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Background: Transcarotid artery revascularization (TCAR) is an interventional therapy for symptomatic internal carotid artery disease. Currently, the utilization of TCAR is contentious due to limited evidence. In this study, we evaluate the safety and efficacy of TCAR in patients with symptomatic internal carotid artery disease compared with carotid endarterectomy (CEA) and carotid artery stenting (CAS)., Methods: A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that used TCAR for the treatment of symptomatic internal carotid artery disease. The primary outcomes included a 30-day stroke or transient ischemic attack, myocardial infarction, and mortality. Secondary outcomes comprised cranial nerve injury and major bleeding. Pooled odds ratios (ORs) for each outcome were calculated to compare TCAR with CEA and CAS. Furthermore, subgroup analyses were performed based on age and degree of stenosis. In addition, a sensitivity analysis was conducted by excluding the vascular quality initiative registry population., Results: A total of 7 studies involving 24 246 patients were analyzed. Within this patient cohort, 4771 individuals underwent TCAR, 12 350 underwent CEA, and 7125 patients underwent CAS. Compared with CAS, TCAR was associated with a similar rate of stroke or transient ischemic attack (OR, 0.77 [95% CI, 0.33-1.82]) and myocardial infarction (OR, 1.29 [95% CI, 0.83-2.01]) but lower mortality (OR, 0.42 [95% CI, 0.22-0.81]). Compared with CEA, TCAR was associated with a higher rate of stroke or transient ischemic attack (OR, 1.26 [95% CI, 1.03-1.54]) but similar rates of myocardial infarction (OR, 0.9 [95% CI, 0.64-1.38]) and mortality (OR, 1.35 [95% CI, 0.87-2.10])., Conclusions: Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS. Prospective randomized trials comparing the 3 modalities are needed., Competing Interests: Disclosures Dr Matouk is a consultant for Silk Road Medical, MicroVention, Inc, and Penumbra, Inc. Dr Derdeyn is involved in data and safety monitoring at Penumbra (MIND and THUNDER trials), NoNO (ESCAPE NEXT and FRONTIER), and Silk Road (NITE trial); has stock options in Euphrates Vascular; and is a professor and a chair at The University of Iowa. Dr Levy is a shareholder and has ownership interest in NeXtGen Biologics, Claret Medical, Inc, Imperative Care, Inc, Rebound Therapeutics, StimMed, and Three Rivers Medical; is a consultant at Clarion, GLG Consulting, Guidepoint Global, Misionix, Mosaic, and StimMed and at Medtronic Vascular, Inc, Microvetion, and Penumbra, Inc; and has stock options in Rapid Medical Ltd. Dr de Havenon has stock options at Certus and TitinKM, received grant/contract from the National Institutes of Health, and is a consultant at Novo Nordisk. Dr Leira received a grant/contract from the American Stroke Association and is a professor of neurology, neurosurgery, and epidemiology at the University of Iowa. Dr Henninger received a grant/contract from the National Institutes of Health and the US Department of Defense and is an associate professor at the University of Massachusetts Medical School. Dr Chaturvedi received a grant/contract from Mayo Clinic. The other authors report no conflicts.

Symptomatic carotid stenosis and carotid dissection are acute conditions of extracranial cerebrovascular vessels determining transient ischemic attack or stroke. Medical, surgical, or endovascular management are different options to treat these pathologies. This narrative review focused on the management, from symptoms to treatment, of the acute conditions of extracranial cerebrovascular vessels, including post-carotid revascularization stroke. Symptomatic carotid stenosis (> 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria) with transient ischemic attack or stroke benefits from carotid revascularization-primarily with carotid endarterectomy associated with medical therapy-within 2 weeks from symptom onset to reduce the risk of stroke recurrence. Different from acute extracranial carotid dissection, medical management with antiplatelet or anticoagulant therapy can prevent new neurologic ischemic events, considering stenting only in case of symptom recurrence. Stroke after carotid revascularization can be associated with the following etiologies: carotid manipulation, plaque fragmentation, or clamping ischemia. Medical or surgical management is therefore influenced by the cause and timing of the neurologic events after carotid revascularization. Acute conditions of the extracranial cerebrovascular vessels include a heterogeneous group of pathologies and correct management can reduce symptom recurrence substantially., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Carotid endarterectomy (CEA) has been the standard therapy for carotid artery stenosis (CAS). Modified eversion carotid endarterectomy (mECEA) was recently introduced to treat CAS. However, the short-term safety and long-term efficacy of mECEA are still controversial among studies. This systematic review aims to summarize the current literatures about safety and efficacy of mECEA in treating CAS., Methods: A systematic review of mECEA was conducted in the main bibliographic databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Clinical studies on the safety and efficacy of mECEA in treating CAS with clinical results of transient ischemic attack (TIA), stroke, death, and restenosis were included., Results: The initial search and screening found 15 references from the main databases, and 7 studies were finally included after full-text article assessment, which consisted of 3 single-arm studies and 4 comparative studies. The risks of postoperative complications including TIA, stroke, myocardial infarction (MI), and death ranged from 1.1% to 2%, 0% to 2.5%, 0% to 4.4%, and 0% to 2.32%, respectively. The mECEA was significantly related to lower risk of carotid artery occlusion, incision numbness, and shorter lengths of stay in hospital and average scar when separately compared with conventional CEA (cCEA), CEA with patch closure (pCEA), and eversion CEA (eCEA)., Conclusions: The mECEA is a promising surgical option for CAS with acceptable clinical outcomes. In order to prove its safety and efficacy, future practices need to be conducted by more medical workers in more large-scale trials., Competing Interests: None

Background: We aimed to assess the effect of surgeons' shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients., Methods: We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010-2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days)., Results: Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P =0.09) and death (0.4% versus 0.5%; P =0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P =0.02) was achieved by routine shunters for CEA performed <2 days after an ischemic stroke. Among selective shunters, a higher stroke rate occurred in case of shunt use (2.9% versus 2.3%; P <0.01), mainly due to cases presenting with stroke (3.5% versus 2.4%; P <0.01) but not transient ischemic attack (1.8% versus 1.5%; P =0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P =0.349)., Conclusions: In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed <2 days after an ischemic stroke. Among selective shunters, intraoperatively indicated shunting determined an increased stroke rate, likely due to intraoperative hypoperfusion. These data may guide the decision regarding timing of CEA and shunting intention in symptomatic patients.

Objective: Blood pressure (BP) management is a vital aspect of stroke prevention and post-stroke care. Different surgical carotid endarterectomy (CEA) techniques may impact on BP control post-operatively. Specifically, the carotid sinus nerve, which innervates the carotid baroreceptors and carotid body, is commonly left intact during conventional CEA but is routinely transected as part of eversion CEA. The aim of this study was to assess long term BP control after eversion and conventional CEA., Methods: Patients from the International Carotid Stenting Study (ICSS cohort) and a personal series of patients from the Stroke Clinical Trials Unit at University College London (UCL cohort) were separately analysed and divided into eversion and conventional CEA groups. Mixed effect linear models were fitted and adjusted for baseline demographic data and antihypertensive treatment to test for changes in BP from baseline over a three year follow up period after the respective procedures., Results: There were no differences in changes in baseline BP readings and follow up readings between eversion and conventional CEA in the ICSS or UCL cohorts. In the ICSS cohort a mild but significant systolic (-8.6 mmHg; 95% confidence interval [CI] -10.6 - -6.6) and diastolic (-4.9 mmHg; 95% CI -6.0 - -3.8) BP lowering effect was evident at discharge in the conventional group but not in the eversion CEA group. BP monitoring during follow up did not reveal any consistent BP changes with either conventional or eversion CEA vs. baseline levels., Conclusion: Neither conventional nor eversion CEA seem to result in clinically significant long term BP changes. Potential concerns related to either short or long term alterations in BP levels with transection of the carotid sinus nerve during eversion CEA could not be substantiated., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA., Methods: This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results., Results: A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P < 0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P < 0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P < 0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563)., Conclusions: Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Thromboembolic stroke attributable to an ipsilateral carotid artery plaque is a leading cause of disability in the United States and a major source of morbidity. Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy and carotid stenting at minimizing stroke risk in patients with minor stroke and transient ischemic attack. However, there is no consensus on guidelines for medical management and the timing of revascularization in patients with multiple recurrent episodes of transient ischemic attack over hours or days, an acute neurological event known as crescendo transient ischemic attack., Objective: To review the management of and timing of intervention in patients presenting with crescendo transient ischemic attack., Evidence Review: This systematic review included all English-language articles published from January 1, 1985, to January 1, 2019, available from PubMed (MEDLINE) and Google Scholar. Articles were excluded if they did not include analysis of patients with symptoms, did not report the timing of intervention after crescendo transient ischemic attack, or mixed analysis of patients with stroke in evolution with patients with crescendo transient ischemic attack. The quality of the evidence was assessed with the modified rating from the Oxford Centre for Evidence-based Medicine., Observations: Patients with crescendo transient ischemic attack were found to have a higher risk of stroke or death after carotid endarterectomy compared with patients with a single transient ischemic attack or stable stroke. With medical therapy alone, a considerable number of patients with crescendo transient ischemic attack experience a completed stroke within several months and have a poor prognosis without intervention. Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients. There have been several reports of operative treatment within the first 24 hours of presentation; however, review of these reports does not show any additional benefit from emergency treatment. Carotid artery stenting is reserved only for selected patients with prohibitive surgical risk for endarterectomy. The literature does not clearly support any additional benefit of intravenous heparin therapy over mono or dual antiplatelet therapy prior to carotid endarterectomy., Conclusions and Relevance: Crescendo transient ischemic attack is best managed with optimal medical management as well as urgent carotid endarterectomy within 2 days of presentation. Surgical endarterectomy appears to be preferred because of the increased embolic potential of bifurcation plaque, whereas stenting is an option for patients with contraindications for surgery. With ongoing advances in cerebrovascular imaging and medical treatment of stroke, there is a need for better evidence to determine the optimal timing and preoperative medical management of patients with crescendo transient ischemic attack.

Introduction: We analyzed trends in carotid artery stenting (CAS) and carotid endarterectomy (CEA) in hospitalized cases in Germany in the years 2010-2015., Methods: Data from national statistics (DRG statistics) published by the Federal Statistical Office in Germany describing the number of hospitalized patients treated with CEA and CAS were used. In addition, numbers of patients hospitalized with the principal diagnosis stroke associated with precerebral lesions (ICD code I63), transitory cerebral ischemic attacks (G45) and precerebral carotid artery stenosis (I65) treated by CEA and CAS were analyzed for the year 2015., Results: Total number of CEA decreased by 4.0% from 24.067 (2010) to 23.104 (2015) and CAS increased by 5.1% from 5.703 to 5.992. In 2015, 79.4% of all procedures coded concerning the internal carotid artery were CEA and 21.6% CAS. From 27.798 cases hospitalized with the principal diagnosis stroke associated with precerebral lesions, CEA was performed in 3.921 (14.1%) and in 2.132 (7.7%) CAS was documented, with CAS making up one-third of all treatments within the stroke group. In 28.273 cases hospitalized with a TIA, CEA was specified in 853 (3.0%) and CAS in 255 (0.9%) cases. In 27.553 cases with an occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction, 17.036 (61.8%) had a CEA and 3.156 (11.5%) a CAS procedure., Conclusion: CEA is still the primary treatment of extracranial artery stenosis. The impact of CAS becomes mainly apparent in cases presenting with acute strokes.

Introduction: We reviewed the literature for preoperative computed tomography carotid angiography and/or carotid duplex to determine their respective sensitivity and specificity in assessing the degree of carotid stenosis. We aimed to identify whether one imaging modality can accurately identify critical stenosis in patients presenting with transient ischaemic attack or symptoms of a cerebrovascular accident requiring carotid endarterectomy., Methods: Systematic search of MEDLINE, Embase, Cochrane database of systematic reviews, all Evidence-Based Medicine Reviews (Cochrane Database of Systematic Reviews, ACP Journal club, Database of Abstracts of Reviews of Effects, Cochrane Clinical Answers, Cochrane Controlled Trials Register, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database) for primary studies relating to computed tomography carotid angiography (CTA) and/or carotid duplex ultrasound (CDU). Studies included were published between 1990 and 2018 and focused on practice in the UK, Europe and North America., Results: The sensitivity and specificity of CTA and CDU are comparable. CDU is safe and readily available in the clinical environment hence its use in the initial preoperative assessment of carotid stenosis. CDU is an adequate imaging modality for determining stenosis greater than 70%; sensitivity and specificity are improved when the criteria for determining greater than 70% stenosis are adjusted. Vascular laboratories opting to use duplex as their sole imaging modality should assess the sensitivity and specificity of their own duplex procedure before altering practice to preoperative single imaging for patients., Conclusions: The sensitivity and specificity of CTA (90.6% and 93%, respectively) and CDU (92.3% and 89%, respectively) are comparable. Both are dependent on criteria used in vascular laboratories. CDU sensitivity and specificity was improved to 98.7% and 94.1%, respectively, where peak systolic velocity and end diastolic velocity were assessed. Either modality can be used to determine greater than 70% stenosis, although a secondary imaging modality may be required for cases of greater than 50% stenosis.

Objective: Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors., Methods: Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting., Results: On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02)., Conclusions: cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

Background: Internal carotid artery occlusion (ICAO) causes transient ischemic attack and cerebral infarction. ICAO management remains clinically challenging. We discuss a hybrid treatment combining carotid endarterectomy and endovascular intervention (E-I) for patients with nontaper or nonstump lesions of symptomatic ICAO., Methods: We treated 32 patients with consecutive nontaper or nonstump ICAO with neurological symptoms with hybrid treatment or E-I. We analyzed the epidemiology, symptoms, angiographic morphology, technical success rate, and perioperative complications., Results: Of the 32 patients, 17 were treated with hybrid surgery and 15, E-I. The demographic data and lesion characteristics were similar between the 2 groups. The overall recanalization success rate was 71.9%. The rate for hybrid surgery was better than that for E-I (88.2% vs. 53.3%). The postoperative cerebral hyperperfusion rate showed no difference between the 2 groups (11.8% vs. 6.7%). Ipsilateral cerebral perfusion improved after treatment. The mean transition time and time to peak were greater than normal (normal values, <6 seconds and <8 seconds, respectively). Both increased significantly after treatment (mean transition time, 11.30 seconds vs. 7.25 seconds; time to peak, 19.30 seconds vs. 15.50 seconds). The incidence of perioperative complications from hybrid surgery was less than that with E-I (5.9% vs. 40.0%). Recurrent cerebrovascular events (5.9% vs. 13.3%) and the 3-month modified Rankin scale score (2.76 ± 0.66 vs. 2.93 ± 0.70) did not differ between the 2 groups., Conclusions: Recanalization of nontaper or nonstump ICAO with hybrid treatment was more successful than that with E-I, with fewer perioperative complications. The carotid endarterectomy procedure enables easier wire crossing across the occlusion and reduces potential technology-related complications by requiring a shorter lesion and fewer dissections and minimizing the effect of calcification., (Copyright © 2018. Published by Elsevier Inc.)

Background and Purpose- Patients undergoing surgery on the weekend may experience worse outcomes, but this weekend effect has not been studied in carotid endarterectomy (CEA). Methods- We identified patients undergoing isolated CEA in the Vascular Quality Initiative between 2003 and 2018. Our primary outcome was in-hospital stroke or perioperative death (stroke/death), stratified by symptom status. For asymptomatic patients, we also compared rates of the Centers for Medicare and Medicaid Services quality metric prolonged length of stay (>2 days or failed discharge home). We calculated propensity scores and used multilevel, inverse probability weighted logistic regression clustering at the hospital level. Results- There were 86 123 repairs during the study period, 53% asymptomatic lesions and 47% symptomatic. Only 0.7% of asymptomatic patients underwent CEA on the weekend, compared with 3.1% of symptomatic patients. Patients undergoing weekend repairs were more often white, with lower rates of most comorbidities. In asymptomatic patients, weekend operations were associated significantly higher odds of stroke/death (odds ratio [OR], 2.3 [1.1-4.8]; P=0.02), and prolonged length of stay (OR, 3.6 [2.7-4.7]; P<0.001). In symptomatic patients, weekend operations were associated with significantly higher adjusted odds of stroke/death (OR, 1.7 [1.2-2.4]; P=0.007) and longer postoperative length of stay (3.3 days versus 2.0 days, P=0.002). However, the difference in stroke/death was driven by patients presenting with stroke (OR, 2.2 [1.5-2.3]; P<0.001), rather than those presenting with transient ischemic attack (OR, 1.2 [0.6-2.1]; P=0.56). Conclusions- We found evidence of a significant weekend effect in CEA, as weekend operations in asymptomatic patients and patients who presented with stroke were associated with higher rates of stroke/death and prolonged length of stay. However, there was no evidence of such an effect in patients with transient ischemic attack. These data suggest that weekend CEA should be avoided except in the case of expedited revascularization after transient ischemic attack.

Objective: To evaluate in patients with TIA and ipsilateral high-grade internal carotid artery (ICA) stenosis whether changes in cognitive performance and cerebral hemodynamics occurred after carotid endarterectomy (CEA) and to explore their relationship., Methods: Participants were patients who underwent CEA, had TIA within the last 6 months, and had an ipsilateral severe ICA stenosis. Coloured Progressive Matrices (CPM) plus Complex Figure Copy Test (CFCT) and phonemic (ph) plus categorical (ca) Verbal Fluency (VF) tests were performed to assess right and left hemisphere cognitive functions, respectively. Hemodynamics was assessed with transcranial Doppler ultrasonography by means of the cerebral vasomotor reactivity (CVR) to hypercapnia., Results: A total of 137 patients were included. Before CEA, patients with right ICA obtained lower scores on the CPM and CFCT; patients with left ICA stenosis performed worse on the phonemic and categorical VF tests. The CVR was decreased on the side of the stenosis. At 6 months from CEA, CVR and cognitive performance were significantly improved. The performance change in cognitive tests exploring the revascularized hemisphere was positively associated with the ipsilateral CVR variation (CPM: R 2 for linear regression = 0.759, adj R 2 = 0.737; CFCT: R 2 = 0.734, adj R 2 = 0.710; (ph)VF: R 2 = 0.774, adj R 2 = 0.749; (ca)VF: R 2 = 0.732, adj R 2 = 0.703)., Conclusion: Cognitive performance was enhanced at 6 months since CEA, and the improvement was related to the CVR increase. Cerebral hemodynamics may be an independent and potentially reversible determinant of cognitive dysfunction in severe carotid artery disease., (Copyright © 2017 American Academy of Neurology.)

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Background: For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA., Methods: We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups., Results: Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines., Conclusions: Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.

Background: In patients who have suffered a transient ischemic attack (TIA) or ischaemic stroke, diagnostic imaging often reveals an occlusion in the extracranial internal carotid artery (ICA) on the symptomatic side. It is generally assumed that no follow-up is needed., Case Description: A 57-year-old man reported to the emergency department with global aphasia. Two weeks previously he had been diagnosed with an occlusion of the left ICA following a TIA. On the basis of CT angiography we diagnosed an ischaemic stroke in the left middle cerebral artery territory and a severe stenosis of the left ICA. Several days later the patient underwent a successful carotid endarterectomy., Conclusion: Following an acute symptomatic occlusion of the extracranial ICA, recanalisation of the artery can take place. In these patients we advise considering a repeat of the diagnostic imaging of the ICA within a week.

Background and Purpose: Carotid angioplasty and stenting (CAS) is associated with higher risk of periprocedural stroke and death when compared with carotid endarterectomy (CEA). By contrast, the risk of myocardial infarction (MI) was higher after CEA than after CAS in randomized trials. However, numbers were small, and risk factors are unknown., Methods: We performed a systematic review and a meta-analysis of studies published from January 1980 to June 2014 and collected unpublished data. We extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, type stenosis, and clinical presentation). We selected studies with data available on MI in at least 1 subgroup, calculated absolute and relative risks, and identified differential effects on risks of MI., Results: The 30-day absolute risk of MI was 0.87% (95% confidence interval, 0.69-1.07) after CEA and 0.70% (95% confidence interval, 0.54-0.88) after CAS (Pint=0.38). After CAS, patients with symptomatic stenosis and restenosis were at higher risk of MI, whereas men were at lower risk. After CEA, age, history of coronary artery disease, peripheral artery disease, and restenosis increased the risk of MI. Only the effect of sex differed between CAS and CEA with men being at lower risk of MI than women after CAS, whereas there was no difference between after CEA (Pint=0.01)., Conclusions: The risk of MI after CEA and CAS did not significantly differ. Risk factors for MI are overall similar in both techniques except that men are at lower risk of MI after CAS but not after CEA., (© 2015 American Heart Association, Inc.)

Symptomatic cervical carotid artery stenosis is one of the common causes of ischemic stroke in octogenarians. The records for 90 consecutive patients with symptomatic cervical carotid artery stenosis treated by carotid endarterectomy(CEA)were analyzed retrospectively. The patients were divided into two groups:21 patients aged 80 years or over and 69 patients aged less than 80 years. CT angiography revealed that ulcer formation was significantly more common and the length of carotid artery stenosis was significantly greater in the octogenarians. Histological examination of the plaque revealed no significant difference between the two groups in terms of ulcer formation, lipid content, and intraplaque hemorrhage. However, all three of these pathological findings were present in a significantly higher number of octogenarians. No significant difference was observed for new ischemic lesions on diffusion-weighted MR imaging, neurological complications, or cardiac and pulmonary complications. However, treatment with an albumin preparation and loop diuretics was significantly more common in octogenarians after CEA. The present study suggests that with careful postoperative management CEA can be safely performed in symptomatic patients aged 80 years or over with almost the same risk as that for patients aged less than 80 years.

Background and Purpose: Although the latest recommendations suggest that carotid endarterectomy (CEA) should be performed in symptomatic carotid artery stenosis (sCAS) patients within 2 weeks of the index event, only a minority of patients undergo surgery within the recommended time-frame. The aim of this international multicenter study was to prospectively evaluate the safety of early CEA in patients with sCAS in everyday clinical practice settings., Methods: Consecutive patients with non-disabling acute ischaemic stroke (AIS) or transient ischaemic attack (TIA) due to sCAS (≥ 70%) underwent early (≤ 14 days) CEA at five tertiary-care stroke centers during a 2-year period. Primary outcome events included stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria., Results: A total of 165 patients with sCAS [mean age 69 ± 10 years; 69% men; 70% AIS; 6% crescendo TIA; 8% with contralateral internal carotid artery (ICA) occlusion] underwent early CEA (median elapsed time from symptom onset 8 days). Urgent CEA (≤ 2 days) was performed in 20 cases (12%). The primary outcomes of stroke and MI were 4.8% [95% confidence interval (CI) 1.5%-8.1%] and 0.6% (95% CI 0%-1.8%). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (95% CI 2.0%-9.0%). Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (P > 0.2) with a higher 30-day stroke rate., Conclusions: Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling AIS or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks (or even within 2 days) from symptom onset., (© 2014 The Author(s) European Journal of Neurology © 2014 EAN.)

Carotid endarterectomy (CEA) is the established standard to treat occlusive extracranial atherosclerotic carotid disease. Complications of CEA must be recognized and dealt with efficiently due to the potentially catastrophic neurologic sequelae. A 67-year-old African American man was transferred from an outside hospital for an acute stroke. He had initially presented with a small right frontal subcortical infarct and had undergone a right CEA 2 days prior to transfer. He had a fluctuating examination with left-sided hemiplegia to slight hemiparesis and inconsistent neglect. Head CT demonstrated a watershed infarct of the right hemisphere. CT angiography demonstrated high grade stenosis at the distal aspect of the CEA anastomosis. He was promptly taken for angiography and underwent acute stenting of the right internal carotid artery. This case demonstrates that carotid artery stenting is a safe management strategy for the treatment of complications associated with failed distal anastomosis during CEA., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

To analyze the outcome of urgent carotid endarterectomy (CEA) performed within less than six hours in patients with crescendo transient ischemic attack (TIA) and stroke in progression. From January 1998 to December 2008, 58 urgent CEAs were done for acute neurological ischemic events--46 patients with crescendo TIA and 12 patients with stroke in progression. Brain computed tomography (CT) was done prior and after the surgery. Disability level was assessed prior to and after urgent CEA using modified Rankin scale. Median follow-up was 42.1 ± 16.6 months. In the early postoperative period stroke rate was 0% for the patients in crescendo TIA group while in patients with stroke in progression group 3 patients (25%) had positive postoperative brain CT, yet neurological status significantly improved. Mid-term stroke rate was 2.2% in crescendo TIA group and 8.3% in stroke in progression group. In the early postoperative period there were no lethal outcomes, mid-term mortality was 8.3% in stroke in progression while in crescendo TIA group lethal outcomes were not observed. In conclusion, based on our results urgent CEA is a safe and effective treatment option for patients with crescendo TIA and stroke in progression with acceptable rate of postoperative complications.

Background: The highest risk period for suffering a stroke after a transient ischaemic attack (TIA) or temporary monocular blindness (TMB) is the first 14 days and this is the recommended threshold for performing carotid endarterectomy (CEA). However, evidence suggests that TMB patients face significant delays in starting medical therapy and undergoing CEA. This study audited management practices in an ophthalmology department, 3 years after introducing a daily TIA clinic that offered single-visit imaging and the implementation of best medical therapy., Methods: Sequential audit (July 2011, July 2012) of ophthalmology staff at Leicester Royal Infirmary., Results: TIA clinic awareness increased to 90%, but 80% remained unaware of the 14-day target for performing CEA. Most (81%) were aware that ophthalmologists could refer TMB patients to the clinic, but virtually no one used this service, preferring to request an outpatient carotid ultrasound scan and then refer on as appropriate. The majority (86% in 2012) were happy to prescribe aspirin, but virtually nobody would prescribe statins., Conclusion: There is a need to improve professional awareness of the importance of starting best medical therapy and performing CEA as soon as possible after onset of TMB., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Carotid endarterectomy is the gold standard as a therapeutic regimen for patients with high grade symptomatic stenosis of the internal carotid artery (ACI). This study analyzed the effect of early carotid endarterectomy in patients undergoing an operative procedure 2-3 weeks after the development of ischemic neurologic symptoms, considering the frequency and type of complications in the postoperative period. Patients included in this study were those with significant symptomatic ACI stenosis (70%-99%), which caused ischemic stroke or transient ischemic attacks (TIA). Patients with ischemic stroke were operated within twenty days of the initial neurologic event, whilst in those with symptoms of TIA, surgery was performed immediately after diagnostic work-up. In all cases, carotid endarterectomy was performed under general anesthesia with the use of protective intraluminal shunt. In the vast majority of cases, tucking or Kunlin's sutures of the distal intima were applied. All procedures were performed between January 2008 and October 2012, and the total number of patients was 69. All patients underwent the same follow up program. Follow up carotid ultrasound was performed routinely on postoperative day 7 and at 1, 3, 6 and 12 months. In this study, 27 (39%) patients suffered minor ipsilateral stroke and 42 (61 %) patients had TIA symptoms with verified significant ACl stenosis. Postoperative complications were observed in four (5.26%) patients. Two (2.63%) patients developed ischemic stroke after the procedure and two (2.63%) patients developed ACI restenosis in the late postoperative period and were treated by endovascular stenting. In conclusion, we found that early carotid endarterectomy was of greater benefit than delayed endarterectomy, which is in keeping with the published studies. The leading observation was that in selected patients, early carotid endarterectomy was not associated with a higher risk of postoperative complications in comparison with delayed endarterectomy and could be performed safely.

Background and Purpose: To establish whether the Scottish Intercollegiate Guidelines Network guidelines (SIGN 2008) publication has improved the delay from neurological event to carotid endarterectomy (CEA). This ideally should be performed within two weeks of a patient experiencing their first neurological event., Methods: Data for 255 consecutive, symptomatic CEA procedures carried out under local anaesthetic, between March 2007 and June 2010 at The Edinburgh Vascular Surgery Service (EVSS) were extracted from the National Vascular Database. The mean, median and range was calculated for days from symptoms to vascular referral, vascular assessment to surgery and symptoms to surgery, subdivided according to four hospitals referring to the EVSS and whether CEA was performed pre- (n = 128) or post-publication of guidelines (n = 127)., Main Findings: Median delays from symptoms to vascular referral, vascular assessment to surgery and symptoms to surgery have decreased in all hospitals since the publication of the guidelines. The proportion of patients undergoing CEA within two weeks after their initial event increased from 25% pre-guidelines to 40.2% post-guidelines (p = 0.04). The proportion of patients undergoing CEA within four weeks of their event also improved from 57% to 74%. Patient presentation (41.8%), late referrals (29.9%) and lack of resources (22.4%) were the main causes for delay., Conclusions: Guidelines have improved service provision for CEA at the EVSS. However, more work is required to address the subgroup of patients whose surgery was delayed as a result of late presentation, late referral and lack of surgical resources., (Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective is to see if use of the ACIST™ device during carotid stenting would be feasible without an increase in primary end points when compared to historic controls., Background: Carotid stenting has been studied as an effective alternative to endarterectomy in high-surgical-risk patients. Traditional angiography involves manual contrast injection. It leads to excess contrast volume and greater fluoroscopy times. The Acist contrast injection device helps with the regulation and lowering of contrast volume., Methods: This is a consecutive, non-randomized, open-label, multiple-operator-based study. Inclusion criteria were as follows: (a) subject is considered at high risk for carotid endarterectomy, (b) subject requires percutaneous carotid angioplasty and stenting for carotid disease, and (c) subject must be asymptomatic with ≥80% stenosis of the internal and/or common carotid artery. The primary end points measured were, death from any cause, myocardial infarction, transient ischemic attack or stroke within 30 days of intervention. Secondary end points were contrast volume and fluoroscopy time., Results: Four operators in one institution performed interventions from June 2007 to May 2012 on 133 consecutive patients. They were predominantly men (59.4%). The mean age (SD) was 73.64 (7.952) years. Stroke occurred in 3% (N=4), transient ischemic attack in 0.8% (N=1) and myocardial infarction in 0.8% (N=1). Three study subjects died (2.3%). The mean (SD) contrast volume was 121.24 (67.79) mL. The mean (SD) fluoroscopy time was 18.34 (11.31) minutes., Conclusions: The use of the ACIST™ device was feasible in carotid stenting in a high-risk population without an increase in end points when compared to historic controls., (© 2013.)

Carotid endarterectomy (CEA) is the established standard to treat occlusive extracranial atherosclerotic carotid disease. Complications of CEA must be recognized and dealt with efficiently due to the potentially catastrophic neurologic sequelae. A 67-year-old African American man was transferred from an outside hospital for an acute stroke. He had initially presented with a small right frontal subcortical infarct and had undergone a right CEA 2 days prior to transfer. He had a fluctuating examination with left-sided hemiplegia to slight hemiparesis and inconsistent neglect. Head CT demonstrated a watershed infarct of the right hemisphere. CT angiography demonstrated high grade stenosis at the distal aspect of the CEA anastomosis. He was promptly taken for angiography and underwent acute stenting of the right internal carotid artery. This case demonstrates that carotid artery stenting is a safe management strategy for the treatment of complications associated with failed distal anastomosis during CEA.

Introduction: Carotid artery stenting (CAS) is believed to be an alternative to carotid endarterectomy (CEA); however, recent studies have demonstrated an increase of complications with stenting that does not reflect our experience. We thus wanted to compare the periprocedural and 1-year follow-up outcomes of CAS with those of CEA among patients with symptomatic extracranial carotid stenosis in a population from eastern Turkey., Methods: The hospital records of all patients who underwent carotid artery revascularization were retrospectively reviewed. Patients were divided into two groups based on the type of carotid revascularization performed, namely CEA or CAS. Comparisons were made with respect to 30-day and 1-year outcomes of transient ischemic attack (TIA), myocardial infarction (MI), stroke, and all-cause death rates. Composite endpoints for both groups were also analyzed., Results: Thirty-two CEA and 33 CAS procedures were performed for symptomatic occlusive carotid disease. Baseline characteristics were similar between both groups except for the incidence of diabetes mellitus. No significant differences were found with respect to 30-day mortality, MI, and neurologic morbidity endpoints for CEA and CAS procedures. In the postprocedural 1-year follow-up, only TIA was observed to be significantly higher in the CAS group; the other endpoints did not differ significantly. One-year composite endpoints did not differ between both groups (log-rank P = 0.300)., Conclusion: In our trial of patients with symptomatic carotid artery stenosis, no significant difference could be shown in periprocedural outcomes, postprocedural outcomes except TIA, and in composite endpoints between the CEA and CAS groups. CAS is a safe and efficacious alternative for the treatment of symptomatic carotid artery stenosis.

Background and Purpose: The purpose of this study was to analyze the 30-day outcome after introduction of a rapid carotid endarterectomy (CEA) program. Reasons for delay in CEA and the incidence of early recurrence neurological symptoms were recorded., Methods: This is a prospective population-based study of delays to CEA and 30-day outcome in patients with symptomatic carotid stenosis. Neurological recurrence (NR) rate was determined after initiation of urgent best medical treatment (loading dose aspirin/clopidogrel and duel therapy with aspirin plus clopidogrel with a statin) until CEA and compared with NR ≤90 days prior index event., Results: Of a total of 4905 (transient ischemic attack/ischemic stroke, and ocular events) patients, 115 symptomatic patients underwent CEA, 42% within 14 days of the index event and 99% within 14 days of surgical referral. The overall NR from index event to CEA in symptomatic carotid stenosis patients was significantly lower (2.5% [95% confidence interval, 1%-6%]) after best medical treatment when compared with NR ≤90 days in those before referral to a stroke clinic (29% [95% confidence interval, 22%-37%]; P<0.00001). There were no significant differences in outcomes among 48 early (<14 days), 46 intermediate (14-30 days), and 21 delayed (>30 days) CEAs., Conclusions: CEA can be performed in the subacute period without significantly increasing the operative risk. The urgent best medical treatment was associated with significant reduction in the risk of early NR in CEA patients. It seems that urgent aggressive best medical treatment may obviate the need for urgent CEA.

Background and Purpose: The goal of carotid artery stenting is to decrease the risk of stroke or other adverse events from carotid artery disease. Choosing a treatment strategy requires patient-specific information regarding periprocedural risk of adverse neurologic events. The aim of this study was to predict individual patient risk after carotid artery stenting in patients at higher risk for carotid endarterectomy., Methods: Subjects enrolled in the Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) worldwide study underwent carotid artery stenting with distal protection. Only patients with at least 1 anatomic or comorbid factor associated with elevated surgical risk were included. Preprocedural factors were used to develop a model and integer-based risk score predicting stroke or death within 30 days. The model was calibrated and internally validated using bootstrap resampling., Results: Ten thousand one hundred eighty-six patients were included in the analysis. The overall rate of stroke or death was 3.6% at 30 days after carotid artery stenting. Independent predictors of adverse outcomes were increased age (P=0.006), history of stroke (P<0.001), history of transient ischemic attack presentation (P=0.001), recent (<4 weeks) myocardial infarction (P=0.006), dialysis treatment (P=0.007), need for cardiac surgery in addition to carotid revascularization (P=0.005), a right-sided carotid stenosis (P=0.006), a longer carotid plaque (P=0.012), the presence of a Type II or III aortic arch (P=0.035), and a tortuous carotid arterial system (P=0.004). The optimism-adjusted C-statistic was 0.691., Conclusions: Commonly collected clinical and anatomic variables can identify patients at high and low risk for stroke or death after carotid artery stenting.

Background: Vascular reconstructions are the established treatment for ischemic cerebrovascular disease. Cerebral hyperperfusion syndrome (CHS) is occasionally seen after vascular reconstruction and manifest clinical symptoms. The purpose of this study is to investigate the incidence and clinical features of CHS after vascular reconstruction., Methods: A total of 144 patients with ischemic cerebrovascular disease (53 carotid endarterectomy [CEA] for carotid artery stenosis, 48 carotid artery stenting [CAS] for carotid artery stenosis, 20 bypass surgery for atherosclerotic cerebrovascular disease, 40 bypass surgery for moyamoya disease [MMD]) underwent vascular reconstruction. Patients were examined neurologically and radiologically, including computed tomography, magnetic resonance imaging, and single-photon-emission computed tomography, and then CHS was evaluated., Results: CHS developed in 1 (1.9%) CEA, 1 (2.1%) CAS, 1 (5.0%) bypass surgery for atherosclerotic cerebrovascular disease, and 6 (15.0%) bypass surgery for MMD. The incidence of CHS was significantly higher in patients with MMD. Aged patients and impairment of cerebrovascular reserve were correlated with CHS. Patients manifested disorientation after CEA and complained of headache after CAS. Diffuse hemispheric hyperperfusion was detected by single-photon-emission computed tomography. However, MMD patients manifested focal neurologic deficit, focal cerebral edema, and increased regional cerebral blood flow around vascular anastomosis. These patients were treated with blood pressure control and administration of free radical scavengers, and recovered without permanent deficits., Conclusions: The incidence of CHS is significantly higher in patients with MMD and results in vasogenic edema visible on magnetic resonance imaging., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We report a case that developed watershed infarcts after undergoing carotid endarterectomy. Our patient had been having episodes of transient ischaemic attacks before admission. Carotid Doppler scan before admission showed severe unilateral carotid stenosis on left side. She underwent a carotid endarterectomy procedure. Her continuous blood pressure monitoring stayed normal during and after the procedure. One and half hour after the procedure, she developed right arm weakness. CT scan later revealed watershed infarcts in left cerebral hemisphere. The pathogenesis of watershed infarcts remain debated despite haemodynamic and embolic mechanisms being postulated.

Unlabelled: Some controversy exists on the best moment to treat symptomatic carotid artery disease. This controversy concerns mainly neurologically unstable patients and patients who suffered a minor stroke. The authors discuss recent literature data on the feasibility and the safety of performing urgent (within 24 to 72 hours) carotid endarterectomy (CEA) in patients presenting repetitive transient ischaemic attacks or progressing stroke. Neurologically unstable patients, suffering ischemic brain deficit caused by carotid artery stenosis, are defined according to the following criteria: two or more transient ischaemic attacks (crescendo TIAs) or a fluctuating neurological deficit evolving no longer than 24 hours (progressing stroke), no impairment of consciousness, cerebral infarct of limited size on diffusion-weighted magnetic resonance imaging of the brain and a carotid artery stenosis of 70% or more on the appropriate side. In the past, these patients were often considered at too high risk to undergo immediate carotid surgery. Many neurologists remain reluctant to confine these neurologically unstable patients for urgent carotid endarterectomy and prefer to stabilise the neurological status, arguing the increased stroke morbidity in the urgent setting. Nevertheless, the natural history of stroke- in-evolution or repetitive transient ischemic attacks is far from benign, exposing the patient to a high risk of subsequent spontaneous stroke, even under best medical treatment. Another controversy exists on the timing of surgery in patients who suffered a minor, non-disabling stroke. Is a waiting period of 6 weeks safe? Once more, the operative risk should be balanced against the anticipated natural history. Published series, and sub-analysis of the recent carotid surgery trials (NASCET, ECST) plaid for carotid surgery within two weeks of a minor stroke., Conclusions: Contemporary literature argues that neurologically unstable patients, presenting repetitive transient ischaemic attacks or progressing stroke, should be managed by urgent (within 24 to 72 hours) carotid endarterectomy, even if the peri-operative stroke-death rate is slightly higher than in the elective setting. Despite an inherent increased operative morbidity-mortality, urgent carotid endarterectomy seems to us justified by the fact that waiting for the surgery may lead to the development of a more profound stroke in these neurologically unstable patients. Their only chance for neurological recovery (partial or complete) is in the early phase (12 to 60 hours after the acute onset of the neurological syndrome of crescendo-TIAs or stroke-in-evolution). For patients presenting a minor stroke, with limited brain infarction, carotid endarterectomy should preferentially be done in a semi-urgent fashion, within two weeks.

Rationale: In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure., Aims: Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions., Design: Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy ( operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system,and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient,starting from their initial symptom,and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups., Outcomes: Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups., (© 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.)

Objectives: To document our experiences, technical procedure and outcomes of carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis., Material and Methods: A total of 49 consecutive patients underwent 53 CEAs (three bilateral, one redo) for severe carotid artery stenosis. There were 39 males and 10 females, with mean age of 63 years. All patients underwent neck Doppler, computed tomography/magnetic resonance angiography/digital substraction angiography and a detailed cardiological evaluation. Antiplatelet drugs were continued perioperatively. Surgery was performed under general anesthesia with propofol cerebral protection, mild hypothermia and continuous electroencephalogram monitoring. The procedure was done under microscope and closure was done using 6-0 prolene. Clinical and radiological follow-up was done., Results: Our mean follow-up was 4.69 years. All patients underwent primary suturing except one redo CEA done with venous patch graft. Three patients required intraoperative shunting. One patient died secondary to myocardial infarction peroperatively prior to carotid manipulation. One patient had stroke within 6 h, secondary to operative site intraluminal thrombus and was re-explored. Two patients had transient postoperative hemiparesis and aphasia while two patients had altered sensorium, all self-limiting, with normal imaging. One patient developed temporary twelfth-nerve paresis. One patient had persistent transient ischemic attack on the follow-up. Thus, the perioperative mortality rate was 1.89% and stroke rate was 1.89%., Conclusions: CEA for severe carotid stenosis is a safe procedure with good protection from ischemic events. Detailed preoperative cardiac evaluation and appropriate patient selection is essential.

Objective: To summarize clinical experience of carotid endarterectomy (CEA) in treating severe carotid stenosis., Methods: Between October 1998 and January 2010, 215 patients with carotid stenosis were treated with CEA. There were 140 males and 75 females with an average age of 66 years (range, 51-88 years). Transient ischemic attack (TIA) occurred in 127 cases, and 31 cases had history of cerebral infarction. All cases were diagnosed definitely by selective angiography and/or CT angiography, and stenosis degree was more than 80%; contralateral carotid artery was also involved in 45 cases. Ninety-six cases were found to have coronary artery stenosis by coronary angiography. CEA and coronary artery bypass grafting were performed simultaneously in 25 cases. Peripheral arterial disease was found in 43 cases and treated at the same time., Results: A total of 155 patients were followed up 6-72 months. The clinical symptom significantly alleviated in 148 cases postoperatively. Two cases had complication of cerebral hemorrhage within 1 week postoperatively; one died and the other was resumed after the conservative treatment. One case had hypoglossal nerve injury. Four cases had injuring marginal mandibular branch of the facial nerve, and no special treatment was given. Restenosis was found in 25 patients, and the stenosis degree was less than 25%; moreover, the patients had no TIA. One case died of heart attack at 3 years of follow-up period., Conclusion: CEA is an effective and safe method for treating severe carotid stenosis.

Background: Whether surgery is beneficial for patients with asymptomatic carotid stenosis is controversial. Better methods of identifying patients who are likely to develop stroke would improve the risk-benefit ratio for carotid endarterectomy. We aimed to investigate whether detection of asymptomatic embolic signals by use of transcranial doppler (TCD) could predict stroke risk in patients with asymptomatic carotid stenosis., Methods: The Asymptomatic Carotid Emboli Study (ACES) was a prospective observational study in patients with asymptomatic carotid stenosis of at least 70% from 26 centres worldwide. To detect the presence of embolic signals, patients had two 1 h TCD recordings from the ipsilateral middle cerebral artery at baseline and one 1 h recording at 6, 12, and 18 months. Patients were followed up for 2 years. The primary endpoint was ipsilateral stroke and transient ischaemic attack. All recordings were analysed centrally by investigators masked to patient identity., Findings: 482 patients were recruited, of whom 467 had evaluable recordings. Embolic signals were present in 77 of 467 patients at baseline. The hazard ratio for the risk of ipsilateral stroke and transient ischaemic attack from baseline to 2 years in patients with embolic signals compared with those without was 2.54 (95% CI 1.20-5.36; p=0.015). For ipsilateral stroke alone, the hazard ratio was 5.57 (1.61-19.32; p=0.007). The absolute annual risk of ipsilateral stroke or transient ischaemic attack between baseline and 2 years was 7.13% in patients with embolic signals and 3.04% in those without, and for ipsilateral stroke was 3.62% in patients with embolic signals and 0.70% in those without. The hazard ratio for the risk of ipsilateral stroke and transient ischaemic attack for patients who had embolic signals on the recording preceding the next 6-month follow-up compared with those who did not was 2.63 (95% CI 1.01-6.88; p=0.049), and for ipsilateral stroke alone the hazard ratio was 6.37 (1.59-25.57; p=0.009). Controlling for antiplatelet therapy, degree of stenosis, and other risk factors did not alter the results., Interpretation: Detection of asymptomatic embolisation on TCD can be used to identify patients with asymptomatic carotid stenosis who are at a higher risk of stroke and transient ischaemic attack, and also those with a low absolute stroke risk. Assessment of the presence of embolic signals on TCD might be useful in the selection of patients with asymptomatic carotid stenosis who are likely to benefit from endarterectomy., Funding: British Heart Foundation., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Early carotid endarterectomy (CEA) after stroke or transient ischaemic attack is the proposed standard of care to prevent recurrent ischaemic events in selected patients. The aim of this study was to investigate if this standard is achieved in a tertiary vascular unit., Methods: This was a clinical audit. CEAs performed from 1 January 2006 to 31 December 2008 at Christchurch hospital were identified. The value stream from initial presentation to surgery was mapped in two phases (phase 1; 2006-2007 and phase 2; 2008). Patients who had carotid intervention for asymptomatic carotid lesions were excluded., Results: The relevant patient journey was documented in 81 patients (55 phase 1; 26 phase 2). Median time from initial presentation to carotid ultrasound was 5 days in phase 1 and 6 days in phase 2. Time from presentation to vascular surgery review was 22 days in phase 1 and 13 days in phase 2. Time from presentation to CEA significantly reduced from 83 to 32 days between phases (P < 0.005)., Conclusions: There has been a significant decrease in time from presentation to operation between phase 1 and 2. The most significant change is reduced delay between vascular surgery review and CEA. There has been no improvement in urgency of referral for imaging or surgical review. This part of the patient journey is a target for improvement.

Purpose: A major stroke after carotid endareterectomy (CEA) is an event that should be managed according to a planned strategy. Literature data on this issue are not definitive. We reviewed our series in the attempt to define an algorithm of treatment if this complication occurs., Methods: A consecutive series of 413 CEAs in 390 patients was considered. All operations were performed under general anaesthesia and EEG monitoring. An indwelling shunt was inserted only according to EEG changes. Direct closure of the arteriotomy was performed in all cases. Intraoperative ultrasound was not routinely employed before 2004. Patients who suffered from the new onset of an ischaemic hemispheric deficit or the worsening of a pre-existing deficit within 72 h after surgery were included in the present study., Results: Sixteen patients (3.9%) suffered from perioperative stroke. Seven patients presented neurological deficits that rapidly and spontaneously resolved. In nine cases (2.2%) a major stroke occurred. Acute occlusion of the internal carotid artery (ICA), with or without embolic blocking of the omolateral M1 segment, occurred in eight cases; in one case a patent ICA was associated with the occlusion of two frontal branches of the omolateral middle cerebral artery. Seven cases were reoperated on. The ICA was reopened in all these cases except one. Among these seven cases, three (42%) had a good outcome., Conclusions: A major stroke after CEA is caused, in most of cases, by the acute ICA occlusion with or without intracerebral embolic occlusion. Reopening of the occluded ICA gives good results when intracerebral vessels are patent and when the occluded ICA is satisfactorily reopened. An algorithm of planned reactions in case of perioperative stroke is finally proposed.

Background: Carotid endarterectomy is performed less often in women than in men, but it is unknown whether this reflects differences in screening rates, disease prevalence, or other factors., Methods: This was a cohort study of consecutive patients with acute stroke or TIA admitted to 11 Ontario stroke centers participating in the Registry of the Canadian Stroke Network between July 1, 2003, and September 30, 2007. We compared rates of carotid imaging, the severity of carotid stenosis, and rates of carotid endarterectomy or angioplasty within 6 months of the index event in women vs men., Results: We studied 6,389 patients (48% women) with ischemic stroke or TIA. Women were less likely than men to undergo carotid imaging (81% vs 86%, p < 0.0001); however, when the analysis was limited to patients without apparent contraindications to surgery, 92% received carotid imaging, with no difference between women and men. Women were less likely than men to have severe carotid stenosis (7.4% vs 11.5%, p < 0.0001). Women were half as likely as men to undergo carotid revascularization within 6 months of the index event (odds ratio 0.51, 95% confidence interval 0.37 to 0.70), but this gender difference was no longer significant in the subgroup with severe carotid stenosis (odds ratio 0.75, 95% confidence interval 0.49 to 1.15)., Conclusions: Although women with ischemic stroke or TIA are less likely than men to undergo carotid screening and revascularization, this difference is largely explained by potential contraindications to surgery and by sex differences in the severity of carotid disease.

Introduction: Timing of intervention in symptomatic carotid disease is critical. The UK Department of Health's National Stroke Strategy published in December 2007 recommends urgent carotid intervention within 48 h, in appropriate patients, who have suffered a transient ischaemic attack (TIA), amaurosis fugax or minor stroke. Despite the running of a rapid-access clinic for patients with symptoms of TIA, the time from symptom to surgery is rarely less than 2 weeks. To date, there has been little published research on the UK public response to the symptoms of TIA, and no study at all of the response of primary care to such patients. The aim of this study was to ascertain both these responses to see whether a 48-h target is achievable., Patients and Methods: A total of 402 men attending our aortic aneurysm screening sessions were asked to complete a questionnaire requesting their most likely response to an episode of amaurosis fugax or TIA. All 45 GP practices in the hospital catchment area were asked how they would respond to patients requesting to be seen with the symptoms used in the questionnaire., Results: Nearly one in six patients would ignore the symptom unless it recurred, approximately half would request a GP appointment and a third would see an optician if they had amaurosis fugax. The mean waiting time to see a GP was 2 days for a routine appointment and within 24 h for an emergency appointment., Conclusions: It is clear that a significant number of people would ignore the first symptom of carotid ischaemia; for those with amaurosis fugax, nearly a third would initially seek help from their optician. Those given a routine GP appointment would have to wait a minimum of 2 days. If the Department of Health is serious about reducing the incidence of stroke and introducing a target of 48 h from symptom to treatment, then there needs to be a wide-spread public and healthcare education programme, in particular alerting opticians and GP receptionists that these symptoms constitute a medical emergency.

Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3-9.7, p < or = .0001) for combined stroke or death compared with surgery for "standard" indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1-9.3, p < or = .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.

Background: This study compares ropivacaine and levobupivacaine when administered for cervical plexus block. The authors therefore compared the arterial pressure profile and the incidence of hypotension between drugs., Methods: Forty-eight patients scheduled for carotid artery surgery (American Society of Anesthesiologists [ASA] 2-3) were randomly assigned to receive levobupivacaine or ropivacaine (24 patients each). Neurological status, arterial pressure profile and control of postoperative pain were the main observed parameters. All patients had severe carotid stenosis (>80%) and/or had suffered transient ischemic attacks (TIAs) or preoperative strokes. The same team performed anesthesia and surgery for carotid endarterectomy; the cervical block was performed according to Moore's technique.Arterial pressure, heart rate and S(a)O(2p) were monitored continuously with particular regard to T0 (baseline), T1 (immediately before carotid clamping), T2 (immediately before declamping) and T3 (at the end of the procedure). Hypotension was defined as the fall of arterial systolic pressure 30% below baseline or less than 100 mmHg., Results: Arterial pressure fell significantly in both groups at T1 with respect to T0 (P<0.0001). Levobupivacaine patients showed higher mean arterial pressure on T0 (112+/-12 mmHg versus 103+/-7 mmHg; P<0.05), thus suggesting a more pronounced vasodilator effect, as confirmed by the larger drop of arterial diastolic pressure (P=0.007). An absolute 6% difference of hypotension-related drug was recorded with levobupivacaine (19%) as compared with ropivacaine (13%) (P=0.28)., Conclusions: Levobupivacaine has a greater vasodilatory effect than ropivacaine. Its higher incidence of hypotension, although not statistically significant, suggests ropivacaine as the drug of choice for cervical plexus block.

The aim of the present case-control study was to assess patients with acute neurological symptoms requiring urgent carotid endarterectomy (CEA) and compare the outcome of the procedure in this group with that achieved in stable patients. Twenty-eight CEAs were performed in patients with an acute neurological deficit and 302 in stable patients from December 2006 to April 2008. Those selected for urgent surgery fulfilled the following criteria: acute onset of hemispheric neurological symptoms or crescendo TIAs, significant carotid pathology, the absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Perioperative mortality in the stable patients' cohort was 0.33%. One patient died during the hospital stay because of myocardial infarction. Perioperative neurological events were observed in 2.2%: one ipsilateral stroke in stage II A, one contralateral stroke in stage I A, and a prolonged neurological deficit with complete restitution at the time of discharge in five patients. No mortality or neurological morbidity was encountered in those who underwent urgent CEA. Compared to stable patients with stage I, II or IV disease, neither mortality nor morbidity was increased in those who underwent urgent CEA. Urgent CEA after non-disabling stroke or crescendo TIAs is a safe procedure with a favorable outcome.

Aim: To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA)., Methods: A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured, with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient inverted exclamation mark s contra-lateral hand., Results: Fifty-nine patients had awake CEA, 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20%) patients and symptomatic stenosis in 47 (80%). Seven (12%) patients required shunting, one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting, 22% (6/27) of patients with a mean SP of < 50 mmHg required shunting and only 3% (1/32) with a mean carotid SP of > 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of < or = 40 mmHg as the threshold for shunting, 40% (4/10) of patients required shunting and 3% (1/31) with a mean carotid SP of > 40 mmHg required shunting. This was statistically significant. Thirteen (22%) patients were complicated by transient hoarseness of voice. One (2%) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications., Conclusion: Even though the sample in this study was small, awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia.