Fig 1
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Carotid artery stenosis is responsible for between 10–20% of all ischaemic strokes. Interventions, such as carotid end-arterectomy and carotid stenting, effectively reduce the risk of stroke in selected individuals. This review describes the history of carotid interventions, and summarises reliable evidence on the safety and efficacy of these inter...
Context in source publication
Context 1
... in asymptom- atic patients. Then in the 2000s and 2010s, CEA was compared to CAS in symptomatic and asymptomatic patients. We have now turned full circle, with several current clinical trials reassessing the benefits and risks of carotid interventions compared to contemporary medical therapy alone in symptomatic and asymptom- atic patients (Fig. 1). While observational studies pro- vide insight into the absolute stroke risk and risk fac- tors for individuals with carotid stenosis, they have limited value in assessing the efficacy and safety of carotid interventions. The inherent bias of observa- tional studies, i.e. through confounding, reverse causa- tion, recall and detection ...
Similar publications
Background: Improved stroke risk stratification may improve stroke prevention. We aimed to study the value of a novel Doppler method, superb microvascular imaging (SMI), in correlating plaque thickness and evidence of intra-plaque neovascularization with a history stroke and TIA involving any cerebrovascular territory among community residents cons...
Stroke is a serious condition that results from an occlusion of blood vessels that leads to brain damage. Globally, it is the second highest cause of death, and deaths from strokes are higher in older people than in the young. There is a higher rate of cases in urban areas compared to rural due to lifestyle, food, and pollution. There is no effecti...
Background and Purpose
Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, su...
Objectives
The aim of this study was to compare procedure-related ipsilateral cerebral embolism with a conventional (Acculink, Abbott Vascular) versus a MicroNet-covered (CGuard, InspireMD) stent in carotid artery stenting (CAS).
Background
The MicroNet-covered stent may reduce periprocedural cerebral embolism in CAS, but level 1 evidence is lacki...
Stroke is a leading cause of adult mortality and disability worldwide. Extracranial atherosclerotic disease (ECAD), primarily, carotid artery stenosis, accounts for approximately 18%-25% of ischaemic stroke. Recent advances in neuroimaging, medical therapy and interventional management have led to A significant reduction of stroke from carotid arte...
Citations
... Atherosclerotic plaques, upon losing contact with the vascular endothelium and entering the brain, are responsible for 10-20% of ischemic strokes [10,11]. Consequently, the common carotid arteries undergo endarterectomy and stent procedures [12], which reduce the risk of ischemic strokes from around 3.8% to over 15%, depending on the severity of carotid artery stenosis [13]. ...
... 1 Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are 2 essential surgical prosedures applied to manage carotid stenosis. Although, CEA has been considered as the "golden standart" in operation of carotid artery stenosis so far, CAS has progressively become the recent prosedure as an alternative to CAE. [2][3][4][5] It was previously indicated that 20-25% nearly all type of stroke incidents are resulted from carotid stenosis. 6 Likewise, approximately 63% individuals with carotid artery stenosis were found to be associated with cardiac events especially in terms of myocardial infarction. ...
... At the worldwide level, occurrence of carotid artery stenosis disease is predicted to be 1.5% in 2020. 1 Despite the observed increase in utilization of CAS prosedure in terms of widespread use of tools in carotid artery stenosis, increased in physicians' clinical knowledge, and patients preferences, the ultimate effect of CAS with CEA precudures remain debatable most notably in mid-term and long-term outcomes. 5,6 In this reseach, we systematically reviewed the randomized controlled trials (RCTs) comparing outcomes of CAS versus CEA in both symptomatic and asymptomatic carotid stenosis in terms of mid-term (post-operaif beyond 30 days) outcomes of any stroke, all-cause mortality, and myocardial infarction. ...
... An across-the-board literature was searched from 1994 (when metal stents placed in 2 patients with carotid artery stenosis at first) to December 31, 2021 for all RCTs that compared CAS with CEA in the operation of carotid stenosis reported mid-term outcomes. 5 Most popular databases such as ScienceDirect, Pubmed, Web of Science, Sage, Ebscohost, Scopus and Cochrane Central was searched. While searching in databases key terms as "carotid artery stenosis", "endarterectomy", "stenting", "randomized controlled trial", "stroke", "death", "mortality", and "myocardial infarction" was entered. ...
... Several studies and stroke risk criteria in carotid stenosis focused on the structure and composition of plaque, but few investigated the possible association of symptoms with hemodynamic modifications [20][21][22][23]. In our study, the presence of SWI-MHVs was associated with a history of previous cerebrovascular symptoms (21 in 37 participants (56.8%); p = 0.031). ...
Purpose
Patients with steno-occlusive arterial disease may develop cerebral hypoperfusion with possible neurologic sequelae. The aim of the study is to verify the possible role of SWI, as a marker of cerebral hypoperfusion, in the identification of patient subgroups with significant chronic occlusions/stenoses at risk of critical cerebral hypoperfusion.
Methods
We retrospectively identified 37 asymptomatic patients with chronic intra-extracranial occlusion/stenosis of the anterior circulation from a prospective brain MRI register between 2016 and 2020. All patients underwent 3 Tesla MRI. The imaging protocol included the following: SWI, 3D-FLAIR, DWI sequences, and 3D-TOF MRA. SWI findings were graded for the presence of asymmetric intracranial cortical veins (grades 1 to 4). The presence of collateralization was assessed with concomitant multiphase-CTA. FLAIR was evaluated for the presence of distal hyperintense vessels (DHVs), a described marker of flow impairment, and possible collateralization. Cerebral blood flow and arterial transit artifacts (ATAs) were evaluated at pCASL in 29 patients.
Results
SWI showed multiple hypointense vessels (MHVs) in 22/37 patients in the cerebral hemisphere ipsilateral to vessel occlusion/stenosis. SWI-MHV grade 1 was found in 15 patients (40.5%), grade 2 in 18 patients (48.7%), and grade 3 in 3 patients (8.1%); in one patient, SWI was graded as 4 (2.7%). A significant relationship was found among MHV, DHV, collaterals, ATAs, and hypoperfused areas on pCASL and with patients’ previous neurological symptoms.
Conclusion
SWI-MVH correlates with chronic cerebral flow impairment and is related to hypoperfusion and collateralization. It may help identify a subgroup of patients benefitting from revascularization.
... Carotid atherosclerosis leads to plaque formation, artery stenosis, atheromatous narrowing of the common and internal arteries (1). In the case of plaque rapture, patients can experience thrombus formation, leading to increased risk of ischemic stroke (1), cardiovascular events (2), and overall mortality (3). ...
... Carotid atherosclerosis leads to plaque formation, artery stenosis, atheromatous narrowing of the common and internal arteries (1). In the case of plaque rapture, patients can experience thrombus formation, leading to increased risk of ischemic stroke (1), cardiovascular events (2), and overall mortality (3). Albeit previous studies have shown favorable outcomes in patients with carotid stenosis treated with carotid endarterectomy (CEA) (4), the long-term risk of ischemic stroke and death remain significant (5). ...
Background: A strong association between aortic valve sclerosis (AVSc), the earliest manifestation of calcific aortic valve disease, and atherosclerosis exists. The aim of the study was to evaluate the predictive capabilities of AVSc on long-term all-cause mortality, in patients requiring carotid endarterectomy (CEA).
Methods and Results: 806 consecutive CEA patients were enrolled. Preoperative echocardiography was used to assess AVSc. Computed tomography angiography was applied for plaque characterization. Kaplan-Meier curves, Cox linear regression, and area under the receiving operator characteristic (AUC) curve analyses were used to evaluate the predictive capability of AVSc. Overall, 348 of 541 patients had AVSc (64%). Age, diabetes, and estimated glomerular filtration rate (eGFR) were associated with AVSc. In the 5-year follow-up, AVSc group had a mortality rate of 16.7% while in no-AVSc group was 7.8%. Independent predictors of all-cause mortality were age, sex, eGFR, left ventricular ejection fraction, and AVSc. After adjustments, AVSc was associated with a significant increase in all-cause mortality risk (hazard ratio, HR = 1.9; 95%CI: 1.04–3.54; p = 0.038). We stratify our cohort based on carotid atheromatous plaque-type: soft, calcified, and mixed-fibrotic. In patients with mixed-fibrotic plaques, the mortality rate of AVSc patients was 15.5% compared to 2.4% in no-AVSc patients. In this group, AVSc was associated with an increased long-term all-cause mortality risk with an adjusted HR of 12.8 (95%CI: 1.71–96.35; p = 0.013), and the AUC, combing eGFR and AVSc was 0.77 ( p < 0.001).
Conclusions: Our findings indicate that AVSc together with eGFR may be used to improve long-term risk stratification of patients undergoing CEA surgery.
... The technique of carotid endarterectomy is known to bear a relatively low perioperative stroke risk of around 0.7-1.5%. However, it remains to be a social health problem in terms of outcomes and long duration of treatment after stroke despite this relatively low risk (1). Monitoring of cerebral perfusion during carotid endarterectomy (CEA) helps to institute early intervention to prevent risk of ischemia during the operation. ...
Aim: Monitoring of cerebral perfusion during carotid endarterectomy helps to institute early intervention to prevent risk of ischemia during the operation. We aimed to evaluate if the disadvantages of high systemic pressure can be avoided by keeping arterial blood pressure below 150mmHg during cross-clamping of the internal carotid artery by correlating our findings of NIRS values with clinical results Material and Method: This was designed as a prospective study that included elective patients scheduled for an operation of carotid artery stenosis under general anesthesia. A total of 60 patients operated on between August and October 2019 were included in the study. Results: Patients' NIRS findings on the right and left hemispheres were analyzed separately to be able to differentiate any possible changes of NIRS of the cerebral hemisphere ipsilateral to the clamped carotid artery. The analysis of the right and left NIRS findings in these 60 patients revealed a significant decrease between intubation and incision NIRS values (p=0.008 and p= 0.02respectively). Conclusion: Considering the NIRS findings and clinical observations of the patients in the postoperative period, we think that ICA endarterectomy operations may be safe to perform in a suitable patient group while the systolic arterial blood pressure is maintained below 150mmHg during cross-clamping.
... The narrowing of the carotid arteries with plaque formation is a major risk factor for ischemic stroke. 1 One standard option for treating significant carotid stenosis is the carotid angioplasty and stenting (CAS) procedure, which has been shown to be beneficial for stroke risk reduction. 2 When the stenosis is severe (!70% stenosis), blood flow via the carotid arteries is impacted, leading to decreased cerebral perfusion. 3 This potentially can result in clinically significant cognitive impairments in several domains, and notably in executive functioning and working memory 4 However, the effects of CAS on cognition are not well understood. ...
Background
The narrowing of the carotid arteries with plaque formation represents a major risk factor for ischemic stroke and cognitive impairments. Carotid angioplasty and stenting is a standard clinical treatment to reduce stroke risk. The cognitive effect of carotid angioplasty and stenting remains largely unknown.
Purpose
This study aims to provide direct evidence of possible effects of carotid angioplasty and stenting on cognition, using task-phase functional magnetic resonance imaging.
Material and Methods
This study received harmonized institutional ethics board approval (Grant number REB ID =H18-02495/FHREB 2018-058). Two patients had MRI scans pre-carotid angioplasty and stenting and two-month post-carotid angioplasty and stenting. Case 1 had severe (>95%) flow-limiting stenosis in the right carotid artery. Case 2 had 70% non-flow limiting stenosis in the left carotid artery. At each scan, patients completed two functional magnetic resonance imaging sessions while performing a working memory task. Accuracy, reaction time, and brain activation were analyzed for each patient for possible pre-post carotid angioplasty and stenting changes.
Results
Case 1 showed increased activation in the right (treated-side) frontal and temporal lobes post-carotid angioplasty and stenting; associated with improvements in accuracy (from 58% to 74%) and task completion rate (from 17% to 72%). Case 2 completed the tasks pre- and post-carotid angioplasty and stenting with >90% accuracy, while decreased functional magnetic resonance imaging activation in the contralateral (untreated) hemisphere and mildly increased activation in the left (treated -side) anterior circulation territory were observed post-carotid angioplasty and stenting.
Conclusion
These cases provided the first task-phase functional magnetic resonance imaging data demonstrating that carotid angioplasty and stenting improved cognitive function in the re-perfused vascular territory. The finding supports the role of carotid angioplasty and stenting in improving cognitive performance beyond reducing stroke risk.
... The application further provides the possibility to enter supplementary information regarding the patient as well as information regarding the measurement. Patient related information incorporates but is not limited to: comorbidities such as diabetes, hypertension or coronary disease; previously performed invasive treatment such as angioplasty or endarterectomy, 23 prescribed medication or the grading of an already diagnosed stenosis eg, according to the "North American Symptomatic Carotid Endarterectomy Trial" (NASCET) grading system 24 or the "European Carotid Surgery Trial" (ECST) definition. 25 Measurement related information include the sensing location eg, anatomical reference points, left/right carotid and heart rate at the beginning and at the end of the measurement. ...
Introduction
Atherosclerotic diseases of the carotid are a primary cause of cerebrovascular events such as stroke. For the diagnosis and monitoring angiography, ultrasound- or magnetic resonance-based imaging is used which requires costly hardware. In contrast, the auscultation of carotid sounds and screening for bruits – audible patterns related to turbulent blood flow – is a simple examination with comparably little technical demands. It can indicate atherosclerotic diseases and justify further diagnostics but is currently subjective and examiner dependent.
Methods
We propose an easy-to-use computer-assisted auscultation system for a stable and reproducible acquisition of vascular sounds of the carotid. A dedicated skin-transducer-interface was incorporated into a handheld device. The interface comprises two bell-shaped structures, one with additional acoustic membrane, to ensure defined skin contact and a stable propagation path of the sound. The device is connected wirelessly to a desktop application allowing real-time visualization, assessment of signal quality and input of supplementary information along with storage of recordings in a database. An experimental study with 5 healthy subjects was conducted to evaluate usability and stability of the device. Five recordings per carotid served as data basis for a wavelet-based analysis of the stability of spectral characteristics of the recordings.
Results
The energy distribution of the wavelet-based stationary spectra proved stable for measurements of a particular carotid with the majority of the energy located between 3 and 40 Hz. Different spectral properties of the carotids of one individual indicate the presence of sound characteristics linked to the particular vessel. User-dependent parameters such as variations of the applied contact pressure appeared to have minor influence on the general stability.
Conclusion
The system provides a platform for reproducible carotid auscultation and the creation of a database of pathological vascular sounds, which is a prerequisite to investigate sound-based vascular monitoring.
... On the other hand, the surgery benefits were partially counterweigh by its peri-procedural risks of major cardio-cerebrovascular complications such as ischaemic stroke, myocardial infarction and death. In the surgical groups this ranged from 4.5% to 7.0%, while in the medical therapy groups it is from 2.4% to 6.1% (19). Looking at these data, the patient undergoing CEA should have a perioperative risk less than 6% (4). ...
... Looking at these data, the patient undergoing CEA should have a perioperative risk less than 6% (4). If a period of three years of follow-up is taken into account, patients with minor or moderate SCS not benefitted from CEA, while the recurrence of ipsilateral stroke and death in SCS ≥80% (ECST method) was lower in CEA group (6.8%) compared with medical group (20.6%) (19,20). It is important to note that these studies do not include the best current medical treatment, considering the current guidelines on statins, antiplatelet agents, blood pressure control, smoking cessation, and glycaemic control. ...
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of "pragmatism" of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
... However, the annual risk of stroke in asymptomatic patients with carotid artery stenosis is low, at least when comparing the event rates to the risk of perioperative death or stroke when performing carotid endarterectomy. [5] Furthermore, the stroke rate has decreased in recent years following the introduction of aggressive medical treatments (e.g., antiplatelet, statin and hypertension treatment) and improving the impact of public attention to reducing risk factors in the industrialized countries (e.g., decreasing smoking and increasing physical activity). [6] The current annual risk of ipsilateral ischemic symptoms in asymptomatic patients with significant carotid artery stenosis (>50%) is in the region of 1%/year. ...
Stroke and other thromboembolic events in the brain are often due to carotid artery atherosclerosis, and atherosclerotic plaques with inflammation are considered particularly vulnerable, with an increased risk of becoming symptomatic. Positron emission tomography (PET) with 2-deoxy-2-[Fluorine-18] fluoro-D-glucose (18F-FDG) provides valuable metabolic information regarding arteriosclerotic lesions and may be applied for the detection of vulnerable plaque. At present, however, patients are selected for carotid surgical intervention on the basis of the degree of stenosis alone, and not the vulnerability or inflammation of the lesion. During the past decade, research using PET with the glucose analog tracer 18F-fluor-deoxy-glucose, has been implemented for identifying increased tracer uptake in symptomatic carotid plaques, and tracer uptake has been shown to correlate with plaque inflammation and vulnerability. These findings imply that 18F-FDG PET might hold the promise for a new and better diagnostic test to identify patients eligible for carotid endarterectomy. The rationale for developing diagnostic tests based on molecular imaging with 18F-FDG PET, as well as methods for simple clinical PET approaches, are discussed. This is a systematic review, following Preferred Reporting Items for Systematic Reviews guidelines, which interrogated the PUBMED database from January 2001 to November 2019. The search combined the terms, “atherosclerosis,” “inflammation,” “FDG,” and “plaque imaging.” The search criteria included all types of studies, with a primary outcome of the degree of arterial vascular inflammation determined by 18F-FDG uptake. This review examines the role of 18F-FDG PET imaging in the characterization of atherosclerotic plaques.
... The epidemiology of recurrent strokesis described in a relatively small number of publications [16][17][18]. The frequency of stroke occurrence in the first three months after a cerebral infarction is assessed as 14.5-18.3%. ...
... The first domain is represented by the researches assessing the effectiveness of modern methods of secondary prevention of stroke in patients with atrial fibrillation [16]. The second domain is related to the studies on the effectiveness of revascularizing surgical interventions on the large brachiocephalic vessels [17]. Finally, there are studies on the prevention of cryptogenic (ESUS) strokes [18]. ...
... Finally, there are studies on the prevention of cryptogenic (ESUS) strokes [18]. Published data do not allow us to draw unambiguous conclusions about the frequency of recurrent strokes in the various regions of the world, however, in general, the number of repeated strokes is higher in third world countries and in the post-Soviet space [5][6][7][8][9][10][11][16][17][18]. ...
The aim of the study was to assess the epidemiology of clinical variants of ischemic stroke in the different countries of the world. The depth of information search is 15 years, it was performed in the databases EMBASE, PubMed, OVID, EBSCOhost, ProQuest, Google Scholar, IRBIS, РИНЦ (RISC). 30 articles were selected for further analysis. There was found that at the beginning of 2019, there were 847 RCTs in the world dedicated to the diagnosis and treatment of acute stroke, most of which were performed in Europe, the USA and China. 90 % of all cases of stroke in the world are associated with modifiable risk factors. The highest incidence rates of ischemic stroke are registered in the developing nations and post-Soviet countries. The frequency of recurrent strokes is determined by the clinical variants of the primary stroke: for POCI, the frequency of repeated strokes is 20-25%, for TACI and PACI - 17%, for LACI - 9%, and in most cases of recurrent strokes they occur in the same cerebral artery as the primary ones. Global trends in the clinical epidemiology of ischemic stroke are associated with the aging of the population, increasing role of comorbid pathology and the progress of medical diagnosticand treatment technologies. The observed regional differences could be explained by the various levels of socio-economic development and the resource base of national health systems, differences in the compliance of the applied secondary prevention, as well as by the availability of national registers and large epidemiological studies.
