mL) were statistically significant (P = .0299). Differences in D-dimer levels were also found to be statistically significant (P = .0258) between CKD5D (+)stroke (1.83 ± 0.42 μg/mL) and (−)stroke (0.89 ± 0.13 μg/mL) groups. The ages of the (+) neurovascular disease groups were found to be significantly elevated compared to the (−) neurovascular disease groups (P = .0002 carotid AD; P < .0001 ICAD; P = .0157 stroke). D-dimer levels were positively correlated with age in CKD5D (P = .0375). With the possible exception of NALP3 for CCAD, profiling levels of specific biomarkers for risk stratification of neurovascular diseases in the CKD5D population warrants further investigation.

Selective Shunting Based on Dual Monitoring with Electroencephalography and Stump Pressure for Carotid Endarterectomy

Purpose

The aim of this study is to analyze postoperative outcomes for carotid endarterectomy (CEA) in addition to the preoperative clinical characteristics related to selective shunting based on dual monitoring with stump pressure (SP) and electroencephalography (EEG).

Materials and Methods

We retrospectively reviewed medical records of 70 patients who underwent CEA from March 2010 to December 2017. CEA was performed under general anesthesia and selective shunting was done if the SP was lower than 35 mmHg regardless of EEG or if intraoperative EEG showed any changes different from preoperative one regardless of SP.

Results

There was no postoperative 30-day adjusted mortality or adverse cardiac events. Three patients (4.3%) had postoperative minor stroke finally reaching pre-operative neurologic status at the time of discharge. Twenty-six patients (37.1%) used shunting and severe contralateral internal carotid stenosis or occlusion was related to shunting (P<0.010). There were larger number of symptomatic patients in shunt group in spite of no statistical significance (P=0.116).

Conclusion

Perioperative stroke rate was 4.3% for CEA under general anesthesia based on dual intraoperative monitoring with SP and EEG. There was no 30-day adjusted mortality and adverse cardiac event. Severe stenosis or occlusion of contralateral internal carotid artery is related to shunting (P<0.010).

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Hemodynamic analysis of carotid artery after endarterectomy: a preliminary and quantitative imaging study based on computational fluid dynamics and magnetic resonance angiography

Background

The carotid blood flow following carotid endarterectomy (CEA) is not fully understood. Computational fluid dynamics (CFD) is a promising method to study blood flow. This study is to investigate local hemodynamic characteristics after CEA via the use of unenhanced magnetic resonance angiography (MRA) and CFD.

Methods

Eight carotid arteries with atherosclerosis and sixteen normal carotid arteries were included in this study. Time-of-flight (TOF) and phase contrast (PC) MRA were applied for the measurement of three-dimensional artery geometries and velocity profile under CFD simulation. The hemodynamic parameters of the proximal internal carotid artery (ICA) including velocity, ICA/common carotid artery (CCA) velocity ratio, mean, maximum, minimum and gradient of wall shear stress (WSS_mean, WSS_max, WSS_min and WSSG) were calculated before and after CEA. Morphologic characteristics of the carotid including bifurcation angle, tortuosity and planarity were also analyzed.

Results

Compared with pre-CEA, there was a significant reduction in post-CEA velocity, WSS_max, WSS_mean, and WSSG, by 87.24%±13.38%, 86.86%±14.97%, 57.32%±56.71% and 69.74%±37.03% respectively, whereas WSS_min was almost unchanged. ICA/ CCA velocity ratios increased significantly after CEA. We also found that the post-CEA flow conditions were positively remodelled to approximate the conditions in normal arteries. The correlation between PC-MRA and CFD was excellent for the measurement of maximum velocity at the external carotid artery (r=0.846).

Conclusions

Our preliminary results indicated that major flow dynamics were restored shortly following CEA, and CFD based on MRA measurements could be useful for quantitative evaluation of hemodynamic outcomes after CEA.

Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to a chronically infected polyethylene terephthalate patch

Carotid endarterectomy (CEA) remains the treatment for significant carotid stenosis and stroke prevention. Approximately 100,000 CEAs are performed in the United States every year. Randomized trials have demonstrated an advantage of patch carotid angioplasty over primary closure. Complications from patches include thrombosis, transient ischemic attack, stroke, restenosis, pseudoaneurysm (PA), and infection. PA after CEA is rare, with a reported average of 0.37% of cases. We describe an unusual case of PA after polyethylene terephthalate (PTFE) patching for CEA. An 88-year-old female with Alzheimer's disease living in a nursing facility with a history of skin cancer on her right chest developed a new area of intermittent brisk bleeding on her right neck which was initially believed to be related to her skin cancer. She had a remote history of right CEA with a PTFE patch approximately a decade ago. A computed tomography angiograph-head-and-neck with showed a partially thrombosed PA in the region of her right common carotid artery bifurcation with a tract containing gas and fluid extending to the skin surface suspicious for a partially thrombosed, leaking PA. She was taken urgently to the operating room on broad-spectrum antibiotics where we performed a right neck exploration, ligation of a bleeding carotid PA by ligation of the right common, internal, and external carotid arteries, explantation of a chronically infected polyethylene terephthalate patch, and closure with a sternocleidomastoid advanced flap with multilayered closure. She was discharged to her nursing facility with 6 weeks of ceftriaxone intravenous (IV) and metronidazole IV through a peripherally inserted central catheter (PICC) line with no neurological sequelae.

Neuroprotection by Propofol Post-Conditioning: Focus on PKMζ/KCC2 Pathway Activity

Critical and major operations are often accompanied by brain ischemic complications. Previous studies found that propofol post-conditioning provided neuroprotective functions through upregulating the expression of potassium chloride cotransporter 2 (KCC2) in gamma-aminobutyric acid (GABA) interneurons. Membrane expression and phosphorylation represents KCC2 activity, which were modulated by a protein kinase C (PKC)-dependent mechanism. However, the role of propofol in increasing KCC2 phosphorylation and the involvement of protein kinase Mζ (PKMζ), a major subtype of PKC, in the KCC2 pathway remained unclear. In this study, we established middle cerebral artery occlusion model in rats to evaluate the long-term recovery of brain functions using behavioral experiments. KCC2 and PKMζ were assessed via western blot. We used the selective inhibitor, zeta inhibitory peptide (ZIP), to investigate the relationship between KCC2 and PKMζ. Intracellular chloride concentration in the hippocampal CA1 area was measured to determine KCC2 activity. We found that propofol, infused at a speed of 20 mg kg-1 h-1 for 2 h at the onset of reperfusion, improved neurological deficits and cognitive dysfunction following ischemia/reperfusion injury. PKMζ expression was significantly upregulated, which improved KCC2 membrane expression and phosphorylation in the ischemic hippocampal CA1 area, and these effects could last up to 28 days. But ZIP inhibited this process. Ultimately, we showed that propofol increased KCC2 phosphorylation and PKMζ was the upstream of KCC2. Propofol led to long-term recovery of brain functions by upregulating the activity of the PKMζ/KCC2 pathway.

Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis

Background

Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis.

Methods

From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study.All patients had suggestive evidence of unstable plaque or plaque ulceration.

Results

Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years.

Conclusions

This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.

Cosmetic effects of skin-crease camouflage incision versus longitudinal incision following carotid endarterectomy

Introduction

Despite the increasing use of carotid angioplasty and stenting (CAS), carotid endarterectomy (CEA) nonetheless remains a more medically beneficial method of treatment for carotid artery stenosis. Therefore, one possibility for progress within this procedure may be to use minimally invasive carotid surgery, especially when the scar is in plain sight: the use of the natural wrinkles (skin crease) as a camouflage of the skin incision provides significant cosmetic improvements.

Aim

To compare the cosmetic effects of classic and trans-wrinkle CEA. To assess the distance between the carotid artery bifurcation (CAB) and the skin-crease incision whilst attempting CEA.

Material and methods

It was a randomized prospective study with two groups: patients undergoing classic surgery (control group; n = 100) and skin-crease trans-wrinkle camouflaged CEA (study group; n = 100). Follow-up was at 2 months and 1 year.

Results

The medical results of the treatment were similar in both groups. The cumulative count of strokes and myocardial infarctions was 0.5% within 30 days, and after one year 3.5% (and 5.5% including cases of death). The superiority of the transverse crease being hidden compared to the conventional longitudinal technique was proven in the Patient and Observer Scar Assessment Scale (POSAS) score, respectively 11.4 ±1.0 vs. 14.1 ±3.4 (p = 0.0001) after 2 months and 13.5 ±2.8 vs. 14.1 ±3.4 (p = 0.039) after a year.

Conclusions

Trans-wrinkle incision gives better cosmetic results, can be safely performed in most cases, and offers a comfortable approach during CEA.

Carotid Atherosclerotic Plaque Features in Patients with Acute Ischemic Stroke

OBJECTIVE

To investigate the carotid atherosclerotic plaque features in patients with acute ischemic stroke.

METHODS

A total of 288 patients meeting the included criteria were enrolled and divided into an ulcerated plaque group (n = 139) and a nonulcerated plaque group (n = 149). Patients in the ulcerated plaque group were further subdivided into <50% and ≥50% stenosis groups. Carotid plaque component characteristics including luminal stenosis, carotid plaque volume, hypoechoic plaque volume, and hyperechoic plaque volume were analyzed by color Doppler ultrasound measurement. Associations between ulcerated plaque and carotid plaque features were also evaluated. The relationships among the levels of MMP-9, hs-CRP, and carotid stenosis rate were detected by enzyme-linked immunosorbent assay.

RESULTS

The plaque volume, hypoechoic plaque volume, and luminal stenosis in the ulcerated plaque group were higher than that of the nonulcerated plaque group (P < 0.05). Ulcerated plaque was positively associated with luminal stenosis, plaque volume, and hypoechoic plaque volume after adjusting for sex and age. The result remained similar after adjusting for age, sex, and carotid luminal stenosis. The levels of MMP-9 and hs-CRP in the ulcerated plaque group were significantly higher than those of the nonulcerated plaque group (P < 0.01). For the ulcerated plaque group, the higher the carotid stenosis rate, the higher the level of MMP-9 and hs-CRP.

CONCLUSIONS

Higher carotid atherosclerosis plaque volume, hypoechoic plaque volume, and luminal carotid stenosis may be symptoms of ulcerated plaque. Increased MMP-9 and hs-CRP levels could be used as adjunctive therapies of carotid stenosis at the molecular level.

Stenotic lesion level did not affect outcomes of carotid endarterectomy

Background Carotid endarterectomy is the established treatment for carotid artery stenosis, and remains the primary surgical option due to its superior outcomes compared to carotid arterial stenting. However, Japanese patients are known to have unfavorable anatomical conditions for carotid endarterectomy, with a relatively higher level of the carotid artery bifurcation than in the Western population. We investigated the outcomes of carotid endarterectomy in our institute and evaluated the procedural quality by comparing patients based on higher or lower lesion levels. Methods The clinical data of 65 patients who underwent carotid endarterectomy were collected retrospectively. The outcomes reviewed included stroke-free survival and stroke-free rate. The patients were divided into a higher group ( n = 25) and a lower group ( n = 40), based on lesion location in respect of the 2nd cervical vertebral level. Results There was no perioperative death and only one case of stroke in the higher group within 30 days after carotid endarterectomy. At 5 years after carotid endarterectomy, the stroke-free survival rates were 83.4% in the higher group and 87.8% in the lower group, while the stroke-free rates were 96.0% and 94.0%, respectively; there were no significant differences between groups. Conclusions Stenotic lesion level did not affect the outcome or procedural quality of carotid endarterectomy.

A Cost Analysis of Regional Versus General Anesthesia for Carotid Endarterectomy

BACKGROUND

Medical care in the United States has evolved into a more cost-conscious value-based health care system that necessitates a comparison of costs when there are alternative interventions considered to be acceptable in the treatment of a disease. This study compares the cost differences between regional anesthesia (RA) and general anesthesia (GA) for carotid endarterectomy (CEA).

METHODS

Data from 346 consecutive patients who underwent CEA between January 2012 and September 2014 were retrospectively reviewed for the type of anesthesia used, outcomes data, and cost variables. Overall hospital day costs were compared between RA and GA. Medians and interquartile ranges were compared using Wilcoxon-Mann-Whitney test. A P < 0.05 was considered statistically significant using 2-sided tests.

RESULTS

Median overall costs for GA were significantly higher than median costs for RA (medians [with interquartile ranges], $10,140 [$7,158-$12,658] versus $7,122 [$5,072-$8,511], P < 0.001). Median total operative time for GA was significantly longer than median time for RA (168 [144-188] versus 134 [115-147] min, P < 0.001). Median in-hospital length of stay (LOS) for GA was significantly longer compared with RA (2.0 vs 1.2 days, P < 0.001). Patients who received GA were also more likely to be admitted to the intensive care unit.

CONCLUSIONS

Decreased cost, operating room expenses, postoperative resources, and overall LOS were observed for individuals who underwent RA for CEA as compared with GA. In summary, RA is more cost-effective and should be the optimal choice when clinically appropriate.

Rapid High-Volume Population Screening for Three Major Risk Factors of Future Stroke: Phase I Results

Three proximate risk factors for stroke are carotid stenosis, atrial fibrillation, and hypertension. Phase I of this prospective study was designed to establish the prevalence of these conditions among a population of health maintenance organization beneficiaries by using a rapid screening protocol in order to risk-stratify patients for appropriate management and subsequent cohort analysis. Patients at a tertiary care medical center were screened for stroke risk by using directed history, a 3-minute carotid “quick-scan” protocol, an EKG lead II rhythm strip, and bilateral arm blood pressures. Patients with any abnormal result underwent specific diagnostic consultation with vascular surgery, cardiology, or primary care. These evaluations included formal carotid duplex ultrasound, 12-lead EKG ± Holter monitor, and 5-day blood pressure check. Patients were then stratified into risk cohorts for appropriate management and future analysis of stroke incidence and outcomes. In 8 hours on a single day in October 2002, 294 patients (mean age 69) were screened. Combining history with results of screening and diagnostic tests, the overall prevalence of carotid stenosis was 6% (n= 17/294), atrial fibrillation 7% (n= 21/294), and severe hypertension 5% (n= 16/294). Fifty-nine patients (20%) screened positive for carotid stenosis by “quick-scan,” and 29% (n= 17/59) of these had confirmed stenosis (>50%) in 1 or both arteries by formal duplex. The prevalence of confirmed carotid stenosis was 37% among those screening positive for 1 artery (odds ratio [OR] 14.6; p <0.001) and 75% among those screening positive for both (OR 74.7; p <0.001). Significant independent predictors of carotid stenosis by multivariate analysis included coronary artery disease or myocardial infarction, smoking, stroke or transient ischemic attack, male gender, and white race (all p <0.05). The prevalence of confirmed stenosis was 10% with any 3 predictors alone (OR 2.5; p <0.05), 31% with any 4 (OR 21.2; p <0.001), and 50% with all 5 (OR 46.5; p <0.001). Thirty-three patients (11%) were found to have a previously unidentified and untreated arrhythmia, and 12% (n= 4/33) of these had confirmed new atrial fibrillation; 158 patients (54%) had moderate hypertension and 16 (5%) had severe hypertension (>180/100). Overall, 82% (n= 242/294) of patients screened required additional diagnostic tests. Based on these results, 11% (n= 31/294) of patients were stratified as high risk, 64% (n= 188/294) as moderate risk, and 25% (n= 75/294) as low risk for future stroke. Rapid and efficient screening of a large population for stroke risk factors is feasible. The prevalence of undiagnosed, unsurveilled, and untreated carotid stenosis, atrial fibrillation, and severe hypertension is significant, as 75% of patients screened had 1 or more confirmed major risk factors for stroke. Phase II of this study will investigate the degree of stroke risk reduction possible with a multidisciplinary approach to early identification and aggressive treatment of these risks.

Angioplasty and Stenting of the Extracranial Carotid Arteries

Purpose:

To study the feasibility and safety of stent-supported angioplasty in the treatment of atherosclerotic stenoses of the extracranial carotid arteries.

Methods:

Carotid angioplasty was attempted in 174 arteries (163 patients: 126 males; mean age: 71 ± 10 years, range 47 to 93). Mean lesion length was 15.1 ± 4.1 mm, and mean percent stenosis was 83.8% ± 7.3% (reference diameter 5.8 ± 0.7 mm). The majority (106, 65%) were asymptomatic (51% of all patients had severe coronary disease, 32% had peripheral vascular diseases). Patients underwent independent neurological examination, computed tomography, duplex ultrasonography, and angiography preprocedurally, 24 hours after the procedure, and at 6-month follow-up intervals. Most (142, 82%) carotid arteries were treated without cerebral protection, but a protective triple coaxial catheter was used in 32 (18%) patients. Stents (primarily Palmaz and Wallstent) were deployed routinely in all cases; 18% were implanted without predilation.

Results:

Immediate technical success was 173 of 174 (99.4%) (1 access failure referred electively to surgery). Eight (4.6%) neurological complications occurred in the periprocedural period: 3 transient ischemic attacks, 2 minor strokes, and 3 major strokes (1 amaurosis and 2 hemiplegias). Two major complications developed despite cerebral protection. There were no deaths or myocardial infarctions and only 3 cervical access site hematomas. Over a mean 12.7 ± 9.2 month follow-up (range 1 to 36), no ipsilateral neurological complications have been seen. There were 4 (2.3%) restenoses (3 redilated, 1 treated medically) and 1 mild Palmaz stent compression, all found within the first 6 months. Primary and secondary patencies at 3 years are 96% and 99%, respectively.

Conclusions:

Angioplasty with routine stenting seems feasible and safe for treating certain types of carotid stenoses even in high-surgical risk patients; however, randomized trials are necessary before this treatment can be offered as an alternative to endarterectomy.

Carotid Revascularization Using Endarterectomy or Stenting Systems (CARESS): Phase I Clinical Trial

Purpose:

To determine whether carotid stenting with embolic protection is equivalent to carotid endarterectomy (CEA) in a broad risk population of patients with symptomatic and asymptomatic carotid stenosis.

Methods:

A prospective, multicenter Phase I trial was conducted comparing standard CEA to carotid stenting systems (CSS) in patients with symptomatic (≥50%) and asymptomatic (≥75%) carotid stenosis. Patients were enrolled using selection criteria reflective of broad clinical practice. The enrollment ratio at each clinical site was designed to be 2:1 (CEA to CSS) to achieve a planned enrollment of 450 patients: 300 in the CEA arm and 150 in the CSS cohort, which would ensure adequate precision with a coefficient of variation ≤0.35. The primary endpoint for comparison was 30-day all-cause mortality and nonfatal stroke.

Results:

Between April 2001 and December 2002, 14 clinical sites enrolled 439 patients, of which 397 (247 men; mean age 71 years, range 44–89) were treated: 254 with CEA and 143 patients with CSS (ratio 1.8 to 1.0). More than 90% of patients had >75% stenosis; ∼68% of patients were asymptomatic. There were no significant differences in baseline patient characteristics between the treatment groups with the exception of a more frequent history of prior CEA (30% CSS versus 11% for CEA, p<0.0001) and prior carotid stent placement in the CSS group (6% versus 0% for CEA, p = 0.0002). There was no significant difference in the 30-day combined all-cause mortality and stroke rate by Kaplan-Meier estimate between CEA (2%) and CSS (2%). There was no significant difference in the secondary endpoint of combined 30-day all-cause mortality, stroke, and myocardial infarction between CEA (3%) and CSS (2%).

Conclusions:

This study suggests that the 30-day risk of stroke or death following carotid stenting with cerebral protection is equivalent to standard carotid endarterectomy in a broad risk population of patients with carotid stenosis.

Results and Future of Carotid Endarterectomy in a Medium-Sized Finnish Central Hospital

Background and Aims:

Carotid endarterectomies (CEA) should, by general agreement, be performed only at specialised institutions and on patients who are expected to have a low rate of complications, i.e., a 6% surgical risk for patients with symptomatic and a 3% risk for patients with asymptomatic carotid artery disease. We have reviewed the midterm results after CEA in amedium-sized Finnish central hospital to audit whether our results fulfil current quality standards.

Patients, Materials and Methods:

There were 116 consecutively operated patients at the Päijät-Häme Central Hospital during the years 1999–2003 on whom 122 CEAs were made. All CEAs were performed by conventional methods and shunts and patches were used when necessary.

Results:

The overall survival rate was 81.0% during the 3.6 ± 1.5 years [range 1.3–6.3 years] follow-up. The incidence of early major stroke was 2.5% and of late major stroke 1.6%. Other complications included cranial nerve deficit (2.5%), wound haematoma (3.3%) and postoperative hypertension (3.3%) or hypotension (2.5%). Significant changes in medication were needed after surgery in several patient subgroups.

Conclusions:

The results of CEA at the Päijät-Häme Central Hospital are at least acceptable. The primary prevention of strokes with pharmacotherapy needs aggressive improvement.

Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis

OBJECTIVE

This study assessed the value of modern medical treatment (MMT) with and without carotid endarterectomy (CEA) in patients with asymptomatic severe carotid artery stenosis.

METHODS

We conducted a randomized trial involving 55 patients with 70% to 79% carotid stenosis at three Russian centers. Between 2009 and 2013, 31 patients were randomized to undergo CEA with MMT (CEA group) and 24 to receive MMT alone. The primary end point was nonfatal ipsilateral stroke or death from any cause during a follow-up period of 5.0 years. The secondary end point was any nonfatal stroke, carotid revascularization, or death from any cause during follow-up.

RESULTS

The trial was stopped after a median follow-up of 3.3 years (maximum, 5.0 years). There were two primary events in the CEA group and nine events in the MMT group. The 3.3-year cumulative primary event rates were 6.5% in the CEA group and 37.5% in the MMT group (hazard ratio for the MMT group, 5.06; 95% confidence interval, 1.53-16.79; P = .008). The 3.3-year cumulative secondary end point was 12.9% in the CEA group and 50.0% in the MMT group (hazard ratio for the MMT group, 4.23; 95% confidence interval, 1.55-11.53; P = .0048).

CONCLUSIONS

CEA as an initial management strategy could reduce the risk of death and major cerebrovascular events when added to MMT.

Previous chronic cerebral infarction is predictive for new cerebral ischemia after carotid endarterectomy

Background

The purpose of this study was to investigate the relation between preoperative chronic cerebral ischemia and postoperative new cerebral ischemia in patients undergoing carotid endarterectomy (CEA).

Methods

We reviewed the diffusion weighted magnetic resonance images (DWI) of the 51 patients (37 men, mean age 68.8 ± 8.4 years) undergoing isolated CEA in the preoperative and early postoperative period. The number, anatomic location and the size of new ischemic lesions were recorded.

Results

In the preoperative period, 28 (54.9 %) patients were symptomatic. There was chronic cerebral infarction in the preoperative DWI images of 17 patients (33.3 %). In the postoperative period, there was newly developed cerebral ischemia in postoperative DWI images of eight (15.7 %) patients. Six of the eight patients with newly developed cerebral ischemia had chronic cerebral infarction in their preoperative DWI images. The incidence of newly developed cerebral ischemia after CEA in patients with preoperative chronic cerebral ischemia was significantly higher than the incidence in patients without preoperative chronic cerebral ischemia (p = 0.01).

Conclusion

The results of the present study suggest that preoperative chronic cerebral ischemia may aggravate postoperative newly developed cerebral ischemia in patients undergoing CEA.

Selective Patch Angioplasty and Intraoperative Shunting in Carotid Endarterectomy: A Single-Center Review of 141 Procedures

Objective: Open surgical treatment of carotid artery stenosis, namely, carotid endarterectomy (CEA), has evolved since its inception in 1953. Despite improvements in the treatment of carotid occlusive disease through technological and surgical innovations, the use of patch grafting in CEA’s remains controversial. We evaluate the durability of the primary closure and the safety of selective shunting during carotid endarterectomy (CEA) as determined by intraoperative EEG and postoperative outcomes.

Methods: A consecutive series of CEA’s performed by the senior author at a single academic medical center from 2001 to 2012 were reviewed. All cases were performed under continuous intraoperative electroencephalography (EEG). Patch angioplasty was used in cases where there was tortuosity of the vessel within the region of the endarterectomy and narrow vessel diameter at the distal end of the arteriotomy. Shunting was used when intraoperative EEG showed a > 50% reduction in a waveform in any lead. Patients were evaluated for restenosis via imaging or ultrasound at six months and subsequently annual follow-up.

Results: One hundred and forty-one CEA’s were performed on 132 (76 male, 56 female) patients with an average age of 71 years (range: 40–95 years). Four (3%) cases required patch angioplasty and three (2%) required intraoperative shunts. The cross-clamp time ranged from 22 to 74 minutes, and the duration increased with the use of shunts and patches. Complications were rare and included recurrent stenosis (n=2), postoperative transient ischemic attack (n=1), ischemic stroke in (n=1), temporary hypoglossal nerve weakness (n=2), temporary marginal mandibular nerve weakness (n=6), and neck hematoma (n=1).

Conclusion: Intraoperative EEG data suggests that primary closure and selective shunting in CEA can result in outcomes comparable with routine patch angioplasty and shunting.

The relationship between carotid artery plaque stability and white matter ischemic injury

Higher local carotid artery strain has previously been shown to be a characteristic of unstable carotid plaques. These plaques may be characterized by microvascular changes that predispose to intraplaque hemorrhage, increasing the likelihood of embolization. Little is known however, about how these strain indices correspond with imaging markers of brain health and metrics of brain structure. White matter hyperintensities (WMHs), which are bright regions seen on T2-weighted brain MRI imaging, are postulated to result from cumulative ischemic vascular injury. Consequently, we hypothesized that plaques that are more prone to microvascular changes and embolization, represented by higher strain indices on ultrasound, would be associated with an increased amount of WMH lesion volume. This relationship would suggest not only emboli as a cause for the brain degenerative changes, but more importantly, a common microvascular etiology for large and small vessel contributions to this process. Subjects scheduled to undergo a carotid endarterectomy were recruited from a neurosurgery clinic. Prior to surgery, participating subjects underwent both ultrasound strain imaging and brain MRI scans as part of a larger clinical study on vascular health and cognition. A linear regression found that maximum absolute strain and peak to peak strain in the surgical side carotid artery were predictive of WMH burden. Furthermore, the occurrence of microembolic signals monitored using transcranial Doppler (TCD) ultrasound examinations also correlated with increasing lesion burden. It is becoming increasingly recognized that cognitive decline is often multifactorial in nature. One contributing extra-brain factor may be changes in the microvasculature that produce unstable carotid artery plaques. In this study, we have shown that higher strain indices in carotid artery plaques are significantly associated with an increased WMH burden, a marker of vascular mediated brain damage.

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We examine how carotid artery plaque strain indices correspond with MRI metrics.

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Strain in the ICA predicts increased white matter hyperintensity lesion burden.

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Subjects with embolizing plaques have greater white matter lesion burden.

Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization

BACKGROUND

Current American Heart Association guidelines recommend carotid revascularization for asymptomatic patients on the basis of life expectancy.

OBJECTIVE

To determine the rates and predictors of 5-year survival in elderly patients with asymptomatic carotid artery stenosis who underwent either carotid artery stent placement (CAS) or carotid endarterectomy (CEA).

METHODS

The rates of 5-year survival were determined by use of Kaplan-Meier survival methods in a representative sample of fee-for-service Medicare beneficiaries ≥65 years of age who underwent CAS or CEA for asymptomatic carotid artery stenosis with postprocedural follow-up of 3.4 ± 1.7 years. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality for patients in the presence of selected comorbidities, including ischemic heart disease, chronic renal failure, and atrial fibrillation, after adjustment for potential confounders such as age, sex, race/ethnicity, and procedure type.

RESULTS

A total of 22,177 patients with asymptomatic carotid artery stenosis were treated with either CAS (n = 2144) or CEA (n = 20,033). The overall estimated 5-year survival rate (±SE) was 95.3 ± 0.00149; it was 95.5% and 93.8% in patients treated with CEA and CAS, respectively. After adjustment for potential confounders, relative risk of all-cause 5-year mortality was significantly higher among patients with atrial fibrillation (relative risk, 1.8; 95% confidence interval, 1.5-2.1) and those with chronic renal failure (relative risk, 2.1; 95% confidence interval, 1.7-2.6).

CONCLUSION

Risks and benefits must be carefully weighed before carotid revascularization in elderly patients with asymptomatic carotid artery stenosis who have concurrent atrial fibrillation or chronic renal failure.

[Complications after supra-aortic reconstruction]

BACKGROUND

Surgical interventions on the supra-aortic vessels are common procedures to avoid cerebral ischemia or arm pain during exercise. The safety and efficacy has been confirmed by clinical studies. Complications are rare but have serious consequences.

OBJECTIVES

What special indications and recommendations are there for the diagnostics and treatment in the perioperative phase?

METHODS

The current article is a literature-based review that considers international studies, guidelines and personal experiences.

RESULTS

There is a broad range of complications. A simple systematic physical examination is often sufficient to give indications of the problem. Confirming clinical apparative examinations are mostly intraoperative angiography or sonography, whereas postoperative procedures include color-coded duplex sonography (FKDS) and angiography computed tomography (angio-CT). Important basic principles and aspects of operative procedures are presented. Evidence-based differences between the treatment options with resulting complications are mostly unknown; therefore, clinical management mostly relies on expert recommendations.

CONCLUSION

There are several modern treatment options for invasive therapy. Despite a decrease in previous complication rates, typical perioperative complications must be considered. The diagnosis and therapy is carried out according to established strategies.

Anterior segment neovascularization in diabetic retinopathy: a masquerade

Purpose

Anterior segment neovascularization (ASNV) could be a masquerade for ocular ischemic syndrome (OIS) in diabetic patients which misleads diagnosis and treatment. The purpose of our study is to find the relationship between blood flow velocity in carotid siphon and the development of ASNV in diabetic.

Methods

We reviewed 34 eyes of 17 diabetic patients who had Transcranial Color Doppler (TCD) examination with unilateral ASNV. The circulatory parameters of both eyes of each patient were compared and analyzed. In addition, 9 patients with more than 50% stenosis of extracranial internal carotid artery (ICA) and low velocity flow through TCD had been treated by carotid revascularization surgery.

Results

The maximal velocity in systole (Vmax) of carotid siphon (SCA) was lower in the eyes with ASNV than in the eyes without ASNV (P<0.05). ASNV of all the 9 patients regressed totally and BCVA improved significantly (P<0.05). Stenosis of ICA and arm-retina time (ART) decreased significantly (P<0.01) and SCA and ophthalmic artery (OA) increased significantly (P<0.01).

Conclusions

Our study showed ASNV could be a masquerade for OIS in patients with diabetic retinopathy. The decreased blood flow velocity in carotid siphon is related to the development of ASNV. Circulatory parameters screening of SCA by TCD is important to help us to evaluate the blood flow in SCA, the possibility of development of ASNV, and the prognosis of the patient. Interference such as carotid endarterectomy (CEA) or carotid artery stenting (CAS) can be performed if necessary to improve the blood flow in SCA and make ASNV regression.

The presence of variant genotype of the mannose-binding lectin gene (MBL2) is not associated with increased restenosis rate in carotid surgery

BACKGROUND

We investigated the role of mannose-binding lectin (MBL) variant genotypes in patients with significant carotid restenosis after carotid endarterectomy (CEA) and who underwent a revision CEA.

METHODS

This was a cross-sectional analysis of 97 patients enrolled between 2001 and 2013. Three groups were investigated: group A included patients with internal carotid artery restenosis, group B included patients without restenosis after CEA, and group C included patients with peripheral arterial disease but without any signs of a carotid stenosis. Venous blood samples were drawn for the genotyping for MBL2 by polymerase chain reaction and for the determination of the MBL serum concentration by enzyme-linked immunoabsorbent assay.

RESULTS

The serum concentration of MBL was higher in patients with the normal genotype than in those with the genotype variants of MBL (95% confidence interval, 272.8-1008.7 μg/L; P = .001). There was no statistically significant difference among groups A, B, or C with respect to the presence of a variant genotype. Similarly, there was no significant gender difference regarding the presence of a variant genotype (P = .325).

CONCLUSIONS

The presence of a variant genotype of the MBL2 gene (and the correspondingly lower serum concentration of this molecule) was not correlated with the development of carotid restenosis after CEA beyond a follow-up of 12 months.

Pathophysiology of Acute Cerebrovascular Syndrome in Patients With Carotid Artery Stenosis

BACKGROUND:

The mechanisms underlying acute cerebrovascular syndrome in patients with carotid artery stenosis remain unclear.

OBJECTIVE:

To assess the relationships among infarct localization, hemodynamics, and plaque components.

METHODS:

This prospective study included 38 patients with acute cerebrovascular syndrome resulting from ipsilateral carotid artery stenosis. Cerebral infarct localization was categorized into 3 patterns (cortical, border zone, and mixed pattern). Carotid plaque components were evaluated with T1-weighted magnetic resonance imaging and time-of-flight imaging. Cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) were also quantified.

RESULTS:

Infarcts were identified in 38 patients with the use of diffusion-weighted magnetic resonance imaging. On the basis of the assessment of hemodynamics, the cortical pattern was seen in 18 of 21 patients with type 1 ischemia (normal CBF, normal CVR), whereas the mixed pattern was seen in 2 patients with type 2 ischemia (normal CBF, impaired CVR) and 12 of 15 patients with type 3 ischemia (impaired CBF, impaired CVR). The plaque components were categorized into fibrous (4 patients), lipid-rich (14 patients), and intraplaque hemorrhage (IPH; 20 patients). Of the patients with fibrous plaque, 2 had border-zone and 2 had mixed-pattern infarcts. Of the patients with lipid-rich plaque, 7 had cortical and 6 had mixed-pattern infarcts. Of patients with intraplaque hemorrhage, 11 had cortical and 9 had mixed-pattern infarcts.

CONCLUSION:

Cortical infarction occurs as a result of vulnerable plaque. Reduced cerebral perfusion induces border-zone infarction. Both factors are implicated in mixed-pattern infarction. Developments in noninvasive diagnostic modalities allow us to explore the mechanisms behind acute cerebrovascular syndrome in carotid artery stenosis and to determine the ideal therapies.

Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: onset of new ischemic stroke

Background

The degree of stenosis of carotid arteries is recognized as an important risk factor for ischemic stroke. However, high-grade stenosis does not always cause cerebrovascular events, whereas low- to moderate-grade stenosis may often cause strokes. It has been reported that there is an association between carotid intraplaque hemorrhage (IPH) and new brain ischemic events.

Case presentation

We present three patients with asymptomatic moderate carotid artery stenosis and carotid IPH who underwent both neurological and MRI at baseline and after at least 1 year's follow-up. These patients were admitted to our hospital (after 15–35 months of follow-up) because of neurological deficits. Diffusion-weighted MRI of the brain showed ipsilateral new ischemic lesions due to carotid artery plaques. The patients were treated with carotid artery stenting and discharged uneventfully.

Conclusions

Whether plaques with severe stenosis already had severe stenosis at the onset of events or plaques with moderate stenosis progressed owing to an acute change, such as growth of an IPH, remains unclear, because no carotid imaging was carried out just before the events. This is the first case report which presents neurological symptoms and MRI at both baseline and follow-up in patients with asymptomatic moderate carotid artery stenosis and carotid IPH.

Carotid artery stenting

Carotid artery stenting (CAS) has achieved clinical equipoise with carotid endarterectomy (CEA), as evidenced by 2 large U.S. randomized clinical trials, multiple pivotal registry trials, and 2 multispecialty guideline documents endorsed by 14 professional societies. The largest randomized trial conducted in patients at average surgical risk of CEA, CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) found no difference between CAS and CEA for the combined endpoint of stroke, death, and myocardial infarction (MI) after 4 years of follow-up. The largest randomized trial comparing CAS and CEA in patients at increased surgical risk, SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy), looked at 1-year stroke, death, and MI incidence and found no difference in symptomatic patients, but a significantly better outcome in asymptomatic patients for CAS (9.9% vs. 21.5%; p = 0.02). Given that >70% of carotid revascularization procedures are performed in asymptomatic patients for primary prevention of stroke, it is incumbent upon clinicians to demonstrate that revascularization has an incremental benefit over highly effective modern medical therapy alone.