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Objective: To investigate the influence of carotid endarterectomy (CEA) on cerebral perfusion and cognitive function in patients with internal carotid artery stenosis (ICA)., Methods: Patients were prospectively enrolled in this study. Shunted patients were excluded. Cerebral perfusion was measured by magnetic resonance (MR) perfusion weighted imaging (PWI) and diffusion weighted imaging (DWI) in 46 patients with >65% ICA (31 males, 64.5 ± 6.7 years) 1 week before and 6 weeks after CEA. Cognitive function was assessed using the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) 1 week before and 6 weeks after CEA., Results: After CEA, perfusion parameters from PWI decreased, including mean transit time (MTT) (21.07 ± 7.36 vs. 14.27 ± 6.22, p < .0001), time to peak (TTP) (28.69 ± 8.54 vs. 23.45 ± 4.25, p = .001), arrive time (T0) (19.89 ± 7.32 vs. 15.20 ± 3.51, p = .001), and relative cerebral blood volume (rCBV) (11.48 ± 3.50 vs. 7.53 ± 3.17, p < .0001). A significant improvement was observed in MoCA (20.48 ± 1.70 vs. 22.04 ± 1.48, p = .001). Spearman's rank correlation analysis between TTP and MoCA scores demonstrated a linear relationship with an excellent correlation coefficient (R = -.893, p < .001). Linear regression indicated that diabetes was a risk factor for cognitive improvement in patients with ICA (p = .014). Further analysis showed that patients with DM performed worse in MoCA after the procedure (with-DM 21.15 ± 1.28 vs. non-DM 22.4 ± 1.46, p = .010) while the baselines were similar (non-DM: 20.3 ± 1.8 vs. with-DM: 20.9 ± 1.4, p = .362)., Conclusion: CEA could improve the cerebral perfusion and the cognitive function in un-shunted ICA patients. Cerebral reperfusion was an important factor for cognitive improvement. Diabetes had a negative effect on cognitive improvement after CEA., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Aim: The aim of this study was to deal with complications that can be managed by vascular surgery., Methods: From March 2000 through May 2004, 171 patients (112 male, 59 female, mean age 66.2 years) underwent carotid artery stenting (CAS). Of these 171 interventions, 154 were CAS with percutaneous trasluminal angioplasty (PTA), 5 CAS without PTA, and 12 patients had only a PTA., Results: In 171 patients who received CAS, 5 suffered a stroke within 7 days and 3 a transient ischemic attack. Twenty-one percent of the patients developed an in-stent restenosis >50% within 6 months following the intervention. Twenty-two patients with a recurrent in-stent restenosis were treated by re-PTA. Eight patients of this group of 22 re-PTAs developed a recurrent in-stent restenosis. They were converted with patch angioplasty or PTFE interposition. These 8 conversions were performed without morbidity or mortality., Conclusions: The preferable operative technique in patients with recurrent in-stent restenosis is open conventional operation with stent removal and patch angioplasty or graft interposition. The procedure can be performed at a low risk. In our series, we had no morbidity and mortality, and no cranial nerve lesion.

Background: Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy. Cerebral embolization is the most devastating complication of CAS, and the echogenicity of carotid plaque has been indicated as one of the risk factors involved. This is the first study to analyze the role of a computer-assisted highly reproducible index of echogenicity, namely the gray-scale median (GSM), on the risk of stroke during CAS., Methods and Results: The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) registry included 418 cases of CAS collected from 11 international centers. An echographic evaluation of carotid plaque with GSM measurement was made preprocedurally. The onset of neurological deficits during the procedure and the postprocedural period was recorded. The overall rate of neurological complications was 3.6%: minor strokes, 2.2%, and major stroke, 1.4%. There were 11 of 155 strokes (7.1%) in patients with GSM < or =25 and 4 of 263 (1.5%) in patients with GSM >25 (P=0.005). Patients with severe stenosis (> or =85%) had a higher rate of stroke (P=0.03). The effectiveness of brain protection devices was confirmed in those with GSM >25 (P=0.01) but not in those with GSM < or =25. Multivariate analysis revealed that GSM (OR, 7.11; P=0.002) and rate of stenosis (OR, 5.76; P=0.010) are independent predictors of stroke., Conclusions: Carotid plaque echolucency, as measured by GSM < or =25, increases the risk of stroke in CAS. The inclusion of echolucency measured as GSM in the planning of any endovascular procedure of carotid lesions allows stratification of patients at different risks of complications in CAS.

Carotid restenosis after endarterectomy is observed in up to 24.1% of patients with long-term follow up. Indication for reintervention in asymptomatic patients however should be reserved for greater than 80% stenosis. Treatment options include repeat surgical reconstruction as well as intraoperative or percutaneous balloon angioplasty +/- stenting. We compared our past experience with 66 operative reconstructions in 64 patients with a recent series of 60 patients who underwent intraoperative balloon-dilatation and stenting. After conventional surgery 2 patients (3.1%) suffered a permanent neurological deficit, one patient developed a TIA (1.5%). After intraoperative dilation and stenting 8 patients (13.3%) suffered a stroke; 2 patients died after surgery (one stroke, one myocardial infarction) (mortality 3.3%). When compared to conventional operative repair intraoperative carotid balloon angioplasty and stenting of restenosis is complicated by a substantial increase in morbidity and mortality and cannot be recommended as routine therapy.

Carotid restenosis has been a well-recognized, though not well-understood, long-term complication of carotid endarterectomy. Various factors contribute to recurrent stenosis, but the chief cause is technical faults during the primary procedure. Redo endarterectomy or graft reconstruction are the traditional and most effective procedures for treating symptomatic or high-grade (> 80%) asymptomatic restenotic lesions. To reduce the potential for carotid restenosis, eversion endarterectomy is recommended as the technique of choice for de novo carotid disease treatment. Angioscopy is useful in detecting correctable technical errors that could predispose to restenosis.

Objectives: To detect subtle cognitive dysfunction in non-demented patients with either cerebral (cAD) or peripheral (pAD) arteriosclerotic disease, and to evaluate in these patients the effects on cognitive functions of carotid endarterectomy and bypass surgery, respectively., Design: Case-control study., Setting: Tertiary care referral center., Participants: Eighty consecutive patients with moderate to high-grade stenosis of the internal carotid artery (ICA) (mean age +/- SD, 62 +/- 8 years), 53 patients with stenoses of the peripheral arteries (60 +/- 10 years), and 80 healthy volunteers (58 +/- 15 years) enrolled in a study on healthy aging. Cerebral and peripheral arteriosclerotic disease was verified by digital subtraction angiography, and all patients were screened for confounding effects of concomitant diseases., Main Outcome Measures: Cognitive functions by event-related visual P300 potentials., Results: Patients with cAD showed prolonged P300 latencies and reduced P300 amplitudes, whereas pAD patients had reduced P300 amplitudes only. On an individual scale, 25% of cAD patients, but only 6% of pAD patients, revealed P300 abnormalities. In the cAD, but not in the pAD patients, the P300 latencies were especially prolonged in the older patients, but other factors such as sex, cerebral symptoms, degree of ICA stenosis, and premorbid intelligence did not play any role in either group. Within 1 to 2 weeks of surgery, the P300 latencies shortened in both cAD and pAD patients with high initial values., Conclusions: As demonstrated by P300 potentials, even nondemented arteriosclerotic patients reveal signs of subtle cognitive dysfunction affecting especially the older cAD patient. In the short-term, carotid endarterectomy presumably improves cognitive functions unspecifically in nondemented patients with a higher initial degree of P300 abnormality.

In case of multi-locular supra-aortic lesions the correction of a hemodynamic carotid stenosis has priority over any reconstruction of another supra-aortic lesion. Thus carotid endarterectomy leads to an improvement of the global cerebral perfusion. Patients with a classical vertebro-basilar insufficiency profit most by these operations. A subclavian or vertebral reconstruction or PTA is indicated only if the patient is not symptom-free after the carotid endarterectomy.