Atherosclerotic stenosis of the carotid artery is a major cause of ischemic stroke. We aimed to identify extracranial and intracranial features associated with cerebral ischemic events in patients with severe carotid artery stenosis using carotid ultrasonography and transcranial Doppler.

We retrospectively enrolled 130 patients with severe carotid artery stenosis and 45 age- and sex-matched healthy controls. Extracranial carotid artery parameters included carotid plaque morphology, echogenicity, and the gray-scale median (GSM). Intracranial features, mainly dynamic cerebral autoregulation (dCA), were assessed using transfer function analysis. Correlations between extracranial and intracranial parameters and cerebral ischemic events were analyzed using univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curves were compared.

Sixty-six patients (50.8 %) experienced cerebral ischemic events upon admission. Extracranial features (proportion of ulcerated plaques and echogenicity classification) significantly differed between the asymptomatic and symptomatic groups. The mean GSM of carotid plaques (48.9 ± 17.3 vs. 62.1 ± 18.3, P < 0.001) and intracranial parameters were significantly lower in the symptomatic group. Plaque ulceration, hypoechoic plaques, and impaired dCA [lower ipsilateral phase at very-low frequency (VLF)] were independently associated with cerebral ischemic events in patients with severe carotid artery stenosis. The combined GSM and ipsilateral phase at VLF had the highest area under the ROC curve (0.784).

Combined extracranial and intracranial assessments may help predict cerebral ischemic events in patients with severe carotid artery stenosis. Ultrasound-based carotid plaque characteristics, combined with dynamic cerebral autoregulation, could be imaging biomarkers of cerebral ischemic events in patients with severe carotid artery stenosis.

Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the United States Food and Drug Administration in 2015.

All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the Vascular Quality Initiative decreased from 2.3% to 1.0% as endovascular methods became more available (P < .001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) despite an improvement in the death rate (P = .009). From 2003 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.14-2.73; P = .007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

The proportion of rCEAs done yearly in the United States has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within Society for Vascular Surgery guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.

Carotid artery atherosclerotic stenosis is an important annual cause of stroke in the United States. Moreover, the incidence of carotid artery stenosis is significantly increasing due to the widespread popularity of high fat and high salt diets, sedentary lifestyles, and the increasing age of the population. Of major importance to cardiovascular specialists is the fact that individuals with atherosclerotic carotid artery stenosis can have a prevalence of atherosclerotic coronary artery disease as high as 50 to 75%. Vascular screening for carotid artery stenosis with Doppler ultrasound should be considered for all symptomatic patients with possible carotid stenosis and also considered for asymptomatic patients with (1) symptomatic peripheral arterial disease, coronary artery disease, or atherosclerotic aortic aneurysm or, (2) multiple atherosclerotic risk factors. Carotid artery atherosclerotic plaques that are at high risk for rupture and thrombosis or cerebral embolization are characterized by large lipid cores, intraplaque hemorrhage, thin fibrous caps less than 165 μms that are infiltrated by macrophages and T cells or have surface ulcer(s) or fissures. Carotid artery plaque rupture with cerebral embolism can cause a stroke, transient ischemic attacks (TIA), or ipsilateral blindness (amaurosis fugax). Medical treatment based on the recommendations of the American and European Societies for Vascular Surgery and the American Heart Association for symptomatic patients with carotid stenosis and also asymptomatic patients with high risk carotid stenosis plaques include antiplatelet drugs, antihypertensive drugs for hypertension control and lipid lowering drugs. Management strategies and decisions about carotid revascularization in asymptomatic patients with high risk carotid stenosis should involve a multidisciplinary team and shared decision-making is recommended. The 30 day and five to 10 year outcomes in asymptomatic carotid stenosis patients who have undergone carotid endarterectomy, carotid stenting and/or optimal medical therapy are summarized from the Veterans Administration Cooperative Study, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trials. The current Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) should help to resolve the debate regarding carotid artery revascularization versus primary medical treatment in asymptomatic patients with >70% carotid artery stenosis. Symptomatic patients who present within 4.5 hours of stroke onset require evaluation for acute intravenous pharmacologic thrombolysis and patients who present with large vessel occlusion within 24 hours of symptom onset should be considered for mechanical thrombectomy to reduce the neurologic deficit. Patients with carotid artery stenosis who present with a history of cerebral infarct in the preceding six months due to cerebral embolism require medical treatment and evaluation by a multidisciplinary team for carotid revascularization in order to prevent future strokes or TIAs. The outcomes of the North American Symptomatic Carotid Endarterectomy Trial, Carotid Revascularization Endarterectomy Versus Stent Trial, Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial, and the Safety and Efficacy Study for Reverse Flow Used during Carotid Artery Stenting Procedure trials for symptomatic patients with carotid stenosis are reviewed. A synopsis of treatment guidelines for symptomatic and asymptomatic carotid stenosis patients from the American and European Societies of Vascular Surgery and the American Heart Association/American Stroke Association are presented. Each patient with carotid artery stenosis must be carefully evaluated to determine the best treatment based on the clinical presentation, the imaging and laboratory diagnostic information, the treatment guidelines, and the patient needs and preferences as well as the patient's social and cultural factors.

While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR.

A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes.

Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]).

In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.

To investigate associations between individual embolic protection device (EPD) use and respective center policy with periprocedural outcomes after carotid artery stenting (CAS).

This analysis is based on the nationwide German statutory quality assurance database and was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their policy towards EPD use, hospitals were categorized as routine EPD (>90%), selective EPD (10-90%), or sporadic EPD (<10%) centers. Primary study outcome was in-hospital stroke or death. Univariate and multivariate regression analyses were performed.

Overall, 19 302 patients who had undergone CAS between 2013 and 2016 were included. The highest in-hospital stroke or death rate was found in sporadic EPD centers, followed by selective and routine EPD centers (3.1% vs 2.9% vs 1.8%; P<0.001). Across the whole cohort, EPD use was associated with a lower in-hospital stroke or death rate (OR=0.60; 95% CI 0.50 to 0.72). In the multivariate regression analysis, EPD use was independently associated with a lower in-hospital stroke rate (aOR=0.66; 95% CI 0.46 to 0.94). Regarding center policy, routine EPD centers showed a significantly lower in-hospital mortality compared with sporadic EPD centers (aOR=0.44; 95% CI 0.22 to 0.88).

In a contemporary real-world cohort with low risk of selection bias, EPD use was associated with a lower in-hospital risk of stroke. A center policy of routine EPD use was associated with lower mortality. These data support routine use of EPD during CAS to enhance patient safety.

Background/Objective: Transcutaneous Doppler ultrasound is a fundamental tool in evaluating carotid stenosis cross-sectional severity (CS-CSS) in clinical practice because peak-systolic and end-diastolic velocities (PSV, EDV) increase with angiographic diameter stenosis. We tested the hypothesis that lesion length (LL) may affect PSV and EDV. Methods: CARUS (Carotid Artery IntravasculaR Ultrasound Study) prospectively enrolled 300 consecutive patients (age 47-83 years, 64.3% men, 63.3% symptomatic) with carotid stenosis ≥50% by Doppler ultrasound considered diagnostic (corelab analyst). We correlated stenosis LL (mm) and minimal lumen area (MLA, mm2) with PSV and EDV. Results: IVUS imaging (20 MHz Volcano/Philips) was uncomplicated. As IVUS probe forward/backward movement with systole/diastole ("jumping"-related artifact superimposed on motorized pullback) restrained LL (but not MLA) determination, LL measurement was angiographic. Final data set included 293 patients/stenoses (applicable to seven angiograms unsuitable for LL measurement). Irrespective of CS-CSS, a significant LL effect on PSV and EDV occurred with LL ≥ 7 mm (n = 224/293, i.e., 76.5% study patients/lesions; r = 0.38 and r = 0.35); for MLA irrespective of CS-CCS the coefficients were r = 0.49 (PSV) and r = 0.42 (EDV); p < 0.001 for all. For LL and MLA considered together, the correlations were stronger: r = 0.61 (PSV) and r = 0.54 (EDV); p < 0.0001 for both. Combined LL and MLA effect was represented by the following formulas: PSV = 0.31 × LL/MLA + 2.02 [m/s]; EDV = 0.12 × LL/MLA + 0.63 [m/s], enabling to correct the PSV (EDV)-based assessment of CS-CSS for the LL effect. Conclusions: This study provides, for the first time, systematic evidence that the length of carotid stenosis significantly affects lesional Doppler velocities. We established formulas incorporating the contribution of both stenosis length and its cross-sectional severity to PSV and EDV. We advocate including stenosis length measurement in duplex ultrasound reports when performing PSV (EDV)-based assessment of carotid cross-sectional stenosis severity.

Background: Calcifications in the carotid and vertebral arteries may be present on cranial and temporal bone CT imaging of pediatric patients. Few studies have investigated the frequency, location, and patterns of carotid artery calcifications in this age group. However, these studies are outdated and do not include data on the vertebral artery. The aim of this study was to determine the frequency, location, and pattern of incidental carotid and vertebral artery calcifications on cranial CT and temporal bone CT images in children under 15 years of age. We also aimed to investigate possible associations between these calcifications and various diseases. Methods: A total of 300 CT images of the cranial and temporal bone of 300 pediatric patients were retrospectively evaluated for the presence of calcification in the carotid and vertebral arteries. The evaluation included determining the presence of calcification in the artery, the pattern of calcification, the degree of calcification, and its anatomical location. Results: In the current study, 300 CT images were analyzed, and calcifications were found in the vertebral artery in 17 patients (5.6%) and the carotid artery in 82 patients (27.3%). The supraclinoid segment and the carotid siphon regions are the most common locations of carotid artery calcifications, with 62 patients (20.7%). The V4 segment is also the most common location for vertebral artery calcifications, with 15 patients (5%). Focal punctate calcification is the most common pattern (65 patients, 21.7%). Incidental carotid and vertebral artery calcifications did not correlate with other diseases. Conclusions: Carotid and vertebral artery calcifications are common incidental findings in pediatric patients. In our study, no association was found between other diseases and incidental carotid and vertebral artery calcifications.

Carotid artery stenosis is one of the causes of acute ischaemic stroke. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the main procedural treatment options. This study investigates the changing trends in carotid revascularisation in Australia over the last 30 years.

Two population level datasets were used, the Australian Institute of Health and Welfare (AIHW) and Medicare Australia. Patients who had either CEA or CAS procedures between 1993 and 2024 were identified, and procedural trends were analyzed over a 30-year period.

Data from AIHW was available from 2000 to 2021, over which 66 983 patients underwent carotid revascularisation (58 932 CEA and 8051 CAS). There was a 47.4% relative decrease in the absolute number of CEA procedures over the study period (3702-1948). There was a relative 23.1% increase in CAS procedures over this period (524-645). Data from the Medicare dataset was available from 1993 until 2024, over which 41 860 patients had carotid revascularisation (38 118 CEA and 3742 CAS). There was a relative 51.0% decrease in the absolute number of CEA procedures (1733-849). There was a 1.6% relative decrease in the absolute number of CAS procedures over the study period (187-184).

The number of carotid revascularisation procedures performed has steadily decreased over the last 30 years. CEA procedures have declined to a greater extent compared to CAS procedures, though CEA procedures remain significantly more common. These trends likely reflect evolving medical therapy for carotid artery disease.

This study aimed to evaluate the prognostic value of combined carotid plaque reporting and data system (RADS) score and pericarotid fat density (PFD) for predicting stroke recurrence risk, and to explore its utility in stroke risk stratification.

We developed a novel binary comprehensive risk index (CRI) that integrates the carotid plaque-RADS and PFD: low CRI (RADS <3 and PFD ≤ -74 HU) and high CRI (RADS ≥3 or PFD > -74 HU). Net reclassification improvement, Kaplan-Meier survival analysis, multivariate logistic regression, receiver operating characteristic curves (ROC), and decision curve analysis (DCA) were used to assess the predictive value of CRI over stenosis degree.

During a mean follow-up period of 17.24±11.93 months, 64 of 272 patients (23.3%) experienced recurrent stroke. CRI significantly improved stroke recurrence risk stratification in mild-to-moderate stenosis patients. Kaplan-Meier survival analysis revealed significant differences in stroke recurrence rates across varying plaque-RADS and CRI (P < 0.0001). Independent predictors of stroke recurrence included plaque-RADS ≥ 3 (OR=2.68, 95% CI: 1.03-6.96), CRI (OR=8.25, 95% CI: 2.23-30.44), affected-side PFD (OR=0.97, 95% CI: 0.94-0.99), and bilateral PFD difference (OR=1.09, 95% CI: 1.05-1.13). The combined model incorporating stenosis degree, plaque-RADS, affected-side PFD, bilateral PFD difference, and CRI demonstrated superior prediction performance, achieving an area under the ROC curve of 0.892.

Integrating carotid plaque-RADS and PFD significantly enhances the accuracy of stroke recurrence risk prediction, especially in patients with mild-to-moderate stenosis. This combined assessment model provides valuable insights for personalized prevention and treatment strategies for stroke recurrence.

Carotid web is a rare and likely underrecognized cause of ischemic stroke, particularly in young patients. Given the high risk of recurrence, diagnostic delays may have serious consequences. This study aimed to assess the incidence and impact of delayed carotid web diagnosis after a first ischemic event.

We conducted a retrospective analysis using data from the French ongoing multicenter prospective CAROWEB (Carotid Web registry). We included patients with a first-ever ischemic stroke or transient ischemic attack in the anterior circulation, attributed to an ipsilateral carotid web with no other identifiable cause, between September 2013 and April 2023. Patients with missing data on the date of the first ischemic event or carotid web diagnosis, or with prior stroke history, were excluded. Participants were categorized into early diagnosis (≤30 days) and delayed diagnosis (>30 days) groups. Factors associated with diagnostic delay were investigated through univariable and multivariable analyses. Stroke recurrence was evaluated using Kaplan-Meier survival analysis.

Of 280 patients in the registry, 225 met the inclusion criteria. A delayed diagnosis occurred in 57 patients (25.3%). Independent predictors of diagnostic delay included lower initial National Institutes of Health Stroke Scale score (odds ratio, 0.92; P=0.002), stroke occurring before 2019 (odds ratio, 0.19; P<0.001), and the absence of computed tomography angiography in the initial work-up (odds ratio, 0.20; P<0.001). Stroke recurrence was significantly higher in the delayed group (3.6 versus 0.38 per 100 patient-years). After adjusting for the National Institutes of Health Stroke Scale and year of stroke onset, delayed diagnosis was associated with a 5-fold increased risk of recurrence (aHR, 5.02; P=0.014).

Delayed carotid web diagnosis remains common, especially in minor strokes, in the absence of early computed tomography angiography, and in events before 2019. Such delays are associated with a significantly increased risk of stroke recurrence, highlighting the need for early vascular imaging in ischemic stroke evaluation.

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04431609.

In symptomatic carotid stenosis, treatment decisions are currently primarily based on stenosis degree. We developed a clinical prediction model (Individualized Magnetic Resonance Imaging-Based Stroke Prediction Score Using Plaque Vulnerability for Patients With Symptomatic Carotid Artery Disease [IMPROVE]) incorporating the strong predictor, intraplaque hemorrhage on magnetic resonance imaging, stenosis degree, and risk factors to identify patients with high stroke risk.

IMPROVE was developed on data from 5 cohorts of 760 patients with symptomatic carotid disease on optimal medical treatment. Inclusion criteria included a recent transient ischemic attack/stroke (<6 months), magnetic resonance imaging-based information on intraplaque hemorrhage, no atrial fibrillation, and no immediate revascularization. IMPROVE was based on Cox regression using 5 expert-selected predictors and converted to 3-year ipsilateral ischemic stroke risk after internal validation. IMPROVE-based stratification was compared with care-as-usual using illustrative cutoffs: high risk was defined in IMPROVE as ≥ median 3-year IMPROVE risk, whereas in care-as-usual, it was ≥50% carotid stenosis.

Sixty-five ipsilateral ischemic strokes occurred during a median follow-up of 1.2 years (interquartile range, 0.5-4.1). The IMPROVE model includes 5 predictors (hazard ratio [95% CI]: degree of stenosis [<50%: reference, 50%-69%: 4.54 (2.46-8.38), 70%-99% stenosis: 7.42 (3.45-15.95)]), presence of intraplaque hemorrhage [5.61 (2.92-10.77)], classification of last event [ocular: reference, cerebral: 3.72 (1.11-12.52)], male sex [1.26 (0.64-2.48)], and age [1.14 (0.84-1.55)] per 10-year increase). Internal validation revealed good accuracy (C statistic, 0.82 [95% CI, 0.77-0.87]) and no evidence of miscalibration (calibration slope, 0.93). Sensitivity for the illustrative IMPROVE cutoff was 92.6% (90.7-94.5) versus 80.6% (77.8-83.4) for care-as-usual. Specificity was 54.2% (50.7-57.8) for IMPROVE versus 52.9% (49.3-56.4) for care-as-usual. Patients stratified by IMPROVE as high risk had a higher incidence of ipsilateral ischemic stroke (24.0%) compared with the care-as-usual classification (20.7%). Among patients classified as lower-risk by IMPROVE and care-as-usual, 2.1% and 5.3%, respectively, experienced an ipsilateral ischemic stroke during follow-up.

Using the presence of intraplaque hemorrhage on magnetic resonance imaging and 4 conventional parameters, the IMPROVE model provides accurate individual stroke risk estimates, which may facilitate stratification for revascularization after external validation.

Symptomatic carotid artery stenosis requires timely intervention to reduce risk of recurrent stroke. However, the optimal timing of revascularization remains debated. This study evaluates outcomes in patients undergoing urgent (<48 hr), early (3-14 days), or delayed (>14 days) carotid artery revascularization.

This retrospective cohort study included 186 interventions in symptomatic patients categorized by timing of intervention defined as urgent (<48 hr from symptom onset, n = 47), early (3-14 days, n = 90), and delayed (>14 days, n = 49). Baseline characteristics, procedural details, and outcomes were analyzed. Outcome measures included perioperative stroke, transient ischemic attack (TIA), myocardial infarction, and mortality at 30 days and on follow-up.

The cohort's mean age was 71.3 ± 9.6 years, with no difference among groups, and with a balanced sex distribution (P = 0.75). Comorbidities included hypertension, hyperlipidemia, and chronic kidney disease, which were similar across groups (P > 0.05). National Institutes of Health stroke scale on admission was significantly different between groups (urgent: 4.7 ± 4.6; early: 8.2 ± 8.1; delayed: 4.0 ± 5.2; P = 0.01). The level of disability measured through the modified Rankin scale at discharge demonstrated no significant difference between groups (urgent: 0.9 ± 1.3; early: 1.1 ± 1.3; delayed: 0.5 ± 1.0; P = 0.09). At 30 days, ipsilateral strokes/TIA occurred in 3 (6.4%) patients in the urgent group, and none in either the early group or delayed group (P = 0.02). Thirty-day mortality was observed in 2 (4.3%) patients in the urgent group and 1 (1.1%) in the early group (P = 0.23). The 30-day composite of stroke, TIA, myocardial infarction, or death was significantly higher in the urgent group (urgent: 8.5%, early: 1.1%, delayed: 0.0%; P = 0.02). At a mean follow-up of 14.6 ± 16.9 months, ipsilateral stroke rates were similar across groups (urgent: 4.3%, early: 5.6%, delayed: 4.1%; P = 1.00). All-cause mortality at follow-up occurred in 21.3% of urgent, 10.0% of early, and 10.2% of delayed patients (P = 0.17). Restenosis and reintervention rates at follow-up were significantly higher in the urgent (10.6%) and delayed (14.3%) groups than the early group (2.2%; P = 0.01).

Urgent carotid revascularization is associated with higher perioperative stroke/TIA rate than early and delayed interventions. Mid-term outcomes were comparable across groups. Restenosis and reintervention rates were higher in the urgent and delayed groups than the early intervention group.

Trans-stenotic pressure ratio (herein denoted by dpPR) has been proposed as a complementary index to stenosis rate (SR) for assessing the functional severity of carotid artery stenosis (CAS); however, it remains unclear how well dpPR can indicate cerebral ischemia. In this study, a physiology-based computational model of the cerebral circulation was developed to yield a tool for generating large-scale in silico data to characterize the changes of the dpPR of the left internal CAS in response to variations in SR and various anatomical/pathophysiological factors that represent inter-patient differences. In addition, a cerebral ischemia index (CII) was defined to evaluate the predictive value of dpPR for cerebral ischemia. Results showed that dpPR was affected by many factors unrelated to the severity of stenosis, such as the anatomical structure and geometrical size of cerebral arteries, mean systemic arterial blood pressure (MAP), flow autoregulation function of cerebral microcirculation (quantified by CFAI), and coexisting contralateral CAS. In comparison with SR, dpPR exhibited a stronger correlation with CII. In particular, the relationship between dpPR and CII was found to be describable by a mathematical function if MAP and CFAI were fixed. The findings not only deepen our understanding of the physiological implications of dpPR but also provide valuable theoretical insights to guide the application of dpPR in clinical practice.

Carotid revascularisation, comprising either carotid endarterectomy or stenting, is offered to patients with carotid stenosis to prevent stroke based on the results of randomised trials conducted more than 30 years ago. Since then, medical therapy for stroke prevention has improved. We aimed to assess whether patients with asymptomatic and symptomatic carotid stenosis with a low or intermediate predicted risk of stroke, who received optimised medical therapy (OMT), would benefit from additional revascularisation.

The Second European Carotid Surgery Trial (ECST-2) is a multicentre randomised trial with blinded outcome adjudication, which was conducted at 30 centres with stroke and carotid revascularisation expertise in Europe and Canada. Patients aged 18 years or older with asymptomatic or symptomatic carotid stenosis of 50% or greater, and a 5-year predicted risk of ipsilateral stroke of less than 20% (estimated using the Carotid Artery Risk [CAR] score), were recruited. Patients were randomly assigned to either OMT alone or OMT plus revascularisation (1:1) using a web-based system. The primary outcome for this 2-year, interim analysis was a hierarchical outcome composite of: (1) periprocedural death, fatal stroke, or fatal myocardial infarction; (2) non-fatal stroke; (3) non-fatal myocardial infarction; or (4) new silent cerebral infarction on imaging. Analysis was by intention-to-treat using the win ratio-ie, each patient in the OMT alone group was compared as a pair with each patient in the OMT plus revascularisation group, with a win declared for the patient with a better outcome within the pair (a tie was declared if neither patient in the pair had a better outcome). The win ratio was calculated as the number of wins in the OMT alone group divided by the number of wins in the OMT plus revascularisation group. This trial is registered with the ISRCTN Registry (ISRCTN97744893) and is ongoing.

Between March 1, 2012, and Oct 31, 2019, 429 patients were randomly assigned to OMT alone (n=215) or OMT plus revascularisation (n=214). One patient allocated to OMT alone withdrew consent within 48 h and was not considered further. The median age of patients was 72 years (IQR 65-78); 296 (69%) were male and 133 (31%) female. No benefit was recorded in favour of either treatment group with respect to the primary hierarchical outcome assessed 2 years after randomisation, with 5228 (11·4%) wins for the OMT alone group, 5173 (11·3%) wins for the OMT plus revascularisation group, and 35 395 (77·3%) ties between groups (win ratio 1·01 [95% CI 0·60-1·70]; p=0·97). For OMT alone versus OMT plus revascularisation, four versus three patients had periprocedural death, fatal stroke, or fatal myocardial infarction; 11 versus 16 had non-fatal stroke; seven versus five had non-fatal myocardial infarction; and 12 versus seven had new silent cerebral infarction on imaging. One periprocedural death occurred in the OMT plus revascularisation group, which was attributed to decompensated aortic stenosis 1 week after carotid endarterectomy.

No evidence for a benefit of revascularisation in addition to OMT was found in the first 2 years following treatment for patients with asymptomatic or symptomatic carotid stenosis of 50% or greater with a low or intermediate predicted stroke risk (assessed by the CAR score). The results support treating patients with asymptomatic and low or intermediate risk symptomatic carotid stenosis with OMT alone until further data from the 5-year analysis of ECST-2 and other trials become available.

National Institute for Health and Care Research; Stroke Association; Swiss National Science Foundation; Dutch Organisation for Knowledge and Innovation in Health, Healthcare and Well-Being; Leeds Neurology Foundation.

Clinical practice guideline recommendations are often informed by systematic reviews. This review aimed to appraise the reporting and methodological quality of systematic reviews informing clinical practice recommendations relevant to vascular surgery.

MEDLINE and Embase.

MEDLINE and Embase were searched from 1 January 2021 to 5 May 2023 for clinical practice guidelines relevant to vascular surgery. Guidelines were then screened for systematic reviews informing recommendations. The reporting and methodological quality of these systematic reviews were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) 2017 tool. Pearson correlation and multiple regression analyses were performed to determine associations between these scores and extracted study characteristics.

Eleven clinical practice guidelines were obtained, containing 1 783 references informing guideline recommendations. From these, 215 systematic reviews were included for synthesis. PRISMA item completeness ranged 14 - 100%, with a mean of 63% across reviews. AMSTAR 2 item completeness ranged 2 - 95%, with a mean of 50%. Pearson correlation highlighted a statistically significant association between a review's PRISMA and AMSTAR 2 score (r = 0.85, p < .001). A more recent publication year was associated with a statistically significant increase in both scores (PRISMA coefficient 1.28, p < .001; and AMSTAR 2 coefficient 1.31, p < .001). Similarly, the presence of funding in a systematic review was shown to be statistically significantly associated with an increase in both PRISMA and AMSTAR 2 scores (coefficient 4.93, p = .024; and coefficient 6.07, p = .019, respectively).

Systematic reviews informing clinical practice guidelines relevant to vascular surgery were of moderate quality at best. Organisations producing clinical practice guidelines should consider funding systematic reviews to improve the quality of their recommendations.

Non-invasive estimation of pressure differences using 2D synthetic aperture ultrasound imaging offers a precise, low-cost, and risk-free diagnostic tool. Unlike invasive techniques, this preserves natural blood flow and avoids the limitations of devices that occupy lumen space. This paper evaluates a previously published estimator, modified to incorporate Singular Value Decomposition (SVD) echo-cancellation, using data from ten healthy volunteers and one patient. It is hypothesized that the estimator will enable precise pressure differences from the common carotid artery with a coefficient of variation of approximately 10% over a 10-second data acquisition period. Here, precision is essential to demonstrate the method's consistency and its ability to differentiate between healthy and diseased arteries at the earliest possible stage. Data are acquired using a GE-9L-D, 5.2 MHz linear transducer connected to a Vantage 256 research scanner. The estimator was applied to the left common carotid artery of ten healthy volunteers, with precision being evaluated over the recorded heart cycles by using the coefficient of variation. Eight out of ten individuals showed precision below 10%, whereas two individuals showed precision above 20%. The best precision was attained by subject_03 with a coefficient of variation of 4.64% (16.1 Pa) and the worst precision was attained by subject 09 with a coefficient of variation of 23.3% (30.2 Pa). The average range of pressure differences across volunteers (from maximum positive to maximum negative pressure difference) was 297 Pa when measured across a 14 mm streamline. The corresponding average coefficient of variation was found to be 9.95% (24.6 Pa). A comparison of peak systolic velocities between the experimental scanner and the reference scanner demonstrates a strong positive linear correlation (R2 = 0.76). The corresponding slope of the linear best fit is 0.95, indicating that the relationship between the two scanners is close to a one-to-one match, with the experimental scanner's measurements being slightly less than those of the reference scanner. Finally, data attained from a single patient example shows pressure differences ranging from -61.81 Pa to 1240.82 Pa with blood velocities as high as 1.73 m/s, which is significantly higher than seen in any of the healthy volunteers, supporting the likelihood of differentiating between stenosis grades in future studies. While this study is limited to 10 healthy volunteers and one patient, a different study design is needed to quantify the severity of stenosis and correlate it with pressure differences.

Various studies have failed to detect a difference in outcomes between carotid endarterectomy (CEA) with patch angioplasty and eversion CEA. This study aimed to assess whether surgical technique and related department policy are associated with in hospital outcomes after CEA.

This was a secondary data analysis based on the German statutory quality assurance database. According to surgical technique policy, hospitals were categorised as routine eversion (> 90%), selective eversion (10 - 90%), or sporadic eversion (< 10%) centres. The primary outcome event (POE) was in hospital stroke or death. Uni- and multivariable regression analyses were performed.

A total of 119 800 patients underwent CEA between 2012 and 2016. Multivariable regression analysis showed the eversion technique to be associated with a lower POE rate (adjusted odds ratio 0.78, 95% confidence interval 0.69 - 0.88). Routine eversion centres showed statistically significantly lower in hospital stroke or death rates compared with selective eversion and sporadic eversion centres (1.7% vs. 1.9% vs. 2.0%; p = .004). After risk adjustment, centre surgical technique policy did not show a significant association with any of the assessed outcomes.

Eversion CEA compared with CEA with patch angioplasty was independently associated with a lower in hospital stroke or death rate. The centre policy with respect to surgical technique did not show an association with the primary or either of the secondary outcomes.

This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals.

This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180-15, 14-8, 7-3, 2-0 days or 'in-hospital index event'. In-hospital delay was divided into: 0-1, 2-3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR).

Prehospital delay was 0-2 days in 34.9%, 3-14 days in 29.5% and >14 days in 18.6%. Higher age (β=-1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=-4.41, p<0.001; stroke: β=-6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2-3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk.

This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2-3 days) were associated with increased risk of perioperative stroke or death.

This study aimed to assess the effects of distal transradial access (dTRA) compared to conventional transradial access (cTRA) on procedure duration and radiation exposure among patients undergoing carotid artery stenting.

The study included 131 patients who underwent cerebrovascular interventional diagnosis and treatment in the Department of Cerebrovascular Diseases at Beijing Anzhen Hospital, Capital Medical University, from January 2022 to April 2024. Patients were categorized into dTRA and cTRA groups based on the puncture site. Clinical and laboratory data, operation duration, and the incidence of puncture-related complications and perioperative adverse events were recorded. Procedure duration and radiation exposure levels were then compared between the two groups.

The dTRA group comprised 47 patients and the cTRA group comprised 84 patients. No statistically significant differences were observed between the groups in terms of risk factors and laboratory parameters (all P > 0.05). Procedure-related comparisons between the dTRA and cTRA groups showed that the operation time for carotid artery stenting was (51.47 ± 10.51) minutes and (50.08 ± 11.37) minutes, respectively; the fluoroscopy time was (20.48 ± 5.55) minutes and (20.96 ± 9.24) minutes, respectively; and the radiation exposure dose was (573.60 ± 185.17) mGy and (567.09 ± 329.96) mGy, respectively. None of these differences were statistically significant (all P > 0.05).

The results suggest that dTRA is comparable to cTRA in terms of procedure duration and radiation exposure during carotid artery stenting.

Background and Objectives: Carotid artery stenosis is a significant risk factor for ischemic stroke due to impaired cerebral blood flow (CBF). Even asymptomatic unilateral stenosis can induce subclinical cerebrovascular changes, potentially affecting both hemispheres through collateral circulation. This study aimed to systematically assess cerebral perfusion in asymptomatic individuals with unilateral carotid artery stenosis by comparing ipsilateral and contralateral hemispheres with healthy controls, challenging the assumption that the contralateral hemisphere remains unaffected. Materials and Methods: This cross-sectional study included 114 participants, comprising 54 asymptomatic individuals (mean age 65.5) with significant unilateral carotid stenosis and 60 age-matched controls (mean age 64.8). Cerebral perfusion was assessed using 1.5T Magnetic Resonance Imaging (MRI) with pseudo-continuous arterial spin labeling (pCASL). CBF was measured bilaterally in four predefined middle cerebral artery (MCA) regions: precentral gyrus, lentiform nucleus, insular cortex, and temporal cortex. Statistical analyses included multivariate analysis of variance (MANOVA), analysis of variance (ANOVA), paired t-tests, and discriminant analysis (DA). Results: Significant bilateral reductions in CBF were observed in individuals with carotid stenosis compared to controls (MANOVA and ANOVA, p < 0.001). The greatest perfusion deficit was in the ipsilateral insular cortex (49.88 ± 10.83 mL/100 g/min), followed by intermediate contralateral perfusion (51.49 ± 8.86 mL/100 g/min) and higher control values (58.78 ± 10.44 mL/100 g/min). DA indicated the insular cortex as the region with the highest discriminative contribution (64.7%). Conclusions: Unilateral carotid artery stenosis in asymptomatic individuals is associated with significant bilateral cerebral hypoperfusion, suggesting widespread hemodynamic effects. Pronounced perfusion deficits in the insular cortex underline its vulnerability. The observed contralateral perfusion reductions challenge the traditional use of the contralateral hemisphere as a reference standard, underscoring the need for comprehensive perfusion assessment in carotid artery disease.

Atherosclerosis (AS), a major cause of cardiovascular diseases, is characterized by lipid accumulation and chronic inflammation within arterial walls. Traditional treatments, such as statins, are often ineffective for many patients, highlighting the need for novel therapeutic strategies.

This study explores the potential of Resibufogenin (RBG) as an NLRP3 inflammasome inhibitor for treating AS in ApoE-/- mice.

We performed experiments encompassing cellular studies, animal model assessments, molecular simulations, and binding assays to assess RBG's impact on the NLRP3 inflammasome, inflammatory cytokine release, and foam cell formation.

RBG treatment alleviated AS in ApoE-/- mice, evidenced by reduced body weight, smaller atherosclerotic plaques, and improved serum lipid profiles. Transcriptomics and molecular biology demonstrated that RBG suppressed the expression of key inflammatory markers such as NLRP3. RBG also reduced macrophage infiltration and promoted polarization toward the anti-inflammatory M2 phenotype. Molecular docking, SPR, Pull-down studies identified a non-covalent interaction between RBG and the CYS-279 residue of NLRP3, confirming its role as a potent NLRP3 inhibitor.

RBG effectively inhibits NLRP3 inflammasome activation, reduces pro-inflammatory cytokine release, and decreases formation of foamy macrophages, thereby slowing the progression of AS. Although these findings highlight RBG as a promising therapeutic approach for cardiovascular diseases, further research is necessary to assess its safety and effectiveness in humans and to investigate possible synergistic effects with other treatments.

Background: Carotid artery stenting (CAS) with neuroprotection is a widely used treatment for carotid artery stenosis. This study aimed to evaluate the long-term outcomes of CAS using the MER stent (Balton, Poland) and various neuroprotection devices, with subgroup analysis based on predilatation. Methods: A prospective analysis was conducted on patients treated with CAS at four high-volume centers in Poland between October 2016 and May 2017. Patients were stratified into two groups based on whether predilatation was performed. Procedural and clinical outcomes, including major adverse events (MAEs) defined as all-cause death, stroke, and myocardial infarction (MI), were evaluated at 30 days and 5 years post-procedure. Kaplan-Meier analysis and Cox regression models were used to assess event-free survival and predictors of MAEs. Results: The study population consisted of 100 patients (males: 61%) with a mean age of 68 years. Dyslipidemia (84.4% vs. 60.0%, p = 0.007) and smoking (67.3% vs. 44.4%, p = 0.022) differed significantly between the predilatation and non-predilatation groups. The procedural success rate (<30% residual stenosis) was 97%. At 5 years, the overall restenosis rate was 7%, and target vessel revascularization was required in 3% of patients. The cumulative mortality rate was 15%, and two strokes (2%) were recorded. Multivariable regression identified prior CABG as an independent predictor of MAEs (HR 3.5, 95% CI 1.14-10.83, p = 0.03). Conclusions: CAS with the MER stent demonstrated high procedural success and favorable long-term outcomes. Predilatation did not impact outcomes. Neuroprotection was effective in all cases, with no device-related complications reported.

Diagnosing carotid near-occlusion (CNO) with colour duplex ultrasound (CDU) is challenging. We hypothesised that CNO is associated with a reduced distal internal carotid artery (ICA) velocity and aimed to assess if distal velocity is able to diagnose CNO accurately. If not, we aimed to develop CDU rule-out and rule-in criteria to diagnose CNO.

This is a prospective cross-sectional study in consecutive participants with suspected ≥ 50% carotid stenosis on CT angiography (CTA). CDU velocities in the common carotid artery, the stenosis and distal to the stenosis were examined. CTAs were assessed for CNO, serving as a reference test. If no CDU parameter was both sensitive and specific for CNO, rule-out (98% sensitive) and rule-in (99% specific) criteria were created.

Of the 315 included participants with ≥ 50% stenosis, 190 (60%) were conventional ≥ 50% stenosis and 125 (40%) CNO. No CDU parameter was both sensitive and specific for CNO. The best exclusion criteria were stenosis end diastolic velocity (EDV) ≤ 63 cm/s and/or distal peak systolic velocity (PSV) > 23 cm/s, seen in 115 (38%) participants. The best rule-in criteria were stenosis EDV ≥ 280 cm/s and/or distal PSV ≤ 23 cm/s, seen in 35 (12%) participants. Of the remaining participants, 143 (47%) were uncertain (74 CNOs) and 9 (3%) were misdiagnosed as carotid occlusion (all CNOs).

CDU alone cannot diagnose CNO but can rule in or rule out CNO in half of participants with ≥ 50% stenosis. These criteria are intended for inclusion in an algorithm, sorting cases needing further exams, such as CTA and/or phase-contrast magnetic resonance angiography.

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.

PurposeRobotic-assisted carotid artery stenting (CAS) procedures are on the rise and have demonstrated benefits compared to manual intervention. The R-OneTM robotic platform has demonstrated safety and efficacy for percutaneous coronary interventions, but its utility for procedures in the common carotid artery has not been thoroughly studied. This study aims to assess the feasibility and initial safety of the R-OneTM robotic platform for treating patients with carotid artery disease (CAD) presenting with carotid web-diaphragm lesions.MethodsThe prospective CArotid Robotic procedure Evaluation study included patients with CAD suitable for CAS. The primary endpoint was procedure technical success, defined as the absence of any unplanned manual assistance or conversion to manual CAS for procedural completion. Secondary endpoints included the absence of intra-procedural complications, primary operator radiation exposure, patient radiation exposure, procedure time, and contrast volume.ResultsA total of seven patients were enrolled (mean age: 49.57 ± 13.10 years; 5 females). Procedure technical success rate was 85.7% (6/7). The absence of intra-procedural complications rate was 100%. Mean overall procedure time was 41.71 ± 9.83 min, mean robotic procedure time was 15.86 ± 7.60 min, and mean CAS procedure time was 27.14 ± 8.71 min. The average patient radiation exposure dose was 135.50 ± 78.88 mGy. The mean overall procedure contrast volume was 68.14 ± 20.14 mL, and the mean robotic procedure contrast volume was 1.43 ± 3.78 mL.ConclusionCAS procedures using R-OneTM are feasible and safe with a good technical success rate without complications. To confirm these findings, larger multi-center trials with a diverse range of patients are necessary.

This study aims to identify factors influencing successful recanalization following endovascular intervention for non-acute basilar artery occlusion (NABAO).

Endovascular treatment (EVT) is a feasible approach for treating non-acute basilar artery occlusion, but it presents significant technical challenges due to the lack of standardized treatment protocols. Therefore, identifying patients most likely to benefit is critical to minimizing procedural risks.

A retrospective analysis was conducted on 115 patients with NABAO treated via EVT. Factors associated with successful recanalization, including clinical symptoms, demographic characteristics, procedural outcomes, and imaging findings, were analyzed using multivariate analysis. A scoring system was developed based on independent predictors.

Successful recanalization (defined as modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b) was achieved in 81.7% (94/115) of cases. Multivariate analysis revealed that occlusion duration >3 months (odds ratio [OR]: 0.187, 95% confidence interval [CI]: 0.051-0.688, p = 0.012), blunt-shaped occlusion ends (OR: 0.236, 95% CI: 0.072-0.777, p = 0.018), occlusion length > 30 mm (OR: 0.144, 95% CI: 0.031-0.669, p = 0.013), and insufficient or absent distal compensation (OR: 0.25, 95% CI: 0.075-0.835, p = 0.024) were independent predictors of reduced technical success. The receiver operating characteristic (ROC) curve index for the scoring system, based on these independent predictors, was 0.817 (95% CI: 0.698-0.936, p < 0.001), with a sensitivity of 71.4% and a specificity of 85.4% at a cutoff of 2.5 points.

Longer occlusion duration (>3 months), blunt-shaped occlusion ends, occlusion length > 30 mm, and insufficient distal collateral compensation are independent negative predictors for successful recanalization in patients with NABAO treated via EVT. The proposed scoring system can help screen patients suitable for treatment and optimize treatment strategies, but further validation in prospective cohorts is needed.

This study aimed to evaluate the safety and feasibility of carotid artery stenting (CAS) using a 6 F guiding catheter via right distal radial artery access.

The clinical data of 32 patients who underwent internal carotid artery C1 stenting via right distal transradial artery access (rdTRA) at the Department of Cerebrovascular Diseases, Beijing Anzhen Hospital, between January 2022 and December 2023, were retrospectively analyzed. Parameters including puncture time, X-ray irradiation time, exposure dose, surgical success rate, surgery-related cardiovascular and cerebrovascular complications, puncture site complications, and postoperative radial artery patency were recorded and assessed.

The procedural success rate of CAS through rdTRA was 100% (32/32). The time from operating room entry to successful puncture ranged from 3 to 36 min, with an average time of 18.56 ± 7.63 min. X-ray exposure time ranged from 12 to 27 min, with an average time of 19.18 ± 4.77 min. One patient experienced a procedure-related transient ischemic attack postoperatively, while another developed bruising along the radial artery course on the third postoperative day. During an out-of-hospital follow-up period averaging 1 to 29 months (median: 5.4 ± 3.6 months), no cardiovascular or cerebrovascular events were reported. The radial pulse was palpable in all patients postoperatively and during the follow-up, with radial artery patency confirmed through patency testing.

Carotid artery stenting through rdTRA using a 6 F guiding catheter is a safe and feasible approach, demonstrating high procedural success and minimal complications.

Carotid endarterectomy (CEA) with patch angioplasty is associated with lower restenosis rates compared with primary closure alone. However, evidence regarding patch-material superiority in the mitigation against neointimal hyperplasia and restenosis is limited. This retrospective observational study investigated medium-term restenosis rates between commercially available biological and synthetic carotid patches.

All primary CEA with patch angioplasty performed between 2007 and 2019 at a single university hospital were identified from theatre records. Restenosis was defined using the European Society for Vascular Surgery duplex criteria, either moderate (50-69%, PSV >213cm/s) or critical (70-99%, PSV >274cm/s). Chi-square tests and Kaplan-Meier curves were used to compare restenosis rates between biological (bovine pericardium) and synthetic patches (Dacron, PFTE and polyester-urethane).

Overall, 127 CEAs were included in the restenosis analysis. Bovine pericardium was the patch material used most frequently (60%, n=75). Median follow-up with duplex was 40.0 months (range 0-144). Moderate restenosis was detected in 14 CEAs (11%) and critical restenosis in 10 (7.8%). Compared with synthetic material, bovine was significantly associated with >50% restenosis but not >70% (p=0.042 and p=0.197, respectively). However, Kaplan-Meier curves demonstrated similar rates of >50% and >70% restenosis between patch types at five years (p=0.081 and p=0.080, respectively). There was no significant difference in peri-operative complication rates between patch types.

These results indicate medium-term restenosis rates after CEA are similar between biological and synthetic patches. However, well-designed randomised control trials are required to definitively answer the question of which patch material is superior for carotid reconstruction.

The association between asymptomatic carotid artery stenosis and impaired cognition, and the cognitive changes after revascularization remain active areas of interest in the field of carotid disease. This narrative review focuses on the association between carotid artery atherosclerosis and impaired cognitive function, proposed mechanisms, and the effects of carotid revascularization on cognition.

A critical review of the literature to identify studies evaluating carotid artery stenosis, cognition, and carotid revascularization was performed using PubMed to query the MEDLINE database through March 2023.

Many studies demonstrate a link between carotid disease and cognitive impairment but direct evidence is lacking. Revascularization may offer cognitive benefits but the effect is likely subtle and affected by the choice of revascularization procedure.

Integrating cognitive outcomes into ongoing randomized controlled trials such as the nested CREST-H arm of the CREST-2 trial hold promise for offering new insight into the role of carotid artery stenosis and carotid revascularization on cognition.

This review examines current evidence regarding management of patients with both coronary and carotid artery disease. It highlights the elevated stroke risk after surgery for this cohort and scrutinizes approaches to minimize this risk. Various revascularization methods are outlined, including carotid endarterectomy (CEA), carotid artery stenting (CAS), and staged versus simultaneous surgical approaches. The importance of judiciously screening coronary artery bypass grafting (CABG) candidates for carotid stenosis is emphasized, suggesting risk factor-based targeted screening is noninferior to indiscriminate screening. Efficacy comparisons are made between revascularization strategies such as staged versus synchronous CEA/CABG, CAS, and hybrid techniques. Controversies surrounding necessity and optimal timing of carotid revascularization in asymptomatic patients are addressed, indicating a need for rigorous randomized controlled trials to establish definitive treatment algorithms.

Current guidelines recommend treatment of patients with asymptomatic carotid stenosis when stroke/death rates less than 3% can be achieved. However, in the Pacific Northwest region of the Vascular Quality Initiative, elevated stroke/death rates have been reported. This study aims to characterize regional and center-specific outcomes for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) and investigate potential underlying drivers.

A retrospective review of asymptomatic patients undergoing TCAR and TF-CAS in the Vascular Quality Initiative for the Pacific Northwest region from 2016 to 2022 was performed. The primary outcome was the composite of stroke or death within 30 days of index hospitalization. Overall regional outcomes and center-specific outcomes were assessed. A high stroke/death rate was defined as greater than 3%. Demographics, comorbidities, and operative risk factors were then compared between centers with high and low stroke/death rates.

A total of 1154 asymptomatic patients across 27 centers underwent carotid stenting in the Pacific Northwest from 2016 to 2022, of which 886 (76.8%) underwent TCAR and 268 (23.2%) underwent TF-CAS. The overall stroke/death rates were 2.5% and 3.0% for TCAR and TF-CAS, respectively. Among centers with stroke/death rates above 3%, for both TCAR and TF-CAS, all were in the top one-half of centers by volume. When patients undergoing TCAR were assessed, those treated at centers with high stroke/death rate underwent revascularization at higher volume centers (12 vs 7 cases per year; P = .03), which treated fewer patients with >80% stenosis (42.1% vs 52.2%; P < .01) and more patients with high-risk anatomy (42.3% vs 35.3%; P = .01), and high-risk physiology as defined by an American Society of Anesthesiologists (ASA) class of 4 or 5 (25.5% vs 17.5%; P < .01). Among patients undergoing TF-CAS, those treated at centers with a high stroke/death rate were more likely to have high-risk anatomy (63.5% vs 48.6%; P = .03), and high-risk physiology as defined by an ASA class of 4 or 5 (23.5% vs 10.4%; P < .01).

High stroke/death rates in the Pacific Northwest appear to be driven by the selection of high-risk patients with less than 80% stenosis. Decreasing the frequency of carotid revascularization in asymptomatic patients with very high physiologic risk including those with ASA class 4 and those with less than 80% stenosis may offer the opportunity for improved outcomes.

Acute Carotid Stent Thrombosis (ACST) is a rare complication of Carotid Artery Stenting (CAS) with a potentially fatal outcome. We report a case of ACST occurring five minutes after the end of a successful CAS procedure that was promptly treated by carotid stent-in-stent implantation using a new percutaneous strategy based on the creation of a modified embolic protection device. Following the procedure, we did not observe brain lesions suggestive of acute cerebral ischemic events at the CT scan performed at 48 hours, as well as no neurological deficits in the following days.

Carotid artery stenting with single-layer stents carries a risk of periprocedural cerebral embolization compared to carotid endarterectomy. Dual-layer micromesh stents were designed for improved plaque coverage and sustained embolic protection. This analysis aimed to confirm the Roadsaver dual-layer micromesh stent safety in a real-world carotid artery stenting cohort.

ROADSAVER was a prospective, single-arm, multicenter, observational study. Patients with carotid artery stenosis, eligible for elective stenting, were enrolled at 52 sites across 13 European countries. All procedures followed standard practice. The primary outcome was the 30-day major adverse event rate, defined as the cumulative incidence of any death or stroke. All deaths, strokes, and carotid artery revascularizations were independently adjudicated.

In total, 1965 patients were analysed (mean age 70.6 ± 8.8 years). Cerebral ischaemia symptoms were present in 49.4% of participants. Radial/ulnar access was used in 26.3% of cases and embolic protection in 63.8%. The 30-day major adverse event incidence was 2.2% (1.6% in asymptomatic and 2.8% in symptomatic patients), with any stroke at 1.9%, any death at 0.8%, and stroke-related death at 0.5%. Predictors of higher 30-day major adverse event risk, identified through multivariable modelling, included residual stenosis ≥ 30%, thromboembolic venous disease, previous myocardial infarction, age ≥ 75 years, family history of atherosclerosis, non-insulin-dependent diabetes mellitus, symptomatic carotid stenosis, and stent length.

Dual-layer micromesh carotid artery stenting is safe, with a low 30-day major adverse event incidence in real-world asymptomatic and symptomatic patients, supporting the sustained embolic protection design concept.

Level 2, observational study (with dramatic effect).