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Purpose: We aimed to evaluate the long-term outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients who underwent both procedures on different sides., Methods: In this single-center retrospective study (2001-2019), 117 patients (men, N = 78; median age at CEA, 64.4 [interquartile range {IQR}, 57.8-72.2] years; median age at CAS, 68.8 [IQR, 61.0-76.0] years) with ≥50% internal carotid artery stenosis who had CEA on one side and CAS on the other side were included. The risk of restenosis was estimated by treatment adjusted for patient and lesion characteristics., Results: Neurological symptoms were significantly more common (41.9% vs 16.2%, P<0.001) and patients had a significantly shorter mean duration of smoking (30.2 [standard deviation {SD}, 22.2] years vs 31.8 [SD, 23.4] years, P<0.001), hypertension (10.1 [SD, 9.8] years vs 13.4 [SD, 9.1] years, P<0.001), hyperlipidemia (3.6 [SD, 6.6] years vs 5.0 [SD, 7.3] years, P = 0.001), and diabetes mellitus (3.9 [SD, 6.9] years vs 5.7 [SD, 8.9] years, P<0.001) before CEA compared to those before CAS. While the prevalence of heavily calcified stenoses on the operated side (25.6% vs 6.8%, P<0.001), the incidence of predominantly echogenic/echogenic plaques (53.0% vs 70.1%, P = 0.011) and suprabulbar lesions (1.7% vs 22.2%, P<0.001) on the stented side was significantly higher. Restenosis rates were 10.4% at 1 year, 22.3% at 5 years, and 33.7% at the end of the follow-up (at 11 years) for CEA, while these were 11.4%, 14.7%, and 17.2%, respectively, for CAS. Cox regression analysis revealed a significantly higher risk of restenosis (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.05-3.10; P = 0.030) for CEA compared to that for CAS. After adjusting for relevant confounding factors (smoking, hypertension, diabetes mellitus, calcification severity, plaque echogenicity, and lesion location), the estimate effect size materially did not change, although it did not remain statistically significant (HR, 1.85; 95% CI, 0.95-3.60; P = 0.070)., Conclusion: Intra-patient comparison of CEA and CAS in terms of restenosis tilts the balance toward CAS., Competing Interests: The authors have declared that no competing interests exist.

Purpose: We aimed to examine the effectiveness of different therapeutic options for and to identify the possible risk factors of recurrent internal carotid artery (ICA) in-stent restenosis (ISR)., Methods: Forty-six ICA ISRs, which were reintervened at least once, were retrospectively analyzed regarding clinical and imaging characteristics, as well as invasive treatment type (percutaneous transluminal angioplasty [PTA] with a plain balloon, PTA with a drug-eluting balloon [DEB], re-stenting) used., Results: The median follow-up was 29.5 months (IQR, 8.5-52.8 months) in patients who underwent reintervention for ICA ISR. Stent occlusion occurred in 3 patients (6.5%). One ISR recurrence was noted in 10 patients (21.7%); reintervention was carried out in 7 cases (7/10 [70%]; PTA, N = 5; PTA with a DEB, N = 1; re-stenting, N = 1), while 3 patients (3/10; 30%) received best medical treatment. Two ISR recurrences were observed in 3 patients (6.5%); all of them underwent reintervention (PTA, N = 1; PTA with a DEB, N = 2). Three ISR recurrences were seen in 1 patient (2.2%), who was treated with PTA. No recurrence was observed in those patients, who had DEB treatment. Multiple logistic regression analysis revealed statin therapy to be a protective factor against recurrent ISR (OR, 0.17; 95% CI, 0.03-0.84; P = .029)., Conclusion: Our study suggests that PTA with a DEB is the most effective for the treatment of recurrent ISR, and confirms the importance of statin use in patients who have had a carotid reintervention.

Összefoglaló. A tudomány jelenlegi állása szerint - csoportok összehasonlítására épülő matematikai-statisztikai eszközökkel - a leginkább hatékonynak és hatásosnak vélt kezelési módszerek szisztematikus elemzése mentén, a bizonyítékokon alapuló irányelveken nyugvó gyógyító munkát tekintjük követendőnek. A nyaki verőérszűkület ellátása esetén az utóbbi években elkészült mind a hazai, mind az európai irányelv, mindemellett a társszakmák irányelveiben is megjelentek kezelési javaslatok. Közleményünkben összehasonlítottuk a témában publikált magyar, angol, német és olasz nyelvű, valamint az európai társaságok által kiadott irányelveket. Az irányelvek alapelveikben hasonlóak, formailag és tartalmilag azonban jelentős (időnként egymásnak ellentmondani látszó) különbségeket találhatunk. Az ellentmondások három leggyakoribb oka: 1) az egyes irányelvek által kitűzött célok különbözősége, 2) az aszimptomatikus és szimptomatikus betegcsoport definíciói, valamint 3) az eltérő evidenciaszintek. Az irányelvek összevetése alapján a tünetes, szignifikáns nyaki verőérszűkületek sebészi ellátása evidenciának tekinthető. A szimptomatikus nyaki verőérszűkület a definíció szerint ellenoldali cerebralis ischaemia okozta, tranziens vagy definitív plegia, paresis, aphasia és az azonos oldali arteria centralis retinae embolisatiója miatti amaurosis fugax. A tünetmentes nyaki verőérszűkületek ellátása tekintetében az európai és a nemzeti irányelvek nem azonosak, ezen esetek terápiás döntése egyéni mérlegelést igényel. Tünetmentes, 70%-os stenosis esetén vascularteam-konzílium javasolt. Orv Hetil. 2020; 161(51): 2139-2145. Summary. The correct practice is the one that is proven to be the most effective based on systematic statistical analyses of different treatment methods, and is applied according to evidence-based principles. In recent years, not only has the European Society of Vascular Surgery created a guideline about the management of supra-aortic steno-occlusive disease, but some nations' vascular surgical societies and related disciplines have also developed their own guidance. In this paper, the guidelines by the European societies on the clinical care of patients with carotid artery luminal narrowing is compared to national guidelines published in Hungarian, English, German, and Italian. Although the fundamental points of the guidelines are similar, there are some important differences among them both in presentation and in content; as a result, they sometimes appear to be contradictory. The three main sources of inconsistency are the various goals, the discrepancy in the definition of symptomatic and asymptomatic carotid artery stenosis, and the bias arising from the use of distinct evidence levels. A comparison of guidelines suggests that the treatment of symptomatic significant carotid artery stenosis with surgery can be considered evidence. Symptomatic carotid artery stenosis is defined as transient or definite plegia, paresis, aphasia due to cerebral ischemia, and monocular blindness caused by embolism in the central retinal artery. However, in the case of asymptomatic 70% or greater carotid artery stenosis, the guidelines are quite heterogeneous, and these patients require individual consideration and a vascular team decision is recommended. Orv Hetil. 2020; 161(51): 2139-2145.

Objective: Our aim was to identify the incidence of and predictors for common carotid artery (CCA) stent fractures (SFs) and to examine the effect of SFs on the development of in-stent restenosis (ISR)., Methods: Seventy patients (37 women; median age, 60.9 years) who were stented for significant (≥60%) proximal CCA stenosis from 2006 to 2016 and revisited us to determine SF using fluoroscopy in 2018 were evaluated. Seventy stents were deployed; among them 87.1% were balloon-expandable and 12.9% were self-expandable. SFs were classified as type I (fracture of one strut), type II (fracture of multiple struts without stent deformity), type III (fracture of multiple struts with stent deformity), type IV (complete fracture of the stent without a gap), and type V (complete fracture of the stent with a gap). Duplex ultrasound examination was used for monitoring stent patency. Mann-Whitney U and Fisher's exact tests, Kaplan-Meier and logistic regression analyses, and a log-rank test and a gamma correlation analysis were applied as statistical methods., Results: The patients were followed for 75.5 months (range, 47-109 months). Significant (≥70%) ISR was observed in eight patients (11.4%). Reintervention was performed in four cases (5.7%). Twenty-seven SFs (38.6%; type I, 8; type II, 10; type III, 4; type IV, 2; and type V, 3) were found. Calcification was shown to be a significant predictor for SF (odds ratio, 13.2; 95% confidence interval, 3.9-45.1; P < .001). There was no significant difference between the fractured and the nonfractured group regarding the number of patients with ISR and reintervention (P = .701 and P = .636, respectively). Neither did the primary patency rates differ significantly (P = .372) in patients with and without SF., Conclusions: Fractures frequently occur in a wide variety of stent devices deployed in the proximal CCA, but SFs seem to have no effect on ISR and reintervention., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Although the association between vulnerable lesions and cardiovascular events is well established, little is known about their relationship to postsurgery restenosis. To address this issue, we initiated a prospective, nonrandomized study to examine the femoral plaques on both sides in patients who were undergoing eversion carotid endarterectomy (CEA) and were longitudinally followed-up for early restenosis development., Methods: The final analysis enrolled 321 patients (189 women) with a median age of 67.0 years (interquartile range, 59.0-73.0 years), who underwent eversion CEA (2005 to 2007). Using duplex ultrasound scanning, we evaluated 321 common femoral atherosclerotic lesions on the day before CEA. A quantitative scale was used to grade the size of plaques as grade 1, one or more small plaques (<20 mm2); grade 2, moderate to large plaques; and grade 3, plaques giving flow disturbances. The plaque morphology in terms of echogenicity was graded as echolucent, 1; predominantly echolucent, 2; predominantly echogenic, 3; echogenic 4; or calcified, 5. The plaque surface was categorized as smooth, irregular, or ulcerated. The patients underwent carotid duplex ultrasound imaging at 6 weeks and at 6, 12, and 24 months after CEA. Mann-Whitney U test, chi2 test, and multivariate logistic regression were used for statistical evaluation., Results: Internal carotid artery restenosis of > or = 50% was detected in 33 patients (10.28%) in the operated region. Neither the size (grade 1, P = .793; grade 2, P = .540; grade 3, P = .395) nor the surface characteristics of the femoral plaques (smooth, P = .278; irregular, P = .281; ulcerated, P = .934) were significantly different between the patients with and without carotid restenosis. Echolucent-predominantly echolucent femoral lesions were an independent predictor of recurrent carotid stenosis (adjusted odds ratio, 5.63; 95% confidence interval, 2.14-10.89; P < .001)., Conclusion: Ultrasound evaluation of femoral plaque morphology before CEA can be useful for identifying patients at higher risk for carotid restenosis., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Carotid stenting is a minimally invasive treatment for extracranial carotid artery stenosis. Stent design may affect technical success and complications in a certain subgroup of patients. We examined the wall adaptability of a new closed-cell carotid stent (NexStent), which has a unique rolled sheet design. Forty-one patients had 42 carotid arteries treated with angioplasty and stenting for internal carotid artery stenosis. The mean patient age was 65 +/- 10 years. All patients underwent high-resolution computed tomographic angiography after the stent implantation. Data analysis included pre- and postprocedural stenosis, procedure complications, plaque calcification, and stent apposition. We reviewed the angiographic and computed tomographic images for plaque coverage and stent expansion. All procedures were technically successful. Mean stenosis was reduced from 84 +/- 8% before the procedure to 15.7 +/- 7% after stenting. Two patients experienced transient ischemic attack; one patient had bradycardia and hypotension. Stent induced kinking was observed in one case. Good plaque coverage and proper overlapping of the rolled sheet was achieved in all cases. There was weak correlation between the residual stenosis and the amount of calcification. The stent provides adequate expansion and adaptation to the tapering anatomy of the bifurcation.

Objective: Homozygotes for the normal (A) allele of mannose-binding lectin (MBL2) gene have higher risks to develop an early restenosis after eversion carotid endarterectomy (CEA). Activation of the lectin pathway is regulated by C1-inhibitor (C1-INH). The objective of the present study was to determine the predictive value of C1-INH in restenosis after CEA., Methods and Results: C1-INH and MBL-associated serine protease-2 (MASP-2) were determined in samples serially taken from 64 patients with CEA, who were followed-up with carotid duplex scan (CDS) examinations for 14 months. MBL2 genotypes were also determined. Patients with >50% restenosis had lower C1-INH levels at 6 weeks (P=0.0052) and at 4 days (P=0.0277) postsurgery. C1-INH levels at 6 weeks correlated inversely with the CDS values at 14 months (r=-0.3415, P=0.0058), but only in MBL2 A/A homozygotes (r=-0.5044, P=0.0015). Patients with low C1-INH levels (C1-INH <115%) had higher CDS values already at 7 months postsurgery. Patients with MBL2 A/A and low C1-INH levels at 6 weeks postsurgery had 13.97 (95% CI:1.95 to 100.21, P=0.0087) times higher risk to develop an early restenosis. Differences in the MASP-2 concentration were not associated with restenosis., Conclusions: Determining C1-INH levels at 6 weeks postsurgery-together with genotyping of MBL2-might be a useful marker in the identification of patients with high risk for early carotid restenosis.

Background and Purpose: Recently we found that the incidence of restenosis after carotid endarterectomy was significantly higher in patients homozygous for the normal genotype of mannose-binding lectin (MBL2) than in with patients with MBL2 variant genotypes. Several growth factors are also known to contribute to restenosis. Therefore, we investigated whether early postoperative changes in serum vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) concentrations and MBL2 genotypes interact in the development of restenosis., Methods: Eighty-two patients who underwent carotid eversion endarterectomy and were followed up by carotid duplex scan sonography for 14 months were studied. Growth factors were measured preoperatively and 4 days after surgery., Results: Pronounced significant increases in both VEGF and PDGF predicted restenosis but only in patients who were homozygous for the normal MBL2 genotype. In this group, the adjusted odds ratios of restenosis at 14 months in patients with high versus low early VEGF and PDGF increases were 27.73 (2.42 to 317.26) and 9.23 (1.45 to 58.70), respectively., Conclusions: These findings indicate that the development of restenosis depends on both complement activation regulated by the MBL2 gene and pathologic processes leading to enhanced production of VEGF and PDGF during the very early postoperative period.

In this paper the indication, technical details and data from randomised controlled trials of carotid stenting (CAS) are reviewed. The audit data of carotis stenting from our centre of 703 CAS patients from the period between January 1, 2003 and July 31, 2006, including perioperative (24-48 hours) complications is also discussed. The success rate and complication rate from our centre is comparable with the internationally excepted levels. The results of ongoing international trials are awaited to get more detailed answers regarding the advantages and disadvantages of CAS compared to carotid endarterectomy.

Early restenosis following carotid endarterectomy (CEA) is an inflammatory process leading to myointimal hyperplasia of smooth muscle cells. The risk for restenosis is increased in homozygous carriers of the normal (A) allele of mannose-binding lectin (MBL2) gene. Our objective was to study the associations of C3 and as control three non-complement acute-phase reactants (APRs) (C-reactive protein, haptoglobin and alpha2HSglycoprotein) with early restenosis following CEA. We also considered, whether MBL2 genotype relates to C3 levels and to the risk of restenosis. Concentrations of the APRs were determined by radial immunodiffusion or immunoturbidimetric methods in 64 patients who underwent eversion CEA and were followed up with carotid duplex scan (CDS) examinations for at least one year. MBL2 genotypes were determined by a PCR-SSP method. C3 levels increased during the follow-up and correlated with the percentage of restenosis detected by CDS at 14 months postsurgery, in MBL2 A/A allele carriers. Patients with high C3 levels had nearly five-fold higher odds for the presence of significant restenosis (>50% reduction in diameter) even after adjusting for MBL2 genotype, age and gender. By contrast, no such associations were detected between the non-complement APRs and early restenosis. C3 is associated with and might have a direct role in the development of an early restenosis following CEA, which is partially related to an intact MBL lectin pathway, thus determining C3 levels might have clinical importance. On the other hand, our results indicate that the regulation of C3 differs from non-complement APRs.

Background and Purpose: Mannose-binding lectin (MBL) is thought to influence the pathophysiology of cardiovascular disease by decreasing the risk of advanced atherosclerosis and by contributing to enhanced ischemia reperfusion injury. Thus, we investigated the role of MBL in restenosis after eversion endarterectomy in patients with severe carotid atherosclerosis., Methods: In a prospective study, 123 patients who underwent carotid endarterectomy were followed-up by carotid duplex scan (CDS) sonography for 14 months. In a retrospective study, we examined 17 patients and 29 patients, respectively, who had or had not at least 50% restenosis 29 months after carotid eversion endarterectomy. MBL genotypes were analyzed by a polymerase chain reaction-based method, and MBL serum concentrations were measured., Results: In the prospective study in the patients homozygous for the normal MBL genotype, CDS values were significantly higher after 14 months of follow-up compared with the values measured 6 weeks after surgery (P<0.001). In contrast, only a slight increase was registered in patients carrying MBL variant alleles. The differences were much more pronounced in female than in male patients. Similar differences were observed when patients with high and low MBL serum concentrations were compared. In the retrospective study, a significant increase in the frequency of MBL variant genotypes was observed in patients not experiencing restenosis compared with the patients with restenosis (P=0.007)., Conclusions: These results indicate that reoccurrence of stenosis after carotid endarterectomy is partially genetically determined and imply that MBL contributes significantly to the pathophysiology of this condition.