Staged carotid artery angioplasty and stenting for patients with high-grade carotid stenosis with high risk of developing hyperperfusion injury: a retrospective analysis of 44 cases

Abstract Carotid artery angioplasty and stenting (CAS) has been shown to be equally effective as carotid endarterectomy (CEA) for carotid stenosis in both symptomatic and asymptomatic disease.1 In patients who are considered high risk for endarterectomy, CAS is safe and effective.2 While this is a common procedure, proper technique is crucial to ensure that the procedure is safe with minimal risk of stroke. This patient consented to treatment. The following is a video detailing the CAS procedure in a 77-yr-old male with a symptomatic 65% carotid stenosis (by NASCET criteria3) in a patient with prior CEA.

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Association between low levels of serum miR-638 and atherosclerotic plaque vulnerability in patients with high-grade carotid stenosis

Journal of Neurosurgery ◽

10.3171/2018.2.jns171899 ◽

2019 ◽

Vol 131 (1) ◽

pp. 72-79 ◽

Cited By ~ 5

Author(s):

Ana Luque ◽

Abduljalil Farwati ◽

Jerzy Krupinski ◽

Josep M. Aran

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Cardiovascular Risk ◽

High Risk ◽

Carotid Artery ◽

Carotid Stenosis ◽

Control Group ◽

High Grade ◽

Plaque Vulnerability ◽

Historical Group

OBJECTIVECarotid artery atherosclerosis is a major cause of ischemic stroke. However, reliable criteria to identify patients with high-risk carotid plaques beyond the severity of stenosis are still lacking. Circulating microRNAs (miRNAs) are being postulated as biomarkers for a variety of vascular immune-inflammatory diseases. The authors investigated whether cell-free circulating miR-638, highly expressed in vascular smooth muscle cells and implicated in proliferative vascular diseases, is associated with vulnerable atherosclerotic plaques in high-risk patients with advanced carotid artery stenosis undergoing carotid endarterectomy (CEA).METHODSThe authors conducted a prospective study in 22 consecutive symptomatic patients with high-grade carotid stenosis undergoing CEA and 36 age- and sex-matched patients without ischemic stroke history or carotid atherosclerosis (control group). In addition, they reviewed data from a historical group of 9 CEA patients who underwent long-term follow-up after revascularization. Total RNA was isolated from all serum samples, and relative miR-638 expression levels were detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and compared among groups. A correlation analysis of serum miR-638 levels with vascular risk factors and treatments, and with plaque features, was performed. The ability of serum miR-638 to discriminate between the non-CEA control group and the different CEA groups was assessed by receiver operating characteristic evaluation. A logistic regression model was employed to examine the association between stratified CEA patients and serum miR-638 levels.RESULTSSerum levels of miR-638 were significantly lower in symptomatic CEA patients (p = 0.009) and particularly in the subgroup of CEA patients who had experienced stroke (p = 0.0006) than in non-CEA controls. Discrimination of high-risk plaques was accurate (area under the curve [AUC] 0.66 for symptomatic CEA patients in general and 0.76 for those who had experienced stroke). When only patients with high cardiovascular risk were considered, the diagnostic value of serum miR-638 from symptomatic CEA patients and CEA patients who had experienced stroke improved (AUC 0.79 and 0.85). Moreover, serum miR-638 was negatively correlated with the occurrence of stroke, smoker status, presence of bilateral pathology, coronary artery disease, and cholesterol treatment; and with the high-risk fibroatheroma plaques extracted from CEA patients. Multivariate logistic regression analysis demonstrated that serum miR-638 was an independent predictor of plaque instability. Furthermore, serum miR-638 appeared to attain good discrimination for atherosclerotic stenosis in CEA patients based on analysis of blood samples obtained in the historical group before and 5 years after intervention (p = 0.04) (AUC = 0.79).CONCLUSIONSAccording to this preliminary proof-of-concept study, serum miR-638 might constitute a promising noninvasive biomarker associated with plaque vulnerability and ischemic stroke, particularly in individuals with elevated cardiovascular risk.

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Angioplasty and stenting for carotid artery stenosis: indications, techniques, results, and complications

Neurosurgical FOCUS ◽

10.3171/foc.1998.5.6.6 ◽

1998 ◽

Vol 5 (6) ◽

pp. E5 ◽

Cited By ~ 1

Author(s):

Giuseppe Lanzino ◽

Richard D. Fessler ◽

Robert A. Mericle ◽

Ajay K. Wakhloo ◽

Lee R. Guterman ◽

...

Keyword(s):

High Risk ◽

Carotid Artery ◽

Carotid Artery Stenosis ◽

Carotid Artery Disease ◽

Artery Stenosis ◽

High Risk Patients ◽

Clinical Series ◽

Risk Patients ◽

Artery Disease ◽

Angioplasty And Stenting

Following the favorable results obtained in the treatment of coronary artery disease, combined angioplasty and stenting has been advocated for the treatment of carotid artery stenosis as well. Although widespread application of angioplasty and stenting for carotid artery disease is neither indicated nor recommended, it may be a viable alternative therapy for select patients who are high-risk patients for surgery. The results of early series have suggested that endoluminal revascularization in these high-risk patients can be performed with an acceptable degree of safety. Although the incidence of death and major stroke rates following angioplasty and stenting procedures compares favorably with surgery, results of more recent clinical series have suggested that the incidence of perioperative transient neurological events and minor strokes may be higher than suggested by earlier reports, especially in patients with recent neurological symptoms and “unstable” plaques. In this article, the authors review the current potential indications for and preliminary results of angioplasty and stenting and describe their procedural technique. In addition, potential applications of stenting to intracranial thromboocclusive carotid artery disease are reviewed.

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Abstract WP162: Impact of Carotid Artery Remodeling by T1 weighted MR Imaging for the Assessment of Plaque Vulnerability in High-grade Carotid Stenosis

Stroke ◽

10.1161/str.44.suppl_1.awp162 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Kenji Fukuda ◽

Koji Iihara ◽

Naoaki Yamada ◽

Hatsue Ueda

Keyword(s):

Carotid Artery ◽

Carotid Stenosis ◽

Average Rate ◽

Intraplaque Hemorrhage ◽

High Grade ◽

Plaque Vulnerability ◽

Rapid Acquisition ◽

Asymptomatic Patients ◽

Artery Remodeling ◽

The Relationship

Background- The relationship between coronary artery remodeling and plaque vulnerability has been described on the basis of symptomatology and histology. However, the association with carotid artery remodeling has not been explored in detail. The aim of this study was to validate the relationship between carotid artery remodeling and plaque vulnerability by comparing the degree of outward remodeling calculated using 3D inversion-recovery-based T1-weighted imaging (magnetization-prepared rapid acquisition gradient-echo [MPRAGE]) with the symptomatology and histology of plaques extracted during carotid endarterectomy (CEA). Methods and Results- Sixty-one patients with high-grade carotid stenosis who underwent CEA and whose plaque could be examined were included. The average rate of stenosis as per the NASCET criteria was 79.8%. The carotid remodeling index (CRI) was determined by measuring the external cross-sectional vessel area (CSVA) of the maximum stenosis of the internal carotid artery (ICA) and dividing it by the external CSVA of the distal ICA unaffected by atherosclerosis using MPRAGE imaging. The relationship between the CRI and plaque vulnerability was evaluated on the basis of symptomatology and histology. The CRI was significantly higher in symptomatic patients than in asymptomatic patients (1.98 ± 0.26 vs. 1.68 ± 0.24, p < 0.0001). A higher CRI was positively correlated with the necrotic core area (r = 0.568, p < 0.0001) as well as significantly associated with severe intraplaque hemorrhage (p < 0.0001) and the prevalence of cap inflammation with macrophage (p = 0.03) and lymphocyte (p = 0.01) infiltration. Conclusion- These results validate the relationship between carotid artery remodeling and plaque vulnerability in high-grade carotid stenosis. MPRAGE imaging is effective to assess plaque vulnerability in terms of the CRI in addition to the signal intensity of carotid plaques.

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Predictors of the pulsatility index in the middle cerebral artery of acute stroke patients

Scientific Reports ◽

10.1038/s41598-020-74056-2 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Olivier Bill ◽

Dimitris Lambrou ◽

Guillermo Toledo Sotomayor ◽

Ivo Meyer ◽

Patrik Michel ◽

...

Keyword(s):

Carotid Artery ◽

Middle Cerebral Artery ◽

Carotid Stenosis ◽

Flow Pattern ◽

Cerebral Artery ◽

Carotid Artery Stenosis ◽

Pulsatility Index ◽

Artery Stenosis ◽

Doppler Velocity ◽

High Grade

Abstract Cervical and transcranial Doppler (TCD) are widely used as non-invasive methods in the evaluation of acute ischemic stroke (AIS) patients. High-grade carotid artery stenosis induces haemodynamic changes such as collateral flow and a so-called post-stenotic flow pattern of the middle cerebral artery (MCA), which appears flattened, with a reduction of the velocity difference between systole and diastole. We studied the influence of carotid artery stenosis and other variables on the flow pattern in the MCA using the pulsatility index (PI), a quantitative TCD parameter reflecting the flow spectrum in a large of cohort AIS patients. We performed ultrasound examinations of 1825 AIS patients at the CHUV from October 2004 to December 2014. We extracted patient characteristics from the ASTRAL registry. Carotid stenosis severity was classified as < 50%, 50–70%, 70–90% and > 90%, or occlusion, according to Doppler velocity criteria. We first determined variables associated with stenosis grade. Then we performed a multivariate analysis after adjusting for baseline differences, using MCA PI as dependent variable. Carotid stenosis > 70% (− 0.07) and carotid stenosis > 90%, or occlusion (− 0.14) and left side (− 0.02) are associated with lower MCA PI values. Age (+0.006 PI units per decade), diabetes (+0.07), acute ischemic changes on initial CT (+0.03) and severe plaque morphology (+0.18) are associated with higher MCA PI values. We found a number of clinical and radiological conditions that significantly influence the PI of the MCA, including high-grade ipsilateral carotid stenosis in AIS patients. We provide for the first time a quantitative evaluation of the effect of these influencing factors from a large cohort of AIS patients.

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Angioplasty and Stenting for High-Grade Internal Carotid Artery Stenosis: Safety Study in 39 Selected Patients

Cerebrovascular Diseases ◽

10.1159/000075785 ◽

2003 ◽

Vol 17 (2-3) ◽

pp. 160-165 ◽

Cited By ~ 1

Author(s):

S. Debette ◽

H. Hénon ◽

J.Y. Gauvrit ◽

S. Haulon ◽

M.A. Mackowiak-Cordoliani ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Artery Stenosis ◽

Internal Carotid ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

High Grade ◽

Safety Study ◽

Angioplasty And Stenting

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Update on Extracranial Carotid Stenosis

European Neurological Review ◽

10.17925/enr.2016.11.01.18 ◽

2016 ◽

Vol 11 (1) ◽

pp. 18 ◽

Cited By ~ 1

Author(s):

Tilman Reiff ◽

Christoph Gumbinger ◽

Sibu Mundiyanapurath ◽

Peter A Ringleb ◽

◽

...

Keyword(s):

Risk Factor ◽

High Risk ◽

Carotid Artery ◽

Ischaemic Stroke ◽

Carotid Stenosis ◽

Medical Therapy ◽

Stroke Risk ◽

Research Results ◽

Carotid Artery Endarterectomy

Carotid stenosis is a risk factor of ischaemic stroke and has an increasing prevalence with age. Stroke risk under optimised medical therapy, as well as recommendations of carotid artery endarterectomy/stenting, as therapy in high risk carotid stenosis, are discussed in consideration of recent research results.

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Selecting an Appropriate Surgical Treatment Instead of Carotid Artery Stenting Alone According to the Patient’s Risk Factors Contributes to Reduced Perioperative Complications in Patients with Internal Carotid Stenosis: A Single Institutional Retrospective Analysis

Neurologia medico-chirurgica ◽

10.2176/nmc.oa.2014-0049 ◽

2015 ◽

Vol 55 (2) ◽

pp. 124-132 ◽

Cited By ~ 1

Author(s):

Kimitoshi SATO ◽

Sachio SUZUKI ◽

Masaru YAMADA ◽

Hidehiro OKA ◽

Akira KURATA ◽

...

Keyword(s):

Risk Factors ◽

Surgical Treatment ◽

Carotid Artery ◽

Carotid Stenosis ◽

Retrospective Analysis ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Perioperative Complications

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Comprehensive Evaluation of Cerebral Hemodynamics and Oxygen Metabolism in Revascularization of Asymptomatic High-Grade Carotid Stenosis

Clinical Neuroradiology ◽

10.1007/s00062-021-01077-3 ◽

2021 ◽

Author(s):

Bernardo Crespo Pimentel ◽

Jan Sedlacik ◽

Julian Schröder ◽

Marlene Heinze ◽

Leif Østergaard ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Stenosis ◽

Transit Time ◽

Carotid Artery Stenosis ◽

Oxygen Metabolism ◽

Brain Lesions ◽

Artery Stenosis ◽

High Grade ◽

Ischemic Brain ◽

Revascularization Procedures

Abstract Introduction Revascularization procedures in carotid artery stenosis have shown a positive effect in the restoration of cerebral oxygen metabolism as assessed by T2’ (T2 prime) imaging as well as capillary homeostasis by measurement of capillary transit time heterogeneity (CTH); however, data in patients with asymptomatic carotid stenosis without manifest brain lesions are scarce. Patients and Methods The effect of revascularization on the hemodynamic profile and capillary homeostasis was evaluated in 13 patients with asymptomatic high-grade carotid stenosis without ischemic brain lesions using dynamic susceptibility contrast perfusion imaging and oxygenation-sensitive T2’ mapping before and 6–8 weeks after revascularization by endarterectomy or stenting. The cognitive performance at both timepoints was further assessed. Results Perfusion impairment at baseline was accompanied by an increased CTH (p = 0.008) in areas with a time to peak delay ≥ 2 s in the affected hemisphere compared to contralateral regions. Carotid intervention improved the overall moderate hemodynamic impairment at baseline by leading to an increase in normalized cerebral blood flow (p = 0.017) and a decrease in mean transit time (p = 0.027), oxygen extraction capacity (OEC) (p = 0.033) and CTH (p = 0.048). The T2’ values remained unchanged. Conclusion This study presents novel evidence of a state of altered microvascular function in patients with high-grade carotid artery stenosis in the absence of ischemic brain lesions, which shows sustained normalization after revascularization procedures.

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