Acute Atherothrombotic Disease and Severe Bleeding: A Difficult Clinical Presentation in Medical Practice

Abstract Management of antithrombotic therapy in elderly patients with unstable atherothrombotic disease and increased risk of bleeding is a major clinical challenge. We report the case of a 79 year-old diabetic man with rheumatoid arthritis on both oral corticosteroids and NSAID therapy with mild renal dysfunction, who presented to our hospital because of disabling claudication. Prior to admission he had several episodes of TIA. He also had recurrent small rectal bleeding and mild anemia attributed to his long-standing hemorrhoid disease. Angiography showed a sub-occlusive left internal carotid artery stenosis associated with a significant LAD stenosis and complex peripheral artery disease. Cataclysmic bleeding and hemorrhagic shock occurred in the third day post admission. Withdrawal of all antithrombotic treatment, blood transfusion and emergency sigmoidectomy were performed for bleeding colonic diverticulosis. Subsequently antiplatelet therapy was reinitiated and the patient successfully underwent left carotid artery endarterectomy and LAD stenting. He was discharged from hospital on the 21st day post admission and is doing well at 24 months follow-up.

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Association between Pre-Existing Coronary Artery Disease and 5-Year Mortality in Stroke Patients with High-Grade Carotid Artery Stenosis

European Neurology ◽

10.1159/000512407 ◽

2020 ◽

pp. 1-7

Author(s):

Ching-I Wu ◽

Chia-Lun Wu ◽

Feng-Chieh Su ◽

Shun-Wen Lin ◽

Wen-Yi Huang

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Carotid Artery ◽

Carotid Artery Stenosis ◽

Significant Risk ◽

Cox Proportional Hazards Model ◽

Artery Stenosis ◽

High Grade ◽

Increased Risk ◽

Artery Disease

Background: The coincidence of coronary artery disease (CAD) and carotid artery stenosis (CAS) was observed. However, the association between pre-existing CAD and ischemic stroke (IS) outcome in patients with high-grade CAS remains unclear. We aimed to investigate the association between pre-existing CAD and outcomes of acute IS patients with high-grade CAS. Methods: From January 1, 2007, to April 30, 2012, we enrolled 372 acute IS patients with high-grade CAS and prospectively observed them for 5 years. Demographic features, vascular risk factors, comorbidities, and outcomes were compared between patients with and without pre-existing CAD. Results: Among 372 individuals, 75 (20.2%) patients had pre-existing CAD and 297 (79.8%) patients did not have pre-existing CAD. The prevalence rates of hypertension, congestive heart failure, chronic kidney disease, and gout in patients with pre-existing CAD were significantly higher than in those without pre-existing CAD (p = 0.017, p < 0.001, p = 0.002, and p < 0.001, respectively). The multivariate Cox proportional hazards model revealed that pre-existing CAD was a significant risk factor for a 5-year all-cause mortality in acute IS patients with high-grade CAS (hazard ratio = 2.26; 95% confidence interval = 1.35–3.79; p = 0.002). Conclusion: Pre-existing CAD was associated with an increased risk of 5-year mortality in acute IS patients with high-grade CAS. Intensive treatment for the pre-existing CAD may reduce long-term mortality in acute IS patients with high-grade CAS.

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Abstract TP127: Prevalence and Clinical Significance of Asymptomatic Extracranial Vertebral Artery Disease in Patients With Symptomatic Internal Carotid Artery Stenosis: Analysis of Stent-protected Angioplasty versus Carotid Endarterectomy (SPACE) Trial

Stroke ◽

10.1161/str.47.suppl_1.tp127 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Adnan I Qureshi ◽

Saqib A Chaudhry ◽

Peter A Ringleb

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Vertebral Artery ◽

Carotid Artery Stenosis ◽

Internal Carotid ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

Vertebral Artery Stenosis ◽

Extracranial Vertebral Artery ◽

Artery Disease

Background: Extracranial vertebral artery disease is seen in patients with internal carotid artery stenosis although the clinical significance not well understood. Methods: We analyzed data that was collected as part of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial which recruited patients with recently symptomatic internal carotid artery stenosis. We used Cox proportional hazards analysis to compare the relative risk of various endpoints between the three categories of extracranial vertebral artery disease (normal/hypoplastic, moderate/severe stenosis, and occlusion). The multivariate analyses were adjusted for age, gender, basic demographics and severity of carotid stenosis. Results: Of the 1181 subjects who had extracranial vertebral artery ultrasound evaluation, moderate to severe stenosis and occlusion of one of both extracranial vertebral arteries was diagnosed in 152(12.9%) and 57(4.8%) subjects, respectively. During the mean follow up period (±SD) of 22.1±7.1 months 102(8.6%) and 60(5.1%) experienced a stroke or died, respectively. Compared with subjects with normal or hypoplastic vertebral artery, there was a non-significant 30% higher risk of any stroke among subjects with moderate to severe vertebral artery stenosis (relative risk [RR]1.3, 95% confidence interval [CI]0.7-2.3) after adjusting for potential confounders. There was a 40% and 50% higher risk of ipsilateral stroke (RR 1.4, 95% CI0.7-2.5) and death (RR 1.5, 95% CI 0.7-3.1) among subjects with moderate to severe vertebral artery stenosis after adjusting for potential confounders. In Kaplan Meir analysis, the estimated 1 and 2 year stroke free survival for subjects with moderate to severe vertebral artery stenosis was 88% (standard error [SE]2.6%). In comparison, the estimated 1 and 2 year stroke free survival for subjects with normal or hypoplastic vertebral artery was 92.5%(SE0.8%)and 91.6%(SE0.9), respectively. Conclusions: There appears to be an increased risk of stroke and death in patients with symptomatic internal carotid artery stenosis with concurrent asymptomatic extracranial vertebral artery stenosis.

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Concomitant Surgical Treatment of Symptomatic Carotid Artery Disease With a Coexisting Shamblin I Carotid Body Tumor

Vascular and Endovascular Surgery ◽

10.1177/1538574416689430 ◽

2017 ◽

Vol 51 (2) ◽

pp. 103-107 ◽

Cited By ~ 2

Author(s):

Carlos A. Hinojosa ◽

Javier E. Anaya-Ayala ◽

Hugo Laparra-Escareno ◽

Adriana Torres-Machorro ◽

Rene Lizola ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Body ◽

Carotid Artery Disease ◽

Duplex Ultrasound ◽

Neurological Deficits ◽

Symptomatic Carotid ◽

Carotid Body Tumors ◽

Carotid Artery Endarterectomy ◽

Artery Disease ◽

Dissection Technique

Symptomatic carotid artery atherosclerotic disease is an indication for carotid artery endarterectomy. The coexistence of carotid body tumors (CBTs) with symptomatic carotid disease is rarely encountered and adds significant challenges to vascular surgeons, with a reported overall mortality for patients who undergo endarterectomy and tumor excision of 8.8%, as opposed to the 2% for those who had CBT excision only. We describe the case of a 79-year-old female who experienced an acute cerebrovascular accident in the left hemisphere; duplex ultrasound revealed high-grade carotid stenosis in the left side and the presence of a Shamblin I CBT. The risks and benefits of the planned operation were reviewed, and the decision was made to proceed with early carotid endarterectomy and concomitant surgical resection of the tumor using the retrocarotid dissection technique. The patient recovered well, and at 11 months from the combined procedure, her neurological deficits improved significantly.

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Progression of external and internal carotid artery stenosis is associated with a higher risk of ischemic neurologic events in patients with asymptomatic carotid artery stenosis

Vascular Medicine ◽

10.1177/1358863x17722626 ◽

2017 ◽

Vol 22 (5) ◽

pp. 418-423 ◽

Cited By ~ 3

Author(s):

Reza Masoomi ◽

Zubair Shah ◽

Buddhadeb Dawn ◽

Karthik Vamanan ◽

Aravinda Nanjundappa ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Artery Stenosis ◽

Internal Carotid ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

Diagnostic Tools ◽

Asymptomatic Carotid ◽

Increased Risk ◽

Asymptomatic Carotid Artery Stenosis

A small percentage of patients with asymptomatic carotid artery stenosis (ACAS) who are on optimal medical management do go on to develop ischemic stroke or transient ischemic attacks (IS/TIA). Several diagnostic tools have been studied to identify those patients who are at increased risk. However, most of these diagnostic tools are not available for routine clinical use or are resource intensive. We performed a retrospective study to assess the incremental value of external carotid artery stenosis progression (ECASP) along with internal carotid artery stenosis progression (ICASP) in predicting risk of ipsilateral IS/TIA in a cohort of patients with ACAS. We conducted a retrospective analysis of patients with ACAS who had at least two serial duplex ultrasounds (DUS) at our center. A total of 356 patients (712 carotid arteries) were included in the study (mean age 74.7±9 years, 49.2% male) with a mean follow-up of 60.7±32.7 months. In univariate analysis, concurrent progression of ICA and ECA stenosis on the same side arteries was associated with a very significant increased risk of ipsilateral IS/TIA (14.7% vs 4.6%, p<0.001). Also, multivariable regression analysis showed that concurrent ECA/ICA progression was an independent predictor of IS/TIA (OR=3.6, 95% CI 1.64–7.8; p=0.001). ECASP along with ICASP is significantly associated with increased risk of ipsilateral IS/TIA and provides incremental risk stratification over that provided by ICASP alone. The ECA is routinely evaluated in clinical practice, and it could serve as an additional marker for identifying higher risk patients with ACAS.

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Transpharyngeal Echocardiographic Diagnosis of Carotid Bulb and Left Internal Carotid Artery Stenosis

Echocardiography ◽

10.1111/j.1540-8175.1999.tb00123.x ◽

1999 ◽

Vol 16 (7) ◽

pp. 671-672 ◽

Cited By ~ 5

Author(s):

NAVIN C. NANDA ◽

CAMILO R. GOMEZ ◽

VIRENJAN KUMAR NARAYAN ◽

SRINATH KADIMI ◽

JOHN B. TERRY ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Artery Stenosis ◽

Internal Carotid ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

Left Internal Carotid Artery ◽

Carotid Bulb

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Coexisting Coronary and Carotid Artery Disease – Which Technique and in Which Order? Case Report and Review of Literature

Clinical Medicine Insights Cardiology ◽

10.1177/1179546820951797 ◽

2020 ◽

Vol 14 ◽

pp. 117954682095179 ◽

Cited By ~ 1

Author(s):

Sina Manthey ◽

Jenna Spears ◽

Sheldon Goldberg

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Carotid Artery ◽

Carotid Artery Stenosis ◽

Treatment Guidelines ◽

Carotid Artery Disease ◽

Myocardial Revascularization ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

Artery Disease

Coexisting carotid artery stenosis and coronary artery disease is common and there is currently no consensus in treatment guidelines on the timing, sequence and methods of revascularization. We report a case of a patient with symptomatic triple vessel coronary artery disease as well as asymptomatic severe right internal carotid artery stenosis. Our patient underwent myocardial revascularization first, because she presented with unstable angina and was asymptomatic neurologically. This article summarizes current literature about the approach to carotid and coronary artery revascularization and addresses the decision-making process regarding the timing and sequence of revascularization.

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Cognitive Function After Carotid Endarterectomy: Greater Risk of Decline in Symptomatic Patients With Left Internal Carotid Artery Disease

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2005.06.003 ◽

2005 ◽

Vol 14 (5) ◽

pp. 221-228 ◽

Cited By ~ 7

Author(s):

Mario Bo ◽

Massimiliano Massaia ◽

Stefania Speme ◽

Giorgetta Cappa ◽

Khenya Strumia ◽

...

Keyword(s):

Cognitive Function ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Endarterectomy ◽

Internal Carotid ◽

Carotid Artery Disease ◽

Left Internal Carotid Artery ◽

Artery Disease

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Transcervical Carotid Stent Placement in the Setting of a Hostile Neck and a Type III Aortic Arch

Vascular and Endovascular Surgery ◽

10.1177/1538574417710601 ◽

2017 ◽

Vol 51 (5) ◽

pp. 346-349 ◽

Cited By ~ 2

Author(s):

Lauren A. Huntress ◽

Naiem Nassiri ◽

Randy Shafritz ◽

Saum A. Rahimi

Keyword(s):

Carotid Artery ◽

Neck Dissection ◽

Aortic Arch ◽

Radical Neck Dissection ◽

Hybrid Approach ◽

Internal Carotid Artery Stenosis ◽

Left Internal Carotid Artery ◽

Symptomatic Carotid ◽

Type Iii ◽

Hostile Neck

Previous radical neck dissection and neck irradiation pose considerable operative risks in patients requiring carotid endarterectomy for symptomatic carotid disease. Carotid stenting is an acceptable alternative for these patients but carries a higher risk of cerebrovascular accidents especially in patients with type III aortic arch anatomy. Herein, we present a technically challenging case of a patient with an irradiated neck and a history of radical neck dissection who presented with a symptomatic high-grade left internal carotid artery stenosis in the setting of a type III aortic arch. He was treated via a hybrid approach for carotid artery stenting.

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II. Improved dark adaptation after carotid endarterectomy

Neurology ◽

10.1212/wnl.49.5.1360 ◽

1997 ◽

Vol 49 (5) ◽

pp. 1360-1364 ◽

Cited By ~ 11

Author(s):

Ulf Havelius ◽

David Bergqvist ◽

Bengt Hindfelt ◽

Torsten Krakau

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Dark Adaptation ◽

Clinical Evidence ◽

Carotid Artery Disease ◽

Internal Carotid Artery Stenosis ◽

Symptomatic Carotid ◽

Control Subjects ◽

Artery Disease ◽

And Control

We have reported that dark vision is impaired in symptomatic carotid artery disease and that the impairment correlates with internal carotid artery stenosis. To find out whether this impairment is reversible after carotid endarterectomy, dark adaptation was examined pre- and postoperatively. Twenty-one consecutive patients were examined by dark adaptometry. Two examinations were done for each eye on two consecutive days pre- and postoperatively. Thirty-one matched control subjects were examined under identical conditions. The control subjects did not have clinical evidence of carotid artery disease. Patients and control subjects were free of ophthalmologic disorders. Dark vision frequently improved remarkably after endarterectomy. The average retinal sensitivity to light in darkness on the operated side doubled, and there was also improvement on the nonoperated side. There was no significant change in dark vision in the control subjects, negating a learning effect. The findings suggest the existence of reversible neuronal ischemia secondary to hemodynamic causes or frequent subclinical microembolization. Because the circulatory conditions are optimized, formerly inactive, surviving neurons may regain function.

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