Carotid Stenting in Asymptomatic Carotid Stenosis: The Calgary Experience

Background:Although carotid endarterectomy is considered the ‘gold standard’ for standard risk symptomatic patients, the treatment of choice for asymptomatic patients remains controversial. Carotid stenting has demonstrated real-world outcomes consistent with established guidelines for carotid endarterectomy in asymptomatic high-surgical risk patients in recent prospective multicenter trials. We describe our experience with asymptomatic patients who underwent carotid stenting at our center in a routine clinical setting.Methods:This is a retrospective, longitudinal cohort study of patients who underwent carotid angioplasty and stenting at the Foothills Medical Center, Calgary, Canada between 1997 and 2007. The qualifying events were categorized as symptomatic and asymptomatic. The procedures were performed by four experienced neurointerventionists. The primary outcome was stroke or death at 30-day follow- up.Results:243 patients underwent 255 carotid stenting procedures. Their ages ranged from 50 to 83 years; the mean age was 72.0 ± 9.3 years; 67(26.3%) were women. Forty one patients (16.1%) were asymptomatic; 214 patients (83.9%) were symptomatic. The patients in the asymptomatic group were significantly younger - 66.0 ± 8.8 years compared to patients in the symptomatic group 73.2 ± 8.9 years (p<0.0001). Intraprocedurally one minor stroke (2.4%) occurred in the asymptomatic group. At 30-day follow-up, no deaths or further strokes were noted in the asymptomatic group; while eight deaths, six major and seven minor strokes occurred in the symptomatic group (p=0.22).Conclusion:Carotid stenting appears to be a safe procedure in asymptomatic patients with severe carotid stenosis in routine clinical settings as witnessed in this single center study.

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The prognostic value of the serum inflammatory biomarkers in patients with carotid atherosclerosis

EUREKA Health Sciences ◽

10.21303/2504-5679.2021.001969 ◽

2021 ◽

pp. 26-33

Author(s):

Olga Dubenko ◽

Tetyana Litovchenko ◽

Victoria Anysienkova ◽

Maryna Nessonova ◽

Liudmyla Kovalenko

Keyword(s):

Ischemic Stroke ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Prognostic Value ◽

Enzyme Linked Immunosorbent Assay ◽

Control Group ◽

Operating Characteristics ◽

Asymptomatic Group ◽

Logistic Regression Models ◽

Asymptomatic Patients

20 % of ischemic stroke appear to originate from carotid artery atherosclerotic disease. Serum biomarkers reflecting the activity of atherosclerotic process and may help for estimate risk of acute cerebrovascular events. Several serum inflammatory markers have been proposed for risk assessment, but their prognostic role less known. The aim of this study is to clarify the prognostic value of biomarkers of atherosclerosis lipoprotein-associated phospholipase A2 (Lp-PLA2) and E-selectin in patients with symptomatic and asymptomatic carotid stenosis. Materials and methods. The study involved 106 patients with atherosclerotic carotid stenosis >50 % (74 men and 32 women, mean age 62.6±0.9) from which 76 symptomatic (35 with acute ipsilateral atherothrombotic stroke and 41 after carotid endarterectomy) and 30 asymptomatic patients. The control group consisted of age- and sex-matched 20 healthy subjects. The level of serum Lp-PLA2 and E-selectin was determined using a commercially available enzyme-linked immunosorbent assay kit. Results. The level of Lp-PLA 2 was in general significantly higher (p<0.05) in patients groups than in the control group and most high Lp-PLA2 concentration was in groups of symptomatic patients who underwent carotid endarterectomy. The level of E-selectin in the study patients was significantly higher than in the control group (p<0.05). The correlation of Lp-PLA 2 with E-selectin was significant for total patients (R=0.365664, p=0.00085) and group after carotid endarterectomy (R=0.429143, p=0.01796), but not for asymptomatic group (p>0.05). Receiver Operating Characteristics curves of logistic regression models which takes into joint both indicators was specificity and sensitive for predicting the occurrence of ischemic stroke. Conclusion. Conducted study show that the levels of Lp-PLA 2 and E-selectin have a significant impact on the development of stroke in patients with atherosclerotic carotid stenosis and can be used to predict it. A multidimensional model of the dependence of the probability of stroke on a linear combination of Lp-PLA 2 and E-selectin allows to obtaining significantly higher characteristics of the accuracy of stroke prediction than models with each factor alone.

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Retrospective study on early outcomes of carotid stenting

Romanian Neurosurgery ◽

10.33962/roneuro-2021-015 ◽

2021 ◽

pp. 94-97

Author(s):

Saurabh Sharma ◽

Prashant Raj Singh ◽

Ram Kumar Goyal ◽

Raghavendra Kumar Sharma ◽

Yashuhiro Yamada ◽

...

Keyword(s):

Myocardial Infarction ◽

Carotid Artery ◽

Carotid Artery Stenosis ◽

Doppler Ultrasonography ◽

Carotid Stenting ◽

Artery Stenosis ◽

Minor Stroke ◽

Safe Alternative ◽

Asymptomatic Patients

Objective: This study is conducted to evaluate the early events after Carotid artery stenting (CAS) among our patients in a single institute. Methods: This study was conducted on 40 patients. These patients underwent stenting of extracranial carotid arteries. Stenting was performed on symptomatic patients with carotid artery stenosis of more than 50 per cent of asymptomatic patients with more than 70 per cent carotid artery stenosis on Doppler ultrasonography. Follow up period for this study was of one month. Results: 40 patients who underwent CAS between August 2018 and June 2019 were included in the study. Self-expandable hybrid stents were implanted in all patients and pre or poststent-dilatation was performed if required after implantation. None of the patients suffered from a stroke, myocardial infarction or death due to CAS during their hospital stay. Only one patient had a minor stroke during follow up, which was managed conservatively. No transient ischemic attack (TIA), myocardial infarction or death during the follow-up period. Re-stenosis was not observed in the follow-up carotid Doppler ultrasonography; flow rates were within normal limits. Conclusions: Carotid stenting is a safe alternative to CEA (carotid endarterectomy) in the treatment of carotid stenosis regardless of age. CAS with cerebral protection can be performed safely in patients who are at high surgical risk, with low perioperative morbidity and mortality. The durability of the procedure must be determined with a longer follow-up. Further high-quality RCTs are required to address other shortcomings and controversies.

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Periprocedural complications and risk factors after carotid stenting in patients with concomitant coronary artery disease

Bulgarian Cardiology ◽

10.3897/bgcardio.27.e75361 ◽

2021 ◽

Vol 27 (4) ◽

pp. 72-79

Author(s):

Georgi Goranov ◽

Petar Nikolov

Keyword(s):

Carotid Stenosis ◽

Coronary Disease ◽

Risk Groups ◽

Carotid Stenting ◽

Minor Stroke ◽

Safe Procedure ◽

Female Ratio ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Concomitant Coronary Artery Disease

Backgrounds and purpose: To analyse the periprocedural CAS complications in patients with concomitant coronary disease. Material and methods: A prospective study analysed the frequency and characteristics of periprocedural complications after CAS in 329 patients, of whom 62.2% had symptomatic carotid stenosis > 50% and 37.8% had asymptomatic > 70%. The mean age was 70.2 (45-88) years, male/female ratio – 253/76. The degree of carotid stenosis was assessed angiographically according to NASCET criteria and was stratified by a newly proposed carotid score in three risk groups. Distal embolic protection was used in all patients. Results: Periprocedural complications were observed in 25/349 CAS interventions: TIA – 4.9%, major stroke – 0.6%, minor stroke – 1.4%, hyperperfusion syndrome – 0.3%. No MI and death were registered. Out of more than 20 factors analysed, previous MI (χ2 = 7,707; p = 0.021) and stroke (χ2 = 9,835, p = 0.043), “slow flow” (χ2 = 3.752; p = 0.001), residual stenosis> 20% (χ2 = 13.752; p = 0.001), radiation time (F = 13.323; p = 0.000), the amount of contrast used (F = 5.297; p = 0.006), contrast- induced OBN (χ2 = 25.845; p = 0.000), females with CKD (χ2 = 8.681; p = 0.013) or with a high carotid score (χ2 = 7.329; p = 0.026) were found to be predictors of complications. Conclusion: CAS is a safe procedure with low risk of MI and death in patients with concomitant coronary disease.

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Treatment of carotid stenosis: surgery and stent in comparison

European Heart Journal Supplements ◽

10.1093/eurheartj/suab099 ◽

2021 ◽

Vol 23 (Supplement_E) ◽

pp. E91-E94

Author(s):

Rocco Giudice ◽

Claudio Spataro

Keyword(s):

Endovascular Treatment ◽

Carotid Stenosis ◽

Carotid Stenting ◽

Perioperative Outcomes ◽

Controlled Clinical Trials ◽

Safe Alternative ◽

Symptomatic Carotid ◽

Asymptomatic Patients ◽

Symptomatic Carotid Stenosis

Abstract Carotid stenosis in the extracranial tract determines 10–15% of all ischaemic strokes. The aim of treatment, therefore, is to prevent major neurological events. Carotid endarterectomy surgery has proved effective in this regard, with various randomized studies that have demonstrated its validity in both symptomatic and asymptomatic patients. As an alternative, since the late 1990s, the endovascular treatment of carotid stenosis by stenting has gradually established itself. Numerous controlled clinical trials have compared surgery and carotid stenting in terms of perioperative outcomes (death, stroke, and myocardial infarction within 30 days of the procedure) and stroke prevention ipsilateral to the lesion treated during follow-up, evaluating both symptomatic and asymptomatic patients. From the systematic review of the data, it is legitimate to state that stenting may represent a safe alternative to conventional surgery in patients with symptomatic carotid stenosis under the age of 70, while endarterectomy is clearly safer and more effective than endovascular treatment for symptomatic older patients. On the other hand, as regards asymptomatic patients, the available evidence is limited and further data are needed to compare the two methods and to compare them with the best current medical therapy in order to draw conclusions.

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Carotid Endarterectomy for Asymptomatic Carotid Stenosis

10.1093/med/9780199384075.003.0005 ◽

2017 ◽

Author(s):

Michael E. Hochman

Keyword(s):

Vascular Surgery ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Study Design ◽

Clinical Case ◽

Asymptomatic Carotid Stenosis ◽

Asymptomatic Carotid ◽

Asymptomatic Patients ◽

Study Intervention

This chapter provides a summary of the landmark surgical study known as the ACST trial, which compared surgical versus nonsurgical treatment for asymptomatic carotid stenosis. Is carotid endarterectomy (CEA) beneficial in asymptomatic patients with severe carotid stenosis? Starting with that question, the chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case involving vascular surgery.

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Abstract 155: Comparative Effectiveness of Carotid Endarterectomy Compared to Medical Therapy Among Patients With Asymptomatic Carotid Stenosis

Stroke ◽

10.1161/str.51.suppl_1.155 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Salomeh Keyhani ◽

Eric Cheng ◽

Katherine Hoggatt ◽

Peter Austin ◽

Paul Hebert ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Medical Therapy ◽

Community Sample ◽

Asymptomatic Carotid Stenosis ◽

Asymptomatic Carotid ◽

Immortal Time Bias ◽

Asymptomatic Patients ◽

Stroke Death

Background: Carotid endarterectomy (CEA) reduces stroke risk compared to medical therapy alone among patients with asymptomatic carotid stenosis. CEA involves a tradeoff between higher perioperative short-term risks in exchange for a lower long-term risk of stroke. However, overall declines in stroke rates raise concerns that CEA may no longer be a preferred treatment. We examined the effectiveness of CEA compared to medical therapy (MT) among asymptomatic patients in preventing stroke and stroke-death within 5 years of follow-up. Methods: We identified Veterans ≥65 years old with carotid stenosis (n=2712 CEA and n=2509 MT patients) who did not have a history of stroke or transient ischemic attack. We propensity score-matched MT patients to CEA patients to control for baseline confounding and used methods to mimic analyses from the Asymptomatic Carotid Stenosis Trial, the last published trial to compare CEA to MT. We accounted for “immortal time” bias by randomizing patients to CEA and MT groups and censoring patients if their actual treatment became inconsistent with the arm in which they were randomized (e.g., patient received CEA, but was randomized to MT). We accounted for the informative censoring by estimating time-dependent inverse probability of censoring weights using measured covariates (demographics and 72 time-varying comorbidities). We computed weighted Kaplan-Meier (KM) curves and estimated the risk of stroke/stroke-death in each group over 5 years of follow-up. Results: The observed stroke or death rate (perioperative complications) within 30 days in the CEA arm was 3%. The 5-year risk were similar among patients randomized to CEA 5.5% (95% CI, 4.3%-6.7%) versus MT 7.6% (95% CI,5.9%-9.2%) (risk difference, -2.1%, 95% CI -4%- 0%) with little difference in the KM curves (logrank p=0.2). Conclusion: CEA was not superior to MT in a community sample of Veterans after 5 years of follow-up, suggesting that CEA may no longer be the preferred treatment strategy.

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Interpretation of Normal and Abnormal Tympanogram Findings in Eustachian Tube Dysfunction

Otolaryngology ◽

10.1177/0194599820965236 ◽

2020 ◽

pp. 019459982096523

Author(s):

Sean M. Parsel ◽

Graham D. Unis ◽

Spenser S. Souza ◽

Heather Bartley ◽

Jeffrey M. Bergeron ◽

...

Keyword(s):

Eustachian Tube ◽

Medical Center ◽

Cross Sectional Study ◽

Eustachian Tube Dysfunction ◽

Asymptomatic Group ◽

Cross Sectional ◽

Symptomatic Group ◽

Asymptomatic Patients ◽

Patient Reported ◽

Tube Dysfunction

Objective To characterize the relationship between objective tympanogram values and patient-reported symptoms and associations with common comorbid conditions. Study Design Cross-sectional study with prospective data collection. Setting Tertiary medical center. Methods Patients undergoing routine audiometric evaluation between October 2018 and June 2019 were included. Participants with temporomandibular joint dysfunction, inner ear hydrops, and similar conditions were excluded. Symptoms were assessed with the 7-item Eustachian Tube Dysfunction Questionnaire. Demographics and medical comorbidities were recorded from the medical record. Analysis of tympanometric peak pressure (TPP), demographics, and comorbidities was performed to determine associations with clinically significant eustachian tube dysfunction (ETD) symptoms. Results A total of 250 patients were included with similar demographics: 101 (40.4%) in the asymptomatic group and 149 (59.6%) in the symptomatic group. The median (interquartile range) TPP was –10 (20) daPa and –25 (100) daPa in the asymptomatic and symptomatic groups, respectively. A diagnosis of rhinitis was more likely to be associated with significant ETD symptoms (adjusted odds ratio, 2.61; 95% CI, 1.23-5.63). A subgroup analysis revealed that symptomatic patients with normal TPP values were negatively skewed as compared with asymptomatic patients. This symptomatic group had a higher prevalence of rhinitis and chronic rhinosinusitis than the asymptomatic group. Conclusion Patients with symptoms of ETD may have a TPP within a range typically considered normal per conventional standards. This suggests that the currently accepted interpretation of tympanometry findings may be insensitive for the diagnosis of less severe cases of ETD.

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Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis

Cardiovascular Revascularization Medicine ◽

10.1016/j.carrev.2018.07.003 ◽

2019 ◽

Vol 20 (5) ◽

pp. 413-423 ◽

Cited By ~ 7

Author(s):

George Galyfos ◽

Georgios Sachsamanis ◽

Christiana Anastasiadou ◽

Ioannis Sachmpazidis ◽

Konstantinos Kikiras ◽

...

Keyword(s):

Medical Treatment ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Meta Analysis ◽

Carotid Stenting ◽

Asymptomatic Patients ◽

Best Medical Treatment

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Carotid artery stenosis – Current evidence and treatment recommendations

Clinical and Translational Neuroscience ◽

10.1177/2514183x211001654 ◽

2021 ◽

Vol 5 (1) ◽

pp. 2514183X2110016

Author(s):

Mandy D Müller ◽

Leo H Bonati

Keyword(s):

Carotid Artery ◽

Carotid Stenosis ◽

Carotid Artery Stenosis ◽

Artery Stenosis ◽

Current Evidence ◽

Asymptomatic Carotid Stenosis ◽

Asymptomatic Carotid ◽

Risk Of Death ◽

Asymptomatic Patients

Background: Carotid artery stenosis is an important cause for stroke. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic carotid stenosis and to some extent in patients with asymptomatic carotid stenosis. More than 20 years ago, carotid artery stenting (CAS) emerged as an endovascular treatment alternative to CEA. Objective and Methods: This review summarises the available evidence from randomised clinical trials in patients with symptomatic as well as in patients with asymptomatic carotid stenosis. Results: CAS is associated with a higher risk of death or any stroke between randomisation and 30 days after treatment than CEA (odds ratio (OR) = 1.74, 95% CI 1.3 to 2.33, p < 0.0001). In a pre-defined subgroup analysis, the OR for stroke or death within 30 days after treatment was 1.11 (95% CI 0.74 to 1.64) in patients <70 years old and 2.23 (95% CI 1.61 to 3.08) in patients ≥70 years old, resulting in a significant interaction between patient age and treatment modality (interaction p = 0.007). The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up also favoured CEA (OR = 1.51, 95% CI 1.24 to 1.85, p < 0.0001). In asymptomatic patients, there is a non-significant increase in death or stroke occurring within 30 days of treatment with CAS compared to CEA (OR = 1.72, 95% CI 1.00 to 2.97, p = 0.05). The risk of peri-procedural death or stroke or ipsilateral stroke during follow-up did not differ significantly between treatments (OR = 1.27, 95% CI 0.87 to 1.84, p = 0.22). Discussion and Conclusion: In symptomatic patients, randomised evidence has consistently shown CAS to be associated with a higher risk of stroke or death within 30 days of treatment than CEA. This extra risk is mostly attributed to an increase in strokes occurring on the day of the procedure in patients ≥70 years. In asymptomatic patients, there may be a small increase in the risk of stroke or death within 30 days of treatment with CAS compared to CEA, but the currently available evidence is insufficient and further data from ongoing randomised trials are needed.

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Endovascular Advances for Extracranial Carotid Stenosis

Neurosurgery ◽

10.1227/neu.0000000000000223 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S92-S101 ◽

Cited By ~ 1

Author(s):

Jorge L. Eller ◽

Travis M. Dumont ◽

Grant C. Sorkin ◽

Maxim Mokin ◽

Elad I. Levy ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Carotid Stenting ◽

Historical Background ◽

Treatment Modalities ◽

Endovascular Management ◽

The Past

Abstract Carotid artery stenting has become a viable alternative to carotid endarterectomy in the management of carotid stenosis. Over the past 20 years, many trials have attempted to compare both treatment modalities and establish the indications for each one, depending on clinical and anatomic features presented by patients. Concurrently, carotid stenting techniques and devices have evolved and made endovascular management of carotid stenosis safe and effective. Among the most important innovations are devices for distal and proximal embolic protection and new stent designs. This paper reviews these advances in the endovascular management of carotid artery stenosis within the context of the historical background.

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