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The acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the COVID-19 disease, a global pandemic. A strong association has been documented between COVID-19 and cardiovascular events, although the exact pathophysiological mechanism is still unclear. Carotid atherothrombosis and ischemic stroke represents one of the possible severe manifestations of COVID-19, as a leading cause of long-term disability and death. Different complex intertwined mechanisms seem to underlie the endothelitis which is the cause of multiple cardiovascular manifestations. To date, few case series describing COVID-19 and acute ischemic stroke caused by cervical carotid thrombosis have been published. All the patients shared common similar radiographic features, comorbidities, and biomarker profiles. The aim of this brief review was to analyze the impact of COVID-19 pandemic in the management of a Vascular Surgery Department, changing the daily vascular practice, as well as to provide practical suggestions for symptomatic carotid stenosis, while reviewing published literature.

Background: Our aim is to report our single center experience with extracranial carotid artery aneurysms (ECAA) open repair., Methods: A retrospective review was performed including the perioperative and postoperative data of all patients who underwent ECAA repair between 2008 and 2015. The operative technique was based on aneurysm size, anatomical features and operative risk., Results: Fourteen patients (6 men and 8 women, mean age 60.5 years) were admitted for ECAA. Thirteen patients (92.8%) were submitted to ECCA open repair while in one patient (7.2%) conservative treatment was realized. Bilateral lesions and concomitant internal carotid artery (ICA) kinking was observed in 2 cases (14.2%). Seven patients (50%) were asymptomatic at diagnosis and ECCA localization involved ICA in 9 cases (64.2-69.2%). Aneurysmectomy with end-to-end anastomosis was performed in 3 cases (23.07-23.1%), patch arterioplasty in 2 cases (15.38-15.4%), prosthetic graft interposition in 4 cases (30.76-30.7%), autologous vein graft bypass in 3 cases (23.07-23.1%) and artery ligation with distal ICA anastomosis in one case (7.6-7.6%). No perioperative deaths, major neurological complications and surgical reinterventions were recorded. Overall survival at a mean follow-up of 19.6 months (range 0-52 months) was 100%., Conclusions: ECAA open repair represents a safe surgical option, with lower prevalence of complications and no need for reintervention in high volume centers.

Transfemoral carotid stenting has struggled to become a suitable alternative to carotid endarterectomy for the treatment of carotid disease because of higher perioperative stroke risks, even with use of embolic protection devices. To reduce the perioperative stroke rates associated with carotid stenting, several advancements in stent design, embolic protection systems, and technical approaches have been developed. Transcarotid artery revascularization (TCAR) was also recently introduced as a novel carotid artery stenting option which circumvents several of the high embolic-risk maneuvers found in transfemoral carotid stenting and employs a flow reversal system that provides continuous embolic protection throughout the procedure. Early results from this technique have shown low stroke/death rates comparable to carotid endarterectomy while maintaining the minimally invasive benefits of carotid stenting. TCAR has a strong potential to become the preferred method of carotid stenting in the near future and may challenge carotid endarterectomy as the preferred carotid artery revascularization method.

Introduction: Several systematic reviews and meta-analyses of primary studies have been published on the relationship between annual case load of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed at hospital level or by individual surgeons, and perioperative outcomes. Many studies on volume-outcome relationship have already been published and high-quality systematic reviews are crucial for further guideline development., Evidence Acquisition: Systematic reviews and meta-analyses on the relationship between hospital or surgeon CEA/CAS volume and periprocedural outcomes were identified through a systematic literature search of Medline, Web of Science, and the Cochrane Database of Systematic Reviews. Methodological quality of the systematic reviews was appraised using the AMSTAR2 tool independently by two authors. Systematic reviews were aggregated in their volume-outcome findings. Quantitative data from primary studies included in the systematic reviews were synthesized. Additionally, volume definitions and the time point of outcome assessment used in primary studies were analyzed., Evidence Synthesis: In total, five systematic reviews published between 2000 and 2018 were identified, each comprising 11-25 primary studies. Methodological quality appraisal of these reviews revealed high quality for only the most recent review, low quality for three reviews, and critically low quality in one review. Aggregation of the systematic reviews revealed a significant inverse relationship between hospital/operator volume and the periprocedural risk of death or stroke following CEA. For CAS, high operator volume was associated with lower outcome rates. Regarding hospital volume, an inverse but non-significant relationship between CAS hospital volume and outcome rate was found. In our synthesis of primary studies from these systematic reviews an inverse CEA hospital and operator volume relationship was present for stroke or death and for CAS for hospital volume, respectively. A high heterogeneity regarding the definitions of volume categories, and of time points assessing outcomes was apparent., Conclusions: For CEA, high quality aggregated evidence revealed an inverse relationship between hospital/surgeon CEA volume and periprocedural rate of stroke or death. The same was true for operator linked CAS volume. Regarding hospital linked CAS volume, no unequivocal evidence was found. Additionally, heterogeneity was found regarding volume definition, and time of outcome assessment. Thus, future studies should aim to harmonize volume definitions and outcome time points.

Carotid artery stenting (CAS) is considered an alternative option to carotid endarterectomy (CEA) for significant carotid stenosis, in both symptomatic and asymptomatic patients. Comparing to CEA, CAS offers significant advantages. The most important arise from the minimally invasive nature of the procedure, which reduces the surgical complications and adds significant comfort to the patient, without compromising the efficacy. Nowadays, CAS can achieve acute and long-term outcome results comparable to CEA, maintaining low rates of periprocedural embolic events. Evolution of the stent design and routine application of protection devices, played an important role to CAS performance. In this review, we aim to present all available new data on stent design and protection devices while we pose a set of unanswered questions that need to be addressed in the future.

Compared with conventional angiogram-guided procedure, intravascular imaging modalities give us a lot of useful information to make the procedure better. Intravascular imaging modalities give us the information about lesion characters, reference vessel diameter and the interaction between the stent strut and the plaque such as stent strut malapposition or plaque prolapse in real time during the procedure. We can change our strategy according to this information. Intravascular ultrasound (IVUS) is a most common intravascular imaging modality during carotid artery stenting (CAS) in these days. Its advantage is easy to use compared with optical coherence tomograpy (OCT) which has been reported recently in some case reports or case series. However, due to its high resolution, OCT provides more detailed information especially about plaque prolapse and strut malapposition. IVUS and OCT have a potential to improve acute result and reduce the procedural complication by providing the data of lesion character, reference vessel diameter and the interaction of stent strut and vessel wall. Interventionalists who perform CAS procedure should acquire proficiency in imaging modalities during CAS procedure.

Background: The aim of this paper was to present single centre experience in the treatment of extra cranial carotid artery aneurysms (ECCA) and to analyze results discussing different treatment modalities., Methods: The study analyzed 60 patients with 62 ECCA treated surgically at the Clinic for vascular and endovascular surgery, Serbian Clinical Center (Belgrade) in the period between 1985 and 2013. Treatment strategy was individually selected and demographic, morphologic, intraoperative and postoperative data were collected., Results: Thirty-day operative mortality was 3.3% and completely stroke related. Besides two fatal strokes one additional was registered making total number of 3 (4.8%) postoperative strokes. Only one (1.6%) early graft thrombosis has been found. The 30-day-patency rate was 98.4%. During the same period seven local complications were found: three (4.8%) hemorrhage and four (6.4%) cranial nerves injuries. In all cases of hemorrhage successful re-intervention was performed without any consequences. Cranial nerves injuries included transient contusions of hypoglossal (2) and superior laryngeal nerve (2)., Conclusions: The etiology, location, and morphology of an ECCA are determining selection of appropriate therapy. Large or tortuous aneurysms, as well as aneurysms involving common carotid or proximal internal carotid artery, are also absolutely indicated to open surgical therapy. Aneurysms which involve the distal internal carotid artery and false anastomotic aneurysms are best managed with endovascular techniques. The ligature is indicated for the treatment of external carotid aneurysms, mycotic aneurysms with local infection and in ruptured ECCA with uncontrolled bleeding.

Timing of treatment in carotid artery disease is still a matter of debate. So far there is controversial literature available concerning the safety of rapid treatment after a qualifying neurological event. Carotid endarterectomy turned out to be more effective in stroke prevention when carried out closer after the onset of symptoms. The initial "two weeks" cut off for surgery meanwhile turned into a "as soon as possible" treatment policy. In case of a cerebral infarction it seems reasonable, however, to delay surgery. Less evidence exists about the ideal timing of carotid artery stenting. Data analysis from the Carotid Stenosis Trialists' Collaboration showed that the early days after plaque rupture carry a high risk for periprocedural complications after carotid artery stenting. The analysis of a large register series showed, that carotid artery stenting carried a significantly higher risk for complications in patients with and without cerebral infarction when performed within 48 hours after the onset of symptoms.

Microembolization during carotid artery stenting (CAS) is the result of embolic events shown by intraprocedural transcranial Doppler (TCD) or postprocedure diffusion-weighted MRI that do not lead to acute neurological deficit. Although the long term clinical outcome of these silent infarcts is not yet well established, there is increasing evidence that these events could be associated with neurological impairments, such as cognitive decline. In order to prevent microembolization due to excessive catheter manipulation at the time of guiding catheter placement in patients with challenging anatomy, a cervical access system with flow reversal protection was developed. Other embolic events are often seen as the result of plaque protrusion through stent struts. A new type of stent, so-called "hybrid" stent, incorporates the flexibility and conformability of an open-cell stent as well as plaque coverage seen with a close-cell stent, with the goal of achieving better plaque stabilization reducing macro and microembolization, while maintaining original vessel anatomy and flow hemodynamic. At the present time there are three different stents under investigation or this application.

Current guidelines recommend performing carotid endarterectomy in patients with symptomatic carotid disease as soon as possible after the neurological index event. However, early stroke risk has not been well documented for this patient group. We therefore conducted a systematic analysis of the current literature on the recurrent risk of ischemic events in patients with symptomatic carotid stenosis. Systematic review was performed by searching the MEDLINE® database from 1950 until June 8, 2015 (key words: cerebral ischemia, transient ischemic attack, amaurosis fugax, stroke, symptomatic carotid stenosis, recurrent risk, outcome, prognosis, follow-up, cohort and natural history). All studies reporting stroke risks in patients with symptomatic carotid stenosis after neurologic index events within a period of 7 days were included. Cumulative stroke risks with 95% confidence intervals after a neurologic index event were recalculated at 2-3, 7, 14 and 30 days and a meta-analysis including an analysis of heterogeneity were performed using the statistical package R and Excel for Mac 2003. Ten studies with a total number of 2634 patients were included. Results of an overall stroke risk were as follows: 2.0-17.2% at 2-3 days, 0-22.1% at 7 days, 0-29.6% at 14 days and 0-11.1% at 30 days in patients with a symptomatic extracranial carotid stenosis. The pooled stroke risk in the six studies with active follow-up was 6.0% (95% CI 2.4-14.4) at 2-3 days, 10.9% (6.1-18.7) at 7 days and 17.6% (9.7-29.9) at 14 days. Pooled stroke risk in the three studies with uncensored populations was even higher with 6.4% (1.5-23.8%) at 2-3 days, 19.5% (12.7-28.7) at 7 days and 26.1% (20.6-32.5%) at 14 days. Significant heterogeneity (P<0.001) could be explained by the different inclusion criteria and the study's design. Retrospective studies with passive follow-up had the lowest stroke risk whereas prospective studies with active follow-up and without bias through early intervention by carotid endarterectomy or carotid stenting had the highest stroke risk. The risk of recurrence of cerebrovascular events in patients with symptomatic carotid stenosis within the first days after a neurologic index event is as high as 6.4% (1.5-23.8), 19.5% (12.7-28.7) and 26.1% (20.6-32.5) after 2-3, 7 and 14 days respectively. Patients with a symptomatic carotid stenosis are therefore at a very high risk of a definitive stroke. Recommendations by current guidelines to perform carotid endarterectomy as soon as possible after the neurologic index event are therefore justified.

Aim: In Germany, every surgical or endovascular procedure on the extracranial carotid artery is documented in a mandatory quality assurance registry. The purpose of this study is to describe the patient characteristics, the indications for treatment, and the short-term outcomes as well as to analyse the corresponding trends from 2003 to 2014., Methods: Data on demographics, peri-procedural measures, and outcomes were extracted from the annual quality reports published by the Federal Agency for Quality Assurance and the Institute for Applied Quality Improvement and Research in Health Care. Data were available from 2003 to 2014 for carotid endarterectomy (CEA) and from 2012 to 2014 for carotid artery stenting (CAS). The primary outcome event of this study is any stroke or death until discharge from hospital. Temporal trends of categorical variables were statistically analysed using the Cochran-Armitage test for trend., Results: Between 2003 and 2014, 309,405 CEAs and 18,047 CAS procedures were documented in the database; 68.1% of all patients were male. The mean age of patients treated with CEA increased from 68.9 years in 2003 to 70.9 years in 2014. The proportion of patients with ASA stages III to V increased from 65% to 71% in CEA, whereas it decreased from 44% to 41% in CAS patients. 53.1% of all CEAs were performed for asymptomatic patients (group A), 34.4% for symptomatic patients treated electively (group B), and 11.2% a in a collective group including other indications for CEA or CAS (such as recurrent stenosis, carotid aneurysms, emergency treatment due to stroke-in-evolution). The corresponding data for CAS are 49.3%, 26.1% and 26.3% respectively. In group B, the interval between the neurological index event and CEA decreased from 28 to 8 days (P<0.001). In patients treated with CAS, this interval was 9 days in 2012 (no further data available). On average, 67.1% and 48.2% of surgically treated patients as well as 77.8% and 69.8% of CAS patients were neurologically assessed before and after the procedure, respectively. From 2003 to 2014, CEA procedures were performed more frequently in locoregional anesthesia (10.1% to 29.1%, P<0.001). The same trend was observed for the application of the eversion technique (37.0% to 41.6%, P<0.001), the neurophysiological monitoring (49.8% to 61.8%, P<0.001), and the intra-procedural assessment of the treated artery (44.5% to 69.7%, P<0.001). In contrast, shunting was used less frequently (48.1% to 43.0%, P<0.001). Averagely 95.7% of all endovascular procedures were performed using stent-angioplasty. In 54.2% a protection device was used. Nitinol and bare metal stents were used in 74.1% and 21.4% of cases, respectively. The in-hospital rate of any stroke or death decreased from 2.0% to 1.1% in asymptomatic patients treated with CEA without a contralateral stenosis ≥75% or occlusion, P<0.001). In patients treated with CAS this rate did not increase (1.7% to 1.8%, p=0.909). The corresponding rates in CEA and CAS patients with severe contralateral stenosis or occlusion varied between 1.9%-3.1% and 2.2%-2.6%, respectively. In symptomatic patients (group B) with a stenosis of 50 percent or more, the rate of any stroke or death decreased significantly after CEA from 4.2% to 2.4% (P<0.001) and remained stable after CAS (3.9% to 3.5%, P=0.577)., Conclusion: This report on 327,452 carotid procedures analysed one of the largest quality registries on CEA and CAS worldwide. Data indicate that treated patients became older and sicker, whereas in contrast, the in-hospital rates of stroke or death are decreasing over time.

Aim: Nerve injuries, wound complications and especially poor cosmetic results still have an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial and cranial nerves lesions, and better aesthetics outcomes. The objective of this retrospective study was to compare the results between the short longitudinal with the short transverse cervical incision and to evaluate their impact on cranial and cervical nerves and aesthetic outcomes., Methods: From January 2007 to December 2009 266 patients underwent 300 consecutive primary CEA procedures. Two-hundred nineteen patients were submitted to short longitudinal cervical incision (group A), in eighty one a short transverse cervical skin incision (group B) was performed. The average of skin incision was about 4-5.5 cm. In all cases a preoperative CEA duplex ultrasounds (US) assisted skin marking was carried out. All patients were submitted to the general anesthesia with Remifentanyl conserved consciousness. Routinely synthetic patch and selective policy intraluminal shunts were used. Incisions were extended when shunts were required or in case of high carotid bifurcation. Preoperative and postoperative cranial nerves evaluation was always performed and a questionnaire about the satisfaction of the aesthetic outcome was proposed to all patients to the discharge and six months follow-up. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and restenosis rate were reported and analyzed through statistical analysis (χ2 and Student's t test)., Results: The 30 days mortality was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2 % in group B (P>0.9). Wound complications were 1.8% and 1.2 % respectively (P>0.1). No statistically differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in restenosis rate was detected (P>0.9). In case of lengthening of the incision for high internal carotid (ICA) stenosis and especially to the need of shunt deployment, the longitudinal approach showed unequivocally to be easier and safer., Conclusion: No differences were achieved between short longitudinal and transverse incision in term of stroke, wound complications or nerves impairment. A good cosmetic outcome was gained in both groups. The Duplex US skin markings pre-CEA permitted localization and limits of the plaque with appropriate short incision. A longitudinal cervical approach is to prefer as can lead to an easier proximal and distal lengthening in cases of atherosclerotic extension of the plaque and shunt deployment.

The management of patients undergoing coronary artery bypass grafting (CABG) who are found to have co-existent carotid artery disease remains controversial. Management options include performing an isolated CABG, synchronous carotid endarterectomy (CEA) plus CABG, staged CEA-CABG, reverse staged CABG-CEA, synchronous CEA+CABG off bypass (OFFCAB) and staged carotid angioplasty with stenting (CAS) followed by CABG. For any of these combined or staged interventions to be clinically effective, the following conditions must be met; (1) CABG must be a proven intervention for ischaemic heart disease, (2) stroke must be an important cause of peri-operative morbidity and mortality, (3) the incidence of post-CABG stroke must be high enough to justify a programme of prevention, (4) carotid disease must be an important cause of post-CABG stroke, (5) CEA (CAS) must be a proven intervention in carotid artery disease and (6) prophylactic CEA (CAS) should reduce the risk of post-CABG stroke. This paper reviews the literature and concludes that conditions 1, 2 and 5 are met and that condition 3 can be achieved provided high risk' subgroups are targeted. However, there is limited evidence to support the contention that carotid disease is a major cause of post-CABG stroke and any potential benefit conferred by prophylactic intervention (whether by CAS or CEA) may be offset by the relatively high procedural risks observed in systematic reviews. Prophylactic carotid intervention is justified in CABG patients with a prior history of stroke or TIA. Debate continues about the role of CEA (CAS) in patients with asymptomatic bilateral carotid disease, but there seems to be little evidence to justify prophylactic CEA or CAS in CABG patients with unilateral asymptomatic carotid disease.

In the absence of randomized trials, the optimal management of patients with concomitant carotid and coronary artery disease remains disputable. The initial studies of combined or staged carotid endarterectomy in these patients were conceived in an attempt to reduce perioperative mortality. Although encouraging results have been reported with combined carotid endarterectomy and cardiac surgery, this combination requires long operative times and remains a surgical challenge. Recent studies have shown that carotid angioplasty and stenting prior to cardiac surgery is a feasible and effective minimal invasive technique. However, the effect of carotid stenting on the incidence of death and stroke after cardiac surgery is indistinct. Carotid stenting followed by cardiac surgery may provide a valuable treatment for patients with combined carotid and cardiac disease. The high rate of freedom from death and stroke during follow-up supports the long-term durability of this strategy. In the present review, we highlight the available data on carotid stenting and cardiac surgery.

Background and Purpose: The natural history of carotid lesions has generally been evaluated in anedoctal series or in clinical trials. The purpose of this study was to evaluate clinical and pathological modifications linked to an increasing waiting list in our region and the related medico-legal implications., Methods: Neurological symptoms that occurred during the waiting period were evaluated in 282 out of 491 patients placed on the waiting list for a carotid stenosis less than 80% or without an unstable plaque. The other 202 patients cancelled their booking. Progression of carotid disease was evaluated by duplex scanning in 116 patients who had a duplex evaluation in our Department both at booking and at the time of operation., Results: The incidence of stroke in a mean waiting period of 8.9 months was 2.6% in symptomatic patients and 1.5% in asymptomatic, respectively; 39 (13.8%) patients experienced an ipsilateral TIA and 4.2% a carotid thrombosis (25% of which symptomatic). The crude mortality-rate was 2.4% with a 1% of related deaths. The cumulative actuarial hard end points rate (stroke, carotid thrombosis and related death) was 7.8% at 12 months and 19.8% at 18 months., Conclusions: This study gives us data about the natural history of carotid stenosis in our country. The high morbidity and mortality-rate related to this lesion and particularly their occurrence within the first 3 months stress the urgency of treatment, and of the planning of specialized Departments in relation to the real incidence of the pathology in order to avoid medico-legal consequences.

We investigated the clinical outcomes and the progression of the internal carotid arterial lesions of a group of patients presenting with hemispheric TIAs. The cumulative frequency of TIAs during a mean follow-up period of 40 +/- 14 months was 14%, and no relationship was found between new TIAs and the presence of known cardiovascular risk factors or plaque characteristics as determined by duplex scanning. With the exception of one patient who died of stroke, none of the patients developed a permanent neurologic deficit. The cumulative death rate was 6.5%; myocardial infarction was the most common cause (3 out of 7). Anatomic progression of plaques was determined by duplex scanning in 22% of the internal carotid arteries. No relationship between progression of these plaques and the development of new TIAs was evident. We conclude that, in this group of patients, TIAs do not inevitably lead to stroke and that TIAs are not predictable based on risk factors or plaques characteristics.

Although attempts to restore patency of occluded internal carotid arteries are now rarely made, endarterectomy in the contralateral artery, external carotid endarterectomy and until recently EC/IC bypass have remained surgical options in the management of such patients. Over a four-year period at this institution 104 patients underwent carotid endarterectomy for stenosis. In this group the contralateral carotid was patent (Group A). Fifty-four patients with unilateral carotid artery occlusion underwent contralateral endarterectomy (Group B), 8 underwent ECA/ICA bypass (Group C) and 4 an ECA endarterectomy (Group D). No statistically significant difference was noted in perioperative stroke and death rates for Groups A and B were (1% and 1%) and (3.7% and 1.9%) respectively. One Group C patient died from perioperative stroke (12.5%). For late events the life table adjusted annual rates for stroke and mortality were similar, Group A (stroke 2.1% and death 5%), and Group B (stroke 1.6% and death 5%). In Group C stroke rate was 10% and death 3%. All four patients undergoing ECA endarterectomy were relieved of their symptoms. It is concluded that in patients with internal carotid artery occlusion TEA may be performed with perioperative morbidity and mortality rates comparable to those when the opposite carotid artery is patent. The late outcome for stroke compares favorably with the reported natural history of the disease and outcome for such patients treated medically in the Joint Study of Extracranial Occlusion and EC-IC Bypass Study. External carotid artery endarterectomy appears useful in the treatment of embolic events on the occluded side. ECA/ICA bypass does not appear to confer benefit.