Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting.

Background and Purpose- Novel double layer micromesh stents have recently been introduced for treatment of patients with significant carotid stenosis. Strict evaluation of safety and patency of such novel devices is required both in elective and in emergency interventions. We report a single center experience with double layer mesh stents for carotid artery revascularization. Methods- Consecutive patients who underwent carotid artery stenting with a double layer mesh stent between June 2015 and September 2018 in our tertiary vascular referral center were included. Treatment indications were emergent carotid artery stenting for intracranial or extracranial carotid stenosis in patients undergoing intraarterial thrombectomy for acute ischemic stroke in the anterior circulation, or elective carotid artery stenting for significant symptomatic or asymptomatic stenosis. End points were postprocedural thrombotic stent occlusion and procedural stroke or death. Results- Fifty-four patients were included; 27 were treated for acute stroke with intracranial and extracranial (tandem) lesions and 27 for elective stenting. Follow-up imaging was available for 9/27 (33%) patients with acute stroke, and 19/27 (70%) electively treated patients. Five stent occlusions occurred, of which 2 were symptomatic with clinical deterioration within one day. Another patient deteriorated on postprocedural day one, but imaging of the carotids was not performed, and the stent turned out occluded on the 30-day duplex. All stent occlusions occurred in patients treated for acute stroke. Conclusions- This study suggests that occlusion of novel double layer mesh stents occurs in a considerable proportion of carotid artery stenting procedures performed in the emergency setting for acute stroke, with occlusion-related symptoms in half the cases. Future prospective studies should clarify the role of double layer mesh stents in this high-risk patient population.

A meta-analysis of the effect of stent design on clinical and radiologic outcomes of carotid artery stenting.

OBJECTIVE: Procedural characteristics, including stent design, may influence the outcome of carotid artery stenting (CAS). A thorough comparison of the effect of stent design on outcome of CAS is thus warranted to allow for optimal evidence-based clinical decision making. This study sought to evaluate the effect of stent design on clinical and radiologic outcomes of CAS. METHODS: A systematic search was conducted in MEDLINE, Embase, and Cochrane databases in May 2018. Included were articles reporting on the occurrence of clinical short- and intermediate-term major adverse events (MAEs; any stroke or death) or radiologic adverse events (new ischemic lesions on postprocedural magnetic resonance diffusion-weighted imaging [MR-DWI], restenosis, or stent fracture) in different stent designs used to treat carotid artery stenosis. Random effects models were used to calculate combined overall effect sizes. Metaregression was performed to identify the effect of specific stents on MAE rates. RESULTS: From 2654 unique identified articles, two randomized, controlled trials and 66 cohort studies were eligible for analysis (including 46,728 procedures). Short-term clinical MAE rates were similar for patients treated with open cell vs closed cell or hybrid stents. Use of an Acculink stent was associated with a higher risk of short-term MAE compared with a Wallstent (risk ratio [RR], 1.51; P = .03), as was true for use of Precise stent vs Xact stent (RR, 1.55; P < .001). Intermediate-term clinical MAE rates were similar for open vs closed cell stents. Use of open cell stents predisposed to a 25% higher chance (RR, 1.25; P = .03) of developing postprocedural new ischemic lesions on MR-DWI. No differences were observed in the incidence of restenosis, stent fracture, or intraprocedural hemodynamic depression with respect to different stent design. CONCLUSIONS: Stent design is not associated with short- or intermediate-term clinical MAE rates in patients undergoing CAS. Furthermore, the division in open and closed cell stent design might conceal true differences in single stent efficacy. Nevertheless, open cell stenting resulted in a significantly higher number of subclinical postprocedural new ischemic lesions detected on MR-DWI compared with closed cell stenting. An individualized patient data meta-analysis, including future studies with prospective homogenous study design, is required to adequately correct for known risk factors and to provide definite conclusions with respect to carotid stent design for specific subgroups.

Comparability of semiautomatic tortuosity measurements in the carotid artery.

PURPOSE: Increased arterial tortuosity has been suggested as a predisposing factor for carotid artery dissection, which is an important risk factor for development of extracranial carotid artery aneurysms (ECAA). Prior to comparison with non-ECAA controls, the optimal measurement technique should be defined. This study describes the difference between software packages in terms of reproducibility and absolute outcome of arterial tortuosity measurements in ECAA patients. METHODS: CT-angiography analysis was performed on 12 ECAA patients selected from our registry, using four software packages: 3mensio Vascular, TeraRecon, Vital Images, and Aycan OsiriX PRO. The tortuosity index (TI) was calculated from the skull base until the carotid bifurcation and aortic arch, and was defined as the centerline's true length divided by the straight line distance. Intraclass correlation coefficients (ICC) with 95% confidence intervals were calculated to quantify inter- and intra-observer variability within one software package, and differences in measured TI between packages. RESULTS: Inter-observer agreement was nearly perfect for 3mensio, excellent for Vital Images and OsiriX, and substantial for TeraRecon, with ICC 0.99 (0.96-1.0), 0.90 (0.69-0.97), 0.84 (0.53-0.95), and 0.72 (0.28-0.91), respectively. Intra-observer agreement ranged from ICC 1.0 for 3mensio to 0.91 for TeraRecon. Agreements in TI ranged from ICC 0.99 (0.98-1.0) for 3mensio vs. OsiriX, to 0.95 (0.82-0.98) for 3mensio vs. TeraRecon. Median time needed to complete one round of measurements was highest for OsiriX (p = 0.013). CONCLUSIONS: Carotid artery tortuosity measurements are reproducible and comparable between current commercially available software packages, with high intra-observer agreement. Although the reproducibility differed per software packages, all packages scored an acceptable inter-observer agreement.

Cardiovascular magnetic resonance imaging to identify left-sided chronic heart failure in stable patients with chronic obstructive pulmonary disease.

BACKGROUND: Although cardiovascular magnetic resonance imaging (CMR) is well established, its diagnostic accuracy in identifying chronic heart failure (CHF) in patients with chronic obstructive pulmonary disease (COPD) has not yet been quantified. METHODS: Participants were recruited from a cohort of 405 patients aged >or=65 years, with mild to moderate and stable COPD. In this population, 83 (20.5%) patients had a new diagnosis of CHF, all left-sided, established by an expert panel using all available diagnostic information, including echocardiography. In a nested case-control study design, 37 consecutive COPD patients with newly detected CHF (cases) and a random sample of 41 of the remaining COPD patients (controls) received additional CMR measurements. The value of CMR in diagnosing heart failure was quantified using univariable and multivariable logistic modeling in combination with area under the receiver operating characteristic curves (ROC-area). RESULTS: Combination of CMR measurements of left ventricular ejection fraction, indexed left and right atrial volume, and left ventricular end-systolic dimensions provided high added diagnostic value beyond clinical items (ROC-area 0.91) for identifying CHF. Left-sided measurements of CMR and echocardiography correlated well, including ejection fraction. Right ventricular mass divided by right ventricular end-diastolic volume was higher in COPD patients with CHF than in those without concomitant CHF. CONCLUSIONS: Easily assessable morphologic and volume-based CMR measurements have excellent capacities to identify previously unknown left-sided chronic heart failure in mild to moderate COPD patients. There seems to be an adaptive tendency to concentric right ventricular hypertrophy in COPD patients with left-sided CHF.