Abstract W P380: Asymptomatic Carotid Stenosis is Not a Walking Time Bomb

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Catherine Yang ◽  
Chrysi Bogiatzi ◽  
J David Spence
Keyword(s):  
Carotid Stenosis ◽  
Carotid Stenting ◽  
Contralateral Side ◽  
Carotid Occlusion ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Kaplan Meier ◽  
Asymptomatic Patients ◽  
Walking Time ◽  
Prevention Clinic

Background & Objective: Patients with asymptomatic carotid stenosis are often persuaded to have carotid stenting or endarterectomy on the grounds that they are “walking time bombs”, headed for disaster if the artery occludes. However, this approach ignores the protection afforded by the Circle of Willis. We therefore sought to determine the risk of stroke at the time of carotid occlusion, among patients being followed in a vascular prevention clinic. Methods: Complete data were available in 386 asymptomatic patients who had a new carotid occlusion while being followed with annual carotid ultrasound examinations in our clinic. Mean followup after the occlusion was 3.42 ± 4.07 years. Percent stenosis was ≥ 80% in 60% and ≥ 90% in 53% of cases. Prior asymptomatic occlusion on the contralateral side was present in 11 cases. Mean age was 66.5 ± 10.7 years; 71.8% were male, 21% diabetic, and 24.4% still smoking prior to the occlusion. Results: Only 1 patient (0.3%) had an ipsilateral stroke at the time of the new carotid occlusion. Percent stenosis did not predict a higher risk of any stroke/TIA/death during followup in Kaplan-Meier survival analysis ( Log rank p=0.60), nor did prior contralateral occlusion at the time of the index occlusion (p=1.0). Conclusions: The risk of ipsilateral stroke at the time of carotid occlusion is well below the risk of either carotid stenting or carotid endarterectomy. Preventing carotid occlusion is not a valid indication for intervention, and percent stenosis or contralateral occlusion do not identify patients who would benefit from intervention. Patients with ACS should be treated with intensive medical therapy unless they have characteristics such as microemboli on transcranial Doppler, or other features of vulnerable plaque that identify them as high-risk.

Abstract 17291: Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis: CREST-2 update

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
James Meschia ◽  
Brajesh K Lal ◽  
George Howard ◽  
Gary Roubin ◽  
Robert D Brown ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Medical Therapy ◽  
Primary Outcome ◽  
Randomized Clinical Trials ◽  
Carotid Stenting ◽  
Current Treatment ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients

Purpose: The safety of revascularization for asymptomatic carotid stenosis, and the efficacy of medical therapy for stroke prevention have improved. Therefore, results of prior randomized trials may not apply to current treatment decisions. The NINDS-funded CREST-2 will compare carotid endarterectomy and intensive medical therapy (IMT) versus IMT alone (n=1240), and carotid stenting and IMT versus IMT alone (n=1240) in asymptomatic patients with≥70% stenosis. Materials & Methods: CREST-2 consists of two parallel randomized clinical trials to be conducted at a target of ≈120 centers, including within NINDS StrokeNet. The composite primary outcome is stroke or death during the peri-procedural period or ipsilateral ischemic stroke thereafter up to 4 years. Blinded assessment of cognition will be done periodically. Centrally directed IMT includes tight control of blood pressure (systolic target <140 mm Hg) and cholesterol (LDL target <70 mg/dl) as well as lifestyle coaching. Results: As of June 12, 2015, 94 centers have been approved by the Site Selection Committee. Credentialing is ongoing, with 198 approved surgeons and 64 approved interventionists; 124 additional conditionally approved interventionists will be able to submit additional cases for review under the CREST-2 Registry. The Centers for Medicare and Medicaid will offer CAS reimbursement for Registry enrollees. As of June 12, 2015, there are 39 actively enrolling centers, and 37 patients have been randomized. Conclusion: CREST-2 is designed to identify the best approach for asymptomatic carotid stenosis. The first patient was randomized in December, 2014. An update will be provided regarding the numbers of patients randomized, centers certified, as well as surgeons and interventionists fully approved. Registration: ClinicalTrials.gov Identifier: NCT02089217

scholarly journals Carotid artery stenosis – Current evidence and treatment recommendations

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.

Abstract 2956: Carotid Revascularization in Elderly Asymptomatic Patients: Are the Results Optimal?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Rahul H Damani ◽  
Mahmoud Rayes ◽  
Pratik Bhattacharya ◽  
Seemant Chaturvedi
Keyword(s):  
Elderly Patients ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Beta Blockers ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients ◽  
Operative Complications ◽  
Best Medical Therapy

Objectives: Assess the hypothesis that patients with asymptomatic carotid stenosis older than 75 years are not on “best medical therapy” and their operative complication exceeds the AHA/ASA 3% threshold. Background: According to the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Asymptomatic Carotid Surgery Trial (ACST) and recent AHA/ASA guidelines; benefits of carotid revascularization in asymptomatic patient >75 years would be offset if the operative complications rate exceed 3% and it would be more prudent to manage such patients on “best medical therapy”. How often these guidelines are being followed remains unclear. Methods: A retrospective chart review (2009-2011) at three urban, one suburban hospital within 30 miles was performed. Information of carotid revascularization (CEA & CAS) in asymptomatic elderly patients, in-hospital outcomes of stroke/death and/or MI and pre-procedural medications were evaluated. Statistical analysis with chi square testing was used. Results: A total of 114 patients met our inclusion criteria. Their features are described below.At four hospitals, the proportion of carotid revascularization done was 62% (114/185). More then quarter and one-third of patients undergoing carotid revascularization were not on statin and beta-blockers, respectively. Further, the rate of in hospital stroke was 4.4%. Conclusions: The majority of elderly patients with asymptomatic carotid stenosis patients are still undergoing carotid revascularization with operative complications that exceeded the AHA/ASA 3% threshold. More then quarter of patients in this subgroup are not on “best medical therapy”. These results reinforce the need for a new clinical trial comparing aggressive medical therapy alone vs. aggressive medical therapy and revascularization.

scholarly journals Simultaneous assessment of plaque morphology, cerebral micro-embolic signal status and platelet biomarkers in patients with recently symptomatic and asymptomatic carotid stenosis

2019 ◽  
Vol 40 (11) ◽  
pp. 2201-2214
Author(s):  
Stephen J Murphy ◽  
Soon T Lim ◽  
Justin A Kinsella ◽  
Sean Tierney ◽  
Bridget Egan ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Transcranial Doppler Ultrasound ◽  
Plaque Morphology ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Symptomatic Carotid ◽  
Reticulated Platelets ◽  
Asymptomatic Patients ◽  
Symptomatic Carotid Stenosis ◽  
Simultaneous Assessment

The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation. We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray–Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as ‘MES+ve’ or ‘MES-ve’. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets. Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (25 vs. 30; P = 0.31) or between MES+ve vs. MES-ve symptomatic patients (36 vs. 25; P = 0.09). Symptomatic patients with GSM-echodense plaques (GSM ≥25) had higher platelet counts (228 vs. 191 × 109/L), neutrophil–platelet (3.3 vs. 2.7%), monocyte–platelet (6.3 vs. 4.55%) and lymphocyte–platelet complexes (2.91 vs. 2.53%) than ‘ asymptomatic patients with GSM-echodense plaques’ ( P ≤ 0.03). Recently, symptomatic carotid stenosis patients with ‘GSM-echodense plaques’ have enhanced platelet production/secretion/activation compared with their asymptomatic counterparts. Simultaneous assessment with neurovascular imaging and platelet biomarkers may aid risk-stratification in carotid stenosis.

scholarly journals Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Seong Hwa Jang ◽  
Doo Hyuk Kwon ◽  
Moon-Ku Han ◽  
Hyungjong Park ◽  
Sung-Il Sohn ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Standard Dose ◽  
Trend Test ◽  
High Dose ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Asymptomatic Patients ◽  
Significant Difference

Abstract Background Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. Methods Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. Results The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). Conclusions Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

Carotid Endarterectomy for Asymptomatic Carotid Stenosis

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.

Multimodal ultrasound parameters aided carotid plaque risk stratification in patients with asymptomatic carotid stenosis

2021 ◽  
pp. 028418512198918
Author(s):  
Yi Li ◽  
Shuai Zheng ◽  
Jinghan Zhang ◽  
Fumin Wang ◽  
Wen He
Keyword(s):  
Risk Stratification ◽  
Carotid Stenosis ◽  
Carotid Plaque ◽  
Regression Analyses ◽  
Asymptomatic Carotid Stenosis ◽  
Vascular Events ◽  
Asymptomatic Carotid ◽  
Asymptomatic Patients ◽  
Proximal Internal Carotid Artery ◽  
Multivariable Regression

Background Risk stratification of asymptomatic carotid plaque remains an issue in stroke prevention in clinical practice. Purpose To investigate whether a multimodal ultrasound (MMU) model would help plaque risk stratification in patients with asymptomatic carotid stenosis. Material and Methods A prospective study was conducted of symptomatic and asymptomatic patients with > 50% proximal internal carotid artery (ICA) stenosis. All patients underwent MMU examination. Multivariable regression analyses were performed to identify parameters associated with ischemic vascular events (IVE). These parameters were used to develop a scoring nomogram to assess the probability of IVE. We elaborated the diagnostic performance of the MMU nomogram using receiver operating characteristic (ROC) curves. Results From December 2018 to December 2019, 98 patients (75 men, mean age 67 ± 8 years) were included; 50 were symptomatic and 48 were asymptomatic. Multivariable regression analyses revealed that plaque surface morphology (PSM) (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.26–7.12, P = 0.013), intraplaque neovascularization (IPN) grades (OR 3.23, 95% CI 1.77–5.89, P<0.001), and carotid stenosis degree (CSD) (OR 4.12, 95% CI 1.47–11.55, P = 0.007) were independently associated with IVE. For the nomogram, the area under the ROC curve was 0.85 (95% CI 0.77–0.92) and the Hosmer-Lemeshow test P value was 0.822. Conclusions In patients with proximal ICA > 50%, PSM, IPN grades, and CSD were independent variables associated with IVE. The MMU nomogram provided favorable value to risk stratification of IVE. Future large-scale studies with long-term follow-up are needed to validate these findings.

Abstract WP439: Mean Platelet Volume and Platelet Count are not Associated With Coated-Platelet Levels Among Patients With Asymptomatic Carotid Stenosis

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Angelia C Kirkpatrick ◽  
Adrienne M Elias ◽  
Andrea S Vincent ◽  
Fabiola M Donna-Ferreira ◽  
George C Malatinszky ◽  
...  
Keyword(s):  
Platelet Count ◽  
Carotid Stenosis ◽  
Multiple Regression ◽  
Mean Platelet Volume ◽  
Univariate Analysis ◽  
Asymptomatic Carotid Stenosis ◽  
Platelet Volume ◽  
Asymptomatic Carotid ◽  
Asymptomatic Patients ◽  
Confounding Variables

Background: Coated-platelets, a subset of activated platelets observed with dual-agonist stimulation with collagen and thrombin, represent 30% of the platelet population in normal controls. In recently published work, we have shown that elevated coated-platelet levels (>45%) are predictive of stroke in asymptomatic carotid stenosis. We now investigate if platelet count and mean platelet volume (MPV) are related to coated-platelet levels. Methods: Coated-platelet levels were measured in a cohort of asymptomatic outpatients referred for carotid ultrasound studies. Platelet count and mean platelet volume for each subject were recorded from the VA electronic medical record at the closest possible time period (within ≤6 months) to the date of coated-platelet sample. Correlations between each parameter and coated-platelet levels were determined and those reaching significance at p≤0.1 were included in a multiple regression model with LDL and systolic blood pressure (SBP), variables previously known to correlate with coated-platelet levels. Results: Platelet count and mean platelet volume data were available within the specified period for 289 patients (96% male, mean age 66 years). On univariate analysis, coated-platelet levels correlated with platelet count (r = 0.15, p=0.01), but not with MPV (r=-0.04, p=0.53). When platelet count was included in a multiple regression analysis with LDL and SBP, platelet count was no longer significantly associated with coated-platelet levels. In the final model, higher coated-platelet levels were associated with LDL (p=0.008) and SBP (p=0.007) after controlling for all potentially confounding variables, including medications and comorbidities. Conclusions: Among asymptomatic patients with carotid atherosclerosis, neither MPV, which has been previously shown to correlate with platelet aggregation, nor platelet count are significantly associated with coated-platelet levels after accounting for all potential confounding variables. These findings support the notion of coated-platelets as a unique measure of platelet procoagulant potential.

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