Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients.

OBJECTIVE: Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS: All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS: Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS: IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.

Decision aids for patients with carotid stenosis.

BACKGROUND: Shared decision-making tools have been underused by clinicians in real-world practice. Changes to the National Coverage Determination by Medicare for carotid stenting greatly expand the coverage for patients, but simultaneously require a shared decision-making interaction that involves the use of a validated tool. Accordingly, our objective was to evaluate the currently available decision aids for carotid stenosis. METHODS: We conducted a review of the literature for published work on decision aids for the treatment of carotid disease. RESULTS: Four publications met inclusion criteria. We found the format of the decision aid impacted patient comprehension and decision making, although patient characteristics also played a role in the therapeutic decisions made. Notably, none of the available decision aids included the widely adopted transcarotid artery revascularization as an option. CONCLUSIONS: Further work is needed in the development of a widespread validated decision aid instrument for patients with carotid stenosis.

Patient decision-making in the era of transcarotid artery revascularization.

OBJECTIVE: The National Coverage Determination on carotid stenting by Medicare in October 2023 stipulates that patients participate in a shared decision-making (SDM) conversation with their proceduralist before an intervention. However, to date, there is no validated SDM tool that incorporates transcarotid artery revascularization (TCAR) into its decision platform. Our objective was to elicit patient and surgeon experiences and preferences through a qualitative approach to better inform the SDM process surrounding carotid revascularization. METHODS: We performed longitudinal perioperative semistructured interviews of 20 participants using purposive maximum variation sampling, a qualitative technique designed for identification and selection of information-rich cases, to define domains important to participants undergoing carotid endarterectomy or TCAR and impressions of SDM. We also performed interviews with nine vascular surgeons to elicit their input on the SDM process surrounding carotid revascularization. Interview data were coded and analyzed using inductive content analysis coding. RESULTS: We identified three important domains that contribute to the participants' ultimate decision on which procedure to choose: their individual values, their understanding of the disease and each procedure, and how they prefer to make medical decisions. Participant values included themes such as success rates, "wanting to feel better," and the proceduralist's experience. Participants varied in their desired degree of understanding of carotid disease, but all individuals wished to discuss each option with their proceduralist. Participants' desired medical decision-making style varied on a spectrum from complete autonomy to wanting the proceduralist to make the decision for them. Participants who preferred carotid endarterectomy felt outcomes were superior to TCAR and often expressed a desire to eliminate the carotid plaque. Those selecting TCAR felt it was a newer, less invasive option with the shortest procedural and recovery times. Surgeons frequently noted patient factors such as age and anatomy, as well as the availability of long-term data, as reasons to preferentially select one procedure. For most participants, their surgeon was viewed as the most important source of information surrounding their disease and procedure. CONCLUSIONS: SDM surrounding carotid revascularization is nuanced and marked by variation in patient preferences surrounding autonomy when choosing treatment. Given the mandate by Medicare to participate in a SDM interaction before carotid stenting, this analysis offers critical insights that can help to guide an efficient and effective dialog between patients and providers to arrive at a shared decision surrounding therapeutic intervention for patients with carotid disease.

Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease.

OBJECTIVE: Patients with chronic kidney disease (CKD) are considered a high-risk population, and the optimal approach to the treatment of carotid disease remains unclear. Thus, we compared outcomes following carotid revascularization for patients with CKD by operative approach of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid arterial revascularization (TCAR). METHODS: The Vascular Quality Initiative was analyzed for patients undergoing carotid revascularizations (CEA, TFCAS, and TCAR) from 2016 to 2021. Patients with normal renal function (estimated glomular filtration rate >90 mL/min/1.72 m2) were excluded. Asymptomatic and symptomatic carotid stenosis were assessed separately. Preoperative demographics, operative details, and outcomes of 30-day mortality, stroke, myocardial infarction (MI), and composite variable of stroke/death were compared. Multivariable analysis adjusted for differences in groups, including CKD stage. RESULTS: A total of 90,343 patients with CKD underwent revascularization (CEA, n = 66,870; TCAR, n = 13,459; and TFCAS, n = 10,014; asymptomatic, 63%; symptomatic, 37%). Composite 30-day mortality/stroke rates were: asymptomatic: CEA, 1.4%; TCAR, 1.2%; TFCAS, 1.8%; and symptomatic: CEA, 2.7%; TCAR, 2.3%; TFCAS, 3.7%. In adjusted analysis, TCAR had lower 30-day mortality compared with CEA (asymptomatic: adjusted odds ratio [aOR], 0.4; 95% confidence interval [CI], 0.3-0.7; symptomatic: aOR, 0.5; 95% CI, 0.3-0.7), and no difference in stroke, MI, or the composite outcome of stroke/death in both symptom cohorts. TCAR had lower risk of other cardiac complications compared with CEA in asymptomatic patients (aOR, 0.7; 95% CI, 0.6-0.9) and had similar risk in symptomatic patients. Compared with TFCAS, TCAR patients had lower 30-day mortality (asymptomatic: aOR, 0.5; 95% CI, 0.2-0.95; symptomatic: aOR, 0.3; 95% CI, 0.2-0.4), stroke (symptomatic: aOR, 0.7; 95% CI, 0.5-0.97), and stroke/death (asymptomatic: aOR, 0.7; 95% CI, 0.5-0.97; symptomatic: aOR, 0.6; 95% CI, 0.4-0.7), but no differences in MI or other cardiac complications. Patients treated with TFCAS had higher 30-day mortality (aOR, 1.8; 95% CI, 1.2-2.5) and stroke risk (aOR, 1.3; 95% CI, 1.02-1.7) in symptomatic patients compared with CEA. There were no differences in MI or other cardiac complications. CONCLUSIONS: Among patients with CKD, TCAR and CEA showed rates of stroke/death less than 2% for asymptomatic patients and less than 3% for symptomatic patients. Given the increased risk of major morbidity and mortality, TFCAS should not be performed in patients with CKD who are otherwise anatomic candidates for TCAR or CEA.

Treatment of symptomatic carotid webs.

OBJECTIVE: The present study aims to describe the clinical characteristics and treatment outcomes of patients with symptomatic carotid web treated at a single institution in South America. MATERIALS AND METHODS: Retrospective study of a single-center experience of patients with carotid webs surgically treated from September 2019 to September 2023. RESULTS: 10 patients had carotid webs, six (60%) were females. Median age was 54.5 years (range: 35-77 years). All patients were symptomatic. Diagnosis was made in 90% (n=9) of the patients with either computed tomography angiography or magnetic resonance alone. One (10%) patient underwent angiography for definite diagnosis. The median interval from the first neurological event to intervention was 90 months (range: 3 days- 108 months). Four (40%) patients underwent surgical treatment within one month from symptom onset and carotid web diagnosis, with a median of 3.5 days (range: 3-9 days). Six (60%) patients underwent delayed surgical treatment since the cause of the neurological event was uncertain, with a median of 54 months (range: 6 - 108 months). These six patients had recurrent neurological events. Three (30%) patients underwent carotid endarterectomies with polyurethane patch and three (30%) by eversion technique. Three (30%) patients underwent segmental resection and reanastomosis of the internal carotid artery. One underwent internal carotid artery plasty with saphenous vein. At a median follow-up of 30 months (range: 6-46 months), one patient persists with mild aphasia, another patient has severe aphasia and right hemiparesis, both as sequalae of their initial strokes, and another patient has suffered 3 non-ischemic episodes of brief transient right hemiparesis attributed to epileptic seizures. The other seven patients remain without new neurological events. CONCLUSION: Neurological events of carotid distribution deserve accurate imaging work up, keeping in mind the diagnosis of carotid web. Surgical treatment for carotid web seems effective for preventing recurrences; nevertheless, further studies are warranted to define the best management for these patients.

2023 Update on Vascular Anesthesia.

The authors thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.

Impact of continued clopidogrel use on outcomes of patients undergoing carotid endarterectomy.

OBJECTIVE: The aim of this study was to evaluate the use of clopidogrel at the time of carotid endarterectomy (CEA) and its association with postoperative complications. METHODS: Single-institution, retrospective review of a prospective database. RESULTS: From 2010 to 2017, CEA was performed in 1066 consecutive patients (median age, 73 years; 66% men). The indications for operation included ≥70% asymptomatic stenosis (458; 43%), prior stroke (314; 29%), and transient cerebral or retinal ischemia (294; 28%). At the time of operation, 509 (48%) patients were taking aspirin alone, 441 (41%) were taking clopidogrel (374 in combination with aspirin, 67 as sole therapy), 83 (8%) were on no documented antiplatelet medication, and 33 (3%) were taking warfarin (with therapeutic international normalized ratio). The likelihood of clopidogrel use at the time of operation was higher for patients with a history of symptomatic carotid disease (P = .002). Over the study period, clopidogrel use increased from 31.9% in 2010 to 56.8% in 2017, which corresponds to an 11% (95% confidence interval, 6%-15%) increase annually. Postoperative strokes occurred in 15 patients (overall incidence, 1.4%), the majority of which were minor (12/15; 80%). Six strokes occurred in patients taking aspirin alone (6/509; 1.2%), two in patients on clopidogrel and aspirin (2/441; 0.5%), two in patients taking clopidogrel alone (2/67; 2.9%), three in patients on no documented antiplatelet medication (3/83; 3.6%), and two in those taking warfarin (one of which was secondary to a fatal intracranial hemorrhage within 30 days of discharge [2/33; 6.1%]). The 30-day mortality rate was 0.03% (3/1066); the risk for the combined endpoint of any stroke, death, or myocardial infarction (MI) was 2.3% (25/1066), and the risk for major stroke, death, or MI was 1.2%. There was no apparent association between clopidogrel use and the incidence of postoperative bleeding (P = .59) or any other postoperative complication (stroke, death, MI, cranial nerve injury; P = .15). CONCLUSIONS: Clopidogrel use in our CEA practice has increased over time and has not been associated with an increased risk of postoperative complications, including bleeding. These data suggest that clopidogrel should not be discontinued prior to CEA and should be considered as part of 'optimal medical therapy' in patients undergoing CEA.

Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes.

OBJECTIVE: Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter. METHODS: We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome. RESULTS: Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052). CONCLUSIONS: tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.

Importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease.

Stroke is a leading cause of death and disability worldwide. Women are disproportionately affected by stroke, exhibiting higher mortality and disability rates post-stroke than men. Clinical stroke research has historically included mostly men and studies were not properly designed to perform sex- and gender-based analyses, leading to under-appreciation of differences between men and women in stroke presentation, outcomes, and response to treatment. Reasons for these differences are likely multifactorial; some are due to gender-related factors (i.e. decreased social support, lack of stroke awareness), yet others result from biological differences between sexes. Unlike men, women often present with 'atypical' stroke symptoms. Lack of awareness of 'atypical' presentation has led to delays in hospital arrival, diagnosis, and treatment of women. Differences also extend to carotid atherosclerotic disease, a cause of stroke, where plaques isolated from women are undeniably different in morphology/composition compared to men. As a result, women may require different treatment than men, as evidenced by the fact that they derive less benefit from carotid revascularization than men but more benefit from medical management. Despite this, women are less likely than men to receive medical therapy for cardiovascular risk factor management. This review focuses on the importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease, summarizing the current evidence with respect to (i) stroke incidence, mortality, awareness, and outcomes, (ii) carotid plaque prevalence, morphology and composition, and gene connectivity, (iii) the role of sex hormones and sex chromosomes in atherosclerosis and ischaemic stroke risk, and (iv) carotid disease management.

3D Ultrasound Reconstructions of the Carotid Artery and Thyroid Gland Using Artificial-Intelligence-Based Automatic Segmentation-Qualitative and Quantitative Evaluation of the Segmentation Results via Comparison with CT Angiography.

The aim of this study was to evaluate the feasibility of a noninvasive and low-operator-dependent imaging method for carotid-artery-stenosis diagnosis. A previously developed prototype for 3D ultrasound scans based on a standard ultrasound machine and a pose reading sensor was used for this study. Working in a 3D space and processing data using automatic segmentation lowers operator dependency. Additionally, ultrasound imaging is a noninvasive diagnosis method. Artificial intelligence (AI)-based automatic segmentation of the acquired data was performed for the reconstruction and visualization of the scanned area: the carotid artery wall, the carotid artery circulated lumen, soft plaque, and calcified plaque. A qualitative evaluation was conducted via comparing the US reconstruction results with the CT angiographies of healthy and carotid-artery-disease patients. The overall scores for the automated segmentation using the MultiResUNet model for all segmented classes in our study were 0.80 for the IoU and 0.94 for the Dice. The present study demonstrated the potential of the MultiResUNet-based model for 2D-ultrasound-image automated segmentation for atherosclerosis diagnosis purposes. Using 3D ultrasound reconstructions may help operators achieve better spatial orientation and evaluation of segmentation results.

Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery.

BACKGROUND: There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB. METHODS: A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation. RESULTS: From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischaemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days. CONCLUSION: Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.

CT angiography for diagnosis of carotid near-occlusion: a digital subtraction angiography validation study.

INTRODUCTION: Carotid near-occlusion (CNO) is a variant of severe stenosis where there is a distal luminal collapse of the internal carotid artery (ICA) beyond a tight stenosis. This study aimed to validate new visual extracranial diagnostic CT angiography (CTA) criteria, for the diagnosis of CNO. The new criteria include distal ICA diameter smaller than contralateral ICA and distal ICA diameter less than or equal to the ipsilateral external carotid artery (ECA). We also assessed the previously described CTA criteria: stenosis ≤ 1.3 mm, ipsilateral distal ICA ≤ 3.5 mm, ipsilateral distal ICA/contralateral distal ICA ratio ≤ 0.87, ipsilateral distal ICA/ipsilateral ECA ≤ 1.27. METHODS: Fifty-eight patients with ICA stenosis (including the near-occlusion variant) or occlusion on digital subtraction angiography (DSA) were included. These patients had DSA and CTA studies completed within 30 days of each other. DSA was considered the reference test. Two neuroradiologists blinded to the DSA results assessed the CTA images and evaluated the new and previously published CNO diagnostic criteria. RESULTS: Twenty-eight CNO were identified with DSA. The "distal ICA diameter less than or equal to the ipsilateral ECA" criterion had 79% sensitivity and 83% specificity with excellent interobserver agreement (kappa = 0.80), while three or more of the previously published criteria reached 82% sensitivity and 90% specificity, with a good interobserver agreement (kappa = 0.64). CONCLUSIONS: CT angiography may be useful for CNO diagnosis. The new visual diagnostic criteria provide acceptable results of sensitivity and specificity with an excellent interobserver agreement. However, false-negative and positive results persist.

Atherosclerosis and Atrial Fibrillation: Double Trouble.

PURPOSE OF REVIEW: This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis. RECENT FINDINGS: MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.

Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes.

OBJECTIVE: Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis. METHODS: We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated. RESULTS: A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies). CONCLUSIONS: The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.

Computational methods to automate the initial interpretation of lower extremity arterial Doppler and duplex carotid ultrasound studies.

BACKGROUND: Lower extremity arterial Doppler (LEAD) and duplex carotid ultrasound studies are used for the initial evaluation of peripheral arterial disease and carotid stenosis. However, intra- and inter-laboratory variability exists between interpreters, and other interpreter responsibilities can delay the timeliness of the report. To address these deficits, we examined whether machine learning algorithms could be used to classify these Doppler ultrasound studies. METHODS: We developed a hierarchical deep learning model to classify aortoiliac, femoropopliteal, and trifurcation disease in LEAD ultrasound studies and a random forest machine learning algorithm to classify the amount of carotid stenosis from duplex carotid ultrasound studies using experienced physician interpretation in an active, credentialed vascular laboratory as the reference standard. Waveforms, pressures, flow velocities, and the presence of plaque were input into a hierarchal neural network. Artificial intelligence was developed to automate the interpretation of these LEAD and carotid duplex ultrasound studies. Statistical analysis was performed using the confusion matrix. RESULTS: We extracted 5761 LEAD ultrasound studies from 2015 to 2017 and 18,650 duplex carotid ultrasound studies from 2016 to 2018 from the Indiana University Health system. The results showed the ability of artificial intelligence algorithms and method, with 97.0% accuracy for predicting normal cases, 88.2% accuracy for aortoiliac disease, 90.1% accuracy for femoropopliteal disease, and 90.5% accuracy for trifurcation disease. For internal carotid artery stenosis, the accuracy was 99.2% for predicting 0% to 49% stenosis, 100% for predicting 50% to 69% stenosis, 100% for predicting >70% stenosis, and 100% for predicting occlusion. For common carotid artery stenosis, the accuracy was 99.9% for predicting 0% to 49% stenosis, 100% for predicting 50% to 99% stenosis, and 100% for predicting occlusion. CONCLUSIONS: The machine learning models using LEAD data, with the collected blood pressure and waveform data, and duplex carotid ultrasound data with the flow velocities and the presence of plaque, showed that novel machine learning models are reliable in differentiating normal from diseased arterial systems and accurate in classifying the extent of vascular disease.

Dolichoarteriopathies of the extracranial internal carotid artery: The Plaque At RISK study.

BACKGROUND AND PURPOSE: Dolichoarteriopathies of the extracranial part of the internal carotid artery (ICA) are associated with cerebrovascular events, yet information on their prevalence and risk factors remains limited. The aim of the present study therefore was to study the prevalence and risk factors of dolichoarteriopathies in a sample of patients with cerebrovascular symptoms from the Plaque At RISK (PARISK) study. METHODS: In a random sample of 100 patients from the PARISK study, multidetector computed tomography angiography (MDCTA) was performed as part of clinical workup. On MDCTA, we evaluated the extracranial trajectory of the ICA by measuring the length (in millimeters), the tortuosity index (TI; defined as the ICA length divided by the shortest possible distance from bifurcation to skull base), and dolichoarteriopathy type (tortuosity, coiling or kinking). Next, we investigated the association between cardiovascular risk factors and these measurements using linear and logistic regression analyses. RESULTS: The mean (standard deviation) length of the ICA was 93 (± 14) mm, with a median (interquartile range) TI of 1.2 (1.1-1.3). The overall prevalence of dolichoarteriopathies was 69%, with tortuosity being the most common (72%), followed by coiling (20%), and kinking (8%). We found that age and obesity were associated with a higher TI: difference per 10-year increase in age: 0.05 (95% confidence interval [CI] 0.02-0.08) and 0.16 (95% CI 0.07-0.25) for obesity. Obesity and hypercholesterolemia were associated with a more severe type of dolichoarteriopathy (odds ratio [OR] 2.07 [95% CI 1.04-4.12] and OR 2.17 [95% CI 1.02-4.63], respectively). CONCLUSION: Dolichoarteriopathies in the extracranial ICA are common in patients with cerebrovascular symptoms, and age, obesity and hypercholesterolemia may play an important role in the pathophysiology of these abnormalities.

Workup following retinal artery occlusion-experience from an outpatient retina clinic and the delay in workup.

PURPOSE: Acute retinal artery occlusion (RAO) is an urgent ophthalmic condition often indicative of future ischemic pathology. Patients diagnosed at an outpatient retina clinic must present to an emergency department (ED) or primary care clinic to obtain a systemic workup. We review the overall compliance and suspected delay in completing the required testing. DESIGN: Retrospective cohort study METHODS: Patients presenting with a symptomatic RAO from June 2009 to January 2019 at a vitreoretinal practice (The Retina Institute, St. Louis, MO) were included. Documentation of carotid vasculature and echocardiographic imaging was requested from the patient's primary care physician (PCP), cardiologist, or neurologist. Time to workup (TTW) from RAO diagnosis to receiving appropriate workup and site of workup (ED vs. outpatient setting) were recorded. RESULTS: One hundred forty-seven patients were included. A total of 132 (89.8%) patients were documented as having completed at least one type of cardiovascular or carotid imaging. Seventy-seven patients (52.3%) were documented to have completed both carotid and echocardiographic imaging. Following RAO diagnosis, 97 (66.0%) patients were referred to an outpatient facility while 35 (23.8%) were evaluated at an ED. Mean TTW through an ED setting vs. outpatient was 2.20 days (1.10 STDM, range 0-29) vs.13.6 days (2.23 STDM, range 0-149) respectively (p=0.003). CONCLUSION: Our study gives objective data to the delay suspected in referring patients with acute symptomatic RAO for outpatient workup. We recommend all outpatient ophthalmology and retina practices establish a relationship with a comprehensive or primary stroke center to facilitate urgent testing through an emergency department.

Conventional Angiography in the Assessment of Recently Symptomatic Patients with Ipsilateral Carotid Stenosis.

BACKGROUND AND PURPOSE: Benefits of revascularization for moderate and severe (≥50%) carotid stenosis were established based on digital subtraction angiography (DSA). We aimed to assess the discrepancy between invasive and non-invasive angiography in a consecutive, prospective cohort of patients with recent stroke and non-invasive imaging suggesting ≥50% ipsilateral carotid stenosis. MATERIALS AND METHODS: We reviewed prospectively-collected data for consecutive patients admitted with recent stroke/TIA and ≥50% ipsilateral carotid stenosis on non-invasive imaging over 28 months. All patients underwent DSA to confirm the degree of stenosis per NASCET criteria. All patients with <50% stenosis by DSA were treated with medical therapy only and their recurrent event rates were assessed at 6 months. RESULTS: 148 symptomatic patients with ≥50% ipsilateral carotid stenosis on CTA (82%) and MRA (18%) underwent DSA to confirm degree of stenosis. Median age was 73 years and 64% were male. DSA demonstrated <50% stenosis in 28 patients (19%). Median presenting NIHSS was 1 (IQR 0-3). Median carotid stenosis evaluated by non-invasive imaging was 70% (IQR 60-85%) and by DSA was 40% (IQR 30-45%). One of 28 patients (4%) experienced recurrent nondisabling stroke (NIHSS 1) after stopping dual antiplatelet therapy. CONCLUSION: In nearly one-in-five cases with recent stroke due to ipsilateral carotid stenosis deemed to be candidates for revascularization based on CTA or MRA, DSA led to institution of medical therapy only due to insufficiently severe stenosis. In patients treated with medical therapy based on the findings of <50% stenosis on DSA, the rate of recurrent stroke is low.

The relationship between carotid disease and retinopathy in diabetes: a systematic review.

BACKGROUND: Since studies of the relationship between carotid disease and diabetic retinopathy (DR) have shown apparent inconsistencies, the aim of this study was to conduct a systematic review of available published data. METHODS: Electronic databases were searched independently by two reviewers, according to an iterative protocol, for relevant articles. The search term used was "diabetes AND (carotid disease OR intima-media OR carotid plaque OR carotid stenosis OR carotid arterial disease OR carotid artery disease OR carotid atherosclerosis) AND (retinopathy OR diabetic retinopathy)". RESULTS: From 477 publications, 14 studies were included. There were differences in the variables used as markers of carotid disease and DR across the included studies. Ten studies used carotid disease as the dependent variable, and the remainder used DR. All but one study involved cross-sectional data. Most studies reported a statistically significant association between at least one parameter of carotid disease as assessed by ultrasound and DR presence or severity. Only four studies reported no significant association. A common limitation was the use of convenience participant sampling. CONCLUSIONS: There appears to be an increased likelihood of DR when there is ultrasonographic evidence of carotid disease, and vice versa. The available studies suggest that there may be a direct relationship between DR and carotid macrovascular disease and/or that these complications co-exist due to shared risk factors. If carotid disease is detected, retinal assessment should be performed. If DR is identified, intensive cardiovascular disease risk management should be considered. Additional longitudinal studies are needed to assess the directionality of the association.

Presentation and outcomes of carotid endarterectomy in active smokers.

OBJECTIVE: Smoking is a significant modifiable risk factor in the pathogenesis of carotid artery disease and has been shown to be a predictor of worse outcomes after vascular surgery. However, the effect of active smoking on outcomes of patients undergoing carotid endarterectomy is unknown. This study analyzed the outcomes of carotid endarterectomy by smoking status in a large national database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program targeted carotid endarterectomy files (2011-2017) were reviewed. Patients were stratified according to smoking status, and outcomes were compared using propensity score matching (1:1) based on preoperative characteristics. RESULTS: During the study period, 26,293 patients underwent carotid endarterectomy, with 19,282 (73.34%) nonsmokers and 7011 (26.66%) smokers. Smokers were more likely to be younger, to have chronic obstructive pulmonary disease, to have a symptomatic presentation, and to have higher anatomic risk (P < .05). Smokers were also more likely to have emergent surgery, to have general anesthesia, and to be reintubated (P < .05). After propensity matching, 5354 nonsmokers were matched with 5354 smokers who underwent carotid endarterectomy. Smokers were at significantly higher risk for death, with an odds ratio of 1.93 (confidence interval, 1.18-3.13). CONCLUSIONS: Smokers are at increased risk for death after carotid endarterectomy compared with matched counterparts. Smoking should be considered an important risk factor for worse outcomes, and patients should be strongly counseled on the importance of smoking cessation before undergoing carotid endarterectomy.