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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., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

BACKGROUND Recruitment maneuvers (RMs) are used to reduce pulmonary atelectasis in patients under general anesthesia, but they can lead to a decrease in cerebral hemodynamics. MATERIAL AND METHODS Thirty patients undergoing carotid endarterectomy were randomized to a manual sustained inflation (SI) group or a stepwise increase in PEEP (IP) group. During both RMs, the peak airway pressure (Ppeak) was maintained at 30 cmH₂O for 30 s. Electrical impedance tomography was used to evaluate pulmonary aeration changes. Mean velocity of blood flow in the middle cerebral artery (Vm) and cerebral oxygen saturation (rScO₂) was monitored intraoperatively. RESULTS IP improved lung aeration better at Ppeak=30 cmH₂O than SI (58.2±8.4% vs 46.0±8.3%, P=0.001) and this persisted until the end of surgery. Dorsal (dependent) ventilation 30 min after extubation in the SI group was lower than that before surgery (7.7±2.6% vs 9.9±3.8%, P=0.003). Vm and rScO₂ returned to baseline immediately after RM in the SI group, while it remained below baseline in the IP group (42.5±12.6 vs 50.9±18.8 cm/s, P<0.001 and 68.1±3.5% vs 70.6±3.7%, P=0.001). Heart rate declined significantly during RM only in the SI group (55.9±6.6 vs 52.2±6.9 bpm, P=0.008). CONCLUSIONS Compared with SI, IP performed better in improving lung aeration, with greater hemodynamic stability. IP resulted in slower recovery of cerebral blood flow and oxygenation.

BACKGROUNDː: Stroke, primarily resulting from ischemic conditions, is the foremost cause of mortality and long-term impairment and is frequently associated with narrowing of the carotid arteries. Although carotid endarterectomy (CEA) is the treatment of choice, it carries the risk of cerebral ischemia and reduced blood flow. Transcranial Doppler (TCD) ultrasound offers a nonintrusive method to assess cerebral blood circulation during CEA, potentially enhancing surgical outcomes. The objective of this study was to assess the clinical utility and safety of TCD monitoring during CEA and to identify factors influencing postoperative complications. METHODS: This retrospective analysis included 158 CEA patients (from January 2021-August 2023) who underwent TCD monitoring and whose data were compared to historical standard care data. The primary outcomes were operation duration and artery occlusion time. Secondary outcomes included carotid shunt usage, seven-day postoperative complications, and six-month carotid artery patency. Logistic regression identified factors linked to adverse reactions, and a predictive model was evaluated with a receiver operating characteristic (ROC) curve. RESULTSː: Comparative analysis indicated significant reductions in both the duration of surgery (113.26 ± 7.29 min) and artery occlusion time (21.85 ± 2.92 min) for patients monitored with TCD (P < 0.001) and an increase in carotid shunt implementation (25% as opposed to traditional care). The observed postoperative complications were minor, with a nonsignificant trend that favored the use of TCD-monitored procedures (1% vs. historical rates). Factors such as patient age and plaque echogenicity were found to be predictive of postoperative issues, with plaque echogenicity emerging as a significant predictive factor (OR = 10.70, 95% CI: 2.14-202, P = 0.02) upon multivariate analysis. The predictive model exhibited high precision (AUC = 0.93). CONCLUSION: This retrospective evaluation suggested that TCD monitoring in the CEA may reduce procedural time and potentially decrease postoperative complications, supporting its use for personalized surgical planning., (© 2024. The Author(s).)

This article explores two anesthetic strategies for carotid endarterectomy: cervical plexus block and general anesthesia. Regional anesthesia is increasingly favoured for its ability to enable continuous neurological monitoring and maintain hemodynamic stability. General anesthesia remains essential for certain patients, offering comfort, optimal control of physiological conditions, and extended cerebral protection. We also discuss pathophysiological considerations, crucial elements for understanding patient responses to these techniques. The development of ultrasound-guided cervical plexus block emerges as a promising alternative to general anesthesia, enhancing the options available for safer and more effective anesthetic management. However, an individualized approach remains crucial to optimize clinical outcomes. This approach is part of the concept of «personalized medicine», in which contemporary anesthesia must necessarily be adapted to the specific needs of each individual.

For patients presenting with a cerebral episode of vascular origin whose pathogenetic mechanism is due to large vessel disease affecting the carotid arteries, different intervention strategies for secondary prophylaxis are available: medical (single or dual antiplatelet therapy), surgical or endovascular. In this review, these strategies will be described, along with suggestions for appropriate application in clinical practice. These suggestions may vary depending on whether early or long-term secondary prophylaxis is considered.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction: Vulnerable plaques have been shown to predict ipsilateral cerebral ischemic events and identifying them leads to appropriate secondary stroke prevention strategies. We evaluated the diagnostic accuracy of MR carotid plaque imaging in identifying plaque vulnerability when compared with histopathological findings in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA)., Methods: A prospective cohort of forty-five consecutive patients with moderate to severe symptomatic carotid stenosis who underwent CEA at a tertiary Indian hospital had 3 T MRI plaque imaging with multi-parametric protocol between November 2021 and December 2022. Images were analyzed by a vascular radiologist blinded to histopathological data. High-risk plaque characteristics such as lipid rich necrotic core (LRNC), intraplaque hemorrhage (IPH), thin fibrous cap and ulceration were assessed and correlated with histopathological findings as per American Heart Association (AHA) classification using Cohen's kappa statistics to obtain diagnostic accuracies., Results: Of the 45 patients, 38(84 %) were males. The mean age was 65 ± 7.7 years and mean duration to CEA from the most recent event was 57 days (57 ± 46 days). A significant correlation between MR plaque imaging and histopathology was noted for IPH (sensitivity-91 %, specificity-86 %, κ = 0.774, p < 0.001), LRNC (sensitivity-92.1 %, specificity-85.7 %, κ = 0.697, p < 0.001), and plaque ulceration (sensitivity-84.6 %, specificity-78.1 %, κ = 0.563, p < 0.001). MRI had an overall sensitivity and specificity of 92.3 % and 84.2 % respectively (κ = 0.77, p < 0.001) in discriminating high risk plaques., Conclusion: MR plaque imaging shows a very good correlation with histopathology and can identify unstable high-risk plaques with high accuracy. This may have implication in selection of patients for carotid revascularization in symptomatic carotid stenosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

We outline the indications and contraindications of carotid endarterectomy (CEA) and appraise four key areas still debated to this day; shunting versus non-shunting, patch angioplasty (PA) versus primary closure (PC) and local anaesthesia (LA) versus general anaesthesia (GA). Importantly, we compare CEA with Best Medical Therapy (BMT), which is an area that is still largely debated, principally because many of the studies conducted to date do not reflect the era of modern BMT practices, and these outcomes are eagerly awaited. Literature searches were conducted using Pubmed with the keywords 'carotid', and 'endarterectomy', which provided a wide variety of journals and articles. We further stratified our data by using only randomised control trials (RCTs), meta-analyses, and systematic reviews, and then excluded studies with asymptomatic disease, diabetes, and plaque-imaging studies, including studies that did not fit our four desired topics for discussion. For each of the different domain's, results demonstrated similar peri-operative outcomes when comparing shunting vs. non-shunting and modality of anaesthesia and therefore practice still remains dependent on operator experience and preference. Patch-angioplasty reduces the risk of subsequent stroke, transient ischaemic attack (TIA), and re-stenosis compared to PC. In carotid stenosis >50% BMT offers limited benefits without accompanying surgical intervention and BMT alone tends to be advantageous primarily for patients with <50% carotid stenosis. Where CEA is appraised in terms of superiority of the procedural components; the literature does not support wildly contrasting outcomes to change majority practice. However, the area of considerable interest is superiority of BMT to surgical intervention in terms of both carotid artery stenting (CAS) and CEA and more studies need to be conducted in this area.

Internal carotid artery atherosclerosis is a major risk factor for stroke, accounting for 15-20% of ischaemic strokes. Revascularisation procedures-either carotid endarterectomy or carotid artery stenting-can reduce the risk of stroke for those with significant (>50%) luminal stenosis but particularly for those with more severe (70-99%) stenosis. However, advances in medical pharmacotherapy have implications for the relative benefit from surgery for symptomatic carotid atherosclerosis, as well as our approach to asymptomatic disease. This review considers the evidence underpinning the current medical and surgical management of symptomatic carotid atherosclerosis, the importance of factors beyond the degree of luminal stenosis, and developments in therapeutic strategies. We also discuss the importance of non-stenotic but high-risk carotid atherosclerotic plaques on the cause of stroke, and their implications for clinical practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Proximal carotid tandem lesions are defined as multilevel lesions with significant (> 50%) atherosclerotic disease involving the internal carotid artery (ICA) in combination with the proximal ipsilateral common carotid artery (CCA) or innominate artery (IA). It is a relatively rare disease with an incidence of less than 5% in all patients with carotid stenosis at the level of the bifurcation., Methods: These patients are at high surgical risk and were, therefore, excluded from current randomized controlled trials. Although the effectiveness of carotid endarterectomy (CEA) and carotid stenting (CAS) in stroke prevention for patients is established, the optimal treatment approach for the subgroup of patients with a proximal tandem lesion is still controversial. Treatment of this condition is not well understood because it is difficult to determine the risk of each individual lesion becoming symptomatic. Therefore, concurrent treatment of severe (> 70% stenosis) proximal lesions is recommended when treating severe stenosis at the carotid bifurcation., Conclusion: This disease can lead to embolic ischemic strokes or hemodynamic compromise. It is not possible to determine diagnostically which lesion led to the clinical symptoms, which is why both lesions should be corrected., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Cerebral Revascularization (CR) remained an indispensable arm in the neurosurgical arsenal, especially managing symptomatic hemisphere with misery perfusion (SHMP)., Method: We described an a mid-aged gentleman diagnosed with progressive middle cerebral steno-occlusion following carotid endarterectomy by employing individualized arterial reconstruction with tentative clamping method (TCM) under supervision of intraoperative monitoring. An operative video was also accompanied to demonstrate further details., Conclusion: The optimal treatment strategy for SHMP should be tailored by individuals. The risk of postoperative adverse sequel can be minimized and improved neuro-cognitive status was accomplished with an aid of TCM for such prophylactic procedure., Clinical Trial Registration: NA., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Patients with symptomatic chronic internal carotid artery occlusion (ICAO) face a high risk of recurrent stroke despite receiving aggressive medical therapy. This study aimed to evaluate the effectiveness and safety of hybrid surgery in treating symptomatic chronic ICAO., Methods: This retrospective case series was conducted at a single center. From January 2019 to December 2022, patients with symptomatic chronic ICAO who underwent hybrid surgery were included. We collected baseline data, lesion characteristics, revascularization rates, perioperative complications, and follow-up outcomes., Results: The study enrolled 27 patients, comprising 22 males and 5 females, with symptomatic chronic ICAO. The hybrid surgery achieved a technical success rate of 100% for revascularization (n = 27), with a perioperative complication rate of 14.8% (n = 4). Following a median follow-up of 6.0 months (IQR, 4-10), 21 patients underwent a DSA or CT angiography reexamination, confirming a vascular patency rate of 90.5% (n = 19). One patient required surgery for severe in-stent restenosis, and another experienced asymptomatic occlusion. Clinical follow-ups were conducted for all 26 patients; no new strokes were reported in the qualifying artery territory, with 13 patients scoring 0, 12 scoring 1, and 1 scoring 2 on the mRS., Conclusion: Although hybrid surgery represent a promising option for treating chronic ICAO, they are also associated with a relatively high incidence of treatment-related complications. The application of composite surgery should be based on standardized technical guidelines and the careful selection of patients who are genuinely at high risk for recurrent strokes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery., Methods: Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine., Results: Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries., Discussions: Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries ., Conclusions: Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function., (© 2024. The Author(s).)

It is important to examine the ocular hemodynamic changes after carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with internal carotid artery stenosis (ICAS). We aimed to compare the differences in retinal and optic nerve head blood flow after 2 surgical methods. The ipsilateral eyes of 34 patients who had over 50% ICAS with no ocular findings and 30 healthy controls were included in the study. Foveal avascular zone vessel density in the superficial retinal capillary plexus, deep retinal capillary plexus (DCP), and radial peripapillary capillary plexus (RPCP) were measured with an optical coherence tomography angiography device. These measurements were repeated 1 month after CAS or CEA in patients with ICAS. The preoperative and postoperative values of the patients were compared both within themselves and with the control group. When patients with ICAS were compared with the control group, lower vessel density values were found in the DCP parafovea, RPCP whole image, and peripapillary regions both before and after the procedure. There was no significant difference in terms of other parameters. Furthermore, there was no significant difference in any parameter examined between the pre- and postprocedural values of the patients who underwent CAS and CEA. DCP and RPCP are mostly affected in patients with ICAS. We observed that after application of the CAS and CEA methods, the effects on ocular blood flow were similar., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Carotid endarterectomy (CEA) is effective in treating carotid artery stenosis to prevent stroke. Historically, this operation has been performed utilizing loupe magnification with or without the operating microscope (OM). However, there remains a need for continued improvement in operative visualization and surgical ergonomics. Recently, newly developed digital 'exoscope' has provided the surgeon with unique lighting and magnification as well as improvements in surgical ergonomics and working angle. We sought to review our cumulative experience using a novel 4K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for CEA surgery., Methods: All CEA surgery cases at our institution between 2013 and 2019 using the 4K-HD 3D EX were reviewed. Operative parameters, patient outcome and operator's assessment of the EX compared to OM-assisted cases was conducted., Results: 28 patients were treated, 10 of which were operated using the EX. All procedures were performed without perioperative complications, or significant differences in operative parameters (blood loss <20 cm 3 and 164 ± 49.5 minutes) compared to OM-assisted cases. Operators reported improved level of comfort performing 'high' bifurcation surgery and improved visualization and posture during inspection of the distal ICA lumen as primary advantages of EX-assisted CEA over OM-assisted CEA., Conclusions: The ORBEYE EX, albeit a learning curve necessitating a short period of the OR team, provided safety and outcome comparable to OM-assisted surgery. Potential advantages noted were improved visualization and ergonomics specifically for when extreme working angles were required. Our experience suggests that the exoscope may become a valuable alternative to standard magnification tools in CEA surgery.

Background: Whether the optimization of cerebral oxygenation based on regional cerebral oxygen saturation (rSO 2 ) monitoring reduces the occurrence of cerebral ischemic lesions is unknown., Methods: This multicenter, randomized, controlled trial recruited adults admitted for scheduled carotid endarterectomy. Patients were randomized between the standard of care or optimization of cerebral oxygenation based on rSO 2 monitoring using near-infrared spectroscopy. In the intervention group, in case of a decrease in rSO 2 in the intervention, the following treatments were sequentially recommended: (1) increasing oxygenotherapy, (2) reducing the tidal volume, (3) legs up-raising, (4) performing a fluid challenge and (5) initiating vasopressor support. The primary endpoint was the number of new cerebral ischemic lesions detected using magnetic resonance imaging pre- and postoperatively. Secondary endpoints included new neurological deficits and mortality on day 120 after surgery., Results: Among the 879 patients who were randomized, 665 (75.7%) were men. There was no statistically significant difference between groups for the mean number of new cerebral ischemic lesions per patient up to 3 days after surgery: 0.35 (±1.05) in the standard group vs. 0.58 (±2.83), in the NIRS group; mean difference, 0.23 [95% CI, -0.06 to 0.52]; estimate, 0.22 [95% CI, -0.06 to 0.50]. New neurological deficits up to day 120 after hospital discharge were not different between the groups: 15 (3,39%) in the standard group vs. 42 (5,49%) in the NIRS group; absolute difference, 2,10 [95% CI, -0,62 to 4,82]. There was no significant difference between groups for the median [IQR] hospital length of stay: 4.0 [4.0-6.0] in the standard group vs. 5.0 [4.0-6.0] in the NIRS group; mean difference, -0.11 [95% CI, -0.65 to 0.44]. The mortality rate on day 120 was not different between the standard group (0.68%) vs. the NIRS group (0.92%); absolute difference = 0.24% [95% CI, -0.94 to 1.41]., Conclusions: Among patients undergoing carotid endarterectomy, optimization of cerebral oxygenation based on rSO 2 did not reduce the occurrence of cerebral ischemic lesions postoperatively compared with controlled hypertensive therapy., Trial Registration: ClinicalTrials.gov identifier: NCT01415648., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background and Objectives: Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database., Methods: The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching., Results: After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts., Conclusion: In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Asymptomatic high-grade carotid stenosis is an important therapeutic target for stroke prevention. For decades, the ACAS (Asymptomatic Carotid Atherosclerosis Study) and ACST (Asymptomatic Carotid Surgery Trial) trials provided most of the evidence supporting endarterectomy for patients with asymptomatic high-grade stenosis who were otherwise good candidates for surgery. Since then, transfemoral/transradial carotid stenting and transcarotid artery revascularization have emerged as alternatives to endarterectomy for revascularization. Advances in treatments against atherosclerosis have driven down the rates of stroke in patients managed without revascularization. SPACE-2 (Stent-Protected Angioplasty Versus Carotid Endarterectomy-2), a trial that included endarterectomy, stenting, and medical arms, failed to detect significant differences in stroke rates among treatment groups, but the study was stopped well short of its recruitment goal. CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will be able to clarify whether revascularization by stenting or endarterectomy remains efficacious under conditions of intensive medical management. Transcarotid artery revascularization has a favorable periprocedural risk profile, but randomized trials comparing it to intensive medical management are lacking. Features like intraplaque hemorrhage on MRI and echolucency on B-mode ultrasonography can identify patients at higher risk of stroke with asymptomatic stenosis. High-grade stenosis with poor collaterals can cause hemispheric hypoperfusion, and unstable plaque can cause microemboli, both of which may be treatable risk factors for cognitive impairment. Evidence that there are patients with carotid stenosis who benefit cognitively from revascularization is presently lacking. New risk factors are emerging, like exposure to microplastics and nanoplastics. Strategies to limit exposure will be important without specific medical therapies., Competing Interests: None.

Rationale: Dissection of the cervical arteries is the most commonly identified cause of stroke in young patients. This report helps to investigate the etiology, diagnosis, and treatment of cervical artery dissection (CAD)., Patient Concerns: A 40-year-old female presented with a 3-week history of right carotid artery dissection due to a fall. The patient was admitted to the local hospital 3 weeks ago with a right neck impingement after a fall, and presented with right neck pain. The local hospital CT scan showed a dissection of the middle segment of the right common carotid artery., Diagnoses: The patient clinical manifestations and imaging tests confirmed that right carotid artery dissection., Interventions: Medical treatment with antiplatelet failed, and the CT scan showed progression of dissection. Carotid endarterectomy (CEA) was performed, and the prognosis is good., Outcomes: This patient was followed up at 1 and 6 months after the operation, CT scan showed the original stenotic vessels returned to standard diameter., Lessons: Diagnosis of CAD mainly depends on clinical manifestations and imaging. we recommend that clinicians can prescribe either anticoagulants or antiplatelet therapy. CAD can be effectively treated by surgical reconstruction, if medical treatment with anticoagulation or antiplatelet fails or if carotid aneurysms and/or high-grade carotid stenosis persisted or have newly developed., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: This study sought to ascertain whether a staged approach involving carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) holds superiority over the synchronous (Syn) strategy of CAS or carotid endarterectomy (CEA) and CABG in patients necessitating combined revascularization for concurrent carotid and coronary artery disease., Method: Studies were identified through 3 databases: PubMed, EMBASE, and the Cochrane Library. Statistical significance was defined as a P value of less than .05 for all analyses, conducted using STATA version 12.0., Results: In the comparison between staged versus Syn CAS and CABG for patients with concomitant severe coronary and carotid stenosis, 4 studies were analyzed. The staged procedure was associated with a lower rate of 30-day stroke (OR = 8.329, 95% CI = 1.017-69.229, P = .048) compared to Syn CAS and CABG. In the comparison between staged CAS and CABG versus Syn CEA and CABG for patients with concomitant severe coronary and carotid stenosis, 5 studies were examined. The staged CAS and CABG procedure was associated with a lower rate of mortality (OR = 2.046, 95% CI = 1.304-3.210, P = .002) compared to Syn CEA and CABG., Conclusion: The Syn CAS and CABG was linked to a higher risk of peri-operative stroke compared to staged CAS and CABG. Additionally, patients undergoing staged CAS and CABG exhibited a significantly decreased risk of 30-day mortality compared to Syn CEA and CABG. Future randomized trials or prospective cohorts are essential to confirm and validate these findings., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: To compare carotid endarterectomy patch angioplasty (p-CEA) with eversion carotid endarterectomy (e-CEA) and associated risks of early cardio-cerebrovascular complications., Methods: The study was a prospective randomized single-blind trial, monocentric, clinically applicable, descriptive analytical and comparative. From June 2021 to June 2023, 62 consecutive patients with symptomatic and asymptomatic stenosis of the internal carotid artery, admitted to our department and randomized into two groups: carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. Follow-up for 30 days after surgery., Results: During surgery e-CEA, 70% patients had an arrhythmia, and 24 hours after 66.7%, seven days after 46.7% and month after 13.3%. During surgery p-CEA, 33.3% patients had an arrhythmia, 24 hours later 33.3%, 7 days after 13.3% and 30 days after 13.3% patients. Statistically significant difference observed during surgery (Fishers p =0.004). One day after the surgery rate of patients with arrhythmia that were treated e-CEA has decreased, but it was still higher than after p-CEA (Fishers p =0.010)., Conclusion: The frequency and categorization of postoperative cardiac arrhythmias after eversion carotid endarterectomy, the clinical implications of various postoperative heart rhythm disturbances and their long-term effects on patients need to be further investigate through sufficiently powered randomized controlled studies., (Copyright: © Saudi Medical Journal.)

Competing Interests: Disclosures None.

Carotid stenosis constitutes a common vascular disease that significantly affects cerebral blood flow and thus is associated with patients' cognitive functions. Carotid revascularization techniques [carotid endarterectomy (CEA) and carotid artery stenting (CAS)] may benefit cognition, though there are opposing findings, reporting an apparent decrement in cognitive function, no effect, or an apparent improvement after revascularization. A great number of studies are trying to evaluate the effect of carotid revascularization (CEA, CAS) on patients' cognitive functions, as well as on their psychological condition and quality of life through a baseline and follow-up neuropsychological examination. Recent reviews refer only to the narrow limits of cognitive deficits that may be attributed to carotid stenosis, rather than elucidating the outfit of all aspects of mental and cognitive correlations. Most of those findings depict controversy in current literature as far as the neuropsychological effects of carotid revascularization techniques are concerned, while clinical entities of "vascular dementia" and "vascular depression", as well as intercurrent vascular risk factors are also addressed. This might be taken into consideration, when determining the optimal therapeutic strategy for tackling carotid artery occlusive disease, while best practice clinical decisions should be still focused on stroke prevention and symptoms alleviation, until further research on the field of neuroangiology presents undisputable conclusions regarding the underlying effects of revascularization on mood and cognition. Τhe neurovascular interface, as far as mental and neurocognitive impact of carotid stenosis is concerned, also, comprises, the conceptual pathophysiological entity of "atheroinflammation", underscoring the association of vascular lesions with cognitive impairment, major depressive disorder and bipolar disorder. Chronic recurrent ischemia and chronic low perfusion are also addressed from neurocognitive aspect, regarding therapeutic strategies that might be preferred so as to reduce the burden of chronic cerebrovascular disease in both symptomatic and asymptomatic patients, given the fact that inflammatory processes of vascular complexion underlie both neuroinflammation and atherosclerosis, affecting cerebral perfusion as well as cortical blood flow.

Carotid occlusive disease has been related to ischaemic strokes and cerebral hypoperfusion, thus affecting patients' quality of life, mainly because of cognitive decline and depressive symptoms. Carotid revascularization techniques [carotid endarterectomy (CEA) and carotid artery stenting (CAS)] may, postoperatively, have a positive impact on patients' quality of life and mental condition, though there have been also presented elusive findings and controversial results. The aim of the present study is to evaluate the effect of carotid revascularization (CEA, CAS) on patients' psychological condition and quality of life through a baseline and follow-up examination. We present data of a group of 35 patients (age range:60-80 years, ΜA=70,26-SD=9,05) with severe, left or right, carotid artery stenosis (>75%), presented with or without symptoms, who underwent surgical treatment with CEA or CAS. Baseline and follow-up (6 months post-surgery) evaluation was conducted in order to assess patients' depressive symptoms and quality of life, through completion of the Beck Depression Inventory and WHOQOL-BREF Inventory, respectively. No statistically significant (p < 0,05) effect of the revascularization process on mood or quality of life assessment could be documented for our patients, regardless of the applied technique (CAS or CEA). Our study supports existing evidence that all of the traditional vascular risk factors represent active participants in the inflammatory process, which has also been implicated in the pathophysiology of depression as well as in pathogenesis of atherosclerotic processes. Thus we have to illuminate new links between the two nosological entities, in the crossroads of psychiatry, neurology and angiology, through the pathways of inflammatory reactions and endothelium dysfunctions. Even though the effects of carotid revascularization on patient's mood and quality of life, are often characterized by opposing results, pathophysiological processes of "vascular depression" and "post stroke depression" remain a promising interdisciplinary medical domain, sharing both scientific and clinical interests between the fields of neurosciences and vascular medicine. Our results, regarding the bilateral connection of depression and carotid artery disease, advocate a most probable causality link between atherosclerotic process and depressive symptoms, rather than justifying a direct association between depressive disorders and carotid stenosis and inferred cerebral blood flow reduction per se.

Background: Carotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA., Objective: To compare the safety and effectiveness of different techniques., Methods: Data on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed., Results: A total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44-89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall., Conclusions: This study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke., (© 2024. The Author(s).)

Background: Neuromonitoring during carotid endarterectomy (CEA) under general anesthesia is desirable and may be useful for preventing brain ischemia, but the selection of the most appropriate method remains controversial., Purpose: To determine the effectiveness of near infrared spectroscopy (NIRS) compared to multimodality intraoperative neuromonitoring (IONM) in indicating elective shunts and predicting postoperative neurological status., Methods: This is a retrospective observational study including 86 consecutive patients with CEA under general anesthesia. NIRS and multimodality IONM were performed during the procedure. IONM included electroencephalography (EEG), somatosensory evoked potentials (SSEPs) and transcranial motor-evoked potentials (TcMEPs). Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated for each neuromonitoring modality., Results: NIRS presented a sensitivity and a specificity for detecting brain ischemia of 77.7% and 89.6%, respectively (PPV = 46.6% and NPV = 97.2%). In contrast, a 100% sensitivity and specificity for multimodality IONM was determined (PPV and NPV = 100%). No significant difference (in demographical or clinical data) between "true positive" and "false-positive" patients was identified. Among the methods included in multimodality IONM, EEG showed the best results for predicting postoperative outcome after CEA (PPV and NPV=100%)., Conclusion: NIRS is inferior to multimodality IONM in detecting brain ischemia and predicting postoperative neurological status during CEA under general anesthesia., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Competing Interests: Declaration of Competing Interest None.

To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6-48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion., (© 2024. The Author(s).)

Options for treatment of symptomatic carotid bifurcation disease include carotid endarterectomy (CEA) and carotid artery stenting (CAS). While over the years CEA has established itself as the gold standard for carotid artery revascularization, results from recent trials have shown CAS to be safe and effective in selected patients. This review details the evolution of carotid artery bifurcation disease by highlighting key clinical trials., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG., Methods: Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30 days. Additionally, the composite endpoint of these events was investigated., Results: At 30 days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patients suffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62 min vs. 84 ± 29 min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint., Conclusion: Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article., (© 2024. The Author(s).)

Background: Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse., Methods: Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments., Results: In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm., Conclusions: According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse., (Copyright © 2024 Elsevier Inc. All rights reserved.)

As the average life expectancy increases, neurosurgeons are likely to encounter patients aged 80 years and above with carotid stenosis; however, whether old age affects clinical post-treatment outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) remains inconclusive. Thus, this study aimed to evaluate the outcomes following CEA or CAS in patients aged 80 years and above. This study included older over 80 years (n = 34) and younger patients (<80 years; n = 222) who underwent CEA or CAS between 2012 and 2022. All of them were followed up for a mean of 55 months. All-cause mortality, the incidence of vascular events, ability to perform daily activities, and nursing home admission rates were assessed. During follow-up periods, 34 patients (13.3%) died due to coronary artery disease, malignancy, and pneumonia, and the incidence was significantly higher in the elderly group than in the younger group (P = 0.03; HR, 3.01; 95% CI, 1.53-5.56). The incidence of vascular events did not differ between the older group (29.5%) and the younger group (26.9%, P = 0.58); however, the incidence was significantly higher in patients with high-intensity plaques than in those without that (P = 0.008; HR, 2.83, 95%CI, 1.27-4.87). The decline in the ability to perform daily activities and increased nursing home admission rates were high in elderly patients (P < 0.01). Although the mortality rate was higher in the elderly group, subsequent vascular events were comparable to that in the younger group. The results suggest that CEA and CAS are safe and useful treatments for carotid stenosis in older patients, especially to prevent ipsilateral ischemic stroke.

Background: Technological and surgical approaches to carotid artery stenting (CAS) have evolved. Modern randomised controlled trials comparing CAS and carotid endarterectomy (CEA) are limited, and information about updated post-intervention outcomes are mostly from retrospective, small studies., Aims: This study aims to compare the 30-day outcomes of stroke, transient ischaemic attack (TIA), acute myocardial infarction (AMI) and death with propensity-matched groups of CEA and CAS in asymptomatic and symptomatic patients over a recent study period of new CAS technologies and approaches., Methods: A retrospective, observational, multicentre analysis was conducted including consecutive symptomatic and asymptomatic patients treated with either primary CEA or CAS for internal carotid artery stenosis, between 2015 and 2022. Patients were propensity score-matched based on comorbidities and assessed according to symptom status. Primary endpoints include composite ipsilateral stroke, TIA, AMI and death within 30 days. Secondary endpoints include technical success and length of hospital stay., Results: From a cohort of 1,110 patients, propensity matching produced 269 distinct treatment pairs (n=538). Most patients were asymptomatic (n=456, 85%). All 6 strokes were minor (CEA=2; CAS=4) and registered among asymptomatic patients. One AMI (CEA) and 1 patient death (CAS) were reported among symptomatic patients. Composite stroke/AMI/death were not significantly different between both types of symptom status and both revascularisation techniques (p=0.44 and p=1, respectively). Technical success was 100%. The length of hospital stay was significantly shorter in asymptomatic patients treated with CAS compared to those treated with CEA (p=0.05), but no difference was registered among symptomatic patients (p=0.32)., Conclusions: Propensity-matched analysis suggests that CAS has similar postprocedural outcomes for stroke, AMI and death at 30 days compared to CEA.

Objective: Little guidance exists on the conduct of randomised clinical trials (RCT) that seek to randomise patients away from standard of care. We sought to test the technique of network meta-analysis (NMA) to ascertain best available evidence for the purposes of informing the ethical evaluation of RCTs under these circumstances. We used the example of RCTs for patients with symptomatic, moderate to severe carotid stenosis that seek to compare surgical intervention plus medical therapy (standard of care) versus medical therapy (less than standard of care)., Study Design and Setting: Network meta-analysis of RCTs of adults with symptomatic carotid artery stenosis of 50%-99% who were treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy (MT). The primary outcome was any stroke or death until end of follow-up, and secondary outcome was 30-day risk of ipsilateral stroke/death., Results: We analysed eight studies, with 7187 subjects with symptomatic moderate/severe stenosis (50%-99%). CEA was more efficacious than MT (HR = 0.82, 95% credible intervals [95% CrI] = 0.73-0.92) and CAS (HR 0.73, 95% CrI = 0.62-0.85) for the prevention of any stroke/death. At 30 days, the odds of experiencing an ipsilateral stroke/death were significantly lower in the CEA group compared to both MT (OR = 0.58, 95% CrI = 0.47-0.72) and CAS (OR = 0.68, 95% CrI = 0.55-0.83)., Conclusion: Our results support the feasibility of using NMA to assess best available evidence to inform the ethical evaluation of RCTs seeking to randomise patients away from standard of care. Our results suggest that a strong argument is required to ethically justify the conduct of RCTs that seek to randomise patients away from standard of care in the setting of symptomatic moderate to severe carotid stenosis., (© 2023 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Objectives: To analyze the outcomes of carotid endarterectomy in individuals with carotid artery stenosis in the context of a tertiary care center., Methods: We carried out a retrospective cohort investigation between 2015-2022. Patient data includes demographics, risk factors, preoperative medications, and operative details. The primary outcomes were 30-day postoperative stroke and mortality rates, while the secondary outcome of the study was to assess the morbidity of the procedure., Results: The mean age of the 54 patients was 66.9±9.88 years, and 57.4% were men. The 30-day stroke rate was 3.7%, and the mortality rate was 1.9%. Most patients did not develop postoperative complications; however, surgical site hematoma was the most common complication encountered (12.9%). Long-term follow-up showed disease regression in 68.5% of patients, with a minority of patients developing ipsilateral restenosis. Admission to an intensive care monitoring unit was the only independent predictor of postoperative complications., Conclusion: This study provided insights into the outcomes of carotid endarterectomy in patients with carotid artery stenosis, emphasizing the importance of careful patient selection and postoperative monitoring. Perioperative risks, including stroke and mortality, were within acceptable limits. Further research incorporating structured and non-structured data for predictive analyses, should explore refining patient profiling and optimizing treatment approaches for different carotid artery stenosis clinical and morphological presentations., (Copyright: © Saudi Medical Journal.)

Background: Transcarotid artery revascularization (TCAR) is an interventional therapy for symptomatic internal carotid artery disease. Currently, the utilization of TCAR is contentious due to limited evidence. In this study, we evaluate the safety and efficacy of TCAR in patients with symptomatic internal carotid artery disease compared with carotid endarterectomy (CEA) and carotid artery stenting (CAS)., Methods: A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that used TCAR for the treatment of symptomatic internal carotid artery disease. The primary outcomes included a 30-day stroke or transient ischemic attack, myocardial infarction, and mortality. Secondary outcomes comprised cranial nerve injury and major bleeding. Pooled odds ratios (ORs) for each outcome were calculated to compare TCAR with CEA and CAS. Furthermore, subgroup analyses were performed based on age and degree of stenosis. In addition, a sensitivity analysis was conducted by excluding the vascular quality initiative registry population., Results: A total of 7 studies involving 24 246 patients were analyzed. Within this patient cohort, 4771 individuals underwent TCAR, 12 350 underwent CEA, and 7125 patients underwent CAS. Compared with CAS, TCAR was associated with a similar rate of stroke or transient ischemic attack (OR, 0.77 [95% CI, 0.33-1.82]) and myocardial infarction (OR, 1.29 [95% CI, 0.83-2.01]) but lower mortality (OR, 0.42 [95% CI, 0.22-0.81]). Compared with CEA, TCAR was associated with a higher rate of stroke or transient ischemic attack (OR, 1.26 [95% CI, 1.03-1.54]) but similar rates of myocardial infarction (OR, 0.9 [95% CI, 0.64-1.38]) and mortality (OR, 1.35 [95% CI, 0.87-2.10])., Conclusions: Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS. Prospective randomized trials comparing the 3 modalities are needed., Competing Interests: Disclosures Dr Matouk is a consultant for Silk Road Medical, MicroVention, Inc, and Penumbra, Inc. Dr Derdeyn is involved in data and safety monitoring at Penumbra (MIND and THUNDER trials), NoNO (ESCAPE NEXT and FRONTIER), and Silk Road (NITE trial); has stock options in Euphrates Vascular; and is a professor and a chair at The University of Iowa. Dr Levy is a shareholder and has ownership interest in NeXtGen Biologics, Claret Medical, Inc, Imperative Care, Inc, Rebound Therapeutics, StimMed, and Three Rivers Medical; is a consultant at Clarion, GLG Consulting, Guidepoint Global, Misionix, Mosaic, and StimMed and at Medtronic Vascular, Inc, Microvetion, and Penumbra, Inc; and has stock options in Rapid Medical Ltd. Dr de Havenon has stock options at Certus and TitinKM, received grant/contract from the National Institutes of Health, and is a consultant at Novo Nordisk. Dr Leira received a grant/contract from the American Stroke Association and is a professor of neurology, neurosurgery, and epidemiology at the University of Iowa. Dr Henninger received a grant/contract from the National Institutes of Health and the US Department of Defense and is an associate professor at the University of Massachusetts Medical School. Dr Chaturvedi received a grant/contract from Mayo Clinic. The other authors report no conflicts.

Carotid endarterectomy is the main way to combat atherosclerosis of the carotid arteries, which disrupts cerebral circulation. The generally accepted marker of atherogenesis risk are hemodynamic indices associated with near-wall shear stress. The purpose of the work is to conduct a comparative analysis of hemodynamic indices in various carotid bifurcation models. The influence of a virtual change in the geometric shape of the model in order to optimize hemodynamic indices is also being studied. On the basis of computed angiography data, carotid bifurcation models are constructed, in which critical zones of hemodynamic indices are built using computational fluid dynamics. A comparative analysis of the critical zones for different classes of models is carried out. Comparison of averaged indices for critical zones between 'normal' and post-operative groups gave more than 5-x worse results for the latter. The same results for the near-bifurcation parts of the zones give a 25% better result for postoperative models. Virtual 'removal' of insignificant plaques leads to a deterioration of the indices of up to 40% in the places of the plaque's former location. The described method makes it possible to build the indices critical zones and compare them for various types of models. A technique for virtual changing the shape of a vessel (virtual surgery) is proposed. The novelty of the approach lies in the use for comparative analysis both real vessel models and hypothetical 'improved' virtual ones, as well in the proposed division of post-operative model's critical zones into subzones of different genesis., (© 2024 IOP Publishing Ltd.)

Introduction and Objectives: Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy., Material and Methods: From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis., Results: Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM)., Conclusions: In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia., (Copyright © 2023 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Carotid artery stenosis causes up to 20% of ischemic strokes. Stenting is used as an alternative to endarterectomy in symptomatic patients. Each commercially available stent offers numerous stent diameters/lengths. Most centers thus carefully match each individual stenosis to a specific stent length/diameter stent size. However, this process can be time-consuming and costly while the relative benefit of a custom stent sizing versus one-size-fits-all approach has not been well evaluated yet. We hypothesized that a 'one-size-fits-all' default approach to carotid stenting results in comparable results to a customized approach., Methods: We conducted a descriptive retrospective cohort study on 154 patients who presented to our academic carotid revascularization clinic with symptomatic carotid artery stenosis who underwent carotid artery stenting for peri- and postprocedural carotid artery stenting complications. The primary outcomes were periprocedural (within 24 hours of the procedure) or postprocedural (within 30 days of the procedure) TIA, stroke, or death. The secondary outcome was the estimated degree of stenosis on follow-up ultrasound performed within 6 months of the procedure., Results: The complication rate within the first 24 hours was 4.5% while that during the first 30 days postprocedure was 6.5%. Age over 80 and degree of stenosis on postprocedural cerebral angiogram were associated with an increased risk of complications. Severe restenosis was reported in 16.8% of patients within 6 months postprocedure., Conclusion: Our study suggests that using a simplified, one-size-fits-all, approach to carotid stenting results in safe and effective outcomes, suggesting an alternative to simplify a complex medical procedure.

Aim: Analysis of in-hospital and long-term results of carotid endarterectomy (CEE) in patients with different severity of coronary atherosclerosis., Material and Methods: This comparative, retrospective, open study for the period from January 2013 to April 2020 included 1719 patients operated on for occlusive-stenotic lesions of the internal carotid arteries (ICA). Classical and eversion CEA were used as revascularization strategies. The criteria for inclusion in the study were: 1. Presence of coronary angiography within six months before the present CEE; 2. A history of myocardial revascularization in patients with severe coronary lesions. Depending on the severity of coronary atherosclerosis, all patients were divided into 3 groups: Group 1-871 (50.7 %) patients - with the presence of hemodynamically significant stenosis of the coronary arteries (CA) with a history of myocardial revascularization; Group 2-496 (28.8 %) patients - with the presence of hemodynamically insignificant lesions of the coronary artery (up to 70 %, not inclusive, and the trunk of the left coronary artery, up to 50 %, not inclusive); Group 3-352 (20.5 %) patients - without signs of atherosclerotic lesions of the coronary artery. In group 1, the observation period was 56.8±23.2 months, in group 2-62.0±15.6 months, in group 3-58.1±20.4 months., Results: During the hospital observation period, there were no significant intergroup differences in the number of complications. All cardiovascular events were detected in isolated cases. The most common injury was damage to the cranial nerves, diagnosed in every fifth patient in the total sample. The combined endpoint (CET), including death + myocardial infarction (MI) + acute cerebrovascular accident/transient ischemic attack (stroke/TIA), was 0.75 % (n=13). In the long-term follow-up period, when comparing survival curves, group 3 revealed the largest number of ischemic strokes (p = 0.007), myocardial infarction (p = 0.03), and CCT (p = 0.005). There were no intergroup differences in the number of deaths (p=0.62)., Conclusion: The results of the study showed that there was no significant intergroup difference in the development of complications at the hospital postoperative stage. However, in the long-term follow-up period, a group of patients with isolated lesions of the ICA demonstrated a rapid increase in the number of MI, stroke/TIA, and a combined endpoint, which was apparently associated with low compliance and progression of atherosclerosis in previously unaffected arteries., Competing Interests: Declaration of Competing Interest None in the template., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Previous literature has established an association between acute silent ischemic lesions (ASILs) and elevated susceptibility to future adverse clinical outcomes. The present study endeavors to scrutinize the prognostic significance of preprocedural ASILs, as detected through diffusion-weighted imaging and apparent diffusion coefficient metrics, in relation to subsequent adverse events-namely, stroke, myocardial infarction, and all-cause death-following carotid revascularization in a cohort of patients with symptomatic carotid stenosis., Materials and Methods: Subjects were extracted from a comprehensive retrospective dataset involving symptomatic carotid stenosis cases that underwent carotid revascularization at a tertiary healthcare institution in China, spanning January 2019 to March 2022. Of the 2663 initially screened patients (symptomatic carotid stenosis=1600; asymptomatic carotid stenosis=1063), a total of 1172 individuals with symptomatic carotid stenosis were retained for subsequent analysis. Stratification was implemented based on the presence or absence of ASILs. The primary endpoint constituted a composite measure of in-hospital stroke, myocardial infarction, or all-cause death. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) treatment modalities were individually subjected to propensity score-matched analyses., Results: Among the 584 subjects who underwent CEA, 91 ASIL-positive and 91 ASIL-negative (NASIL) cases were propensity score-matched. Notably, the ASIL cohort demonstrated a statistically significant augmentation in the risk of primary outcomes relative to the NASIL group [10.99 vs. 1.10%; absolute risk difference, 9.89% (95% CI: 3.12-16.66%); RR, 10.00 (95% CI: 1.31-76.52); P =0.01]. Similarly, within the 588 CAS-treated patients, 107 ASIL-positive and 107 NASIL cases were matched, revealing a correspondingly elevated risk of primary outcomes in the ASIL group [9.35 vs. 1.87%; absolute risk difference, 7.48% (95% CI: 1.39-13.56%); RR, 5.00 (95% CI: 1.12-22.28); P =0.02]., Conclusions: ASILs portend an elevated risk for grave adverse events postcarotid revascularization, irrespective of the specific revascularization technique employed-be it CEA or CAS. Thus, ASILs may serve as a potent biomarker for procedural risk stratification in the context of carotid revascularization., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)