Carotid sinus syndrome in carotid angioplasty with stenting

Introduction. Significant progress has been made in primary stroke prevention, including through the widespread use of carotid angioplasty with stenting (CAS). At the same time, there is a growing number of publications reporting the development of carotid sinus syndrome (CSS) (haemodynamic instability) in the periope- rative period, as well as cerebral and cardiac complications and death, which requires in-depth study to improve the quality of medical care for patients with carotid artery stenosis. The aim of the study was to determine the frequency, risk factors, clinical features and outcomes of CSS in patients with carotid artery stenosis undergoing CAS. Materials and methods. The study included 120 patients with carotid artery disease, who underwent an elective surgical intervention consisting of transluminal balloon angioplasty. All patients underwent comprehensive clinical and laboratory tests and imaging studies. Results. CSS developed in 70% of cases (n = 84) of carotid artery stenosis, and was significantly more common in men than women (71.4% vs. 28.6%, respectively) (p 0.05). The median age of all patients with CSS was 68 (4491) years. Mixed form of CSS was significantly more common than the cardioinhibitory or vasodepressor forms (p 0.05). In more than half of all cases, symptoms developed during balloon dilatation or within an hour afterwards. The duration of CSS was 3040 hours. Contralateral carotid occlusion was detected in 12 (10%) patients, significantly (p 0.05) more often in patients with CSS (13%) compared to patients without CSS (2.8%). Conclusion. Regardless of stenosis severity or symptoms, CAS is accompanied by CSS in 2/3 of cases. The CSS is predominantly a mixed type and can be accompanied by loss of consciousness in rare cases. CSS appears both intraoperatively and in the early postoperative period, and its average duration is 1.5 days. A factor that may be associated with CSS development is contralateral carotid artery occlusion (p 0.05).

Choice of Antithrombotic Therapy for Patients with Atrial Fibrillation Undergoing Carotid Angioplasty and Stenting: A Nationwide Population-Based Study

Non-valvular atrial fibrillation (NVAF) and carotid stenosis are important risk factors for stroke. Carotid angioplasty and stent placement (CAS) is recommended for patients with symptomatic high-grade carotid stenosis. The optimal medical management for patients with NVAF after CAS remains unclear. We aimed to clarify this issue using real-world data from the Taiwanese National Health Insurance Research Database (NHIRD). A total of 2116 NVAF patients who received CAS between January 1, 2010, and December 31, 2016, from NHIRD were divided into groups based on post-procedure medication as follows: only antiplatelet agent (OAP, n = 587); only anticoagulation agent (OAC, n = 477); dual antiplatelet agents (DAP, n = 49); and a combination of antiplatelet and anticoagulation agents (CAPAC, n = 304). Mortality, vascular events, and major bleeding episodes were compared after matching with the Charlson comorbidity index and CHA2DS2-VASc score. The CAPAC and the OAC groups had lower mortality rates than the OAP group (P = 0.0219), with no statistical differences in major bleeding, ischemic stroke, or vascular events. In conclusion, OAC therapy after CAS appears suitable for NVAF patients. CAPAC therapy might be considered as initial therapy or when there is concern about vascular events.

Transcarotid artery revascularization (TCAR): a technical video

Carotid revascularization is an important method of stroke prevention and includes carotid endarterectomy and transfemoral carotid angioplasty and stenting. More recently, a hybrid open-endovascular approach, termed transcarotid artery revascularization (TCAR), is garnering increased attention. Although fundamentally a ‘stenting procedure’, unlike transfemoral carotid angioplasty and stenting, TCAR allows for a proximal neuroprotection strategy based on flow reversal. In this technical video, we will review operative techniques and nuances of the TCAR procedure, with a particular focus on the neurovascular proceduralist looking to adopt this technique into routine clinical practice(video 1).Video 1

Results of carotid stenting for asymptomatic carotid artery stenosis

Objective: prospective analysis of 30-day outcomes from stenting procedure in patients with asymptomatic internal carotid artery stenosis depending on the type of implanted stent. Material and Methods: the study included 108 patients who underwent endovascular surgical treatment for asymptomatic internal carotid artery stenosis from 2012 to 2017. Depending on the type of implanted stent the patients were divided into 4 groups (the first (n = 37) – steel, the second (n = 32) -nitilon, the third (n = 20) – doublelayered stents, the fourth (n = 19) – double-layer stents with an inner layer of polyethylene terephthalate. Results: there was no mortality in the studied groups for 30 days after surgery. The cumulative incidence of cerebral circulation disorders within 30 days of carotid angioplasty and stenting was 9.7% (n = 10), with ischemic stroke occurring in 1.85% (n = 2) cases. Conclusion: carotid angioplasty and stenting is a safe and effective method of secondary prevention of cerebral circulation disorders with the level of perioperative complications not exceeding other preventive procedures.

Abstract P516: A Comparison of Transradial and Transfemoral Approaches for Performance of Carotid Angioplasty and Stent Placement

Context: Over the past few decades, transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS). Objective: To compare the outcomes of CAS performed via transradial approach with those performed using transfemoral approach within the same institution. Methods: We analyzed all the elective CAS procedures performed at our institute in the last 48 months and divided the procedures based on initial approach (transradial or transfemoral). Both approaches were used by same interventionalists to minimize inter-operator variability. We compared the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 120 elective CAS procedures were performed at our institution; 84 patients (70%) were initiated as transfemoral and 36 patients (30%) were initiated as transradial approach. There were 6 (16%) CAS procedures initiated as trans-radial but later switched to transfemoral due to anatomical and/or technical difficulties. Similarly, 1(1.2%) procedure was switched to transradial from transfemoral. So finally, 89 (74%) patients had transfemoral approach and 31 (26%) patients had transradial approach to CAS. The median age was similar between the two groups (66.5 years versus 67.3 years).The rates of major hemorrhagic complications were 2 (2.2 %) and 0 (0%) in CAS performed using tranfemoral and tranradial approaches, respectively. The rate of any stroke and/or death within 30 days post procedure was 5 (5.6 %) and 1 (3.2 %) in CAS performed using transfemoral and transradial approaches, respectively.The median fluoroscopy time was 36.1 minutes and 34.4 minutes using transfemoral and transfemoral approaches, respectively (p =0.72). Conclusions: Transradial approach is comparable to transfemoral approach for performance of CAS in regard to clinical endpoints although the rates of technical failure remain relatively high in patients in whom CAS was initiated from transradial approach.

Functional MRI evaluation of the effect of carotid artery stenting: a case study demonstrating cognitive improvement

Background The narrowing of the carotid arteries with plaque formation represents a major risk factor for ischemic stroke and cognitive impairments. Carotid angioplasty and stenting is a standard clinical treatment to reduce stroke risk. The cognitive effect of carotid angioplasty and stenting remains largely unknown. Purpose This study aims to provide direct evidence of possible effects of carotid angioplasty and stenting on cognition, using task-phase functional magnetic resonance imaging. Material and Methods This study received harmonized institutional ethics board approval (Grant number REB ID =H18-02495/FHREB 2018-058). Two patients had MRI scans pre-carotid angioplasty and stenting and two-month post-carotid angioplasty and stenting. Case 1 had severe (>95%) flow-limiting stenosis in the right carotid artery. Case 2 had 70% non-flow limiting stenosis in the left carotid artery. At each scan, patients completed two functional magnetic resonance imaging sessions while performing a working memory task. Accuracy, reaction time, and brain activation were analyzed for each patient for possible pre-post carotid angioplasty and stenting changes. Results Case 1 showed increased activation in the right (treated-side) frontal and temporal lobes post-carotid angioplasty and stenting; associated with improvements in accuracy (from 58% to 74%) and task completion rate (from 17% to 72%). Case 2 completed the tasks pre- and post-carotid angioplasty and stenting with >90% accuracy, while decreased functional magnetic resonance imaging activation in the contralateral (untreated) hemisphere and mildly increased activation in the left (treated -side) anterior circulation territory were observed post-carotid angioplasty and stenting. Conclusion These cases provided the first task-phase functional magnetic resonance imaging data demonstrating that carotid angioplasty and stenting improved cognitive function in the re-perfused vascular territory. The finding supports the role of carotid angioplasty and stenting in improving cognitive performance beyond reducing stroke risk.