Abstract 1122‐000038: Anticoagulation Versus Antiplatelet Alone in Acutely Symptomatic Carotid Artery Stenosis

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Juan Carlos Martinez Gutierrez ◽  
Alexis T Roy ◽  
Salvatore A D'Amato ◽  
Jillian M Berkman ◽  
Daniel Montes ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Antiplatelet Agents ◽  
Stroke Severity ◽  
Short Term ◽  
Intraluminal Thrombus ◽  
Timely Initiation ◽  
Symptomatic Carotid ◽  
Time To Surgery ◽  
Symptomatic Carotid Stenosis

Introduction : Acutely symptomatic carotid artery stenoses carry a significant risk of early ischemic recurrence. Timely initiation of effective antithrombotic therapy and revascularization interventions are necessary to reduce the risk of recurrent events. While antiplatelet agents are widely used, there is some limited evidence supporting short term anticoagulation as well. Moreover, most patients require early revascularization with carotid endarterectomy (CEA) which is almost exclusively performed with anticoagulant protection. Thus, we sought to determine the potential safety and efficacy of short term pre‐operative anticoagulation in the secondary prevention of stroke/TIA from acutely symptomatic carotid stenosis. Methods : A prospective single institution registry of carotid revascularization was queried retrospectively. We included all CEA patients who presented to the hospital with acute ischemic strokes or TIAs attributed to the ipsilateral stenotic lesion of the internal carotid artery. Treatment arms were assigned based on exclusive use of antiplatelet agents (AP) or use of anticoagulant (AC) with or without additional antiplatelet agents. Results : 443 patients were identified; 342 treated with anticoagulation (97.7 % IV Heparin) and 101 with antiplatelets alone (95.1% aspirin, 23.8% clopidogrel and 24.8% aspirin and clopidogrel). Baseline characteristics for the antiplatelet and anticoagulation groups were similar except for mean age (73±9.5 vs 71±10.5), premorbid mRS (1.4±1.3 vs 1.0±1.2) and stroke as presenting symptom (53.5 vs 65.8%). Notably the stroke severity (admission NIHSS), degree of stenosis, presence of intraluminal thrombus or median time to surgery was balanced between treatment arms. Patients treated with anticoagulation had significantly lower incidence of recurrent TIA/Stroke (10.9 vs 3.8%, p = 0.006). Symptomatic ICH was only observed in 1 patient in the AC arm and none of the AP group and postoperative bleeding was similar (2 vs 2.3%, p = 0.83). AC appeared to be protective with OR 0.30 (p = 0.007) for incidence of the primary outcome when controlling for degree of stenosis, presence of intraluminal thrombus, stroke severity, premorbid mRS, age, gender and time to surgery. Conclusions : Our findings suggest short term pre‐operative anticoagulation in patients with acutely symptomatic carotid stenosis awaiting revascularization is a potentially safe and effective alternative to antiplatelet agents alone. Confirmatory prospective studies are warranted.

Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis

2008 ◽  
Vol 109 (3) ◽  
pp. 454-460 ◽  
Author(s):  
Miguel Bussière ◽  
David M. Pelz ◽  
Paul Kalapos ◽  
Donald Lee ◽  
Irene Gulka ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Multivariable Analysis ◽  
Balloon Dilation ◽  
Peak Systolic Velocity ◽  
Stent Insertion ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
The Mean

Object Conventional endovascular therapy for carotid stenosis involves placement of an embolic protection device followed by stent insertion and angioplasty. A simpler approach may be placement of a stent alone. The authors determined how often this approach could be used to treat patients with carotid stenosis, and assessed which factors would preclude this approach. Methods Over a period of 6 years, 97 patients with symptomatic carotid stenosis were treated with the intention of using a “stent-only” approach. Arteries in 77 patients (79%) were treated with stents alone, 13 required preinsertion balloon dilation, 6 postinsertion dilation, and 1 both pre- and postinsertion dilation. Results The mean stenosis according to North American Symptomatic Carotid Endarterectomy Trial criteria was reduced from 82 to 40% in the stent-only group and from 89 to 37% in the stent and balloon angioplasty group. The 30-day stroke and death rate was 7.2%. Patients were followed for a mean of 15 months. In the stent-alone group, the mean preoperative Doppler peak systolic velocity (PSV) was 409 cm/second, with an internal carotid artery/common carotid artery (ICA/CCA) ratio of 7.2. At follow-up review, the PSV decreased to 153 cm/second and the ICA/CCA ratio to 2.1. In the angioplasty group the mean preoperative PSV was 496 cm/second and the ICA/CCA ratio was 9.2, decreasing to 163 cm/second and 2, respectfully, at follow-up evaluation. Restenosis occurred in 12.8% of patients at 6 months and in 15.9% at 1 year. One stroke occurred during the follow-up period in each group. Using multivariable analysis, factors precluding the “stent-only” approach were as follows: severity of stenosis, circumferential calcification, and no history of hyperlipidemia. Conclusions Balloons may not be required to treat all patients with carotid stenosis. A stent alone was feasible in 79% of patients, and 79% of patients were alive and free from ipsilateral stroke or restenosis at 1 year. Restenosis rates with this approach are higher than with conventional angioplasty and stent insertion. Carotid arteries with very severe stenoses (> 90%) and circumferential calcification may be more successfully treated with angioplasty combined with stent placement.

Early versus late carotid artery stenting for symptomatic carotid stenosis

2015 ◽  
Vol 42 (3) ◽  
pp. 169-175 ◽  
Author(s):  
Luis Henrique de Castro-Afonso ◽  
Guilherme S. Nakiri ◽  
Lucas M. Monsignore ◽  
Antônio C. Dos Santos ◽  
João Pereira Leite ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

scholarly journals Ultrasound detection of cerebral microembolism in carotid stenoses: progress and perspective (A review of the literature)

2020 ◽  
Vol 31 (1) ◽  
pp. 56-67
Author(s):  
M.V. Globa
Keyword(s):  
Surgical Treatment ◽  
Carotid Artery ◽  
Carotid Stenosis ◽  
Multicenter Study ◽  
Cerebrovascular Disorders ◽  
Transcranial Doppler Sonography ◽  
Vascular Events ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Carotid Stenoses

The review summarizes available information regarding the method of Transcranial doppler sonography (TCD) usage to record microembolism in patients with carotid artery stenosis, search for information was carried out in literature 1997–2020 (PUBMED, MEDLINE).History overview of TCD with embolodetection implementation is presented, as well as ways of its technical and methodological improvement. Evidence-based studies of the method clinical relevance in atherosclerotic carotid stenoses and their surgical treatment are outlined. Observation results of the intraoperative cerebral embolization during carotid endarterectomy and carotid artery stenting are presented along with comparison of TCD-embolodetection data, neuroimaging and clinical outcomes. Individual centres and multicenter study ACES data on prognostic value of registration of embolic signals in asymptomatic carotid stenosis, risk assessment of vascular events in diffe-rent groups of patients and in varying degrees of stenosis of the vessel lumen was analyzed. The role of embolodetection in predicting repeated cerebrovascular disorders in symptomatic carotid stenosis and its importance for monitoring antiplatelet therapy is set out (multicenter study CARESS). The evidence of the reliability of TCD embolodetection as tool for verificarion of at-risk patients with carotid stenosis who may benefit ftom surgical treatment is presented.Recent advances in ultrasound and other imaging techniques for assessing unstable plague are outlined along with prospects for the use of TCD monitoting for cerebrovascular disorders forecasting.

scholarly journals Physician Approaches to Imaging and Revascularization for Acutely Symptomatic Carotid Stenosis: Insights from the Hot Carotid Qualitative Study

2022 ◽  
Vol 2 (1) ◽  
Author(s):  
Aravind Ganesh ◽  
Benjamin Beland ◽  
Gordon A.E. Jewett ◽  
David J.T. Campbell ◽  
Malavika Varma ◽  
...  
Keyword(s):  
Decision Making ◽  
Carotid Artery ◽  
Qualitative Study ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Practice Patterns ◽  
Imaging Modality ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

Background Evidence informing the choice between carotid endarterectomy and carotid artery stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated and does not factor in contemporary therapies or techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis. Methods We used a qualitative descriptive methodology to examine decision‐making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for hot carotids. We conducted semistructured interviews with purposive sampling of 22 stroke physicians from 16 centers in 6 world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons. Results Qualitative analysis revealed several themes regarding clinical decision‐making for hot carotids. Whereas CT angiography was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. Carotid endarterectomy was generally favored over carotid artery stenting, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CT angiography imaging and carotid endarterectomy over carotid artery stenting but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk‐stratification with imaging features other than just degree of stenosis.

An Update on Carotid Stent Trials and Perspectives

2009 ◽  
Vol 4 (1) ◽  
pp. 92
Author(s):  
Stefan Bertog ◽  
Marius Hornung ◽  
Jennifer Franke ◽  
Nina Wunderlich ◽  
Horst Sievert ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
The Elderly ◽  
Symptomatic Carotid ◽  
Stent Restenosis ◽  
Asymptomatic Patients ◽  
Symptomatic Carotid Stenosis ◽  
Increased Risk ◽  
Risk Patients

The presence of carotid artery stenosis is associated with an increased risk of stroke. Carotid endartectomy (CEA) has been demonstrated to reduce the stroke risk in standard-risk patients with symptomatic carotid stenosis as well as in asymptomatic patients, provided that the operative risk is low. The role of percutaneous carotid intervention is less clear. There are no trials that compare percutaneous carotid intervention with medical management. Although trial results comparing CEA with carotid artery stenting (CAS) are variable and/or controversial, some trials have demonstrated promising results and have fostered enthusiasm for the performance of ongoing trials comparing CAS with CEA. This article focuses on the results of completed trials and outlines ongoing and planned trials that aim to clarify the role of CAS in patients with carotid stenosis. In addition, potential unresolved problems associated with CAS, such as CAS in the elderly, in-stent restenosis and distal embolisation, are discussed.

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