Carotid endarterectomy for symptomic and asymptomic stenosis: Report of 65388 cases (Russian register).

AIM: Analysis of in-hospital and long-term results of carotid endarterectomy in patients with asymptomatic and symptomatic stenoses. MATERIALS AND METHODS: The sample was formed by completely including all cases of carotid endarterectomy (n = 65,388) performed during the period from May 1, 2015 to November 1, 2023. Depending on the symptomatic/asymptomatic nature of the stenosis, all patients were divided into two groups: group 1 - n = 39,172 (75.2%) - patients with asymptomatic stenosis; Group 2 - n = 26216 (24.8%) - patients with symptomatic stenosis. The postoperative follow-up period was 53.5 ± 31.4 months. RESULTS: In the hospital postoperative period, the groups were comparable in the incidence of death (group 1: n = 164 (0.41%); group 2: n = 124 (0.47%); p = .3), transient ischemic attack (group 1: n = 116 (0.29%); group 2: n = 88 (0.33%); p = .37), myocardial infarction (group 1: n = 32 (0.08%); group 2: n = 19 (0.07%); p = .68), thrombosis of the internal carotid artery (group 1: n = 8 (0.02%); group 2: n = 2 (0.007%); p = 0, 19), bleeding (group 1: n = 58 (0.14%); group 2: n = 33 (0.12%); p = .45). In group 2, ischemic stroke developed statistically more often (group 1: n = 328 (0.83%); group 2: n = 286 (1.09%); p = .001), which led to a higher value of the combined endpoint (group 1: n = 640 (1.63%); group 2: n = 517 (1.97%); p = .001). In the long-term postoperative period, the groups were comparable in cases of death (group 1: n = 65 (0.16%); group 2: n = 41 (0.15%); p = .76) and death from cardiovascular causes (group 1: n = 59 (0.15%); group 2: n = 33 (0.12%); p = .4). A greater number of ischemic strokes were detected in patients of group 2 (group 1: n = 213 (0.54%); group 2: n = 187 (0.71%); p = .006). In group 1, hemodynamically significant restenosis (≥70%) of the internal carotid artery was more often diagnosed (group 1: n = 974 (2.49%); group 2: n = 351 (1.34%); p < .0001) and myocardial infarction (group 1: n = 66 (0.16%); group 2: n = 34 (0.13%); p < .0001). When analyzing stroke-free survival, analysis of Kaplan-Meier curves showed that a statistically larger number of strokes were diagnosed in group 2 (p < .0001). CONCLUSION: Due to the fact that the patients were initially not comparable for a number of indicators, to achieve balance, we applied propensity score matching analysis. Thus, group 1 consisted of 24,381 patients, and group 2 consisted of 17,219 patients. In the hospital postoperative period, statistically significant differences were obtained only in the combined end point, which was greater in group 2 (group 1: n = 465 (1.9%); group 2: n = 382 (2.2%); p = .02). In the long-term follow-up period, after applying propensity score matching, no statistically significant differences were obtained between groups.

Time Course of Asymptomatic Stenosis in Multiple Lumbar Spinal Stenosis-Five-Year Results of Selective Decompression of Symptomatic Levels.

Background: In the diagnosis of lumbar spinal stenosis (LSS), finding stenosis with magnetic resonance imaging (MRI) does not always correlate with symptoms such as sciatica or intermittent claudication. We perform decompression surgery only for cases where the levels diagnosed from neurological findings are symptomatic, even if multiple stenoses are observed on MRI. The objective of this study was to examine the time course of asymptomatic stenosis in patients with LSS after they underwent decompression surgery for symptomatic stenosis. Materials and Methods: The participants in this study comprised 137 LSS patients who underwent single-level L4-5 decompression surgery from 2003 to 2013. The dural sac cross-sectional area at the L3-4 disc level was calculated based on preoperative MRI. A cross-sectional area less than 50 mm2 was defined as stenosis. The patients were grouped, according to additional spinal stenosis at the L3-4 level, into a double group (16 cases) with L3-4 stenosis, and a single group (121 cases) without L3-4 stenosis. Incidences of new-onset symptoms originating from L3-4 and additional L3-4-level surgery were examined. Results: Five years after surgery, 98 cases (72%) completed follow-up. During follow-up, 2 of 12 patients in the double group (16.7%) and 9 of 86 patients in the single group (10.5%) presented with new-onset symptoms originating from L3-4, showing no significant difference between groups. Additional L3-4 surgery was performed for one patient (8.3%) in the double group and three patients (3.5%) in the single group; again, no significant difference was shown. Conclusion: Patients with asymptomatic L3-4 stenosis on preoperative MRI were not prone to develop new symptoms or need additional L3-4-level surgery within 5 years after surgery when compared to patients without preoperative L3-4 stenosis. These results indicate that prophylactic decompression for asymptomatic levels is unnecessary.

Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET.

OBJECTIVE: It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation. METHODS: Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation. RESULTS: Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points. CONCLUSION: This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.

Risk factors for mortality within 5 years of carotid endarterectomy for asymptomatic stenosis.

OBJECTIVE: The current Society for Vascular Surgery guidelines for the treatment of patients with asymptomatic carotid stenosis recommend endarterectomy for patients with >70% stenosis and acceptable surgical risk. The reduced rate of stroke with modern medical therapy has increased the importance of careful selection in deciding which patients should undergo elective carotid endarterectomy (CEA) for asymptomatic disease. It would, therefore, be very prudent to investigate preexisting variables predictive of 5-year mortality for patients meeting the criteria to undergo CEA. METHODS: The Vascular Quality Initiative was queried from 2003 onward for all cases of CEA. Inclusion in the study required the following: (1) documentation of survival status; (2) complete data on all incorporated demographic study variables; and (3) asymptomatic neurologic status. The variables present at surgery were investigated using binary logistic regression to identify multivariate predictors of 5-year mortality. The highest risk variables were then interrogated for an additive effect regarding long-term mortality. A subanalysis was performed for patients aged >80 years. RESULTS: A total of 30,615 patients met the inclusion criteria, 5414 (18%) of whom had died within 5 years. The highest risk variables were classified as those that had had an adjusted odds ratio >1.25, P < .001, and beta coefficient of ≥0.25. These included a body mass index <20 kg/m2, diabetes mellitus, a history of congestive heart failure, renal insufficiency, end-stage renal disease, chronic obstructive pulmonary disease, living status other than home, prior lower extremity bypass, prior major amputation, Black race relative to other races combined, hemoglobin <10 mg/dL, a history of neck irradiation, and a history of smoking. Age had an annual odds ratio of 1.04 (P < .001). Other variables that achieved a statistically significant (P < .05) association with 5-year mortality were coronary artery disease, a positive stress test or the occurrence of myocardial infarction within 2 years, lower extremity arterial intervention, aneurysm repair, and P2Y12 inhibitor therapy at surgery. The use of statin and aspirin therapy at surgery were both protective against 5-year mortality (P < .001). CONCLUSIONS: We identified 12 particularly high-risk variables, which, in combination, progressively predicted for increasing mortality within 5 years of CEA performed for asymptomatic stenosis. Special attention should be given to patients aged >80 years and patients with any history of congestive heart failure regardless of current symptoms, chronic obstructive pulmonary disease, renal insufficiency or end-stage renal disease, peripheral artery disease, diabetes, and variables associated with frailty (BMI under 20, anemia, assisted living status).

Association of ATP2B1 common variants with asymptomatic intracranial and extracranial large artery stenosis in hypertension patients.

BACKGROUND AND AIMS: Genetic factors play an important role in the cervico-cerebral large-artery atherosclerotic stenosis (LAS), and ATP2B1 gene has been associated with the process of atherosclerosis disorders, such as coronary artery disease and arterial stiffness. But there is little information about the relationship between ATP2B1 gene and atherosclerosis in the intracranial arteries. We hereby investigated the association of common variants in ATP2B1 gene with LAS in asymptomatic Chinese hypertension patients. METHODS: The stenosis of intracranial and extracranial arteries were evaluated in 899 subjects through computerized tomography angiography from the aortic arch to the skull base. A total of 11 ATP2B1 common variants were genotyped. Multivariate logistic regression was carried out in a dominant model with confounding factors adjusted. RESULTS: rs17249754-A (OR = 0.43, p = 0.0002) and rs1401982-G (OR = 0.47, p = 0.0007) were associated with decreased susceptibility of concurrent extra and intracranial stenosis even after Bonferroni correction. These two minor alleles were also significantly associated with less stenotic arteries and moderate-to-severe stenosis. CONCLUSION: rs17249754 and rs1401982 were associated with asymptomatic LAS in stroke-free Chinese hypertension patients and might benefit early recognition of LAS patients in clinical practice.

Asymptomatic carotid stenosis and cognitive improvement using transcervical stenting with protective flow reversal technique.

OBJECTIVES: The relationship between carotid artery stenosis and cognitive function in individuals without a history of stroke is not clear. The possible pathomechanisms of cognitive impairment include silent embolization and hypoperfusion. In this study the aim was to assess cognitive changes after transcervical carotid artery stenting with proximal cerebral protection by flow reversal in patients with asymptomatic carotid stenosis, a novel technique that has been proved to decrease the number intraoperative emboli. METHODS: 25 consecutive patients were assessed, of which 22 were men (88%) mean age of 74 years with severe asymptomatic carotid stenosis who underwent revascularization by carotid artery stenting (CAS) with flow reversal. Patients were evaluated 1 day before and 6 months after the procedure using a standardized neuropsychological battery. Test scores were adjusted according to age, sex, education level and were standardized (0-100). The mean of all the cognitive function scores yielded the global cognitive score (GCS). RESULTS: There were no neurological complications during the procedure or during hospitalization in any patient. No deaths or cardiac complications occurred in any patient. The pre-procedure neuropsychological study showed cognitive impairment in: information processing speed in 15 patients (62.5%), visuospatial function in 14 (56.0%), memory in 18 (72.0%), executive functions in 14 (56.0%), language in three (12.0%), attention in 10 (40.0%), and global cognitive performance in eight (32.0%). Comparison of these scores with those obtained 6-month post-procedure showed significant improvement in GCS in all patients (p = .002), with a particularly marked gain in information processing speed (p = .018). Although significant improvement was not found for the remaining cognitive functions assessed, some gain was documented, and there was no deterioration. CONCLUSIONS: Revascularization by transcervical CAS with flow reversal for cerebral protection results in improved neurocognitive performance in asymptomatic elderly patients with severe carotid artery stenosis.

Management of asymptomatic carotid stenosis.

Patients with asymptomatic carotid stenosis (ACS) are at very high risk of coronary events, so they should all receive intensive medical therapy. What is often accepted as "best medical therapy" is usually suboptimal. Truly intensive medical therapy includes lifestyle modification, particularly smoking cessation and a Mediterranean diet. All patients with ACS should receive intensive lipid-lowering therapy, should have their blood pressure well controlled, and should receive B vitamins for lowering of plasma total homocysteine (tHcy) if levels are high; a commonly missed cause of elevated tHcy is metabolic B12 deficiency, which should be diagnosed and treated. Most patients with ACS would be better treated with intensive medical therapy than with either carotid endarterectomy (CEA) or stenting (CAS). A process called "treating arteries instead of treating risk factors" markedly reduced the risk of ACS in an observational study; a randomized trial vs. usual care should be carried out. The few patients with ACS who could benefit (~15%, or perhaps more if recent evidence regarding the risk of intraplaque hemorrhage is borne out) can be identified by a number of features. These include microemboli on transcranial Doppler, intraplaque hemorrhage, reduced cerebrovascular reserve, and echolucency of plaques, particularly "juxtaluminal black plaque". No patient should be subjected to CAS or CEA without evidence of high-risk features, because in most cases the 1-year risk of stroke or death with intervention is higher with either CEA (~2%) or CAS (~4%) than with intensive medical therapy (~0.5%). Most patients, particularly the elderly, would be better treated with CEA than CAS. Most strokes can be prevented in patients with ACS, but truly intensive medical therapy is required.

Comparison of long-term results of carotid endarterectomy for asymptomatic carotid artery stenosis.

This article summarizes the current study situation on treatment of asymptomatic carotid artery stenosis and discusses the evidence situation in the literature. The 10-year results of the ACST study have shown that in comparison to conservative treatment, carotid endarterectomy (CEA) has retained a positive long-term effect on the reduction of all forms of stroke. All multicenter randomized controlled trials comparing CEA with carotid artery stenting (CAS) and, in particular the SAPHIRE and CAVATAS studies, have in common that despite a basic evidence level of Ib, the case numbers of asymptomatic patients are too small for a conclusive therapy recommendation. In the overall assessment of the CREST study the resulting difference in the questionable endpoint of "perioperative myocardial infarction" in favor of the CAS methods, could not be confirmed for exclusively asymptomatic patients. In the long-term course of the CREST study, both methods were classified as equivalent, even when the 4­year results of periprocedural and postprocedural stroke rates in the separate assessment of the asymptomatic study participants clearly favored the CEA. The results of the ACST-1 study showed an equivalent effect of both treatment methods with respect to all investigated endpoints; however, the unequal sizes of the groups in addition to the statistically insufficient case numbers put a question mark on the validity of the study results. The results of the ASCT-2 and CREST-2 studies are to be awaited, which also investigate the significance of "CEA versus CAS" (ASCT-2) and "CEA/CAS + best medical treatment (BMT) versus BMT alone" in only asymptomatic stenoses. The current S3 guidelines allow operative therapy to be considered in patients with a 60-99% asymptomatic carotid artery stenosis, because the risk of stroke is statistically significantly reduced.

Management of asymptomatic cervical spinal stenosis in the setting of symptomatic tandem lumbar stenosis: a review.

INTRODUCTION: This article reviews the literature regarding tandem asymptomatic cervical stenosis in the setting of symptomatic lumbar stenosis. The presenting features of cervical spondylotic myelopathy are insidious and consistent with upper motor neuron loss. Often, asymptomatic cervical stenosis is encountered in the clinical setting during the workup of a symptomatic lumbar stenosis and degenerative disease. METHODS: A PubMed (1966 to July 2013) electronic database search was conducted for articles pertaining to the diagnosis of incidentally discovered cervical cord compression. Keywords and MESH terms were limited to asymptomatic cervical stenosis, asymptomatic cervical compression, asymptomatic spinal stenosis, asymptomatic cervical spondylosis, and asymptomatic cervical cord signal. The primary literature topics for manuscript inclusion were the development of symptomatic myelopathy from asymptomatic cord signal edema, as well as the presence of tandem stenosis as defined above by incidental cervical stenosis during the workup of lumbar degenerative disease. RESULTS: There were no previous systematic reviews, randomized trials, or prospective studies on the management of tandem cervical and thoracic stenosis. Five studies, all retrospective reviews containing relevant data were included in the review. Asymptomatic cervical stenosis encountered in the investigation of lumbar symptoms was had a 23% incidence. A risk of 5% per year of development of myelopathy previously reported. CONCLUSIONS: There is insufficient evidence in the literature to support the need for preemptive decompression for asymptomatic cervical cord compression with or without a correlative T2 hyperintense cord signal. Early diagnosis of radiculopathy or myelopathy in patients with cervical stenosis (i.e., through conversion of asymptomatic to symptomatic state) is important as each patient with in this clinical setting should be followed closely, as the literature shows the tendency for a clinical progression to eventual cervical myelopathy.

Incidence and risk factors for medical complications and 30-day end points after carotid artery stenting.

With the extensive use of carotid artery stenting (CAS) surgeries, scholars are paying more attention to the safety and efficiency of CAS. Our study aims to analyze the clinical efficiency, safety, and technical feasibility of CAS surgery in the treatment of carotid artery stenosis. A total of 379 cases of CAS were collected and retrospectively analyzed. The outcomes were summarized according to decrease in stenosis extent, incidence of early complications after procedure, 30-day end point events, and the follow-up data. Logistic regression was employed to analyze the correlations between risk factors and complications within 30 days and 30-day end points of stroke, myocardial infarctions (MIs), and mortality. The average extent of stenosis reduced from preoperative (81% ± 17%) to postoperative (26% ± 17%). In all, 53 patients had 72 medical complications, including 6 (1.58%) cerebral hemorrhage, 7 (1.85%) cerebral infarction, 5 (1.32%) transient ischemic attack (TIA), 5 (1.32%) heart failure, 10 (2.63%) symptomatic hypertension, 21 (5.54%) symptomatic hypotension, 10 (2.63%) symptomatic bradycardia, and 8 other complications; 15 patients had at least 2 complications. Advanced age, diabetes, and heart failure were associated with the high incidence of early complications (P < .05). Asymptomatic stenosis (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.131-1.131, P = .0426) and diabetes (OR = 3.38, 95% CI: 1.340-8.574, P = .0099) were correlated with the incidence of 30-day end point events. Diabetes and symptomatic stenosis are independent risk factors for 30-day end point events of CAS. Advanced age, hypertension, and vascular unstable plaque will increase the risk of postoperative complications.