Risk Factors for Recurrent Carotid-Artery Stenosis Following Stenting Treatment

Construction of vulnerable plaque prediction model based on multimodal vascular ultrasound parameters and clinical risk factors

The rupture of vulnerable plaque (VP) are significant pathogenic factors leading to cardiovascular and cerebrovascular diseases. This study aims to construct a vulnerable plaque prediction model (VPPM) by combining multimodal vascular ultrasound parameters and clinical risk factors, and to validate it. A total of 196 atherosclerotic patients who underwent carotid endarterectomy (CEA) from January 2017 to December 2023 were collected and divided into a modeling group (n = 137) and a validation group (n = 59). Clinical information including: hypertension, diabetes, smoking history, and body mass index (BMI) was included in the analysis. All patients underwent carotid ultrasound and contrast-enhanced ultrasound (CEUS) examination after admission, with main ultrasound parameters including thickness, echogenicity types, stenosis degree, and CEUS neovascularization grading of plaques. Independent risk factors for VP in CEA patients were screened through binary Logistic regression analysis, and a prediction model was established along with a nomogram. The calibration curve, receiver-operating characteristic curve (ROC), and decision curve analysis (DCA) were employed to assess the calibration, diagnostic efficacy, and clinical utility of the VPPM model. There were no significant statistical differences in multimodal vascular ultrasound parameters and clinical risk factors between the modeling and validation groups (P > 0.05). Binary Logistic regression analysis identified plaque thickness, echo type, CEUS neovascularization grading, BMI, and smoking history as 5 variables entering the prediction model. The VPPM model showed good diagnostic efficacy, with an area under the ROC curve of 0.959 (95% CI 0.915-0.999). Using the nomogram with a VPPM risk assessment score of 135.42 as the diagnostic cutoff value in the modeling group, the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and Youden index were 88.1%, 94.1%, 14.98, 0.126, and 82.2%, respectively. In the DCA curve, the VPPM model curve was significantly better than two extreme lines, indicating good clinical utility. The VPPM model constructed by integrating multimodal ultrasound parameters and clinical key risk factors has high diagnostic efficacy and is expected to be an auxiliary tool for clinical diagnosis of vulnerable plaques.

Predictors of Occlusion after Carotid Stenting

BACKGROUND

Carotid artery stent (CAS) occlusion is a rare complication not well studied. We used a national dataset to assess real world CAS experience to determine the rate of stent occlusion. The purpose of this study was to 1) Identify risk factors associated with CAS occlusion on long-term follow-up (LTFU) and 2) Determine the adjusted odds of death/transient ischemic attack (TIA)/stroke (cerebrovascular accident (CVA)) in patients with occlusion.

METHODS

The national Vascular Quality Initiative CAS dataset (2016-2021) comprised the sample. The primary endpoint was occlusion on LTFU (9-21 months postoperatively as defined by the Vascular Quality Initiative LTFU dataset) with secondary endpoint examining a composite of death/TIA/CVA. Descriptive analyses used chi-square and Wilcoxon tests for categorical and continuous variables respectively. Adjustment variables were selected a priori based on clinical expertise and univariate analyses. Multivariable logistic regression was used to model the odds of occlusion and the odds of death/TIA/CVA. Generalized estimating equations accounted for center level variation.

RESULTS

During the study period, 109 occlusions occurred in 12,143 cases (0.9%). On univariate analyses, symptomatic indication, prior stroke, prior neck radiation, lesion calcification (>50%), stenosis (>80%), distal embolic protection device (compared to flow reversal), balloon size, >1 stent and current smoking at time of LTFU were predictive for occlusion. Age ≥ 65, coronary artery disease (CAD), elective status, preoperative statin, preoperative and discharge P2Y12 inhibitor, use of any protection device intraoperatively and protamine were protective. On multivariable analyses, age ≥ 65, CAD, elective status and P2Y12 inhibitor on discharge were protective for occlusion, while patients with prior radiation and those taking P2Y12 inhibitor on LTFU were at increased odds. The adjusted odds of death/TIA/CVA in patients with occlusion on LTFU were 6.05; 95% confidence interval: 3.61-10.11, P < 0.0001.

CONCLUSIONS

This study provides an in-depth analysis of predictors for CAS occlusion on LTFU. On univariate analyses, variables related to disease severity (urgency, degree of stenosis, nature of lesion) and intraoperative details (balloon diameter, >1 stent) were predictive for occlusion. These variables were not statistically significant after risk adjustment. On multivariable analyses, prior neck radiation was strongly predictive of occlusion. Elective status, patient age ≥ 65, CAD, and P2Y12 inhibitor upon discharge (but not on LTFU) were protective for occlusion. Additionally, patients who developed occlusion had high odds for death/TIA/CVA. These findings provide important data to guide clinical decision-making for carotid disease management, particularly identifying high-risk features for CAS occlusion. Closer postoperative follow-up and aggressive risk factor modification in these patients may be merited.

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.

Clinical value of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in predicting recurrent stroke of middle cerebral artery stenosis

OBJECTIVE

To evaluate the clinical value of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in the prediction of recurrent stroke in middle cerebral artery stenosis.

METHODS

This is a retrospective study. Patients (n=170) who were hospitalized in the Department of Neurology of the First People's Hospital of Jiangxia District from June 2019 to January 2021 with cerebral infarction or transient ischemic attack were included in the study. Among them, 85 patients with ischemic attack were divided into the non-recurrent stroke group (primary onset, n=40) and the recurrent stroke group (history of cerebral infarction or transient ischemic attack within 5 years prior to the onset, n=45). Routine blood biochemical tests were performed using the Olympus 5800 automated chemical analyzer. Cerebrospinal fluid levels of inflammatory factors (TNF-α, IL-6) were detected by ELISA kits. Special Doppler hyperintensities for microemboli in cerebral blood flow were tested by transcranial Doppler ultrasound.

RESULTS

The mean age, statins and LDL-C were higher in the recurrent stroke group than the non-recurrent stroke group (P<0.05). The levels of cerebrospinal fluid TNF-α, PCT, CRP and IL-6 in the recurrent stroke group were higher than the non-recurrent stroke group (P<0.05). The proportion of grade 0 microemboli in the recurrent stroke group was lower than the non-recurrent stroke group (P<0.05), and the proportion of grade 1, 2, 3, 4 and 5 microemboli was higher than the non-recurrent stroke group (P<0.05). The positive rate of microemboli in the recurrent stroke group was higher than the non-recurrent stroke group (P<0.05). The accuracy rate of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in the recurrent stroke group for the prediction of recurrent stroke due to middle cerebral artery stenosis was higher than that in the non-recurrent stroke group (P<0.05). Increased age, statin use, microembolization, and increased LDL-C, TNF-α, PCT, CRP and IL-6 levels were independent risk factors.

CONCLUSION

Microemboli combined with cerebrospinal fluid inflammatory factor level monitoring can increase the detection rate of recurrent stroke in middle cerebral artery stenosis and prevent vascular events to a great extent.

Prognostic value of color Doppler ultrasound, D-dimer, and Lp-PLA2 levels in carotid atherosclerotic stenosis

BACKGROUND

This research mainly explored the prognostic value of color Doppler ultrasound combined with D-dimer and Lp-PLA2 levels in carotid atherosclerotic stenosis.

METHODS

From January 2018 to August 2020, 67 patients (patient group) who were diagnosed as cerebral infarction by neurology and carotid atherosclerotic stenosis by digital subtraction angiography (DSA) were recruited in this research. Fifty healthy people served as controls and were brought into this research. PI (pulsatility index), RI (resistance index), Vd (end diastolic velocity), and Vs (peak systolic velocity) were obtained by color Doppler ultrasound vascular wall imaging. The levels of D-dimer and Lp-PLA2 in serum were examined. The receiver operating characteristics (ROC) curve was employed to analyze the diagnostic efficacy of color Doppler ultrasound imaging parameters, serum D-dimer, and lipoprotein-associated phospholipase A2 (Lp-PLA2) levels on the prognosis of patients with carotid atherosclerotic stenosis.

RESULTS

The levels of PI, RI, serum D-dimer, and Lp-PLA2 in the patient group were higher than those in the control group (P < 0.05). Levels of Vd and Vs were lower. PI, RI, serum D-dimer, and Lp-PLA2 levels were positively correlated with mRS scores (P < 0.05). Vd and Vs were negatively correlated (P < 0.05). The measurement of VD and Lp-PLA2 levels was more effective in predicting the prognosis of patients with carotid atherosclerotic stenosis.

CONCLUSION

Vd parameters and Lp-PLA2 levels have high clinical values in carotid atherosclerotic stenosis, and are worthy of clinical application.

Smooth muscle cell-specific fibronectin-EDA mediates phenotypic switching and neointimal hyperplasia

Fibronectin-splice variant containing extra domain A (Fn-EDA) is associated with smooth muscle cells (SMCs) following vascular injury. The role of SMC-derived Fn-EDA in SMC phenotypic switching or its implication in neointimal hyperplasia remains unclear. Herein, using human coronary artery sections with a bare metal stent, we demonstrate the expression of Fn-EDA in the vicinity of SMC-rich neointima and peri-strut areas. In mice, Fn-EDA colocalizes with SMCs in the neointima of injured carotid arteries and promotes neointima formation in the comorbid condition of hyperlipidemia by potentiating SMC proliferation and migration. No sex-based differences were observed. Mechanistic studies suggested that Fn-EDA mediates integrin- and TLR4-dependent proliferation and migration through activation of FAK/Src and Akt1/mTOR signaling, respectively. Specific deletion of Fn-EDA in SMCs, but not in endothelial cells, reduced intimal hyperplasia and suppressed the SMC synthetic phenotype concomitant with decreased Akt1/mTOR signaling. Targeting Fn-EDA in human aortic SMCs suppressed the synthetic phenotype and downregulated Akt1/mTOR signaling. These results reveal that SMC-derived Fn-EDA potentiates phenotypic switching in human and mouse aortic SMCs and neointimal hyperplasia in the mouse. We suggest that targeting Fn-EDA could be explored as a potential therapeutic strategy to reduce neointimal hyperplasia.

Computed Tomography Perfusion Imaging Quality Affected by Different Input Arteries in Patients of Internal Carotid Artery Stenosis

BACKGROUND The aim of this study was to explore the influence of different input arteries on the parameters of computed tomography (CT) perfusion imaging for patients with different degree of stenosis of internal carotid artery (ICA). MATERIAL AND METHODS Forty patients were enrolled in the present study and divided into mild, moderate, severe stenosis and occlusion groups respectively with each 10 patients in each group. In reconstruction of cerebral CT perfusion (CTP) images, each raw perfusion image was reconstructed 3 times based on different reference input artery, including bilateral middle cerebral artery (MCA) and basilar arteries (BA). Region of interest (ROI) was drawn in the central territories of bilateral anterior cerebral artery, middle cerebral artery and posterior cerebral artery. And regional cerebral blood flow (rCBF) regional cerebral blood volume (rCBV), mean transit time (MTT), time to peak (TTP) and delay time (DT) were obtained from those ROI corresponding perfusion images. RESULTS In patients with mild and moderate ICA stenosis, there was no significant difference of perfusion parameters based on different input arteries (P>0.05). However, in severe ICA stenosis and occlusion CBF, MTT, and DT were significant different in affect side of the MCA group compared to the others (P<0.05). CONCLUSIONS Large intracranial artery can be selected as the input artery for patients with mild to moderate ICA stenosis, while for patients with severe stenosis and occlusion of ICA, the contra lateral middle cerebral artery or basilar artery would be better choice.

Predicting the Risk of Stroke in Chinese Internal Carotid Artery Stenosis Patients Underwent Carotid Artery Stenting: Validation and Improvement of Siena Carotid Artery Stenting Risk Score

BACKGROUND

Siena carotid artery stenting (CAS) risk score is developed based on Chinese internal carotid artery (ICA) stenosis patients recruited in Italy, whether it is equally applicable in Chinese remains unknown. We aimed to investigate Siena CAS risk score value for predicting stroke risk in ICA stenosis patients underwent CAS and explore additional factors for improving accuracy of scoring system.

METHODS

Totally 401 patients with ICA stenosis who underwent CAS were enrolled. The clinical data (including patient characteristics, lesion features, and procedure-related features) were collected and the Siena CAS score was calculated. Stroke incidence with 30 days was documented.

RESULTS

The incidence of stroke was 4.5%, and the Siena CAS score in stroke patients was higher compared with nonstroke patients, further receiver operating characteristic (ROC) curve illustrated that Siena CAS score was acceptable at predicting stroke risk with area under curve (AUC) of .743 (95%CI: .638-.848). Multivariate logistic regression model revealed that Siena CAS score and current fasting-blood glucose (FBG) greater than 7.1 mmol/l independently predicted higher stroke risk; followed ROC curve disclosed that Siena CAS score combined with current FBG greater than 7.1 mmol/l was of good value in predicting stroke risk (AUC: .770 (95%CI: .677-.863)), which was numerically increased compared with Siena CAS score alone.

CONCLUSIONS

Siena CAS risk scoring system exhibits to be a useful tool to predict stroke risk, and the combination of Siena CAS score and current increased FBG might be a more accurate stratification for stroke risk in Chinese ICA stenosis patients after CAS.