Carotid lesion length independently predicts stroke and death after transcarotid artery revascularization and transfemoral carotid artery stenting.

OBJECTIVES: Prior data from the Carotid Revascularization Endarterectomy vs Stenting Trial suggested that the higher perioperative stroke or death event rate among patients treated with transfemoral carotid artery stenting (TFCAS) appears to be strongly related to the lesion length. Nonetheless, data regarding the impact of lesion length on outcomes of transcarotid artery revascularization (TCAR) with flow reversal are lacking. Herein, we aimed to compare the outcomes of TCAR vs TFCAS stratified by the length of the carotid lesion. METHODS: Our cohort was derived from the Vascular Quality Initiative database for carotid artery stenting between 2016 and 2021. Restricted cubic spline analysis was used to describe the relationship between the primary outcome (in-hospital stroke/death) and the exposure variable (lesion length) in the overall cohort. This relationship was not linear, and knots were identified where significant changes in the slope of the curve occurred. We therefore divided patients based on knot with the most significant inflection into two groups: lesion length <25 mm (short) and lesion length ≥25 mm. Clinically relevant and statistically significant variables on univariable analysis were added to the final logistic regression model clustered by center identifier to study the association between lesion length and in-hospital outcomes stratified by the stent approach. RESULTS: The study cohort included 17,931 TCAR (52.6% with long lesions) and 12,036 TFCAS (53.2% with long lesions) patients. Patients with long lesions had higher rates of being symptomatic among both TCAR (27.2% vs 24.3%, P < .001) and TFCAS (43.5% vs 38.5%, P < .001) and were more likely to undergo general anesthesia in TCAR (84.7% vs 81.9%, P < .001) and TFCAS (21.6% vs 15.8%, P < .001). After adjusting for potential confounders, long carotid lesions were associated with higher odds of stroke, stroke/transient ischemic attack (TIA), and stroke/death compared with short lesions among patients who underwent TCAR or TFCAS. However, when comparing TCAR vs TFCAS outcomes in patients with long lesions, TCAR was found to be associated with a 30% reduction in stroke/TIA (adjusted odds ratio [aOR]: 0.7, 95% confidence interval [CI]: 0.6-0.9, P = .015), stroke (aOR: 0.7, 95% CI: 0.5-0.9, P = .009), and extended length of stay (ELOS) (aOR: 0.7, 95% CI: 0.6-0.8, P < .001). There was also a 40% reduction in the odds of in-hospital stroke/death (aOR: 0.6, 95% CI: 0.5-0.8, P < .001) and a 70% reduction in mortality (aOR: 0.3, 95% CI: 0.2-0.4, P < .001) in TCAR compared with TFCAS. CONCLUSIONS: In this large contemporary retrospective national study, carotid lesion length appears to negatively impact in-hospital outcomes for TCAR and TFCAS. In the presence of lesions longer than 25 mm, TCAR appears to be safer than TFCAS with regard to the risk of in-hospital stroke, stroke/TIA, death, stroke/death, and ELOS. These favorable outcomes seem to confirm the relative advantage of flow reversal compared with distal embolic protection devices in terms of neuroprotection.

The SYNTAX score does not predict presence of carotid disease in a multivessel coronary disease population.

BACKGROUND: Numerous reports have shown the relationship between carotid artery atherosclerosis and coronary artery disease (CAD). However, the association between complex CAD evaluated by SYNTAX score (SxScore) and prevalence of carotid lesion (CL) has not been fully investigated. We sought to assess the prevalence of carotid atherosclerosis in patients with multivessel CAD assessed by SxScore and the relationship between SxScore severity and features of carotid atherosclerosis. METHODS AND RESULTS: Subjects were 204 consecutive patients with multivessel CAD assessed by coronary angiography and no previous history of carotid atherosclerosis that underwent carotid ultrasound scan from June 2012 to 2013. Presence of CL, significant carotid disease (SCD) and carotid plaque morphology was evaluated. At least one CL was found in 159 patients (77.9%) with no significant difference among SxScore groups (P = 0.20 and P = 0.54, respectively). High prevalence of complex carotid plaque (CCP) was found without significant different distribution in SxScore groups (P = 0.69). Age was independently associated with the presence of CL [odds ratio (OR) 1.055; 95% confidence interval (CI): 1.015-1.097; P = 0.007] and SCD (OR 1.057; 95% CI: 1.008-1.097; P = 0.019). Age and diabetes were independently associated with CCP (OR 1.58; 95% CI: 1.023-1.095; P = 0.001; OR 1.848; 95% CI: 1.026-3.327; P = 0.041). SxScore was not independently associated with CL, SCD and CCP (all P > 0.2). CONCLUSIONS: We found high prevalence of CL in patients with multivessel complex CAD. However, SxScore does not seem to correlate with carotid atherosclerosis.

The forensic application of the Glycophorin A on the Amussat's sign with a brief review of the literature.

Even if the Amussat's sign is known since the mid-19th century, few studies have been made in order to assess its real occurrence. In particular, the histopathologic examination of the Amussat's sign lacks in the medicolegal literature. The review of the literature shows indeed a significant range of variability (from 1.1 % up to 25 %) regarding the macroscopic detection of the Amussat's sign. In this study, the authors report that the identification of a vital Amussat's sign is important and may require the immunohistochemical staining for the Glycophorin A (a marker of vital reaction). The victim was a 63-year-old man, who was found suspended from the staircase with a rope. Both the carotid arteries were opened in situ by using fine scissors with blunt tips. A horizontal lesion (length 4 mm) of the intima of the left common carotid artery was documented. A sample was obtained; then, a standard post-fixative histopathologic examination and immunohistochemical staining for the Glycophorin A were carried out. The standard histopathologic examination only revealed the intimal laceration with a poor hemorrhagic infiltration. However, the immunohistochemical staining for the Glycophorin A allowed the clear identification of the hemorrhagic infiltration, which was documented both in the intimal laceration and in the periadventitial soft tissues. The immunohistochemical staining for the Glycophorin A can identify the vitality of an Amussat's sign. When an Amussat's sign is documented, the Glycophorin A may therefore help the forensic pathologist to differentiate a hanging death from a postmortem suspension of the body.

Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance.

BACKGROUND AND AIMS: Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy. METHODS: We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression. RESULTS: Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49-50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38-3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97-92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3-11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8-22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033). CONCLUSIONS: Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.

Lesão transfixante de carótida por espinha de peixe - relato de caso / Carotid artery perforation by fish bone - a case report

Abstract Accidental fish bone ingestion is a common complaint at emergency departments. The majority of cases have a benign course. However, serious complications such as esophagus perforation, cervical vessel injury and cervical abscess can occur in 7.4% of cases. Mortality rates can be as high as 50% when mediastinitis occurs. We report a case of an esophageal perforation caused by a fish bone with a lesion to the right common carotid artery after 20 days of evolution. Surgical exploration occurred with corrections of the lesion in the right common carotid and esophagus. Early identification of this kind of injury is paramount to prevent potentially fatal complications.

Abstract Accidental fish bone ingestion is a common complaint at emergency departments. The majority of cases have a benign course. However, serious complications such as esophagus perforation, cervical vessel injury and cervical abscess can occur in 7.4% of cases. Mortality rates can be as high as 50% when mediastinitis occurs. We report a case of an esophageal perforation caused by a fish bone with a lesion to the right common carotid artery after 20 days of evolution. Surgical exploration occurred with corrections of the lesion in the right common carotid and esophagus. Early identification of this kind of injury is paramount to prevent potentially fatal complications.

SYNTAX Score II predicts carotid disease in a multivessel coronary disease population.

BACKGROUND: The SYNTAX Score (SxScore) is an angiographic tool that evaluates CAD complexity, which we previously reported lacking correlation with the presence of carotid disease. Recently, SxScore II has been developed including both angiographic and clinical variables, which could increase the prognostic accuracy for detection of carotid disease. METHODS AND RESULTS: From January 2013 to June 2014, 244 patients with multivessel CAD (mean age 65.37 years, 84% males) underwent carotid ultrasound scan. At least one carotid lesion (CL) was found in 77% of patients with significant carotid disease (SCD) in 23.4% of cases. Logistic regression analysis revealed no relation between SxScore and CL/SCD (p=0.781 and p=0.368) while SxScore II well correlated with CL (SxScore II-PCI: odds ratio [OR] 1.036; 95% confidence interval [CI]:1.006-1.067; p=0.019; SxScore II-CABG: OR 1.045; 95% CI: 1.015-1.076, p=0.003) and SCD (SxScore II-PCI: OR 1.042; 95% CI: 1.012-1.073, p=0.006; SxScore-CABG: OR 1.054; 95% CI: 1.029-1.080, p<0.0001). The areas under the receiver-operating characteristic curves were: for SxScore 0.512 (95% CI: 0.448-0.577; p=0.77), for SxScore II-PCI and SxScore II-CABG 0.600 (95% CI: 0.536-0.662; p=0.01) and 0.645 (95% CI: 0.581-0.705; p=0.0008), respectively, and 0.527 (95% CI 0.462-0.591; p=0.56), 0.619 (95% CI: 0.555-0.681; p=0.01) and 0.681 (95% CI: 0.619-0.739; p=0.0001), respectively, for the identification of SCD. CONCLUSIONS: The SxScore II, with inclusion of clinical variables over angiographic complexity, seems more suited to predict the presence of carotid disease than the SxScore.