Correlation between Complement C1q A Chain (C1QA) and Macrophages in the Progression of Carotid Atherosclerosis.

Background: There is increasing evidence that macrophages are involved in the development of carotid atherosclerosis (CAS), but the specific mechanism is still unclear. We aimed to explore the key genes that play a regulatory role on macrophages in the progression of CAS. Methods: From 2021 August to 2023 August, GEO datasets GSE100927 and GSE43292 were downloaded and the key gene modules related to CAS were identified by weighted Gene co-expression network analysis (WGCNA). Kyoto Encyclopedia of Genes and Genes (KEGG) pathway analysis was performed on the genes of the key modules to identify common gene enrichment pathways. Differential expression analysis of pathway-related genes was performed by the "limma" package of R software. Case groups were categorized into high and low expression groups based on the expression levels of key genes, and ssGSEA immune infiltration analysis was performed. Results: The turquoise module of GSE100924 (threshold=12) and the brown module of GSE43292 (threshold=7) were obtained through WGCNA analysis. The analysis of KEGG showed that the differentially expressed genes in the turquoise and brown modules were co-enriched in the staphylococcus aureus infection signaling pathway. Differential expression analysis identified 18 common differentially expressed genes, all of which were highly expressed in the case group. C1QA is the gene of interest. According to ssGSEA analysis, the high expression group of C1QA showed a significant increase in the number of macrophages (GSE43292, P=0.0011; GSE100927, P=0.025). Conclusion: This study identified the key gene C1QA involved in regulating macrophage functional activity during the CAS process, providing new ideas for effective control of CAS.

A Case of Complete Resolution of Repeated Syncope Attacks After a Right-Sided Carotid Endarterectomy.

Syncope is a common clinical entity with variable presentations and often an elusive causal mechanism, even after extensive evaluation. In any case, global cerebral hypoperfusion, resulting from the inability of the circulatory system to maintain blood pressure (BP) at the level necessary to supply blood to the brain efficiently, is the final pathway for syncope. Steno-occlusive carotid artery disease, even if bilateral, does not usually cause syncope. However, the patient presented here had repeated syncope attacks and underwent a thorough examination for suspected cardiac disease, but no abnormality was found. Since there was severe stenosis in the right unilateral internal carotid artery (ICA), but no stenosis in the left ICA or vertebrobasilar artery (VBA), and transient left mild hemiparesis associated with syncope, carotid revascularization surgery for the right ICA was performed, and the repeated syncope attacks completely disappeared after the surgery. The patient's condition improved markedly, and no further episodes of syncope have been reported. We report the relationship between carotid artery stenosis and syncope and discuss its pathomechanism.

What Is the Best Technique for Treating Carotid Disease?

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.

Impact of hypertension and arterial wall expansion on transport properties and atherosclerosis progression.

This study explored the impact of hypertension on atheroma plaque formation through a mechanobiological model. The model incorporates blood flow via the Navier-Stokes equation. Plasma flow through the endothelium is determined by Darcy's law and the Kedem-Katchalsky equations, which consider the three-pore model utilized for substance flow across the endothelium. The behaviour of these substances within the arterial wall is described by convection-diffusion-reaction equations, while the arterial wall itself is modelled as a hyperelastic material using Yeoh's model. To accurately evaluate hypertension's influence, adjustments were made to incorporate wall compression-induced wall compaction by radial compression. This compaction impacts three key variables of the transport phenomena: diffusion, porosity, and permeability. Based on the obtained findings, we can conclude that hypertension significantly augments plaque growth, leading to an over 400% increase in plaque thickness. This effect persists regardless of whether wall mechanics are considered. Tortuosity, arterial wall permeability, and porosity have minimal impact on atheroma plaque growth under normal arterial pressure. However, the atheroma plaque growth changes dramatically in hypertensive cases. In such scenarios, the collective influence of all factors-tortuosity, permeability, and porosity-results in nearly a 20% increase in plaque growth. This emphasizes the importance of considering wall compression due to hypertension in patient studies, where elevated blood pressure and high cholesterol levels commonly coexist.

Patients with Amnestic Mild Cognitive Impairment Have Higher Cerebrovascular Impedance Than Cognitively Normal Older Adults.

Brain hypoperfusion is associated with cognitive impairment. Higher cerebrovascular impedance modulus (Z) may contribute to brain hypoperfusion. We tested hypotheses that patients with amnestic mild cognitive impairment (aMCI) (i.e., those who have high risk of developing Alzheimer's disease) have higher Z than age-matched cognitively normal individuals, and that high Z is correlated with brain hypoperfusion. Fifty-eight patients with aMCI (67±7 years) and 25 cognitively normal subjects (CN, 65±6 years) underwent simultaneous measurements of carotid artery pressure (CAP, via applanation tonometry) and middle cerebral arterial blood velocity (CBV, via transcranial Doppler). Z was quantified using cross-spectral and transfer function analyses between dynamic changes in CBV and CAP. Patients with aMCI exhibited higher Z than NC (1.18±0.34 vs. 1.01±0.35 mmHg/cm/s, P=0.044) in the frequency range from 0.78 to 4.29 Hz. The averaged Z in the frequency range (0.78-3.13 Hz) of high coherence (>0.9) was inversely correlated with total cerebral blood flow measured with 2D Doppler ultrasonography normalized by the brain tissue mass (via structural MRI) across both patients with aMCI and NC (r=-0.311, P=0.007), and in patients with aMCI alone (r=-0.306, P=0.007). Our findings suggest that patients with aMCI have higher cerebrovascular impedance than cognitively normal older adults and that increased cerebrovascular impedance is associated with brain hypoperfusion.

A novel imaging biomarker for prediction of cerebrovascular ischemic events: Pericarotid fat density.

BACKGROUND: To investigate the relationship between pericarotid fat density measured in carotid CTA and vulnerable carotid plaque. METHODS: This retrospective study included 374 participants who underwent carotid CTA between June 1, 2021, and December 1, 2021 (234 males, median age 68 years [interquartile range: 61-75]). Two groups, symptomatic and asymptomatic, were defined based on either diffusion-weighted MRI or a clinical history of acute ischemia or TIA within 6 months before or after CTA. The relationship between pericarotid fat density and cerebrovascular ischemic events was assessed using receiver operating characteristic analysis and binary logistic regression analysis. RESULTS: In the symptomatic group (n = 135), mean pericarotid fat density (-63.3 ± 21.7 vs. -81.7 ± 16.9 HU, respectively; p < 0.001) and median maximum plaque thickness (4 [interquartile range: 3-6] vs. 3.7 [interquartile range: 2.6-4.7] mm, respectively; p = 0.002) were higher, while plaque density (42.1 ± 19.6 vs. 50.6 ± 20.4 HU, respectively; p = 0.001) was lower compared to the asymptomatic group. Pericarotid fat density (OR: 1.038, 95% CI: 1.023-1.053, p < 0.001) was identified as an independent predictor for symptomatic patients. The optimal cut-off value for pericarotid fat density predicting symptomatic patients was estimated as -74 HU (area under the curve: 0.753, 95% CI:0.699-0.808, p < 0.001). Inter-reader agreement for pericarotid fat density was found to be almost perfect (intraclass correlation coefficient: 0.818, 95% CI: 0.770-0.856, p < 0.001). CONCLUSION: Pericarotid fat density may serve as an imaging biomarker in predicting acute cerebrovascular ischemic events.

Long-term mortality and morbidity after carotid endarterectomy for symptomatic and asymptomatic carotid stenosis.

OBJECTIVES: To investigate whether the occurrence of ischemic stroke due to carotid stenosis is a marker of the severity of atherosclerotic disease and of an excess risk of cardiovascular morbidity and mortality, and of all-cause mortality, after carotid endarterectomy. METHODS: Patients who had undergone a carotid endarterectomy (CEA) from June 2015 to august 2016 were included. Patients were classified into two groups, namely symptomatic and asymptomatic. Neurological event, myocardial infarction and death during early follow-up were monitored. Major adverse cardiovascular events (MACE), major limb events (MALE), and all-cause mortality were compared for patients with a CEA for an asymptomatic carotid stenosis versus those with a symptomatic stenosis. RESULTS: Among the 190 patients included, 86 (51%) had a CEA for an asymptomatic stenosis and 84 (49%) for a symptomatic stenosis. During the first 30 days, the rate of all-cause death or ischemic stroke was similar in both groups (1%, p=0.986). After 30 days, there were a total of 35 MACE (21.3%) and 15 MALE (9.1%) during mean follow-up of 53 (22.6) months. Overall cardiovascular morbidity and mortality was 30.4%, and did not differ between groups (p=0.565). New ischemic stroke occurred in 11 patients (9.1%) and was significantly more frequent in the asymptomatic group (9 (14.8%) vs 2 (3.6%) in the symptomatic group, (OR: 4.96; CI 95% [1.04-23.77]; p = 0.013)). Overall all-cause mortality was 24% in both groups (p=0.93) CONCLUSION: The occurrence of ischemic stroke of carotid origin prior to revascularization does not appear to be associated with an excess risk of cardiovascular morbidity or mortality or all-cause mortality after surgery.

Association of central arterial stiffness with atrial myopathy: the Atherosclerosis Risk in Communities (ARIC) study.

Atrial myopathy-defined as abnormal left atrial (LA) size and function-is associated with an increased risk of atrial fibrillation, heart failure, and dementia. Central arterial stiffness is associated with increased atrial afterload and fibrosis and may be a risk factor for atrial myopathy. We examined the association of carotid-femoral pulse wave velocity (cfPWV) with LA function and assessed potential causal relationships. We included 2825 Atherosclerosis Risk in Communities (ARIC) study participants from Visit 5 (2011-2013). cfPWV was related to echocardiographic LA function continuously per 1-SD and categorically in quartiles. Mendelian randomization (MR) analysis was performed using U.K. Biobank-derived genetic variants associated with arterial stiffness index and cardiac magnetic resonance measures of LA function. When analyzed per SD increment (297.6 cm/s), higher cfPWV was significantly associated with lower LA reservoir and conduit strain (ß = -0.53%, 95% CI [-0.81, -0.25] and ß = -0.46%, 95% CI [-0.68, -0.25], respectively) after adjusting for demographics, clinical characteristics, systolic blood pressure, and left ventricular (LV) morphology and function. In MR analyses there was a non-significant inverse association of arterial stiffness index with LA total, passive, and active emptying fractions. Higher cfPWV is associated with lower LA reservoir and conduit strain, independent of systolic blood pressure and LV morphology and function. No evidence for a causal relationship between arterial stiffness index and alterations in LA function was found. Future studies should examine the prospective association of central arterial stiffness with LA function alterations.

Quantifying ocular microcirculation in hypertension patients with carotid artery stenosis.

Background: Carotid artery stenosis (CAS) is one of the most common macrovascular complications of hypertension. The ophthalmic artery springs from the internal carotid artery; however, the effect of CAS on ocular microcirculation has not been quantified in hypertension patients. This study aimed to quantify ocular microcirculation metrics in hypertension with CAS (HCAS) patients and to explore the relationship between micro- and macroangiopathy in hypertension. Methods: All participants (community-based) underwent detailed assessments, including carotid ultrasonography, optical coherence tomography angiography (OCTA), and enhanced depth imaging (EDI)-OCT. CAS was diagnosed using carotid ultrasonography. Retinal microcirculation metrics, including vessel density (VD), skeleton density (SD), fractal dimension (FD), and foveal avascular zone (FAZ), were quantified using OCTA and ImageJ software. Choroidal microcirculation metrics, including subfoveal choroidal thickness (SFCT), luminal area (LA), and choroidal vascularity index (CVI), were quantified using EDI-OCT and ImageJ. Retinal vessel caliber metrics, including central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and artery/vein ratio (AVR), were calculated using revised formulas. The above metrics were compared among the HCAS group, hypertension with no CAS (HNCAS) group, and healthy control group. The mutual effects between ocular metrics and CAS were evaluated using regression analyses. Results: In a comparison of the HCAS vs. HNCAS groups, retinal metrics including VD, SD, FD, and choroidal metrics including CVI and LA were significantly decreased in the HCAS group (all p < 0.05); however, FAZ, SFCT, and retinal vessel caliber metrics including CRAE, CRVE, and AVR were comparable between groups (all p > 0.05). In a comparison of HNCAS and the healthy control group, VD, SD, and CRAE showed that AVR was significantly decreased in the HNCAS group (all p < 0.05); meanwhile, choroidal metrics were comparable between groups (all p > 0.05). Linear regression analyses showed that intima-media thickness (IMT) (p = 0.01) and peak systolic velocity (PSV) (p = 0.002) were negatively related to retinal VD in hypertension patients. Logistic regression analyses disclosed that older age (p < 0.001), smoking history (p = 0.002), lower VD (p = 0.04), SD (p = 0.02), and CVI (p < 0.001) were related to the presence of CAS in hypertension patients. Conclusion: CAS in hypertension-induced hypoperfusion in retinal and choroidal microcirculation and the decreased retinal VD and choroidal CVI were significantly associated with the presence of CAS in patients with hypertension, suggesting that hypertension macro- and microangiopathy were mutually affected and share the common pathophysiology. Furthermore, OCT could be a useful tool to assess hypertension patient's CAS risk profiles in a non-invasive way.

Morphological and functional abnormalities of ophthalmic artery in patients with ophthalmic vascular accidents.

Background: By observing and comparing the morphological and functional differences of the ophthalmic artery (OA) in patients with ocular vascular accidents (OVAs) due to iatrogenic embolism or non-iatrogenic occlusion, we propose a classification system based on the characteristics of OA on invasive digital subtraction angiography (DSA). Methods: All patients undergoing ophthalmic arterial DSA within 1 week after the OVAs between January 2017 and December 2021 were enrolled and divided into different types, and the differences between iatrogenic embolism and non-iatrogenic occlusion categories were compared. Results: A total of 27 eyes of 27 patients were included in this study. Based on the results of carotid/intracranial arterial DSA, the morphological and functional abnormalities of OA with OVAs can be divided into five types. The proportion of males (7.14%), ocular ischemic syndrome (OIS) (0.00%) and neovascular glaucoma (NVG) (0.00%) in the iatrogenic embolism category was significantly lower than that (84.62, 61.54, and 69.23%, respectively) of the non-iatrogenic occlusion category (p < 0.001, p = 0.001, p < 0.001, respectively). However, the proportion of no light perception (NLP) (100%), anterior segment ischemia (ASI) (71.43%), and orbital involvement (ophthalmoplegia and ptosis, 42.86%) eventually occurring in the former was significantly greater than that in the latter (23.08, 0.00, 0.00%, respectively) (p < 0.001, p < 0.001, p = 0.010, respectively). Conclusion: Ocular vascular accidents can be divided into five types based on the characteristics of OA on DSA.

Part 2: The development and advancement of the detachable balloon catheter; a historical and technical review.

The detachable balloon catheter (DBC) was a revolutionary technique for the treatment of cerebrovascular pathologies. It was used to treat carotid cavernous fistulas (CCFs), vertebro-jugular fistulas, arteriovenous malformations (AVMs), and aneurysms. The DBC became the foundation for neurointerventional techniques, leading to the development of coil embolization and bioactives. Our team selected relevant articles from PubMed published between 1974 and 2023. Articles were excluded if they did not discuss the use or development of the detachable balloon catheter or subsequent technologies. The DBC was used to occlude vessels, either temporarily or permanently. Dr Gerard Debrun implemented findings from Dr Fedor Serbinenko's research to develop an intravascular detachable balloon technique. He developed many variations using type I and type II balloon catheters that differed in size, length, and material, allowing for the personalization of treatment based on the lesion. This revolutionary thinking showed that every pathology has a different shape and anatomy that require a unique approach. The DBC would offer the first alternative to the conventional practice of carotid occlusion in CCF treatment at the time. The DBC would later be used in aneurysm occlusion and the embolization of AVMs, with additional benefit in traumatic vascular sacrifice. Although the DBC has largely been replaced, it is still useful in a small subset of patients, and has financial incentive as it is more affordable than coils. This technique was a monumental stride in the history of neurointervention and helped propel the specialty to the current era of patient-specific interventions.

Mechanical compression of the carotid artery by the pharynx in the retropharyngeal space during swallowing and the induction of stenosis and embolic stroke: illustrative case.

BACKGROUND: Compression of the carotid artery (CA) by hyoid bony structures, such as the hyoid bone and thyroid cartilage, during swallowing or neck rotation can induce stroke. However, no reports have described ischemic stroke caused by mechanical compression of the CA by the pharynx during swallowing. OBSERVATIONS: A man with left CA stenosis developed recurrent ischemic stroke in his left hemisphere. Computed tomography angiography of the neck showed that the left common carotid artery was trapped by the hyoid bone and thyroid cartilage and that the internal carotid artery (ICA) ran in the retropharyngeal space. Angiography during swallowing of a contrast agent showed dynamic compression of the left CA posterolaterally by the pharynx during swallowing, despite the fact that the CA on the healthy right side moved anteromedially. The retropharyngeal ICA was then transposed to its normal location and endarterectomy was performed. No ischemic events occurred postoperatively, and angiography showed that the left CA now moved anteromedially during swallowing. LESSONS: Movement of the pharynx during swallowing can be a risk factor for CA stenosis. It is important to evaluate the anatomical interaction between the CA and surrounding structures, as well as their dynamics, to ensure appropriate diagnosis and treatment. https://thejns.org/doi/10.3171/CASE2483.

Invasive treatment for extracranial carotid artery aneurysm: a single-center case series and literature review.

BACKGROUND: Extracranial carotid artery aneurysm (ECAA) is a rare peripheral arterial disease. The main treatment strategies include conservative treatment, open surgery, endovascular treatment, and hybrid techniques, and there is no expert consensus or guidelines, with only a few case reports. METHOD: This article reviewed 10 cases diagnosed with "extracranial carotid artery aneurysm" and received invasive treatment from January 2013 to July 2023 in our medical center. RESULTS: There were 10 patients with ECAA admitted to our center, including seven cases of true aneurysms, two cases of pseudoaneurysms, and one case of dissecting aneurysm. There were 3 females and 7 males aged between 24-61 years. Based on the characteristics of ECAA, we designed the individualized procedure including open surgery, endovascular treatment, and hybrid treatment. Procedures were technically successful for all patients, and none of them had any adverse events during the follow-up period except for one patient who developed cerebral hemorrhage on the third postoperative day and recovered after cerebral puncture and drainage. CONCLUSION: The current invasive treatments for ECAA mainly include open surgery, endovascular treatment, and hybrid treatment, and they all appear to be safe and effective.

Spinal Subdural Hematoma Secondary to Ruptured Internal Carotid Artery Ophthalmic Segment Aneurysm: A Case Report and Narrative Review.

Spinal subdural hematoma (SSDH) is a rare condition where the exact pathology is unclear; coagulopathy, bleeding disorders, trauma, and iatrogenic causes are frequently associated with SSDH. SARS-CoV-2 infection and COVID-19 vaccines are unusual causes of SSDH, as reported by multiple studies. Here, we present a rare case report and a narrative review of SSDH resulting from a ruptured cerebral aneurysm. A 53-year-old female presented with an acute, severe suboccipital headache and neck and back pain without radiculopathy. Investigations for cardiovascular diseases and brain images were unremarkable. Further investigation revealed an SSDH extending from T1 to S2. Negative spinal angiography led to a cerebral angiogram, identifying an internal carotid artery ophthalmic segment aneurysm that was successfully treated with endovascular stent-assisted coiling. This case scenario of anterior circulation cerebral aneurysmal rupture manifesting as an isolated SSDH is unique compared to previously reported cases of SSDH resulting from cerebral aneurysms. This case highlights the importance of considering aneurysmal rupture in SSDH cases with no apparent underlying pathology to prevent neurological deficits. Early detection and intervention in such cases can prevent serious neurological deficits and improve patient outcomes.

A stacking ensemble model for predicting the occurrence of carotid atherosclerosis.

Background: Carotid atherosclerosis (CAS) is a significant risk factor for cardio-cerebrovascular events. The objective of this study is to employ stacking ensemble machine learning techniques to enhance the prediction of CAS occurrence, incorporating a wide range of predictors, including endocrine-related markers. Methods: Based on data from a routine health check-up cohort, five individual prediction models for CAS were established based on logistic regression (LR), random forest (RF), support vector machine (SVM), extreme gradient boosting (XGBoost) and gradient boosting decision tree (GBDT) methods. Then, a stacking ensemble algorithm was used to integrate the base models to improve the prediction ability and address overfitting problems. Finally, the SHAP value method was applied for an in-depth analysis of variable importance at both the overall and individual levels, with a focus on elucidating the impact of endocrine-related variables. Results: A total of 441 of the 1669 subjects in the cohort were finally diagnosed with CAS. Seventeen variables were selected as predictors. The ensemble model outperformed the individual models, with AUCs of 0.893 in the testing set and 0.861 in the validation set. The ensemble model has the optimal accuracy, precision, recall and F1 score in the validation set, with considerable performance in the testing set. Carotid stenosis and age emerged as the most significant predictors, alongside notable contributions from endocrine-related factors. Conclusion: The ensemble model shows enhanced accuracy and generalizability in predicting CAS risk, underscoring its utility in identifying individuals at high risk. This approach integrates a comprehensive analysis of predictors, including endocrine markers, affirming the critical role of endocrine dysfunctions in CAS development. It represents a promising tool in identifying high-risk individuals for the prevention of CAS and cardio-cerebrovascular diseases.

Circulating CXCL9, monocyte percentage, albumin, and C-reactive protein as a potential, non-invasive, molecular signature of carotid artery disease in 65+ patients with multimorbidity: a pilot study in Age.It.

Background: Carotid endarterectomy (CEA) for the prevention of upcoming vascular and cerebral events is necessary in patients with high-grade stenosis (≥70%). In the framework of the Italian National project Age.It, a pilot study was proposed aiming at the discovery of a molecular signature with predictive potential of carotid stenosis comparing 65+ asymptomatic and symptomatic inpatients. Methods: A total of 42 inpatients have been enrolled, including 26 men and 16 women, with a mean age of 74 ± 6 years. Sixteen symptomatic and 26 asymptomatic inpatients with ≥70% carotid stenosis underwent CEA, according to the recommendations of the European Society for Vascular Surgery and the Society for Vascular Surgeons. Plaque biopsies and peripheral blood samples from the same individuals were obtained. Hematobiochemical analyses were conducted on all inpatients, and plasma cytokines/molecules, such as microRNAs (miRs), IL-6, sIL-6Ralpha, sgp130, myostatin (GDF8), follistatin, activin A, CXCL9, FGF21, and fibronectin, were measured using the ELISA standard technique. MiR profiles were obtained in the discovery phase including four symptomatic and four asymptomatic inpatients (both plasma and plaque samples), testing 734 miRs. MiRs emerging from the profiling comparison were validated through RT-qPCR analysis in the total cohort. Results and conclusion: The two groups of inpatients differ in the expression levels of blood c-miRs-126-5p and -1271-5p (but not in their plaques), which are more expressed in symptomatic subjects. Three cytokines were significant between the two groups: IL-6, GDF8, and CXCL9. Using receiver operating characteristic (ROC) analysis with a machine learning-based approach, the most significant blood molecular signature encompasses albumin, C-reactive protein (CRP), the percentage of monocytes, and CXCL9, allowing for the distinction of the two groups (AUC = 0.83, 95% c.i. [0.85, 0.81], p = 0.0028). The potential of the molecular signature will be tested in a second cohort of monitored patients, allowing the application of a predictive model and the final evaluation of cost/benefit for an assessable screening test.

A case of type 2 diabetes mellitus with limb-shaking TIA.

Limb-shaking transient ischemic attack (TIA) is a rare manifestation of carotid-occlusive damage. This case report highlights the importance of accurate diagnosis and treatment of bilateral ballism as limb-shaking TIA. Superficial cephalic artery and mid-large artery anastomosis was performed after the initial acute treatment, and involuntary limb shaking disappeared.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions. DATA SOURCES: MEDLINE and Embase. REVIEW METHODS: MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of peripheral vascular interventions in lower extremity, carotid, and visceral arteries via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedural time, fluoroscopy time, and contrast volume. RESULTS: Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedural time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes. CONCLUSION: The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Frailty Scores Impact the Outcomes of Urgent Carotid Interventions in Acute Stroke Patients: A Comprehensive Analysis of Risk and Prognosis.

INTRODUCTION: Carotid artery disease is an important cause of ischemic strokes. Patient selection for urgent carotid interventions (ie. carotid endarterectomy [uCEA] and carotid artery stenting [uCAS]) performed within 2 weeks of event during index hospitalization is primarily based on overall health and risk profile. Identifying high-risk patients remains a challenge. Frailty, a decline in function related to aging, has emerged as an important factor in the treatment of the elderly population. This study aimed to design a quantitative risk score based on frailty for patients undergoing uCEA and uCAS following an acute stroke. METHODS: A total of 307 acute stroke patients treated with uCEA or uCAS were identified from a prospectively maintained database. Frailty scores were calculated using the Hospital Frailty Risk Index based on ICD-10 codes. Stroke-specific risk categories were created based on the incidence of stroke, death, and myocardial infarction (MI) associated with frailty scores. Primary endpoints included 30-day stroke, death, and MI, while the secondary endpoint was discharge modified Rankin scale (mRS). Statistical analyses were performed using SAS software. RESULTS: The average age was 65.9 years; hypertension, history of tobacco use, and hyperlipidemia were the most common comorbidities. The median Hospital Frailty Risk Score was 27, the majority of patients in this study were in the intermediate and high risk frailty groups (50.5% and 41.7%, respectively). uCAS patients had a higher median presenting NIHSS (8 vs. 2, p<0.001) and shorter median time to intervention compared to uCEA patients (1 vs. 3 days, p=<0.001). The 30-day composite stroke, death, and MI rate was 8.1%, with higher rates observed in patients with frailty scores >30 (11.7%) and uCAS (12.2%). Hemorrhagic conversion and death were more common in uCAS patients. Functional independence (mRS 0-2) was observed in uCEA patients after minor stroke and in uCAS patients after minor or moderate stroke. Patients with high-risk frailty score (>30) presenting with a moderate stroke were more likely to be functionally dependent (mRS>2) on discharge (67% vs 41.3%, p<0.001). CONCLUSION: Frailty is a valuable prognosticative tool for clinical outcomes in patients undergoing urgent carotid interventions following an acute stroke. Higher frailty scores were associated with increased stroke, death, and MI rates. Frailty also influenced functional dependence at discharge, particularly in patients with moderate stroke. These findings highlight the importance of considering frailty in the decision-making process for carotid interventions. Further research is needed to validate these findings and explore interventions to mitigate the impact of frailty on outcomes.

Part 1: Pushing the boundaries of neurointerventional surgery: A historical review of the work of Dr Gerard Debrun.

French-American neurointerventionalist and pioneer, Dr Gerard Debrun, laid the groundwork for treatments which have become irreplaceable in neurointerventional surgery today. This article aims to outline the career of Dr Debrun while highlighting his accomplishments and contributions to the field of neurointerventional surgery. We selected relevant articles from PubMed authored or co-authored by Dr Debrun between 1941 and 2023. All included articles discuss the accomplishments and contributions of Dr Debrun. Dr Debrun began his career in France by investigating neurointerventional techniques, most notably the intravascular Detachable Balloon Catheter (DBC). His work was recognized by renowned neurosurgeon Dr Charles Drake, who recruited him to London, Ontario. Dr Debrun created the foundation for homemade manufacturing of DBCs, building on one of the largest series for use of DBCs in cerebrovascular disease. Dr Debrun spent time as faculty at Massachusetts General Hospital (MGH) and Johns Hopkins Hospital, before arriving at the University of Illinois Chicago (UIC) where he remained until his retirement. Dr Debrun's subsequent contributions included the calibrated-leak balloon catheter, pioneering of glue embolization, setting the foundation for preoperative AVM embolizations, and as an early adopter of the Guglielmi detachable coil (GDC), including mastering the balloon remodeling technique for wide neck aneurysms. Dr Debrun established the first integrated neurointerventional surgery program at UIC, establishing a well sought-after fellowship program. Dr Debrun lectured extensively and was a prolific writer on neurointerventional surgery throughout this career. His contributions established the foundation for several techniques which have since become standard practice in present-day neurointerventional surgery.