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Background: The purpose of the present study was to clarify the characteristics of endothelial cell (EC) proliferation in intraplaque microvessels in vulnerable plaques and impact on clinical results., Methods: The present study included 76 patients who underwent carotid endarterectomy. Patients were classified into three groups based on their symptoms: asymptomatic, symptomatic without recurrent ischemic event, and symptomatic with recurrent ischemic event. MR plaque imaging was performed and surgical specimens underwent immunohistochemical analysis. The number of CD31 + microvessels, and Ki67 + and CD105 + ECs in the carotid plaques was quantified, as measurements of maximum CD31 + microvessel diameter., Results: MR plaque imaging yielded 41 subjects (54.0%) diagnosed with plaque with intraplaque hemorrhage (IPH), 14 subjects (18.4%) diagnosed with fibrous plaques, and 21 (27.6%) subjects diagnosed with lipid-rich plaques. The average largest diameter of microvessel in fibrous plaques, lipid-rich plaques, and plaque with IPH was 12.7 ± 4.1 μm, 31.3 ± 9.3 μm, and 56.4 ± 10.0 μm, respectively (p < 0.01). Dilated microvessels (>40 μm) were observed in 9.6% of plaques with IPH but only in 2.8% of lipid-rich plaques and 0% of fibrous plaques (p < 0.01). Ki67 + /CD31 + ECs were identified in 2.8 ± 1.2% of fibrous plaques, 9.6 ± 6.9% of lipid-rich plaques, and in 19.5 ± 5.9% of plaques with IPH (p < 0.01). The average largest diameter of microvessels in the asymptomatic group was 17.1 ± 8.7 μm, 32.3 ± 10.8 μm in the symptomatic without recurrence group, and 55.2 ± 13.2 μm in the symptomatic with recurrence group (p < 0.01)., Conclusion: Dilated microvessels with proliferative ECs may play a key role in IPH pathogenesis. Furthermore, dilated microvessels are likely related to clinical onset and the recurrence of ischemic events. The purpose of the present study was to clarify the characteristics of EC proliferation in intraplaque microvessels in vulnerable plaques and their impact on clinical results, focusing on dilated intraplaque microvessels.

Background: The dual-layer nitinol CASPER stent was designed to prevent plaque prolapse into its strut and periprocedural stroke., Objective: To conduct a clinical trial for government approval of the device in patients at either high or normal risk for carotid endarterectomy (CEA)., Methods: Eligible patients had ≥50% symptomatic stenosis or ≥80% asymptomatic stenosis according to the North American Symptomatic Carotid Endarterectomy Trial methods (peak systolic velocity 130 and 230 cm/s on ultrasonography, respectively). The primary endpoint was the lack of major adverse events (MAEs), defined as death, stroke, and myocardial infarction within 30 days, and ipsilateral stroke within 1 year. The performance goal was set at 90.5%. MAE rates were also compared between the CEA high- and normal-risk groups., Results: 140 carotid artery stenting procedures, including 40% of patients at high risk and 60% at normal risk for CEA, were performed in 13 institutes. MAEs occurred in two cases (one intraprocedural and one postprocedural stroke), and the MAE rate was 1.4%. The non-MAE rate was 98.6% according to Kaplan-Meier analysis, which was superior to the previously set performance goal. The deployment success, target lesion revascularization (TLR), in-stent restenosis, and cerebrovascular event rates were 99.3%, 2.4%, 8.5%, and 7.2%, respectively. The MAE rate in patients with normal CEA risk was 1.2%, which was similar to the high-risk CEA group, with no significant difference due to the small number of MAEs., Conclusions: The MAE rate following use of the CASPER stent was low (1.4%). The MAE, deployment success, TLR, in-stenosis, and cerebrovascular event rates were similar to those of previous reports., Competing Interests: Competing interests: HI received speakers’ bureau/honoraria from Medtronic Japan Co. and Stryker Japan Co. NS received speakers’ bureau/honoraria and research funding from Terumo Co. YM received speakers’ bureau/honoraria from GE Healthcare Co, Stryker Co, Medico’s Hirata Co, Medtronic Japan Co, Century Medical Co, Takeda Pharmaceutical Co, Otsuka Pharmaceutical Co, and Fuji Systems Co. HY received speakers’ bureau/honoraria from JIMRO Co, Terumo Co, Johnson & Johnson Co, Medtronic Japan Co, Medico’s Hirata Co, and Stryker Japan Co. SY received speakers’ bureau/honoraria from Terumo Co, Boehringer-Ingelheim Co, Daiichi Sankyo Co, Bayer Co, Bristol-Meyers Squibb Co, Stryker Japan Co, Medtronic Japan Co, Johnson & Johnson Co, Kaneka Medics Co, Otsuka Pharmaceutical Co, Biomedical Solutions Co, and Sanofi Co. AI received speakers’ bureau/honoraria from Medtronic Japan Co, Stryker Japan Co, Daiichi Sankyo Co, Otsuka Pharmaceutical Co, and Kaneka Medics Co. HO received speakers’ research funding from Terumo Co. TH received speakers’ bureau/honoraria from Stryker Japan Co, Johnson & Johnson Co, Kaneka Medics Co, and Terumo Co, and research funding from Stryker Japan Co. and Medtronic Japan Co. KI received research funding from the Japan Agency for Medical Research and Development, grants-in-aid, the Japan Ministry of Health, Labor and Welfare, KAKENHI grant from the Japan Society for the Promotion of Science, Otsuka Pharmaceutical Co, Eisai Co, and Kaneka Medics Co., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Carotid endarterectomy (CEA) is the main treatment for atherosclerotic plaque of the cervical internal carotid artery. The surgical anatomy of the carotid arteries was studied in the carotid triangle of 49 cadavers. The carotid bifurcation was located at the level of the lower third of C-3. The superior thyroid artery arose from the anterior wall of the external carotid artery in 70% of specimens and from the distal portion of the common carotid artery in 30%. The lingual artery arose as a separate trunk between the origins of the superior thyroid and facial arteries in 81% of specimens, with the facial artery from a common trunk in 18%, and with the superior thyroid artery in 1%. The occipital artery arose from the posterior aspect of the external carotid artery above the level of origin of the facial artery in 57% of specimens, between the origins of the facial and lingual arteries in 32%, and below the origin of the lingual artery in 11%. The origin of the occipital artery was positioned low and the distal portion of the occipital artery was crossed by the hypoglossal nerve in 20%. The ascending pharyngeal artery arose from the posterior wall of the external carotid artery above the level of origin of the lingual artery in 66% of specimens, below the origin of the lingual artery in 9%, from the proximal portion of the occipital artery in 19%, from the carotid bifurcation in 2%, and from the internal carotid artery in 2%. The branches of the external carotid artery are the key landmarks for adequate exposure and appropriate placement of cross-clamps on the carotid arteries. It is necessary to understand the surgical anatomy of the carotid arteries to carry out successful removal of plaque and minimize postoperative complications in a bloodless surgical field.