Study on the Mechanism of Platelet-Released Clusterins Inducing Restenosis after Carotid Endarterectomy by Activating TLR3/NF-κb p65 Signaling Pathway

This study aimed to explore the role of clusterin released by platelet aggregation in restenosis after carotid endarterectomy. 35 patients who underwent carotid endarterectomy due to carotid artery stenosis were enrolled in this study. They were admitted to the Third Affiliated Hospital of Qiqihar Medical University from January 2018 to January 2019. All the patients were divided into two groups: the restenosis group and the nonrestenosis group, according to the follow-up results within 12 months. Peripheral blood was collected on the first day, 6 months, and 12 months after operation. The expression of CLU in serum of plasma and platelet culture medium was detected by an ELISA experiment. The vascular endothelial cells were cultured in vitro with 100 ng/mL of human recombinant CLU added to the medium. Cell proliferation, migration, and invasion were detected by CCK8, scratch, and Transwell invasion tests. The expression level of TLR3 and NF-κb p65 proteins in cells was detected by western blot. TLR3 knockout plasmids in vascular endothelial cell lines were transfected. Cell proliferation and migration were detected by CCK8 and the scratch assay. The CLU content in peripheral blood plasma and supernatant of platelet culture medium was significantly higher in the restenosis group than that of the control group ( p = 0.003 ) 6 months after operation ( p = 0.047 ) and 12 months after operation ( p = 0.011 ). When CLU was added to vascular endothelial cell culture medium, the proliferation and migration were significantly enhanced. The TLR3/NF-κb p65 protein expression level in cells also significantly increased. After the transfection of TLR3 knockout plasmids into vascular endothelial cell lines, CLU cannot promote the proliferation and migration of vascular endothelial cells. Platelet-released clusterin can induce vascular endothelial cell proliferation and migration by activating the TLR3/NF-kb p65 signaling pathway, leading to carotid artery restenosis after carotid endarterectomy.

Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience

Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.

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

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.

Incidence of postoperative, major, adverse cardiac events in patients undergoing carotid endarterectomy: A single-center, retrospective study

Objective: This study aimed to determine the incidence of postoperative major adverse cardiac events for patients undergoing carotid endarterectomy. Methods: This single-center, retrospective study recruited 171 carotid endarterectomy patients between January 1999 and June 2018. Patients who received a carotid endarterectomy in conjunction with other surgery were excluded. The primary outcomes were the incidences of major adverse cardiac events (comprising myocardial infarction, significant arrhythmias, congestive heart failure, and cardiac death) within 7 days, 7–30 days, and > 30 days–1 year, postoperatively. The secondary outcomes were the factors related to major adverse cardiac events and the incidence of postoperative stroke. The patients’ charts were reviewed, and direct contact was made with them to obtain information on their status post discharge. Results: The incidences of major adverse cardiac events within 7 days, 7–30 days, and >30 days–1 year of the carotid endarterectomy were 3.5% of patients (95% confidence interval: 0.008–0.063), 1.2% (95% confidence interval: 0.004–0.028), and 1.8% (95% confidence interval: 0.002–0.037), respectively. The major adverse cardiac events occurring within 7 days were arrhythmia (2.3% of patients), cardiac arrest (1.8%), myocardial infarction (1.2%), and congestive heart failure (1.2%), while the corresponding postoperative stroke rate was 4.7%. Conclusion: The 7-day incidence of major adverse cardiac events after the carotid endarterectomy was 3.5%. The most common major adverse cardiac event during that period was cardiac arrhythmia.