Abstract 4: Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy versus Stenting Trial

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Gary S Roubin ◽  
Jeffrey J Popma ◽  
Alexandra Almonacid ◽  
William F Morrish ◽  
Barry T Katzen ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Disease ◽  
Central Committee ◽  
Lesion Length ◽  
Quantitative Methodology ◽  
Carotid Revascularization ◽  
Qualitative And Quantitative ◽  
Arterial Lumen ◽  
Mouth Ulcer ◽  
Periprocedural Stroke

Background Carotid artery stent (CAS) placement may be used as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. Perhaps because stroke is an uncommon event after CAS, the angiographic predictors of stroke have been incompletely described. Methods A total of 1070 catheter-based angiograms were centrally reviewed in patients undergoing CAS enrolled in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Of these patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed using qualitative and quantitative methodology before and after CAS. Reviews were done blinded to patient outcomes and strokes were adjudicated by a central committee blinded to results of angiography. The view showing the greatest carotid stenosis severity was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results The internal carotid artery reference diameter was 4.2 ± 0.8 mm, the minimal lumen diameter was 1.1 ± 0.6 mm, and the baseline % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke are listed in the Table . Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05). Conclusion In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option.

Multisite artery disease

ESC CardioMed ◽  
2018 ◽  
pp. 2733-2739
Author(s):  
Marco De Carlo
Keyword(s):  
Carotid Artery ◽  
Patient Management ◽  
Carotid Artery Disease ◽  
Systematic Screening ◽  
Carotid Revascularization ◽  
Therapy Strategy ◽  
Carotid Stenoses ◽  
Artery Disease ◽  
One Year ◽  
Asymptomatic Disease

Multisite artery disease (MSAD) is common in patients with atherosclerotic involvement in one vascular bed, ranging from 10-15% in patients with CAD to 60-70% in patients with severe carotid stenosis or LEAD. MSAD is invariably associated with worse clinical outcomes; however, screening for asymptomatic disease in additional vascular sites has not been proven to improve prognosis. In patients with any presentation of PADs, clinical assessment of symptoms and physical signs of other localizations and/or CAD is necessary, and in case of clinical suspicion, further tests may be planned. Systematic screening for asymptomatic MSAD is not indicated for any presentation of PADs as it would not consistently lead to a modification of management strategy. It may be interesting in some cases for risk stratification (e.g. antiplatelet therapy strategy beyond one year in patients who benefited from coronary stenting for ACS). In some situations the identification of asymptomatic lesions may affect patient management. This is the case for patients undergoing CABG, where ABI measurement may be considered especially when saphenous vein harvesting is planned, and carotid screening should be considered in a subset of patients at high risk of carotid artery disease. In patients scheduled for CABG with severe carotid stenoses, prophylactic carotid revascularization should be considered in recently symptomatic cases and may be considered in asymptomatic cases, after multidisciplinary discussion. In patients planned for carotid artery revascularization for asymptomatic stenosis, a preoperative coronary angiography for detection (and revascularization) of CAD may be considered.

Abstract TP141: Can the Human Eye Match a Computer Algorithm in Identifying Hypoperfusion in Asymptomatic Carotid Artery Stenosis?

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Randolph S Marshall ◽  
Ronald M Lazar ◽  
James F Meschia ◽  
Philip M Meyers ◽  
E Sander Connolly ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Carotid Artery Disease ◽  
Artery Stenosis ◽  
Computer Algorithm ◽  
Automated System ◽  
Asymptomatic Carotid ◽  
Vascular Surgeon ◽  
Carotid Revascularization ◽  
Asymptomatic Carotid Artery Stenosis

Background: Perfusion weighted imaging on MRI (MRP) and computerized tomography perfusion (CTP) are increasingly required to manage large vessel disease. Computerized algorithms can quantify perfusion data, but the programs are expensive and not widely used outside acute stroke evaluation. We aimed to determine how well human observers can identify asymmetries in cerebral perfusion images compared with an automated computer algorithm. Methods: Ten clinicians experienced in treating carotid artery disease (4 vascular neurologists, 3 neuroradiologists, 1 vascular surgeon, 1 neurosurgeon, 1 interventional radiologist) were given 28 post-processed, color-coded, axial-slice MRP scans from patients in the Carotid Revascularization Endovascular versus Stenting Trial - Hemodynamics (CREST-H) study. All patients had >70%, unilateral, asymptomatic carotid artery stenosis and had varying degrees of time-to-peak (TTP) delay on the side of stenosis, ranging from 0 to 2 secs, quantified by a semi-automated system that computes quantitative perfusion maps, using deconvolution of tissue and arterial signals (Olea, Cambridge, MA). A minimum volume of 10cc was required for a given TTP delay. Clinicians were asked to determine asymmetry (y/n) and side of occlusion for each case. Number of correct responses that matched the computer output were tallied. Results: We averaged correct responses by the 10 clinicians for cases at each increment of TTP delay; (Figure). At TTP delays ≥1.5 seconds, accuracy was ≥80%. At 1.25 sec accuracy fell to 60%, and at ≤ 1 sec, accuracy was ≤50%. For TTP=0 (no asymmetry), accuracy was 71%. Conclusions: Visual impression of hemodynamic asymmetry among experienced clinicians was reasonably accurate for TTP delays ≥1.5 seconds, but declined with more subtle asymmetries. Depending on the clinical impact of TTP delays (for CREST-H: correlation with cognitive decline), experienced clinicians may perform as well as an automated algorithm.

scholarly journals Management of Patients with Asymptomatic and Symptomatic Carotid Artery Disease: Update on Anti-Thrombotic Therapy

2019 ◽  
Vol 119 (04) ◽  
pp. 576-585 ◽  
Author(s):  
Daniele Pastori ◽  
John Eikelboom ◽  
Sonia Anand ◽  
Manesh Patel ◽  
Jean-Francois Tanguay ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Ischaemic Stroke ◽  
European Society ◽  
Carotid Artery Disease ◽  
Oral Anticoagulants ◽  
Atherosclerotic Disease ◽  
Current Evidence ◽  
Once Daily ◽  
Carotid Revascularization ◽  
Symptomatic Carotid

AbstractThe most common causes of ischaemic stroke are represented by carotid artery atherosclerotic disease (CAAD) and atrial fibrillation. While oral anticoagulants substantially reduce the incidence of thromboembolic stroke (< 1%/year), the rate of ischaemic stroke and other cardiovascular disease events in patients with CAAD remains high, ranging from 8.4 to 18.1 events per 100 patient-years. Similar to any other atherosclerotic disease, anti-thrombotic therapies are proposed for CAAD to reduce stroke and other cardiovascular events. The 2017 European Society of Cardiology (ESC)/European Society for Vascular Surgery (ESVS) guidelines recommend for patients with asymptomatic CAAD ≥60% the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily at the exception of patient at very high bleeding risk. For patients with symptomatic CAAD ≥50%, the use of aspirin 75 to 100 mg once daily or clopidogrel 75 mg once daily is recommended. New perspectives for anti-thrombotic therapy for the treatment of patients with CAAD come from the novel dual pathway strategy combining a low-dose anticoagulant (i.e. rivaroxaban) and aspirin that may help reduce long-term ischaemic complications in patients with CAAD. This review summarizes current evidence and recommendations for the anti-thrombotic management of patients with symptomatic or asymptomatic CAAD or those undergoing carotid revascularization.

National trends in carotid artery revascularization surgery

2012 ◽  
Vol 116 (6) ◽  
pp. 1251-1257 ◽  
Author(s):  
Travis M. Dumont ◽  
Anand I. Rughani
Keyword(s):  
Carotid Artery ◽  
Randomized Trials ◽  
Carotid Artery Disease ◽  
Transluminal Angioplasty ◽  
Carotid Revascularization ◽  
Bilateral Carotid ◽  
Artery Disease ◽  
National Trends ◽  
Revascularization Surgery ◽  
Revascularization Procedures

Object Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]). Methods The Nationwide Inpatient Sample was obtained for the years 1998–2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared. Results The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008. Conclusions The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.

scholarly journals Approach to concurrent coronary and carotid artery disease: Epidemiology, screening and treatment

2017 ◽  
Vol 63 (11) ◽  
pp. 1012-1016
Author(s):  
Patrícia Feitosa Frota dos Reis ◽  
Pedro Vieira Linhares ◽  
Fábio Grunspun Pitta ◽  
Eduardo Gomes Lima
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Disease ◽  
Case Series ◽  
Perioperative Period ◽  
Screening Methods ◽  
Clinical Scenario ◽  
Therapeutic Decision ◽  
Carotid Revascularization ◽  
Disease Epidemiology ◽  
Artery Disease

Summary The concomitance between coronary artery disease and carotid artery disease is known and well documented. However, it is a fact that, despite the screening methods for these conditions and the advances in surgical treatment, little has been achieved in terms of reducing the risk of complications in the perioperative period. Publications are scarce, being mostly composed of reports or case series. There is little agreement on the best initial therapeutic approach (myocardial versus carotid revascularization) or the best technique to be used (surgery with or without extracorporeal circulation, hybrid treatments, etc.). The authors performed a review of the evidence in this clinical scenario, raising pragmatic questions that help in the therapeutic decision.

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