Aortic arch and common carotid artery plaques with soft components pose a substantial risk of cerebral embolization during carotid stenting

Carotid and aortic plaque imaging using 3D gradient-echo imaging and the three-point Dixon method with improved motion-sensitized driven-equilibrium (iMSDE)

BACKGROUND

We devised a method that combines the 3D-Dixon-gradientecho (GRE) method with an improved motion-sensitized driven-equilibrium (iMSDE) to suppress blood flow signals.

PURPOSE

The purpose of this study was to evaluate the effectiveness of the new method we developed plaque imaging method (3D-Dixon-GRE with the iMSDE method).

STUDY TYPE

Retrospective cohort.

POPULATION

Thirty-nine patients who underwent cervical plaque imaging.

FIELD STRENGTH/SEQUENCE

3.0 T/3D-GRE.

ASSESSMENT

Signal intensities of the common carotid artery, aorta, plaque, muscle, and subcutaneous fat were measured through the VISTA and the 3D-Dixon-GRE with iMSDE methods, and each contrast was calculated.

STATISTICAL TEST

Used the Mann Whitney U test. P-values below 0.05 were considered statistically significant.

RESULTS

Plaque and muscle contrast estimated through the VISTA method and 3D-Dixon-GRE with iMSDE method was 1.60 ± 0.96 and 2.04 ± 1.06, respectively, (P < 0.05). The contrast between the flow (common carotid artery and Aorta) and muscle according to the VISTA method and 3D-Dixon-GRE with iMSDE method was 0.24 ± 0.11 and 0.40 ± 0.12, respectively (P < 0.001). Finally, the mean contrast for subcutaneous fat and muscle at six locations was 3.05 ± 1.25 and 0.81 ± 0.23 for the VISTA method and 3D-Dixon-GRE with the iMSDE method, respectively (P < 0.001).

DATA CONCLUSION

Compared to the conventional method (VISTA), the 3D-Dixon-GRE with iMSDE method is preferable in relation to the fat suppression effect, but it is disadvantageous regarding blood flow signal suppression. Therefore, the 3D-Dixon-GRE with the iMSDE method could be considered useful for plaque imaging.

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

OBJECTIVE

Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate.

METHODS

We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS).

RESULTS

Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively).

CONCLUSIONS

CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Three-dimensional multicontrast blood imaging with a single acquisition: Simultaneous non-contrast-enhanced MRA and vessel wall imaging in the thoracic aorta

PURPOSE

To evaluate MRA and vessel wall imaging (VWI) image quality in the thoracic aorta using a novel method named BRIDGE (bright and dark blood images with multishot gradient-echo EPI).

METHODS

The BRIDGE method consists of 3D multishot gradient-echo EPI acquisition using pulse gating, navigator gating, and magnetization preparation with a T₂ -preparation pulse and a nonselective inversion-recovery pulse. The BRIDGE and conventional methods (noncontrast MRA based on 3D turbo-field-echo [TFE] and VWI based on 3D turbo spin echo with variable refocusing flip angle [VRFA-TSE]) were performed in 10 healthy volunteers and 10 patients. The SNR, contrast-to-noise ratio (CNR), and sharpness in the thoracic aorta were compared for MRA evaluation. The values of SNR_lumen , SNR_wall , CNR_wall-lumen , contrast ratio (CR)_lumen-muscle , coefficient of variation, sharpness, lumen area, and wall area in the thoracic aorta were compared for VWI evaluation. Two radiologists independently performed qualitative image-analysis assessments.

RESULTS

When MRA and VWI were acquired, the acquisition time was 26.6% to 27.8% shorter with BRIDGE than the conventional method. In the MRA evaluation, BRIDGE and TFE methods were comparable. In the VWI evaluation, BRIDGE was superior to the VRFA-TSE method in blood suppression and evaluation of the ascending aorta. Because the blood signal suppression of BRIDGE is based on the T₁ value of blood, the blood signal can be suppressed more uniformly than with the VRFA-TSE method, regardless of age, blood flow velocity, or vascular anatomy.

CONCLUSION

The BRIDGE method can provide both MRA, to assess vascular anatomy and luminal changes, and VWI, to assess the vessel wall and detect vulnerable plaques, in a single scan.

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

Patient selection for endovascular intervention in extracranial carotid disease is centered on vascular anatomy. We review anatomical considerations for non-traumatic disease and offer guidelines in patient selection and management. We conducted a systematic literature review without meta-analysis for studies involving anatomical considerations in extracranial carotid intervention for non-traumatic disease. Anatomical considerations discussed included aortic arch variants, degree of vessel stenosis, angulation, tortuosity, and anomalous origins, and atheromatous plaque morphology, composition, and location. Available literature suggests that anatomical risks of morbidity are largely secondary to increased procedural times and difficulties in intervention system delivery. We recommend the prioritization of endovascular techniques on an individual basis in cases where accessible systems and surgeon familiarity provide an acceptable likelihood of rapid access and device deployment.

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach

INTRODUCTION

Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis.

EVIDENCE ACQUISITION

A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded.

EVIDENCE SYNTHESIS

Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I²=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I²=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I²=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I²=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I²=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I²=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I²=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I²=37.6% and 95% CI: 11.3-16.1, P=0.48, I²=0%, respectively).

CONCLUSIONS

TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.

Carotid artery stenting for patients with occipital-vertebral anastomosis

BACKGROUND AND PURPOSE

We report the outcomes of carotid artery stenting for patients with angiographically visible occipital artery-vertebral artery anastomosis.

METHODS

Among 47 consecutive patients who underwent carotid artery stenting from January 2007 to December 2010, seven patients for whom cerebral angiograms clearly showed occipital artery-vertebral artery anastomosis were selected. Four different protection methods were used: distal internal carotid artery protection; carotid flow reversal; seatbelt and airbag technique; and double protection method of protecting both the external and internal carotid artery.

RESULTS

One patient with distal internal carotid artery protection showed a high-intensity lesion at the border of the upper thalamus, internal capsule and lateral ventricle wall after carotid artery stenting. The other patient with the double protection method did not show any high-intensity lesions on postoperative diffusion-weighted imaging in the vertebrobasilar territory. All seven patients with visible occipital artery-vertebral artery anastomosis showed ipsilateral vertebral artery severe stenosis or occlusion.

CONCLUSION

Large occipital artery-vertebral artery anastomosis may be a pathway for embolic materials during carotid artery stenting. External carotid artery protection is recommended for carotid artery stenting in such patients.

Comparison of Clinical and Radiological Outcome of Carotid Angioplasty and Stenting after Direct Navigation Versus Exchange Methods: A Randomized Clinical Trial

BACKGROUND

The purpose of this study was to compare the frequency of microembolic brain infarcts after direct navigation method versus exchange method in carotid artery stenting and vertebral artery origin angioplasty.

METHODS AND MATERIAL

This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran. Consecutive patients undergoing "carotid angioplasty and stenting" and "vertebral artery origin stenting" were randomly assigned into two groups with "direct navigation method" and "exchange method." Subsequently, postprocedural magnetic resonance imaging (MRI) including diffusion weighted imaging and apparent diffusion coefficient were obtained within the first 24 hours after completion of the procedure.

RESULTS

In total, 89 patients were recruited (67% male, mean age: 72 years). Cases comprised of 38 left internal carotid arteries (ICAs), 38 right ICAs, 6 left vertebral artery origin, and 7 right vertebral artery origin. Forty patients underwent exchange method, while 49 underwent direct navigation method. There was only one clinical stroke that occurred in "exchange method" group. Fifteen patients (37.5%) in exchange group and 23 patients (46.9%) in direct navigation group developed diffusion restricted lesions. In exchange group, 13 patients (32.5%) had at least one diffusion restricted lesion ipsilateral to the target vessel, and three patients (7.5%) had at least one diffusion restricted lesion contralateral to the target vessel. In direct navigation group, these measures were 19 (38.8%) and 9 (18.4%). However, no statistically significant intergroup differences were observed. The only significant difference was bilateral infarct percentile, which was more common in the direct navigation method (0.032).

CONCLUSION

Diffusion restricted lesions were more common in the direct navigation method, both ipsilateral and contralateral to the target vessel, and in both carotid and vertebral artery study subgroups. However, differences were not statistically significant.