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Typical examples of cerebral watershed infarcts in patients with carotid artery stenosis. Diffusion weighted imaging (DWI) showing (a) cortical watershed infarction between the posterior cerebral artery (PCA) and middle cerebral artery (MCA) cortical territories, (b) right-hemisphere internal watershed infarction on diffusion weighted imaging, and (c) cortical watershed infarction between the anterior cerebral artery (ACA) and MCA cortical territories.
Source publication
The aim of this study was to compare the clinical outcomes of early versus delayed carotid artery stenting (CAS) for symptomatic cerebral watershed infarction (sCWI) patients due to stenosis of the proximal internal carotid artery. We retrospectively collected clinical data of those who underwent early or delayed CAS from March 2011 to April 2014....
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Citations
... Current guidelines are to pursue early revascularization within 14 days of AIS [2]. Due to the increasing risk of recurrence within the first 2 weeks after the first ischemic event of a symptomatic carotid stenosis, Liu et al. showed improved functional outcomes without increasing the rate of new AIS, myocardial infarction or death in the early CAS group (<1 week) compared to the delayed CAS at 1 month [28]. On the contrary, Song et al. evaluated CAS for 206 patients with moderate-to-severe stenosis and found a significantly higher rate of ipsilateral stroke or death (at 30 days) of 12.8% in the early CAS group (within 14 days) compared to only 0.8% in the delayed CAS group (mean timing of CAS was 52.6 ± 36.94 days) [29]. ...
In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.
... ECST) çalışmaları ve son yıllarda yapılan birçok klinik çalışma, semptomatik karotis darlığı olan hastalarda karotis arter stentlemesi (KAS) veya karotis endarterektomi (KEA) kullanılarak karotis revaskülarizasyonunun yararlarını göstermiştir[10][11][12][13][14][15] . Günümüzde özellikle de yeni geliştirilen cihaz ve yöntemlerle KAS, standart KEA'ya alternatif olarak kabul edilebilir bir tedavi yöntemi haline gelmeye başlamıştır16,17 .Bu çalışmada, akut inme bulguları ile başvuran, kraniyal radyolojik görüntülemelerinde sınır zonu infarktı saptanan ve etiyolojisinde karotis arter darlığı saptanarak karotis arter stentleme yapılan olgular klinik ve radyolojik özellikleri ile stentlemeye ait erken dönem sonuçları açısından incelenmiştir. ...
Objective: Mortality and permanent disability rates are higher in supraaortic large artery occlusions such as the internal carotid
artery. Therefore, early detection of carotid artery stenosis is clinically important. As a result of the atheroma plaque causing stenosis
to a degree that restricts the flow to the distal, "border zone infarction" is more common than normal in carotid artery stenosis and
can be a warning for carotid artery stenosis. In this study, patients who had border zone infarction and carotid artery stenting due to
carotid artery stenosis were evaluated.
Methods: Between January 2017 and July 2019, 120 patients who were followed up with a diagnosis of cerebrovascular disease and
carotid artery stenting were reviewed retrospectively. 31 cases with border zone infarction were included in the study
Results: The mean age of 31 cases (27 male, 4 female) was 68,1 ± 9,6. 8 (25.8%) of these cases had right, 7 (22.6%) of them had left,
and 16 (51.6%) had bilateral carotid artery stenosis. The most seen comorbid disease were hypertension 28 (90.3%), hyperlipidemia
22 (71%) and coronary artery disease 18 (58.1%). There was a transient ischemic attack in 17 (54.8%) cases, and smoking in 24
(77.4%) cases.When 31 cases were evaluated radiologically, 17 (54.8%) internal + external, 5 (16.1%) isolated internal and 9 (29%)
isolated external border zone infarcts were detected. It was determined that stenting was performed on average 22.3 ± 12.2 days after
ischemic stroke.Minor stroke was detected in 3 cases after carotid artery stenting. Due to minor stroke, the hospitalization time of
these cases was observed to increase 6 days on average. The pre-op mean mRS of the cases was 1.35 ± 0.87, while it was 1.13 ± 0.99
30 days after the procedure. In the carotid artery doppler ultrasonography examinations performed at the end of the first month of all
cases, it was determined that the stent patency was fully monitored and no restenosis was detected.
Conclusions: Border zone infarcts are a stimulating ischemic stroke pattern for carotid artery stenosis. Awareness of clinicians should
be increased so that they can effectively fight the disease recognition and treatment processes. This study indicates that the
endovascular stenting method is safe in patients with carotid artery stenosis that comes with border zone infarction, and that early
results result positively in terms of functional outcomes.
... In the past, it was believed that the risk of early recurrent TIA or stroke after the onset of neurological symptoms is not high, so CEA should be delayed for at least 6 weeks after an onset of neurological symptoms, and operating early on a recently symp-tomatic "unstable" carotid plaque was associated with an increased risk of perioperative stroke [2]. In recent years, early surgical intervention within 1-2 weeks of symptom onset has been advocated for patients with symptomatic carotid artery stenosis [3]. Therefore, the timing of CEA surgery has been gradually attracted the attention of all, and studies on it have also increased gradually in recent years. ...
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 (<48 h) (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 (<48 h) (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 (<7 d) (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.
... 4,5 In contrast, other studies supported early CAS within their 7 or 15 days cut-off, showing no significant differences in stroke or deaths at 30 days. 6,7,17,18 A recent prospective study compared CAS to CEA when performed within the first 48 hours and found similar rates of stroke or any cause of death within 30 days (5.1% vs. 4.9%, respectively). 19 Those findings are comparable to the primary outcome rate in our emergency CAS group (5.7%). ...
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 < 0.001) and use of general anesthesia (19% vs. 4%, p = 0.001) than elective CAS. There were no significant differences between emergency and elective CAS in the primary (5.7% vs. 1%, p = 0.161) and secondary (9% vs. 4.8%, p = 0.232) outcomes. We did not find differences in the rate of restenosis/occlusion (7% vs. 11.6%; log-rank test p = 0.3) at a median of 13 months follow-up.
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.
... The North American Symptomatic Carotid Endarterectomy Trial (NASCET), the European Carotid Surgery Trial and many clinical trials conducted in recent years have shown the benefits of carotid revascularization by using carotid artery stenting (CAS) or carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis (8)(9)(10)(11)(12)(13). It is thought that arterial revascularization by endarterectomy or stenting has positive contributions to the clinic of stroke at the early and late stages of stroke (14). ...
Amaç: Karotis arter stentleme (KAS) serebrovasküler hastalıklarda karotis endarterektomiye alternatif olarak kullanılan bir yöntemdir. Serebral koruma cihazlarının geliştirilmesi ile bu işlemin uygulanabilirliği artmıştır. Bu çalışmada, KAS uygulanan hastaların klinik ve radyolojik özellikleri ile erken ve geç dönem sonuçları araştırıldı. Hastalar ve Yöntem: 2008 ile 2014 yılları arasında üniversite hastanesine başvuran ve internal karotis arter (İKA) darlığı saptanıp KAS uygulanan 76 hastanın (54 erkek, 22 kadın) klinik ve radyolojik özellikleri, stentleme sonrası erken ve geç dönem sonuçları geriye dönük olarak incelendi. Bulgular: Başvuruları sırasında tüm hastalar semptomatikti ve yapılan tetkikler sonrasında İKA darlığı tespit edildi. 62 hastada tek taraflı (sağ İKA, %34,2 sol İKA %47,4) 14 hastada bilateral (%18,4) darlık saptandı. Ortalama darlık derecesi 82,1 (Standart sapma: 11,36, Aralık:60-99%) idi. Tüm hastalar İKA darlığı için stentleme ile tedavi edildi (teknik başarı oranı: %100). İşlemler esnasında herhangi bir komplikasyon gelişmedi. 1 yıllık takip süresince hiçbir hastada tekrarlayan iskemik atak olmadı. Karotis arter hastalığı; hipertansiyon, hiperlipidemi, diyabetes mellitus, koroner arter hastalığı, geçirilmiş serebrovasküler olay ve geçici iskemik atak öyküsü ile yüksek oranlarda ilişkiliydi. Sonuçlar: Karotis arter hastalıkları, eşlik eden hastalıklar ve geçirilmiş serebral vasküler olaylar ile birlikte son derece önem arz etmektedir. KAS uygulaması, iyi seçilmiş ve risk analizlerinin medikal tedaviler ile birlikte yapıldığı olgularda ciddi komplikasyon oranının düşük olması nedeniyle güvenle kullanılabilecek bir yöntemdir. Anahtar Kelimeler: Ateroskleroz, carotis arter, endovasküler tedavi, klinik sonuçlar Aim: Carotid artery stenting (CAS) is an alternative approach to carotid endarterectomy in cerebrovascular diseases. The applicability of this procedure has increased as a result of development of cerebral protection devices. In the trial, the clinical and radiological characteristics and early and late outcomes of patients who received CAS were investigated. Patients and Methods: The study had a retrospective design. The clinical and radiological characteristics and early and late outcomes after CAS of 76 patients (54 male, 22 female) who were admitted to a university hospital between 2008 and 2014 due to a diagnosis of internal carotid artery stenosis (ICA) were retrospectively reviewed. Results: All patients were symptomatic during their admissions, and after their workups were completed, ICA stenosis was determined. Unilateral (Right ICA 34.2%, left ICA 47.4%) stenosis in 62 patients and bilateral stenosis (18.4%) in 14 patients were determined. The mean degree of stenosis was 82.1 (SD:11.36, range: 60-99%). All patients were treated with stenting for ICA stenosis (technical success rate: 100%). No complications occurred during these procedures. During the one-year follow-up, no recurrent ischemic attack occurred in any patients. Carotid artery disease is highly associated with hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, a history of cerebrovascular accidents and transient ischemic attack. Conclusions: Carotid artery disease is a critical factor with co-morbidities and history of cerebrovascular incidents. The carotid artery stenting (CAS) procedure is a method that can be used safely because its serious complication rate is low in cases that are well-selected and have had risk analyses performed regarding medical treatments.
... 46,47 However, more recent studies have found reduced risk of second stroke with no difference in perioperative complications after early CEA within 1 to 2 weeks. [48][49][50] Jørgensen et al investigated the association between prior stroke and the risk of major adverse cardiovascular events (MACE) in a large cohort of 481,183 noncardiac elective surgeries of which 7,137 surgeries were performed in patients with a history of stroke. 22 They reported a higher risk of perioperative stroke (odds ratio [OR]: 67.60, 95% confidence interval [CI]: 52.27-87.42) in patients who had prior stroke within 3 months before surgery. ...
An increasing number of patients with a prior history of stroke present for various types of surgeries. They have varying degree of neurological disability and associated co-morbidities, which pose challenges for their perioperative management. There is paucity in literature about their management guidelines for noncardiac, noncarotid surgeries. The available literature suggests higher risk of perioperative stroke, postoperative neurological deficits, and other morbidities. Measures to reduce perioperative risks are discussed in this review. Prior optimization by improving modifiable risk factors, choosing appropriate timing of elective surgery, and careful titration of anesthesia and close monitoring are needed.
... 45 The evidence of the early procedure safeness is more robust for CEA than for CAS which has conflicting results in different studies. [46][47][48] Secondary prevention is indicated in cases of transient ischemic accident or small strokes, due to the high risk of intracranial hemorrhage when performing carotid intervention in the first few weeks after a major ischemic stroke and to the questionable clinical benefit in the long term. 49 Patient with asymptomatic severe carotid lesion ...
Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes.
To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure.
The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event.
There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.
... Twenty percent of ischemic strokes are associated with CA stenosis. 1 Carotid artery stenting (CAS) has been established as an alternative, minimally invasive technique for the treatment of symptomatic and asymptomatic CA stenosis to complement carotid endarterectomy. 2 Self-expanding stents have been developed for the treatment of carotid lesions, including open-cell and closed-cell designs. ...
Introduction
Despite various measures to protect against distal embolization during carotid artery stenting (CAS), periprocedural ischemic lesions are still encountered.
Objective
To evaluate the periprocedural cerebral diffusion weighted imaging (DWI) lesion burden after CASPER stent placement.
Methods
Patients who underwent CAS using the CASPER stent system were reviewed. Degrees of carotid stenosis and plaque configuration were determined. All patients were pretreated with dual antiplatelet agents and cerebral pre- and postprocedural MRI was obtained. All CAS procedures were performed by a single operator.
Results
A total of 110 patients with severe carotid artery stenosis (median degree of stenosis 80%, median length of stenosis 10 mm) were treated with CAS. Hypoechogenic or heterogeneous, mostly hypoechogenic, plaques were documented in 48.6% (52/107) of patients. Carotid ulceration was present in 15.9% (17/107). Postprocedurally, 7.3% (8/110) of patients were found to have ischemic DWI lesions. They were asymptomatic in all patients. Follow-up at 90 days was available in 88.2% (97/110) of patients with excellent functional outcome (modified Rankin Scale score 0–1) in 95.9% (93/97).
Conclusion
Carotid artery stenting using the new CASPER stent in combination with a distal embolic protection device is safe and results in a lower rate of periprocedural DWI lesion burden compared with reported results for historic controls.
... Recent studies have compared morbidity and mortality following early CAS compared to delayed CAS. Liu et al. studied 63 patients with severe stenosis undergoing CAS at less than 1 week compared to 57 patients undergoing delayed intervention at 1 month and found improved functional outcomes and no increased rate of second stroke, MI, or death in the early CAS group [53]. In contrast, Song et al. reported a retrospective analysis of 206 patients undergoing CAS for moderate-to-severe stenosis that found a significantly higher 30-day event rate of ipsilateral stroke or death of 12.8% in the early CAS group (within 14 days) compared to just 0.8% in the delayed CAS group (mean timing of CAS was 52.6 ± 36.94 days) [54]. ...
Opinion statement
Symptomatic carotid artery disease is a significant cause of ischemic stroke, and these patients are at high risk for recurrent vascular events. Patients with symptoms of stroke or transient ischemic attack attributable to a significantly stenotic vessel (70–99% luminal narrowing) should be treated with intensive medical therapy. Intensive medical therapy is a combination of pharmacologic and lifestyle interventions consistent with best-known practices as follows: initiation of antiplatelet agent or anticoagulation if medically indicated, high potency statin medication, blood pressure control with goal blood pressure of greater than 140/90, Mediterranean-style diet, exercise, and smoking cessation. Further, patients who have extracranial culprit lesions should be considered for revascularization with either carotid endarterectomy or carotid angioplasty and stenting depending on several factors including the patient’s anatomy, age, gender, and procedural risk. Based on current evidence, patients with symptomatic intracranial stenosis should be managed with intensive medical therapy, including the use of dual antiplatelet therapy with aspirin and clopidogrel for the first 90 days following the ischemic event. While the literature has shown a stronger benefit of revascularization of extracranial symptomatic disease among certain subgroups of patients with greater than 70% stenosis, there is less benefit from revascularization with endarterectomy in patients with moderate stenosis of 50–69% if the surgeon’s risk of perioperative stroke or death rate is greater than 6%.
