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BACKGROUND: Prophylactic carotid artery stenting (CAS) is an effective strategy to reduce perioperative stroke in patients with severe carotid stenosis who require cardiothoracic surgery (CTS). Staging both procedures (CAS-CTS) during a single hospitalization presents conflicting demands for antiplatelet therapy and the optimal pharmacologic strategy between procedures is not established. The purpose of this study is to present our initial experience with a bridging protocol for staged CAS-CTS. METHODS: A retrospective review of staged CAS-CTS procedures at a single referral center was performed. All patients had multivessel coronary and/or valvular disease and severe carotid stenosis (>70%). Patients not previously on aspirin were also started on aspirin prior to surgery, followed by eptifibatide during CAS (intraprocedural bolus followed by post-procedural infusion which was continued until the morning of surgery). Pre- and perioperative (30 days) neurologic morbidity and mortality was the primary endpoint. RESULTS: 11 CAS procedures were performed in 10 patients using the protocol. The median duration of eptifibatide bridge therapy was 36 h (range 24-288 h). There was one minor bleeding complication (1/11, 9.1%) and no major bleeding complications during the bridging and post-operative period. There was one post-operative, non-neurologic death and zero perioperative ischemic strokes. CONCLUSIONS: For patients undergoing staged CAS-CTS, Eptifibatide bridging therapy is a viable temporary antiplatelet strategy with a favorable safety profile. This strategy enables a flexible range of time-intervals between procedures.

Background: Radiation therapy is an integral component of treatment that can predispose to carotid artery stenosis (CAS) and increase the risk of cerebrovascular events for head and neck cancer survivors. The utility of screening for CAS with carotid ultrasound in asymptomatic head and neck cancer survivors is unclear. Methods: In this prospective, cross-sectional pilot study, 60 patients who have no evidence of cancer at least 2 years from completion of RT will undergo screening carotid ultrasound to identify patients with high risk of cardiovascular events. Results: Outcomes will include clinically significant CAS, carotid intima-media thickness, acceptability/feasibility of screening, barriers to care and preliminary data on changes to medical management because of screening. Correlative multi-omics analyses will examine biomarkers of CAS after radiation therapy. Conclusion: The results of this study will provide valuable data on the prevalence of CAS and preliminary patient-centered data that will inform the design of a future large-scale, multi-site clinical trial. Clinical Trial Registration:NCT05490875 (ClinicalTrials.gov) Plain Language Summary Patients with head and neck cancer are often treated with radiation therapy. Radiation therapy can cause damage to the blood vessels in the neck. This damage can manifest as narrowing of the blood vessels like the carotid artery, which can lead to stroke. Currently, it is not clear if screening head and neck cancer survivors with ultrasound scans of the carotid arteries is feasible or acceptable to patients. This has also not been formally assessed using a prospective clinical trial. In this study, patients with a history of head and neck cancer who have no evidence of their cancer for at least 2 years since completion of their radiation therapy will be enrolled. They will undergo blood testing and a research ultrasound of the carotid arteries to check for narrowing and other findings that may signal a high risk of stroke or another cardiovascular event. Participants will complete surveys on their experience with the process and how likely they are to accept further screening or additional treatment if something is found. They will also complete surveys on their perception of their personal risk of stroke and barriers to care that would prevent them from getting screening ultrasounds. Patients will be followed for up to 6 months after the ultrasound to check for any changes in their medical care that occurred because of the screening ultrasound. Article highlights Carotid artery stenosis in head & neck cancer survivors treated with radiation therapy Radiotherapy for head and neck (HN) cancer may increase the risk of accelerated atherosclerosis and late carotid artery stenosis (CAS) in 25% of patients, and screening of asymptomatic stenosis may be useful and cost-effective in specific high-risk populations. If clinically significant stenosis is identified, risk reduction strategies such as optimal medical management with or without procedural intervention may reduce the risk of stroke. Data supporting the use of carotid ultrasound (CUS) for HN cancer survivors are sparse, and no guideline currently recommends CUS screening for asymptomatic patients. Carotid ultrasound surveillance for detection of asymptomatic carotid artery stenosis after head & neck radiotherapy CUS allows for cardiovascular risk stratification using stenosis and intima-media thickness measurements. Knowledge gaps with regard to the use of CUS screening in this population include patient acceptability, feasibility, and clinical utility. Rates of change in medical management for screen-detected carotid stenosis in HN cancer survivors have not been assessed in a prospective study. Pilot trial of carotid artery ultrasound in head & neck cancer survivors In this single-institution trial, 60 patients with a history of HN cancer treated with radiotherapy will undergo screening CUS. Patients will be evaluated for CAS (peak systolic velocity by Doppler ultrasonography), and intima-media thickness will be measured. Outcomes include patient acceptability, feasibility, barriers to care and perceived stroke risk among participants. In patients with clinically significant stenosis, the rate of resultant medical interventions (e.g., new medication, additional imaging or intervention) will be determined. Conclusion This prospective study for CUS screening in HN cancer survivors will obtain novel preliminary data to better understand the utility and feasibility of a CUS screening program. Preliminary results will inform future trials focused on the efficacy and cost-effectiveness of carotid artery ultrasound screening in this patient population. Correlative analysis will elucidate novel biomarkers and mechanisms of post-radiotherapy CAS. [ABSTRACT FROM AUTHOR]

Background and purpose: Despite the fundamental role of pial collateral vessels in limiting the progression of ischemic tissue injury in acute stroke with large vessel occlusion (LVO), in addition to the fact that collateral vessel abundance varies naturally from person to person for genetic reasons, there is limited knowledge regarding potential factors contributing to inherent interindividual variation in pial collateral supply. As it has been repeatedly hypothesized that chronic carotid occlusive disease may favor pial collateralization, we aimed to investigate the association between quantitatively assessed leptomeningeal collateral supply and pre-existing carotid stenosis in patients with acute stroke due to LVO. Materials and methods: Patients with proximal middle cerebral artery (MCA) occlusion with or without additional internal carotid artery (ICA) occlusion were included. The degree of collateral supply was quantitatively assessed based on signal variance in T2*-weighted time series in perfusion-weighted magnetic resonance imaging (PWI). Patients were stratified into two groups according to quantitative collateral status (poor and fair to good collateral supply). The prevalence of high-grade ICA stenosis (≥70%) was evaluated in both groups. Results: A total of 98 patients (mean age 68.8 ± 16.1 years, n = 52 (53.1%) of whom were female individuals) with MCA and/or ICA occlusion were included in the final analysis. Out of these patients, 42 had poor collateral supply, while 56 exhibited fair to good collateral supply. Additionally, 18 patients showed ipsilateral high-grade ICA stenosis. After classifying the entire cohort based on their collateral status (poor vs. fair to good collateral supply), there was no significant difference in the proportion of the patients with ipsilateral high-grade ICA stenosis between the two groups. Specifically, 6 (14.3%) patients had poor collateral supply, and 12 (21.1%) patients had fair to good collateral supply. The odds ratio (OR) was 1.58, with a 95% confidence interval (CI) of 0.490–5.685 and the p- value of 0.440. In the entire patient cohort, signal variance-based collateral supply was significantly correlated with initial stroke severity (r = −0.360, p < 0.001), baseline ischemic core volume (r = −0.362, p < 0.001), and functional outcomes (score on the modified Rankin Scale) at discharge (r = −0.367, p < 0.01). Conclusion: In this study, we performed a quantitative and observer-independent MRI-based collateral assessment in patients with LVO. We found no significant difference in the prevalence of pre-existing high-grade ICA stenosis between patients with fair to good collateral supply and those with poor collateral supply. The potential influence of demographic and clinical variables on pial collateral supply in patients with acute stroke warrants further exploration in future studies. MRI-based collateral supply is significantly related to initial stroke severity, ischemic core volume, and early functional outcomes. [ABSTRACT FROM AUTHOR]

Retropharyngeal internal carotid artery (ICA) is a rare, yet well-described anatomical variant that poses significant challenges to the management of carotid artery stenosis. In this case report, we discuss the treatment of symptomatic ICA stenosis with a retropharyngeal ICA using the transcarotid artery revascularization (TCAR) technique. A 70-year-old female with comorbidities presented with neurological symptoms and severe ICA stenosis. After diagnostic evaluation, TCAR was chosen for surgical intervention. The patient did well postoperatively. This case emphasizes the importance of considering TCAR when treating ICA stenosis in patients with anatomic variation of ICA location. It also supports adding anatomic variants such as retropharyngeal ICA to the list of indications for TCAR. [ABSTRACT FROM AUTHOR]

Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis. Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P =.049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P =.001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P =.011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P <.001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P =.3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P <.001). CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures. [ABSTRACT FROM AUTHOR]

The Circle of Willis (CoW) serves as the primary source of contralateral blood supply in patients who undergo carotid artery cross-clamping (CC) for carotid endarterectomy (CEA). It has been suggested that the CoW's anatomy influences CEA outcomes. The aim of this study was to evaluate associations between the cerebral collateral circulation, a positive awake test for intraoperative neurologic deficit after carotid CC, and postoperative adverse neurologic events. A systematic review was conducted searching MEDLINE, Cochrane, and Web of Science databases for studies that assessed the cerebral circulation, including CoW variations, using neuroimaging techniques in patients who underwent carotid CC. For the metanalytical incidence, the statistical technique used was weight averaging. Otherwise, descriptive analysis was used due to the excessive heterogeneity of the studies. Eight publications, seven cohort and one case-controlled study, involving 1313 patients who underwent carotid artery CC under loco-regional anesthesia, were included in the systematic review. The incidence of positive awake test in the cohort studies ranged from 4.4% to 19.7%. Carotid artery CC resulted in positive awake test in 5% to 91% of patients with alterations in the anterior portion and in 27% to 74% with alterations in the posterior portion of the CoW. A positive awake test in patients with contralateral carotid stenosis or occlusion ranged from 5.8% to 45.7%. Contralateral carotid stenosis >70% or occlusion were associated with a positive awake test (P <.001). Patients with incomplete CoW did not have statistically significant correlation with intraoperative neurological deficits after CC. Data were insufficient to evaluate the effect of the collateral circulation on early outcome after CEA. In this systematic review, contralateral carotid artery stenosis or occlusion, but not CoW abnormalities, were associated with a positive awake test after carotid artery CC. Further research is needed to evaluate which specific CoW anomaly predicts neurologic deficit after CC and to confirm association between a positive awake test and clinical outcome after CEA. [ABSTRACT FROM AUTHOR]

Introduction: Carotid artery stenting is an alternative interventional treatment to carotid endarterectomy. However, preprocedural considerations and anatomical risk factor analyses for carotid artery stenting are currently insufficient. Therefore, we investigated the high-risk anatomical appearance of carotid artery stenting from the neurointerventionist perspective to predict periprocedural complications. Materials and methods: We retrospectively reviewed patients with carotid stenosis who underwent carotid artery stenting at a comprehensive stroke center between January 2012 and December 2021. We compared the demographic characteristics, medical history, and anatomical appearance of the stenotic segment in patients with and without complications. Results: We analyzed a total of 148 patients (64 women [43.2%]; median age, 73.0 [interquartile range, 65.5-79.0]). Complications occurred in 39 of the 148 patients, primarily minor and transient. Of baseline or procedural characteristics, a high initial National Institutes of Health Stroke Scale score (p = 0.04), symptomatic stenosis (p = 0.01), and curve-centered plaque of the proximal ICA (p = 0.01) were significantly associated with carotid artery stenting complications in unadjusted analysis. Curve-centered plaque remained an independent risk factor for carotid artery stenting complications after adjustment (odds ratio 2.23[1.02-4.88], p = 0.04). Conclusion: High-risk vascular anatomical features, such as curve-centered plaque, are associated with a high frequency of periprocedural complications of carotid artery stenting. Tailored patient selection for carotid stenosis is crucial to prevent complications. Patients with curve-centered plaque should consider alternative treatment options such as carotid endarterectomy to achieve optimal clinical results. [ABSTRACT FROM AUTHOR]

Asymptomatic carotid stenosis (ACS) carries a 4.7% risk of ipsilateral stroke if left untreated. Carotid endarterectomy (CEA) is a surgical intervention that has demonstrated efficacy in reducing stroke risk among symptomatic elderly. However, literature on its efficacy in preventing stroke in patients with ACS remains limited. Our systematic review summarizes evidence on the safety and efficacy of CEA in the asymptomatic elderly. PubMed and Scopus were searched to identify articles that described outcomes after CEA for ACS in patients aged ≥ 65 years old. Articles that did not report outcomes specific to the asymptomatic elderly were excluded. Outcomes of interest were technical success, stroke, death, myocardial infarction and post-operative complications. The Newcastle Ottawa Scale (NOS) was used to perform a qualitative assessment for risk of bias and studies with NOS ≥ 6 were considered high quality. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. After a title and abstract screen, followed by a full-text review, 7 studies reporting outcomes in 76,404 patients were included. Five studies were retrospective and two were prospective. Among studies that reported criteria for intervention in ACS patients, 2 studies performed CEA for 70% stenosis and one performed CEA for 60% stenosis. One study reported outcomes for all ranges of stenosis (mild: 0–50%, moderate: 50–79% and severe: 80–99%). Clinical outcomes varied among included studies, with rates of death stroke and myocardial infarction ranging from 0.39 to 6.1%, 0.5–1.2% and 0.9-3%, respectively. The decision to perform CEA in patients with ACS is made after outweighing risks and benefits of surgery based on various factors like age, comorbidities and frailty. At present, evidence is largely limited to retrospective studies that utilized nationwide databases. Prospective studies and randomized controlled trials could help characterize the risk of CEA in this cohort. [ABSTRACT FROM AUTHOR]