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Introduction Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting. Patients and methods We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up. Results We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p Conclusion In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

Background For patients presenting with symptomatic internal carotid artery stenosis, carotid endarterectomy (CEA) surgery is recommended to be performed generally within a 48-hr to 14-day window. This study aimed to assess timeliness of delivery, and outcomes, of CEA surgery in a tertiary vascular centre. Method Patients with symptomatic internal carotid artery stenosis who underwent CEA between 1 June 2014 and 31 June 2017 were identified and data were obtained from hospital records. The timeline of their journey from presentation to surgery was then mapped together with their outcomes. Results One hundred and seventy-two cases were included in the study. Overall, the median time from development of presenting symptoms to surgery was 9 days and 119 (69%) cases were operated on within 14 days. The median time from development of presenting symptoms to ultrasound imaging was 2 days and the median time from symptoms to vascular referral was also 2 days. There were no deaths, strokes or transient ischaemic attacks within 30 days of CEA. At 1 year, survival was 100% but 15 (8.7%) had experienced at least one transient ischaemic attack or stroke. In the 53 cases operated upon beyond 14 days the dominant cause of delay in 32 (60%) was accessing surgery after review by the vascular service. Conclusion The aim of delivering CEA within 14 days of developing relevant symptoms was achieved in most cases with good outcomes. Nevertheless, points of delay in the patient journey that could be targeted for future quality improvement were identified.

OBJECTIVE To evaluate trends and differences in Near Infrared Spectroscopy (NIRS) monitoring during carotid endarterectomy (CEA) in patients affected by asymptomatic and symptomatic carotid artery stenosis, to predict postoperative neurological complications (PNCs). METHODS NIRS data of CEAs performed in a University Hospital were retrospectively reviewed. All the interventions were performed under general anesthesia and patients with intraoperative complications were excluded. Mean regional Oxygen Saturation Index (rSO2), pre-clamp values (mean baseline value, MBv and Single Mark Baseline value, SMBv) were collected and compared to the lowest rSO2 values during carotid cross-clamp (LSO2v) calculated within 3 minutes (percentage drop, PD). ROC curve analysis with Youden's Test was performed to determine the best threshold value of PD, in order to identify PNCs in both asymptomatic and symptomatic groups. RESULTS Between 2007 and 2015, a total of 399 CEAs were consecutively performed with NIRS monitoring. Three-hundred-seventy-two CEAs in 355 patients were reviewed. Asymptomatic stenoses were 291 (81.9%), eleven (2.9%) PNC were registered (5 in asymptomatic and 6 in symptomatic group). Asymptomatic and symptomatic diseases had different MBv (69.5±7.5 vs71.8±6.9, respectively; p=.011) and similar rSO2 value during carotid clamping (63.7±8.0vs63.7±6.7, respectively: p=.958). Asymptomatic patients experiencing PNCs had a greater PD than non-PNCs group (20.5±10.2% versus 12.5±7.6%, respectively using MBv as baseline value; p = .002), in contrast, in symptomatic patients, in which a low PD was associated with PNCs, it does not reach statistical significance (using MBv, 12.6±5.4% versus 14.8±6.7%, respectively; p = .476). In order to detect PNCs, ROC analysis revealed an optimal PD cut-off value of -17% in asymptomatic CEAs. (Sensibility (Se) 0.80, Specificity (Sp) 0.76, PPV 0.05, NPV 0.99, Youden's index 0.56; p=.020) In symptomatic a threshold value of -9% was found, without reaching statistical significance. CONCLUSIONS NIRS as cerebral monitoring during CEA can predict PNCs in asymptomatic stenosis. Asymptomatic and symptomatic groups differ in baseline and intraprocedural cut-off values to detect an augmented PNCs risk.

Introduction: Despite considered being a safe and efficacious procedure in patients with moderate to severe symptomatic carotid artery stenosis, carotid endarterectomy (CEA) carries a risk of postoperative cerebrovascular accident (POCVA). There is currently a lack of evidence pertaining to the relationship between cranial vascular integrity and its interaction with intraoperative haemodynamic fluctuations and risk of POCVA. Methods: In this retrospective case-control study, we utilised data collected from patients undergoing CEA for symptomatic carotid artery disease between Dec’05 and Oct’19 in the South Mersey Arterial Centre, UK. Patients with three-dimensional CT angiogram (3D-CTA) and evidence of POCVA were considered as cases, matched with those without such evidence that were considered as controls. 3D-CTAs were analysed following a structured proforma, and haemodynamic changes were obtained from operative notes. Results: Out of 951 patients, a total of 21 cases and 55 matched controls were identified. Presence of atherosclerotic disease in the vertebral arteries (VA) in either side, intracranial atherosclerosis (ICAS) (81% vs 40% and 57% vs 27%; + SD 61 + 23 mmHg vs. 44 + 20 mmHg, p Conclusions: These findings highlight the importance of routinely identifying posterior circulation abnormalities during the preoperative assessment, and judicious blood pressure management during the intraoperative period, both of which have the potential to help to develop a personalised risk stratification pre-CEA and greater intraoperative monitoring during CEA.

Background and Purpose. This study is aimed at assessing the differences in postoperative stroke, myocardial infarction (MI), and mortality in patients with symptomatic carotid artery stenosis (sCAS) treated with early or late carotid endarterectomy (CEA) to determine and compare the safety of different operation timing. Design. A systematic document retrieval of studies published in the past 10 years reporting periprocedural stroke/mortality/MI after carotid endarterectomy (CEA) related to the time between CEA and qualifying neurological symptoms. The application database has “PubMed, EMbase and Cochrane databases.” RevMan5.3 software provided by the Cochrane collaboration was used for meta-analysis. Results. A systematic literature search was conducted in databases. A total of 10 articles were included in this study. They were divided into early CEA and delayed CEA with operation within 48 h, 1 w, or 2 w after onset of neurological symptoms. Incidence of the postoperative stroke in patients undergoing delayed CEA (≥48 h) was significantly higher than patients with delayed CEA ( OR = 2.14 , 95% CI: 1.43-3.21, P = 0.0002 ). The postoperative mortality of patients after delayed CEA (≥48 h) was significantly higher than patients after early CEA ( OR = 1.35 , 95% CI: 1.06-1.71, P = 0.02 ). The risk of postoperative mortality of patients treated with delayed CEA (≥7 d) was significantly higher than patients after the early CEA group ( OR = 1.69 , 95% CI: 1.21-2.32, P = 0.001 ). Conclusion. Early CEA is safe and effective for a part of patients with symptomatic carotid stenosis, but a comprehensive preoperative evaluation of patients with carotid stenosis must be performed.

Atherosclerotic disease of the cervical part of ICA is responsible for 20–40% of ischemic strokes [1]. The prevalence of significant asymptomatic carotid stenosis in the general population varies from 0% to 3.1%. [2] Most patients are generally asymptomatic and have a risk of stroke of 1.5% per year and 7.5% per 5 years [3]. Symptomatic carotid artery stenosis usually presents with neurological dysfunctions in the form of transient ischemic attacks, amaurosis fugax, and various forms of stroke. These patients have an increased risk of recurrent cerebrovascular events.

Introduction: Revacept is a novel vascular lesion-directed inhibitor of platelet adhesion and thrombus formation, exhibiting no effects on the homeostatic functions of circulating platelets. Objective: The effects of Revacept on plaque-mediated thrombosis were investigated in patients with symptomatic stenosis of the internal carotid artery (at least 50%, following ECST-criteria). Methods: Within an international, prospective, multicenter (n=16), randomized trial 158 patients could be randomized to receive placebo, or 40/120 mg Revacept by intravenous infusion over 20 minutes. Cerebrovascular events and cardiovascular complications were followed up to 3 months. Results: 158 patients were finally included in the study. Of these, 127 (80.4%) received carotid endarterectomy, 12 received carotid stenting (7.6%) and 19 were referred to intensified conservative treatment (12.0%). Safety data showed cardiovascular events such as transitory ischemic attack (TIA) and ischemic stroke 24 hours after drug administration in 1 (0.6%) and 5 (3.1%) patients, and 3 months after drug administration in 5 (3.1%) and 9 (5.7%) patients, respectively. With regard to bleeding complications, intracerebral hemorrhage was not observed in any of the patients within 24 hours, and in 1 patient (0.6%) at 3 months follow up. Postoperative hematoma of any kind was observed in 9 patients (5.7%). Two other bleeding events (GI-bleeding and ear-bleeding) occurred within 3 months follow up. Coronary vascular events, defined as Troponin-I-elevation, were observed in 2 patients (1.3%) at 24 hours, and in 7 patients (4.4%) at 3 months after drug administration. Coronary intervention was necessary in 1 patient (0.6%) and 5 patients (3.1%), 24 hours and 3 months after Revacept infusion, respectively. These complications rates are comparable to the rate at day 30 follow up within the ICSS-study: ischemic stroke (91 patients 5.3%), intracerebral hemorrhage (8 patients, 0.5%) and any wound hematoma (81 patients, 4.7%) Conclusions: The addition of Revacept to guideline-recommended anti-thrombotic therapy in patients with symptomatic stenosis of the internal carotid artery did not increase bleeding complications within the overall study population compared to previous studies.

Digital subtraction angiography (DSA) is considered the reference method for the assessment of carotid artery stenosis; however, the procedure is invasive and accompanied by ionizing radiation. Velocity estimation with duplex ultrasound (DUS) is widely used for carotid artery stenosis assessment since no radiation or intravenous contrast is required; however, the method is angle-dependent. Vector concentration (VC) is a parameter for flow complexity assessment derived from the angle independent ultrasound method vector flow imaging (VFI), and VC has shown to correlate strongly with stenosis degree. The aim of this study was to compare VC estimates and DUS estimated peak-systolic (PSV) and end-diastolic velocities (EDV) for carotid artery stenosis patients, with the stenosis degree obtained with DSA. Eleven patients with symptomatic carotid artery stenosis were examined with DUS, VFI, and DSA before and after stent treatment. Compared to DSA, VC showed a strong correlation (r = −0.79, p r = 0.68, p = 0.002) and EDV (r = 0.51, p = 0.048) obtained with DUS showed a moderate correlation. VFI using VC calculations may be a useful ultrasound method for carotid artery stenosis and stent patency assessment.

Purpose: To investigate the short-term outcomes and complications of straight vs tapered carotid stent placement for patients with symptomatic carotid stenosis. Methods: A prospective study was conducted to examine if tapered carotid stents (TCS) performed better than straight carotid stents (SCS) in terms of complications and outcomes in patients with a unilateral, symptomatic, internal carotid artery stenosis ⩾70%. Between January 2014 and January 2016, 236 patients were screened; 88 were excluded, leaving 148 patients for 1:1 randomization to carotid artery stenting with either SCS or TCS. The data were analyzed for differences between the groups in terms of complications (hemodynamic depression, cerebral hyperperfusion syndrome, puncture site sequelae) and endpoint events (stroke, myocardial infarction, and death) at 30 days and 6 months. Results: Two patients in the TCS group underwent endarterectomy after allocation, leaving 72 patients (mean age 65.1±8.8 years; 59 men) in the TCS group for analysis vs 74 (mean age 65.0±7.9 years; 58 men) in the SCS group. The technical success was 100% in both groups. The incidence of hemodynamic depression (hypotension and bradycardia) after the procedures were higher in the SCS group (p=0.04), and the patients who underwent SCS procedures had longer hospital stays (p=0.01). There was no difference in the incidences of complications, myocardial infarction, mortality, or stroke at 30 days or 6 months between the SCS and TCS groups. The rates of restenosis (4% SCS vs 1% TCS) were similar (p=0.63); all restenoses were moderate (50%–70%). Conclusion: When compared to straight stents, tapered carotid stents significantly decreased hemodynamic complications and hospital stay.

Introduction: About 30% of patients with carotid artery stenosis (CAS) develop dementia after a cerebral ischemic event (CIE), and 20–50% suffer from CIE recurrence during 6 months. Carotid artery revascularization (CAR) may prevent CIE recurrence, at the cost of new microembolic lesions (MES). The impact of CAR on cognitive function is debatable. Aim : To assess functional and cognitive outcome, cerebral flow on transcranial Doppler (TCD) and brain magnetic resonance imaging (MRI) in patients with symptomatic CAS referred for CAR. Material and methods : Twenty-two patients (aged 69.0 ±7.2 y.o., 15 male) with recent CIE (21.9 ±20.9 days to CAR) related to CAS of mean 89.8 ±3.9% lumen reduction were prospectively evaluated with TCD, diffusion and perfusion MRI, Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) 24 h before, at 24–48 h and 1 month following CAR. Results : New MES were found in 11 (50%) subjects following CAR. CAR resulted in a significant increase of cerebral flow velocity in the middle and anterior cerebral arteries (p < 0.002 and p = 0.003; respectively) and cerebral perfusion measured by time to peak (TTP) and mean transit time (MTT) (p = 0.0009 and p = 0.0002; respectively). Neurologic tests showed improvement in NIHSS (2.4 ±1.6 to 1.5 ±1.2, p = 0.003), mRS (from 1.3 ±0.9 to 0.7 ±0.9, p = 0.005), and MMSE (26.7 ±2.2 to 27.6 ±2.3, p = 0.019) at 1 month, while similar MoCA scores were observed before and 1 month after CAR (23.4 ±3.3 vs. 24.1 ±3.7, p = 0.136). Conclusions : Improvement of cerebral flow and perfusion and functional outcome, as well as at least no cognitive decline, is observed after CAR for symptomatic CAS.

Carotid revascularization for asymptomatic carotid artery stenosis (ACAS) has become increasingly controversial in the past few decades as the best medical therapy has improved. The aim of this study was to assess and define contemporary trends in the rate of carotid revascularization procedures for ACAS in the United States and to characterize outlier physicians performing a higher rate of asymptomatic revascularization compared to their peers.We used 100% Medicare fee-for-service claims to identify all patients who were newly diagnosed with ACAS between 01/2011-06/2018. Patients with symptomatic carotid artery stenosis, those with prior carotid revascularization, and surgeons who performed ≤10 CEAs during the study period were excluded. We used a hierarchical multivariable logistic regression model to evaluate patient and physician characteristics associated with undergoing a carotid endarterectomy or carotid artery stent procedure within 3 months after the initial diagnosis of ACAS. We also assessed temporal trends in carotid revascularization rates over time using the Cochran-Armitage Trend Test.Overall, 795,512 patients (median age 73.9 years, 50.9% male, 87.6% white) had a first-time diagnosis of ACAS during the study period, of which 23,481 (3.0%) underwent carotid revascularization within 3 months. There was a significant decline in overall carotid artery revascularization rates over time (2011: 3.2% vs. 2018: 2.1%; P 0.001). The median and mean physician-specific carotid revascularization rates were 2.0% (IQR 0.0%-6.3%) and 4.7% ± 7.1%, respectively. Three-hundred and fifty physicians (5.2%) had carotid revascularization rates ≥19%, which was more than 2 standard deviations above the mean. After adjusting for patient-level characteristics, physician-level variables associated with carotid revascularization for newly diagnosed ACAS included male sex (adjusted OR 1.59, 95% CI 1.35-1.89), more years in practice (≥31 vs.10 years, aOR 1.64, 95% CI 1.32-2.04), rural practice location (aOR 1.34, 95% CI 1.18-1.52), Southern region practice location (versus Northeast, aOR 1.54, 95% CI 1.39-1.69), and lower volume of ACAS patients (lower versus upper tertile, aOR 2.62, 95% CI 2.39-2.89). Cardiothoracic surgeons had a 1.52-fold higher odds of carotid revascularization compared to vascular surgeons (95% CI 1.36-1.68), whereas cardiologists and radiologists had lower intervention rates (both, P 0.05).The current early revascularization rate for newly diagnosed ACAS is5% among proceduralists in the United States, and has been decreasing steadily since 2014. There are particular physician-level characteristics that are associated with higher rates of carotid revascularization that cannot be fully contextualized without high-level contemporary outcomes data to guide decision making in ACAS.

Background: Risk stratification of asymptomatic carotid artery stenosis (ACAS) is still an issue for carotid revascularization. We sought to identify factors associated with symptomatic carotid artery stenosis (SCAS) using multimodal imaging techniques.Methods: We retrospectively collected data on patients who underwent carotid artery revascularization. Results from duplex sonography, computerized tomography angiography, brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), perfusion-weighted imaging, and demographic profiles were compared between ACAS and SCAS patients. Differences in baseline characteristics between the two groups were balanced by the propensity matching score method. Multivariable regression analysis was performed to identify factors associated with symptomaticity of carotid artery stenosis. We compared the strength of associations between significant imaging factors and symptomatic carotid stenosis using C statistics.Results: A total of 259 patients (asymptomatic 57.1%, symptomatic 42.9%) with carotid stenosis were included. After 1:1 propensity score matching, the multivariable regression analysis revealed that the absence of plaque calcification [Odds ratio 0.41, 95% confidence interval (CI) 0.182–0.870, p = 0.023], deep white matter hyperintensity (DWMH; Odds ratio 3.46, 95% CI 1.842–6.682, p < 0.001), susceptibility vessel sign seen on gradient-echo MRI (Odds ratio 2.35, 95% CI 1.113–5.107, p = 0.027), and increased cerebral blood volume (CBV) seen on perfusion-weighted MRI (CBV; Odds ratio 2.17, 95% CI 1.075–4.454, p = 0.032) were associated with SCAS. The combination of these variables had a fair accuracy to classify SCAS (Area under the curve 0.733, 95% CI 0.662–0.803).Conclusions: We identified several multimodal imaging markers independently associated with SCAS. These markers may provide information to identify ACAS patients with high risk of ischemic stroke. Future studies are needed to predict SCAS using our findings in other independent cohorts.

Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determ...

Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH. RESUMO Trombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanalização foi de 90% (19/20) e a taxa de HIS foi de 5% (1/20). Em três meses, foi obtido bom desfecho neurológico em 35% (7/20) dos pacientes e a mortalidade foi de 20% (4/20). Conclusão A angioplastia com stent de carotída associada ao tratamento endovascular para oclusões combinadas agudas de carótida parece ser efetiva sem um aumento de HIS.

Objectives Anatomic variations of the extracranial carotid artery are rare. Persistent primitive hypoglossal artery appears with a reported incidence between 0.03% and 0.2%. We report a case of recurrent transient ischemic attacks originating from proximal internal carotid artery stenosis associated with ipsilateral persistent primitive hypoglossal artery and give a review of the existing literature. Methods A 78-year-old patient with a medical history of two previous transient ischemic attacks consulted our emergency department with an acute left hemispheric stroke. Intravenous thrombolysis permitted complete resolution of symptoms. Concurrent Computed Tomography (CT) and Magnetic Resonance (MR) angiography revealed an unstable plaque causing 50% stenosis of the left internal carotid artery with a persistent primitive hypoglossal artery dominantly perfusing the posterior circulation, and bilateral hypoplastic vertebral arteries. Results Uneventful carotid artery stenting using a proximal protection device was performed, and the patient was discharged after 12 days. Six months follow-up was uneventful with a patent stent in the internal carotid artery. Conclusions Treatment of symptomatic carotid artery stenosis in the presence of persistent primitive hypoglossal artery is challenging. Management should be driven by patients’ co-morbidities, the anatomical localization of the lesions and local expertise. In the case of a high origin of the persistent primary hypoglossal artery, carotid artery stenting with the use of a proximal cerebral protection device is probably the preferred and simplest approach.

Background: The Dutch Audit for Carotid Interventions (DACI) registers all patients undergoing interventions for carotid artery stenosis in the Netherlands. This study describes the design of the DACI and results of patients with a symptomatic stenosis undergoing carotid endarterectomy (CEA). It aimed to evaluate variation between hospitals in process of care and (adjusted) outcomes, as well as predictors of major stroke/death after CEA.Methods: All patients with a symptomatic stenosis, who underwent CEA and were registered in the DACI between 2014 and 2016 were included in this cohort. Descriptive analyses of patient characteristics, process of care, and outcomes were performed. Casemix adjusted hospital procedural outcomes as (30 day/in hospital) mortality, stroke/death, and major stroke/death, were compared with the national mean. A multivariable logistic regression model (backward elimination at p > 0.10) was used to identify predictors of major stroke/death.Results: A total of 6459 patients, registered by 52 hospitals, were included. The majority (4,832, 75%) were treated Conclusion: CEA in The Netherlands is associated with an overall low mortality and (major) stroke/death rate. Whereas the indicator time to intervention varied between hospitals, mortality and (major) stroke/death were not significantly distinctive enough to identify worse practices and therefore were unsuitable for hospital comparison in the Dutch setting. Additionally, predictors of major stroke/death at population level could be identified. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVES: Carotid artery stenting is an emerging revascularization alternative to carotid endarterectomy. However, guidelines have recommended carotid artery stenting only if the rate of periprocedural stroke or death is < 6% among symptomatic patients and < 3% among asymptomatic patients. The aim of this study is to evaluate and compare clinical outcomes of symptomatic and asymptomatic patients who had undergone carotid artery stenting as a first-intention treatment. METHOD: A retrospective analysis of patients who underwent carotid artery stenting by our interventional neuroradiology team was conducted. Patients were divided into two groups: symptomatic and asymptomatic patients. The primary endpoints were ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage and major adverse cardiac and cerebrovascular events at 30 days. The secondary endpoints included ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage, ipsilateral transient ischemic attack and major adverse cardiac and cerebrovascular events between the 1- and 12-month follow-ups. RESULTS: A total of 200 consecutive patients were evaluated. The primary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral stroke (2.4% vs. 2.7%, p = 1.00), ipsilateral parenchymal hemorrhage (0.8% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (4.7% vs. 2.7%, p = 0.71). The secondary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral ischemic stroke (0.0% vs. 0.0%), ipsilateral parenchymal hemorrhage (0.0% vs. 0.0%), ipsilateral TIA (0.0% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (11.2% vs. 4.1%, p = 0.11). CONCLUSIONS: In this retrospective study, carotid artery stenting was similarly safe and effective when performed as a first-intention treatment in both symptomatic and asymptomatic patients. The study results comply with the safety requirements from current recommendations to perform carotid artery stenting as an alternative treatment to carotid endarterectomy.

The management of patients with extracranial carotid artery stenosis remains controversial. Randomized controlled studies established the value of carotid endarterectomy (CEA) over optimal medical therapy for patients with symptomatic carotid stenosis. For patients with carotid stenosis, optimal medical therapy includes antiplatelet agents, antihypertensives, and lipid-lowering medications along with lifestyle modifications. Some studies and experts have challenged these treatment methods and consider carotid artery stenting with distal protection as an alternative to CEA. In this article, the authors review current guidelines and supporting studies and suggest practical approaches to this common clinical problem.

Symptomatic carotid artery stenosis is an important cause of stroke with significant morbidity and mortality. Revascularization with carotid endarterectomy reduces the recurrence of stroke and until recently was considered the gold standard of therapy. Carotid artery stenting has emerged as an alternative method of revascularization in both high-risk and standard-risk patients. This review appraises the role of surgery versus stenting for patients with symptomatic carotid stenosis.

Object The risk of recurrence of cerebrovascular events within the first 72 hours of admission in patients hospitalized with symptomatic carotid artery (CA) stenoses and the risks and benefits of emergency CA intervention within the first hours after the onset of symptoms are not well known. Therefore, the authors aimed to assess 1) the ipsilateral recurrence rate within 72 hours of admission, in the period from 72 hours to 7 days, and after 7 days in patients presenting with nondisabling stroke, transient ischemic attack (TIA), or amaurosis fugax (AF), and with an ipsilateral symptomatic CA stenosis of 50% or more, and 2) the risk of stroke in CA interventions within 48 hours of admission versus the risk in interventions performed after 48 hours. Methods Ninety-four patients were included in this study. These patients were admitted to hospital within 48 hours of a nondisabling stroke, TIA, or AF resulting from a symptomatic CA stenosis of 50% or more. The patients underwent carotid endarterectomy (85 patients) or CA stenting (9 patients). At baseline, the cardiovascular risk factors of the patients, the degree of symptomatic CA stenosis, and the type of secondary preventive treatment were assessed. The in-hospital recurrence rate of stroke, TIA, or AF ipsilateral to the symptomatic CA stenosis was determined for the first 72 hours after admission, from 72 hours to 7 days, and after 7 days. Procedure-related cerebrovascular events were also recorded. Results The median time from symptom onset to CA intervention was 5 days (interquartile range 3.00–9.25 days). Twenty-one patients (22.3%) underwent CA intervention within 48 hours after being admitted. Overall, 15 recurrent cerebrovascular events were observed in 12 patients (12.8%) in the period between admission and CA intervention: 3 strokes (2 strokes in progress and 1 stroke) (3.2%), 5 TIAs (5.3%), and 1 AF (1.1%) occurred within the first 72 hours (total 9.6%) of admission; 1 TIA (1.1%) occurred between 72 hours and 7 days, and 5 TIAs (5.3%) occurred after more than 7 days. The corresponding actuarial cerebrovascular recurrence rates were 11.4% (within 72 hours of admission), 2.4% (between 72 hours and 7 days), and 7.9% (after 7 days). Among baseline characteristics, no predictive factors for cerebrovascular recurrence were identified. Procedure-related cerebrovascular events occurred at a rate of 4.3% (3 strokes and 1 TIA), and procedures performed within the first 48 hours and procedures performed after 48 hours had a similar frequency of these events (4.5% vs 4.1%, respectively; p = 0.896). Conclusions The in-hospital recurrence of cerebrovascular events was quite low, but all recurrent strokes occurred within 72 hours. The risk of stroke associated with a CA intervention performed within the first 48 hours was not increased compared with that for later interventions. This raises the question of the optimal timing of CA intervention in symptomatic CA stenosis. To answer this question, more data are needed, preferably from large randomized trials.

Saving time to intervention is crucial in patients with symptomatic carotid artery stenosis (SCAS). We introduced a fast-track protocol (FTP). Time frames from the onset of symptoms to intervention before and after the introduction of an FTP were analyzed. SCAS patients (403 patients/405 procedures) were evaluated according to whether surgery was performed before (group 1) or after (group 2) the introduction of the FTP. Time frames to surgery, causes of delay and frequency of recurrent events are reported. The median time delay decreased from 17 to 12 days (p < 0.001), but time to ultrasound examination remained unchanged. Surgery was within 2 weeks in 41% in group 1 and in 57% in group 2 (p = 0.001). Of 181 (30%) patients treated according to the FTP, 54 were operated within 7 days (median), and 80% had the intervention within 2 weeks. Time to surgery decreased significantly after the introduction of the FTP.

Strokes have an extremely significant socioeconomic impact on the healthcare industry with a resultant poor quality of life. The majority of strokes result from embolic phenomenon, a third originating from carotid atheromatous plaque. The gold-standard treatment for symptomatic carotid artery stenosis has been carotid endarterectomy; however, carotid artery stenting over the last decade has become an increasingly accepted and performed alternative. This article describes the outcomes of carotid stenting among symptomatic patients and examines the trials that have been performed regarding the treatment options.

This commentary addresses the issue of optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis. Based on current data, carotid endarterectomy (CEA) should be performed in the majority of patients with symptomatic carotid artery stenosis. Carotid artery stenting (CAS) should be reserved for a minority of these symptomatic patients, in whom CEA is contraindicated. In asymptomatic patients, all should be placed on best medical treatment (BMT). With the use of one or more of the proposed stroke risk stratification models or some as yet undetermined method, the identification of those asymptomatic individuals may be possible in whom stroke risk is higher than usual with BMT. This asymptomatic subgroup, which may be small and is yet to be determined with certainty, could be offered an invasive carotid procedure (either CAS or CEA).

Patients with symptomatic carotid artery stenosis should be counseled on diet, exercise, moderation of alcohol consumption, smoking cessation, and avoidance of environmental tobacco smoke. Medical therapy generally includes a platelet antiaggregant, blood pressure control, and a statin. Other medical therapy depends on specific patient characteristics. Carotid endarterectomy in addition to best medical therapy is of proven benefit in reducing the risk of ipsilateral stroke compared with best medical therapy alone in patients with symptomatic high-grade stenosis, provided the operation can be performed safely. Although limited, data are available to support carotid angioplasty/stenting in patients with symptomatic high-grade stenosis in whom endarterectomy is not feasible because of anatomic or other technical factors. Whether carotid angioplasty/stenting is as efficacious as endarterectomy in patients with average periprocedural risk remains uncertain and is under investigation.

Carotid artery stenting is emerging as an intervention for high-risk nonsurgical patients with high-grade symptomatic carotid artery stenosis. The purpose of this article is to inform advanced practice nurses about research findings related to carotid endarterectomy and carotid artery stenting. This overview of carotid angioplasty and stenting includes complications and guidelines for preprocedural, periprocedural, and postprocedural care. Standards of practice for managing carotid artery disease are highlighted with emphasis on primary and secondary prevention.

Carotid artery stenosis is a disabling disease in all age groups. Elderly people are more prone to recurrent strokes due to advancing age and multiple co-morbidities. Treatment options for symptomatic carotid stenosis in the very elderly are the same as in younger patients although with a higher operative risk. We describe a successful case of carotid artery stenting in a nonagenarian with symptomatic carotid artery stenosis, a subgroup for whom treatment options are rarely discussed in guidelines.

Background: Octogenarians account for a third of ischemic stroke (IS) patients and they have higher morbidity and mortality rate among IS patients. The aim of this study was to evaluate the pri-procedural and long term clinical and angiographic statement of carotid artery angioplasty (CAA) in octogenarians.Methods: In a mono-arm trial 102 patients>80 years old with symptomatic internal carotid artery (ICA) stenosis presented by non-disabling IS or TIA underwent the CAA and were evaluated prospectively from January 2010 to July 2014. All patients had standard stroke care during the study follow up. The peri-procedural complications, cerebrovascular accidents, restenosis in target vessel and mortality rate were recorded to evaluate safety and durability of this secondary stroke prevention method in octogenarians.Results: 48 (47.06%) males and 54 (52.9%) females in a mean period of 24.5±14.1 (6-50 months) were followed. For all patients mean age was 83.39 ±2.53 (range, 80-88) years. The success rate of CAA was 100%, whereas the peri-procedural complication rate was 5.8% (access-site local hematoma and bradycardia during CAA both in 2.94%).There was only one patient who had acute ischemic stroke during the procedure. Restenosis occurred in 3.9% after a mean of 21.5 months. The proportion of recurrent cerebrovascular accident was 9.8% while TIAs occurred in 3.9% and stroke in 1% of patients. Also 4.9% of patients experienced coronary artery disease and the proportion of fatal recurrent cerebrovascular accident was 2.9%. The median patient event-free survival was 20 months.Conclusion: CAA seems to be a safe and durable IS secondary prevention method in octogenarians with symptomatic carotid artery stenosis.

Introduction Ask a dysphasic patient who has received a carotid artery stent if he or she would instead have rather had a troponin enzyme leak or minor myocardial infarction (MI). Although the answer is clear to most of us, there are many interventionalists and clinicians who have inappropriately interpreted recent data from the CREST trial to conclude that carotid artery stenting (CAS) is equivalent to carotid endarterectomy (CEA).

An excellent meta-analysis from Gurm et al. 1 updates the data concerning the treatment of symptomatic carotid stenosis by a surgical or endovascular approach. The last two randomized trials, SPACE2 and EVA3S,3 did not, in fact, confirmed the equivalence of the two methods and there followed a general unfavourable feeling towards carotid stenting. The article by Gurm et al. , 1 which eliminates some old randomized studies such as CAVATAS4 and the stopped Leicester trial,5 appears statistically sound. We can learn that there is no significant difference between carotid stenting (CAS) and endarterectomy (CAE). Today, the data are heterogeneous and difficult to analyse; the authors have shown that we can approach the truth and keep the two options without bringing them into conflict. Patients with symptomatic tight carotid stenosis have to be treated because the risk of a cerebrovascular accident is ∼20% at 1 year. In the 1980s, surgical treatment was compared with medical treatment by lengthy randomized trials such as NACST6 and ECST,7 and has been recognized as the reference treatment. The contribution of antiplatelet agents and statins today offers much better patient care for atherosclerotic disease and raises questions about the validity of these outdated studies. CAS is still in evolution, with a … Corresponding author. Tel: +33 49180 69 05, fax: +33 49180 69 26. Email: pbergeron{at}hopital-saint-joseph.fr; endovasc{at}hopital-saint-joseph.fr

PP-389 Large randomised trials have established carotid endarterectomy (CEA) as the standard treatment for symptomatic severe carotid artery stenosis. Carotid artery stenting (CAS) has been increasingly used for possible alternative treatment to CEA. In this study we aimed to compare the

Overwhelmingproof exists that ischemie stroke can be prevented, or at least delayed, for a large number of individuals. Many strokes that resulted from severe symptomatic carotid artery stenosis need happen no longer. Effective treatments have been established by the time-consuming and expensive process of randomized clinical trials. Alas, all other methods seeking the truth about therapeutic benefit are less perfect and frequently misleading. Paradoxically, endarterectomy is complicated by stroke, the very disaster that it effectively reduces. This paradox demands of the practitioner that the indications for this therapy and the care with which it is administered must be precisely defined and scrupulously monitored. This communication will discuss who should and who should not undergo carotid endarterectomy (CE) by focusing on the arterial imaging methods that will provide the essential preoperative information to help ensure appropriate selection of candidates. 1 PATIENTS PROVEN TO BENEFIT FROM CE The proven indications for

Objective. The purpose of this study was to determine the frequency of thromboembolic events associated with angioplasty and stenting of the carotid artery with special regard to extra- or intracranial localization of stenosis. Methods. Twenty patients with symptomatic intracranial or extracranial internal carotid artery stenosis were treated with stenting and/or angioplasty. In 4 patients stenting was technically not feasible (all in the group with intracranial stenosis). All patients underwent diffusion-weighted imaging (DWI) and neurological examination within 48 hours before and after the procedure to detect periprocedural thrombembolic events. Results. Extracranial carotid angioplasty and stenting (eCAS) was technically feasible and successfull without procedure-related neurological complications in all cases. Intracranial stenting (iCAS) was not feasible in four cases including one patient with a fateful course. Concerning the restoration of the vessel diameter intracranial stenting was not as successful as eCAS, but more effective than balloon angioplasty alone. Incidence of thrombembolic events assessed by DWI was low. The detected periprocedural thrombembolic events were small and clinically silent. Conclusion. The risk of thromboembolic events during the endovascular treatment of symptomatic carotid artery stenosis was rather low for intra- and extracranial stenosis of the ICA in our patient sample, but one fatal course was observed.

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.

The recent guidelines by the American Heart Association/American Stroke Association (AHA/ASA) and several other associations recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients (Class I; Level of Evidence: B). The term "alternative" may easily be misinterpreted as "equivalent" to justify the widespread use of CAS. However, current evidence indicates that for symptomatic patients, CAS produces inferior outcomes compared with CEA. It is likely that with technical improvements, better patient selection, and better physician experience, CAS outcomes will improve in the future. CAS may then become a fair alternative to CEA, at least in certain patient subgroups. Based on current evidence, however, we are not there yet and it seems unfair to spin the AHA/ASA guidelines to conclude that we are.

Most symptomatic patients should not be candidates for carotid artery stenting (CAS); at least not at present. In these patients, CAS is associated with higher stroke, as well as recurrent stenosis rates compared with carotid endarterectomy (CEA). Furthermore, CAS is considerably more expensive than CEA. These facts raise the question, why perform CAS in symptomatic patients when you have CEA, which is associated with lower stroke and recurrent stenosis rates, and is also a more cost-effective option. This article supports the theory that currently most symptomatic patients are not appropriate candidates for CAS.

To describe the experience of two challenging basilar tip aneurysms that involved the origins of bilateral SCAs and PCASs successfully treated with PulseRider bifurcation stent. A large basilar tip aneurysm case that was successfully treated with PulseRider T-shaped bifurcation stent after a failed Y-stenting attempt. Case description Both patients were treated as a part of ANSWER Trial. An early 70s female patient was found to have a broad-based large basilar tip aneurysm during her work up for right symptomatic carotid artery stenosis. The aneurysm incorporated bilateral PCAs and SCAs. Bilateral P1 and P2 segments showed extreme tortuosity, which made single or Y-stenting challenging. The aneurysm was first embolized with double microcatheter and balloon assisted techniques. However, it continued to grow from the large remnant. A Y-stenting attempt failed once due to the PCA tortuosity. The recanalized growing aneurysm measured 20mm in the largest dimension. A 10mm span T-shaped PulseRider was delivered through a 0.021 microcatheter and could be placed within the base of the recanalized aneurysm just above the PCA origins. A total of 25 coils were deployed into the aneurysm. The final angiogram showed complete obliteration of the aneurysm and patency of the PCAs and SCAs. Due to the large size and also aggressive coiling, the patient experienced worsening of mass effect to the midbrain and upper pons, which was successfully treated with steroid. Brain MRI showed FLAIR high signal in the cerebral peduncle and belly of the upper pons. No DWI high signal was found in bilateral PCA territories. Another case was a late 50s female with a previously ruptured small wide-necked basilar tip aneurysm that incorporated the posterior wall of the basilar artery near the origins of PCAs and SCAs. In acute phase, the dome and bleb of the aneurysm was first embolized with balloon assist technique. However, the aneurysm recanalized from the remnant. The largest dimension of the recanalized aneurysm measured 6mm. An eight mm span T-shaped PulserRider was deployed with each tip placed into the PCAs. The wing of the PulseRider delineated the aneurysm neck for the subsequent embolization and the body also provided adequate protection for the embolization of the aneurysm base that incorporated the PCA and SCA origins. The aneurysm was successfully embolized with 10 coils. Conclusion The PulseRider’s unique ability to protect bifurcation branches without catheterizing into those branches enabled the successful embolizations. The body of the pulseRider also provides some protection. Disclosures S. Tateshima: 2; C; Pulsar Vascular. S. Seth: None. C. Liang: None. N. Patel: None. A. Ismail: None. D. Freeman: None. V. Szeder: None. R. Jahan: None. G. Duckwiler: None.

Carotid endarterectomy reduces the risk of stroke in patients with symptomatic carotid artery stenosis, but the optimum time to perform surgery has been uncertain. A large study has shown that surgery within 2 days of stroke or transient ischaemic attack has an unacceptable complication rate, but is safe thereafter.

Since being presented the results of the two major multicenter trials ECST (European Carotid Surgery Trial) and NASCET (North American Symptomatic Carotid Surgery Trial), it is very decisive to precisely evaluate the degree of symptomatic carotid artery stenosis prior to the procedure with regard to the specific therapeutic management decision: carotid endarterectomy in angiographically verified stenosis >70 % or standard medical treatment with antiplatelet agents, primarily aspirin, in mild or moderate stenosis (10, 20). Due to different angiographic measurement formula, the results of both studies are not directly comparable with each other: while in the ECST trial the residual lumina were compared with the estimated original lumina at the site of the stenosis (“local degree of stenosis”), the so-called distal degree of stenosis was calculated by charging the ratio between the residual lumina and the diameter of the intact distal internal carotid artery. These different measurements are the reason, that the local degree of a 82 % stenosis (ECST criteria) corresponds with the distal degree of a 70 % stenosis (NASCET criteria); to a local degree of a 50 % stenosis no distal degree of stenosis can be calculated (0 %).