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Objective: The objective of this study was to define outcomes after carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis (CAS) when patients are operated on within 14 days after onset of symptoms., Methods: Clinical data of consecutive patients who underwent CEA between 2003 and 2012 for symptomatic CAS were reviewed. Patients were classified into group 1, CEA ≤14 days of minor stroke or transient ischemic attack, and group 2, CEA >14 days. Primary end point was stroke/death; secondary end points were stroke, death, and myocardial infarction., Results: There were 233 patients (32% female; mean age, 72 ± 9.1 years) who underwent 238 CEAs. Group 1 included 57 CEAs in 56 patients; 11 CEAs were performed at 0 to 2 days, 23 at 3 to 7 days, and 23 at 8 to 14 days. Group 2 included 181 CEAs in 177 patients. One death (group 2) and five strokes (group 1, four; group 2, one) occurred at 30 days (stroke/death, 2.6%), more in group 1 vs group 2 (7.1% vs 1.1%; P = .03). In group 1, three strokes occurred when the patients were operated on within 2 days (27% [3/11]), more than at 3 to 7 days (0% [0/22]) or 8 to 14 days (4.3% [1/23]; P = .008). Patients operated on between days 3 and 14 had similar stroke/death rate to those operated on after 14 days (2.2% vs 1.1%; P = .49). Myocardial infarction occurred in six patients (2.5%; group 1, 0% [0/57]; group 2, 3.3% [6/177]; P = .34). Median follow-up was 7.0 years (interquartile range, 4.6-9.9 years). Freedoms from stroke/death were similar between groups (hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.75-1.99; P = .42), 69% for group 1 and 76% for group 2 at 5 years. Age ≥80 years, high surgical risk, and no preoperative P2Y 12 antagonist use predicted stroke/death. Freedoms from any stroke were similar in groups (HR, 2.46; 95% CI, 0.95-6.41; P = .06); survivals were also similar (HR, 1.12; 95% CI, 0.67-1.87; P = .67) at 5 years., Conclusions: In this single-center study, CEA in symptomatic patients had a 30-day stroke/death rate of 2.6%. Age ≥80 years and high surgical risk predicted late stroke or death; taking P2Y 12 antagonists was associated with late stroke. High stroke rates when patients were operated on immediately support CEA after 2 days in symptomatic patients with CAS., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Symptomatic carotid artery stenosis needs revascularization within 2 weeks by carotid endarterectomy (CEA) to reduce the risk of symptom recurrence; however, the optimal timing of intervention is yet to be defined in patients with large-volume cerebral ischemic lesion (LVCIL) and modified Rankin scale (mRS) score ≥3. The aim of this study was to determine the most appropriate timing for CEA in patients with a recent stroke and LVCIL. Data from patients with symptomatic carotid stenosis with LVCIL and mRS score of 3 or 4 from 2007 to 2017 were considered. Patients were submitted to CEA if they had a stable clinical condition and life expectancy >1 year. LVCIL was defined as a cerebral ischemic lesion of volume >4000 mm3. Perioperative stroke and death were evaluated by stratifying for timing of CEA by χ 2 test and multiple logistic regression. Patients with similar characteristics (LVCIL and mRS score of 3 or 4) unfit for CEA served as the control group for recurrence of stroke at 1-year follow-up. In an 11-year period, of a total 4020 CEAs, 126 (2.9%) were performed in patients with a moderate stroke and LVCIL occurring in the same admission. The patients' median age was 69 years (interquartile range [IQR], 10 years); 72% (91) were male, with mRS score of 3 (IQR, 1) and LVCIL volume of 20,000 mm3 (IQR, 47,000 mm3). The median time elapsed from symptoms to CEA was 7 weeks (IQR, 8 weeks). Overall perioperative stroke/death was 7.3% (eight strokes and one death). By selective timing evaluation of the postoperative events, CEA performed within 4 weeks was associated with a significantly higher rate of stroke/death compared with patients operated on after 4 weeks: 11.9% (8/67) vs 1.7% (1/59; P =.03). By logistic regression, CEA within 4 weeks was an independent (from sex, cerebral ischemic lesion volume, dyslipidemia, and carotid stenosis) predictor of postoperative stroke/death (odds ratio, 8.2; 95% confidence interval, 1.01-73). In the same period, 101 patients were considered unfit for CEA for dementia (n = 22), severe comorbidities (n = 55), or short (<1-year) life expectancy (n = 24), and 43 (43%) survived at 1 year. At 1 year, the perioperative/recurrent stroke after CEA vs patients unfit for CEA was similar (6.2% vs 13.9%; P =.11), but CEA performed after 4 weeks led to significantly lower perioperative/recurrent stroke (1.7% vs 13.9%; P =.02). The surgical risk of CEA in patients with a recent moderate-severe ischemic stroke and LVCIL is high. However, if the intervention is delayed >4 weeks, its benefit seems significant. [ABSTRACT FROM AUTHOR]

Carotid revascularization performed within 2 weeks of symptoms has proven to reduce risk of recurrent stroke in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization within the 2-week window has yet to be determined. The objective of this study was to perform a comprehensive analysis of in-hospital and long-term outcomes of carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms. We analyzed 2003 to 2016 data from the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network. Only revascularizations performed for symptomatic carotid artery stenosis were included. Procedures were categorized as urgent (0-2 days from latest symptom), early (3-14 days), or late (15-180 days). The primary in-hospital outcome was stroke/death. The primary long-term outcomes of interest were 5-year recurrent ipsilateral stroke/death. Multivariable logistic regression, Kaplan-Meier analysis, and Cox regression were utilized to compare outcomes. A total of 18,970 revascularizations were included: 1130 (6.0%) urgent, 4643 (24.5%) early, and 13,197 (69.6%) late. Earlier CEA had increased odds of in-hospital stroke/death compared with late CEA (urgent: adjusted odds ratio, 1.9; 95% confidence interval [CI], 1.3-2.8; P =.001; early: adjusted odds ratio, 1.7; 95% CI, 1.3-2.2; P <.001). No differences were seen in 5-year risk of stroke/death (urgent: adjusted hazard ratio, 0.95; 95% CI, 0.79-1.15; P =.592; early: adjusted hazard ratio, 0.97; 95% CI, 0.87-1.07; P =.928). Urgent and early CEA were associated with increased perioperative risk without difference in 5-year outcomes compared with late CEA. Short-term recurrent stroke prevention could not be assessed. Updated population-based studies comparing recurrent stroke prevention with urgent or early revascularization vs best medical management are warranted. [ABSTRACT FROM AUTHOR]

Background Carotid artery stenting (CAS) is considered by many as an alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. However, recent trials demonstrated inferior results for CAS in symptomatic patients compared with CEA. We reviewed the literature to evaluate the appropriateness of CAS for symptomatic carotid artery stenosis and to determine the pathogenetic mechanism(s) associated with stroke following the treatment of such lesions. Based on this, we propose steps to improve the results of CAS for the treatment of symptomatic carotid stenosis. Methods PubMed/Medline was searched up to March 25, 2010 for studies investigating the efficacy of CAS for the management of symptomatic carotid stenosis. Search terms used were “carotid artery stenting,” “symptomatic carotid artery stenosis,” “carotid endarterectomy,” “stroke,” “recurrent carotid stenosis,” and “long-term results” in various combinations. Results Current data suggest that CAS is not equivalent to CEA for the treatment of symptomatic carotid stenosis. Differences in carotid plaque morphology and a higher incidence of microemboli and cerebrovascular events during and after CAS compared with CEA may account for these inferior results. Conclusions Currently, most symptomatic patients are inappropriate candidates for CAS. Improved CAS technology referable to stent design and embolic protection strategies may alter this conclusion in the future. [ABSTRACT FROM AUTHOR]

Abstract Objective There is currently no clear consensus regarding the optimal perioperative antiplatelet therapy regimen for carotid surgery. Therefore, associations between different antiplatelet therapies and the risk of stroke or death and perioperative complications after carotid endarterectomy on a national level in Germany were analyzed. Methods Overall, 117,973 elective carotid endarterectomies for asymptomatic or symptomatic carotid artery stenosis between 2010 and 2014 were included. Data were extracted from the statutory nationwide quality assurance database. The primary outcome was any in-hospital stroke or death until discharge from the hospital. Secondary outcomes were any major stroke or death, death alone, stroke, myocardial infarction, local bleeding, and any local complications (cranial nerve palsy, severe bleeding, acute occlusion). Descriptive statistics and multilevel multivariable regression analyses were applied. Single-agent therapy with aspirin was used as reference. Results Patients were predominantly male (68%), with a mean age of 71 years. Carotid stenosis was symptomatic in 40%. Of all patients, 82.8% were treated perioperatively by monotherapy with aspirin alone, 2.7% received other platelet inhibitors, and 4.8% of the patients were operated on under dual antiplatelet therapy. The primary outcome occurred in 1.8% of all patients. Multilevel multivariable regression analysis revealed that the combined stroke and death rate of patients with no perioperative antiplatelet therapy was significantly higher (risk ratio [RR], 1.21; 95% confidence interval [CI], 1.04-1.42) compared with the group of patients receiving monotherapy. The same was true for the major stroke and death rate (RR, 1.23; 95% CI, 1.02-1.48). In contrast, dual antiplatelet therapy was associated with a lower risk of death alone (RR, 0.67; 95% CI, 0.51-0.88) but with a significantly higher rate of secondary bleeding requiring reoperation (RR, 2.16; 95% CI, 1.88-2.50). Conclusions This study shows that the risk of stroke or death was significantly higher in patients without any perioperative antiplatelet therapy. In contrast, dual antiplatelet therapy vs aspirin monotherapy was associated with a lower risk only of perioperative death but with a higher risk of neck bleeding until discharge. Perioperative antiplatelet therapy was significantly associated with a decreased in-hospital stroke and death risk. Further studies are needed to evaluate the risk-benefit ratio of single vs dual antiplatelet therapy. Graphical abstract [ABSTRACT FROM AUTHOR]

Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P =.16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I 2 = 0%; P =.03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P =.0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P =.005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I 2 = 0%; P =.005). A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly. [ABSTRACT FROM AUTHOR]

Background The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. Methods All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm 3 and correlated with 30-day rates of stroke and stroke/death by χ 2 , multivariate analysis, Pearson correlation, and receiver operating characteristic curves. Results A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm 3 (interquartile range [IQR], 7000 mm 3 ). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm 3 (IQR, 31,000 mm 3 ) vs 1000 mm 3 (IQR, 7000 mm 3 ; P = .01) and 4500 mm 3 (IQR, 17,450 mm 3 ) vs 1000 mm 3 (IQR, 7000 mm 3 ; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm 3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm 3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm 3 (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P = .03). Conclusions CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm 3 could be considered a significant predictor for postoperative stroke after carotid revascularization. [ABSTRACT FROM AUTHOR]

The carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies a patient's future embolic risk. In natural history studies, patients with moderate degrees of stenosis have had a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced transient ischemic attack (TIA) or stroke were found to have both moderate and severe degrees of stenosis. We examined the association of carotid artery stenosis severity with the outcomes for symptomatic patients who had undergone carotid intervention, including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcervical carotid artery revascularization (TCAR). The Society for Vascular Surgery Vascular Quality Initiative database was queried for all patients who had undergone TFCAS, CEA, or TCAR between 2003 and 2020. The patients were stratified into two groups according to stenosis severity—nonsevere (0%-69%) and severe (≥70%). The primary end point was periprocedural neurologic events (stroke and TIA). The secondary end points were periprocedural death, myocardial infarction (MI), and the composite outcomes of stroke/death and stroke/death/MI in accordance with the reporting standards for carotid intervention. Of the 29,614 included symptomatic patients, 5296 (17.9%) had undergone TCAR, 7844 (26.5%) TFCAS, and 16,474 (55.6%) CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was significantly lower for the patients with severe stenosis than for those with nonsevere stenosis (2.6% vs 3.2%; P =.024). In the TCAR cohort, the periprocedural neurologic even rate was lower for those with severe stenosis than for those with nonsevere stenosis (3% vs 4.3%; P =.033). No similar difference was noted for the TFCAS cohort, with a periprocedural neurologic event rate of 3.8% in the severe group vs 3.5% in the nonsevere group (P =.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of postprocedural neurologic events after CEA (odds ratio, 0.75; 95% confidence interval, 0.6-0.92; P =.007) and TCAR (odds ratio, 0.83; 95% confidence interval, 0.69-0.99; P =.039) but not after TFCAS. Severe carotid stenosis, in contrast to more moderate stenosis degrees, was associated with decreased rates of periprocedural stroke and TIA in symptomatic patients undergoing TCAR and CEA but not TFCAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology and their inherent risks with carotid revascularization procedures. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective: Postcarotid endarterectomy hypertension (HTN) is associated with neurological and cardiac complications. The purpose of this study was to assess the influence of eversion carotid endarterectomy (E-CEA) and conventional carotid endarterectomy (C-CEA) on postoperative blood pressure in the first 4 days after surgery. Methods: Two hundred seventy-six consecutive CEAs that were performed between February 2008 and September 2009 were reviewed retrospectively with a computerized registry. After exclusion of patients with severe stroke (modified Rankin Scale of 3-5), prior contralateral and ipsilateral carotid surgery and more than 70% stenosis of the contralateral carotid artery, 201 cases remained (E-CEA group: n = 100 vs C-CEA group: n = 101) for analysis. Results in terms of systolic blood pressure, use of intravenous and oral vasodilators, alterations of the existing antihypertensive medications, and perioperative complications (neck hematoma, myocardial infarction, stroke, and death) were compared. Results: Groups were similar with regard to age, sex, and cardiovascular risk factors except for a higher incidence of nicotine use (59% vs 43%; P = .02) in the C-CEA group. Patients in the C-CEA group had a significantly higher percentage of symptomatic carotid artery stenosis (54% vs 23%, respectively; P < .0001). Despite a lower preoperative (baseline) mean systolic blood pressure (130 mm Hg vs 135 mm Hg; P = .02) patients in the E-CEA group had a significantly higher mean systolic blood pressure in the postoperative course up to the day 4 after surgery (134 mm Hg vs 126 mm Hg; P < .0001) and required more frequent intravenous (28% vs 9.9%; P = .001) and oral vasodilators (54% vs 27.7%; P = .0002) compared to those in the C-CEA group. Two-thirds (14 of 21 = 66%) of patients in the E-CEA group with preoperative high blood pressure (systolic blood pressure ≥140 mm Hg and diastolic pressure ≥90 mm Hg) required vasodilators and only one-third (11 of 33 = 33%) in the C-CEA group (P = .03). Atropine use due to bradycardia was necessary after 8 cases (8%) in the C-CEA group and only after 1 case (1%) in the E-CEA group (P = .03). Furthermore, the dosage of existing antihypertensive medications was increased and/or additional medications were prescribed twofold more in the E-CEA group (33% vs 17%; P = .009). No statistically significant difference was noted in the perioperative complication rate. Conclusion: It is concluded that E-CEA is associated with significantly higher postoperative blood pressure that persists for at least 4 days after surgery. Patients with inadequate preoperative high blood pressure control are particularly at risk after E-CEA. [Copyright &y& Elsevier]

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely <14 days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and coronary artery bypass grafting, we suggest CEA before, or concomitant with, coronary artery bypass grafting to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience. [ABSTRACT FROM AUTHOR]

Background and Purpose: Since publication of previous meta-analyses comparing endovascular and surgical treatment of patients with carotid artery stenosis, two further large-scale trials have been conducted, almost doubling the number of patients available for analysis. Therefore, it is justified to update these meta-analyses. Methods: Relevant trials were identified by a search of the literature using an electronic database. Trials with a nonrandomized patient allocation were not included. We focused on events within 30 days after intervention and made two sets of analysis: one with all trials and one with large trials exclusively including symptomatic patients. Results: Only Endartérectomie Versus Angioplastie chez les patients ayant une Sténose carotide Symptomatique Serrée (EVA3S) and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) were identified to be included in the updated meta-analysis. In total, 2985 patients were included in eight trials of which 89% were symptomatic. In contrast to previous analyses, this meta-analysis found a significant difference between the odds ratios of any stroke or death within 30 days after treatment with a disadvantage of endovascular treatment when analysing all trials (odds ratio [OR], 1.38; 95% confidence interval [CI] 1.04-1.83; P = .024). Significant heterogeneity was found for this analysis (P = .03). The increase of the odds of suffering from disabling stroke or death in the endovascular compared with the surgical group was not significant in the analysis of all trials (OR, 1.37; 95% CI, 0.92-2.04; P = .12); no heterogeneity was found for this analysis (P = .27). In the analysis of the large trials with symptomatic patients, the OR for the endpoint any stroke or death was 1.29 (95% CI 0.94-1.76; P = .11); with a hint for heterogeneity (P = .10). For the endpoint disabling stroke or death, the OR was 1.33 (95% CI 0.89-1.93; P =.17) without any heterogeneity (P = .58). Conclusion: The expressiveness of this meta-analysis is limited by the heterogeneity of some tests. The main result is that surgical treatment still remains the gold standard for treatment of patients with symptomatic carotid artery stenosis, who do not have an increased surgical risk. Carotid artery stenting is neither safer than nor as safe as carotid endarterectomy in large clinical trials when short-term stroke and death rates are taken into account. Further recruitment into ongoing randomized trials is strongly recommended. [Copyright &y& Elsevier]

To report results of duplex ultrasound evaluation of consecutive patients after carotid stenting with the double layer Carotid Artery Stent designed to Prevent Embolic Release (CASPER) stent system. Between January 2014 and June 2017, a single-center, retrospective study of 101 consecutive patients (21.8% female; median age, 72.1 years) was performed. Patients with internal carotid artery stenosis treated with the CASPER stent were included. Eligibility criteria for stenting included stenosis of ≥70% of the vessel diameter (or ≥50% diameter with ulceration) in symptomatic carotid artery stenosis or ≥80% stenosis in asymptomatic patients at the carotid artery bifurcation or the proximal cervical internal carotid artery. Duplex ultrasound examination was performed before and within 24 hours of implantation as well as at 14 days, and 3, 6, and 12 months. At the 12-month follow-up visit, moderate in-stent restenosis (ISR) (≥50% and <70%) was detected in three stents (2.8%) and severe (≥70%) ISR in two (1.9%; including one case of stent occlusion). All but the two latter patients remained asymptomatic during the follow-up period. One patient required retreatment for ISR after a minor stroke and another patient with stent occlusion also re-presented with a minor stroke. Multivariable logistic regression was unable to detect any significant factors associated with ISR. Duplex ultrasound examination after carotid stenting is a useful tool for patient follow-up and determination of ISR. We found a low incidence of ISR assessed by duplex ultrasound examination at 12 months after CASPER stenting, but further studies are warranted. [ABSTRACT FROM AUTHOR]

Objective: Increased vascularization is considered an important contributing factor for plaque vulnerability. Microvascular proliferative disease in patients with diabetes results in renal damage and visual loss. We assessed the hypothesis that vascularization in carotid atherosclerotic tissue is increased in diabetic patients, especially in the critical shoulder regions of the plaque. Methods: Carotid endarterectomy specimens, clinical data, and blood samples were collected from patients with symptomatic carotid artery stenosis (median 85 days after clinical event) and pharmacologic treatment for diabetes (n = 26) or no diabetes (n = 85). Plaques were fixed in formalin and transverse tissue sections prepared. Histopathology and immunohistochemistry were performed for detection of endothelial cells (anti-CD34), macrophages (anti-CD68), vascular endothelial growth factor (VEGF), and its receptor (VEGFR-2). Neovascularization was assessed as CD34+ neovessel density in the entire section area and by the presence or absence of CD34+ vessels in the shoulder and cap regions of the plaques. Results: The patient groups did not differ significantly in neovascularization in the entire transverse sections (2.0 vs 2.1 vessels/mm2; P = .61) or in the fibrous cap (52% of the patients in both groups; P = .95). Neovascularization of the plaque shoulder regions was observed in 52% of the diabetic patients and in 26% of the nondiabetic patients (P = .028). VEGF-stained areas were similar in the two patient groups (0.4% and 0.2% of shoulder area; P = .61). Patients with diabetes had more VEGFR-2 (1.0% vs 0.2% of shoulder area; P < .016) and less CD68 staining (0.4% vs 3.6% of shoulder area; P < .008). Time from clinical event to surgery was positively associated with neovascularization of the plaque shoulder regions (≤90 days, 18% of patients; >90 days, 50% of patients; P = .002), independently of diabetes status. Conclusions: Diabetes was associated with increased vascularization of the shoulder regions in patients with symptomatic carotid atherosclerotic plaques. This was accompanied by increased expression of VEGFR-2. The increased vascularization of the plaque shoulder regions may help explain why patients with diabetes are at increased risk of atherosclerotic complications. [ABSTRACT FROM AUTHOR]