cardiovascular-agents and Carotid-Stenosis

Cardiovascular disease represents a source of major health problems worldwide, and although medical and technical advances have been achieved, they are still associated with high morbidity and mortality rates. Personalized medicine would benefit from novel tools to better predict individual prognosis and outcomes after intervention. Artificial intelligence (AI) has brought new insights to cardiovascular medicine, especially with the use of machine learning techniques that allow the identification of hidden patterns and complex associations in health data without any a priori assumptions. This review provides an overview on the use of artificial intelligence-based prediction models in vascular diseases, specifically focusing on aortic aneurysm, lower extremity arterial disease, and carotid stenosis. Potential benefits include the development of precision medicine in patients with vascular diseases. In addition, the main challenges that remain to be overcome to integrate artificial intelligence-based predictive models in clinical practice are discussed.

Topics: Artificial Intelligence; Cardiovascular Agents; Cardiovascular Diseases; Carotid Stenosis; Humans; Machine Learning

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely <14 days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening

Topics: Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Consensus; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Treatment Outcome

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.. We searched multiple data bases for studies addressing five questions: medical management vs carotid revascularization (CEA) in asymptomatic patients, CEA vs carotid artery stenting (CAS) in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high-risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.. Medical management compared with carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low-risk surgical patients, CEA was associated with a lower risk of stroke, but a significant increase in myocardial infarction compared with CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs CEA in symptomatic patients were examined using preplanned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that, over the long term, CEA has a superior outcome compared with transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day 14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from peripheral artery disease, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared with a combined carotid intervention and coronary artery bypass grafting, had better outcomes.. This updated evidence summary supports the Society for Vascular Surgery clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in the long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2 and 14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

Topics: Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Consensus; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Treatment Outcome

Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal.. We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017.. Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention.. Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Combined Modality Therapy; Counseling; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Patient Selection; Risk Assessment; Risk Factors; Risk Reduction Behavior; Stents; Stroke; Treatment Outcome

Stroke is a leading cause of adult mortality and disability worldwide. Extracranial atherosclerotic disease (ECAD), primarily, carotid artery stenosis, accounts for approximately 18%-25% of ischaemic stroke. Recent advances in neuroimaging, medical therapy and interventional management have led to A significant reduction of stroke from carotid artery stenosis. The current treatment of ECAD includes optimal medical therapy, carotid endarterectomy (CEA) and carotid artery stenting (CAS). The selection of treatments depends on symptomatic status, severity of stenosis, individual factors, efficacy and risk of complications. The aim of this paper is to review current evidence and guidelines on the management of carotid artery stenosis, including the comparison of medical and interventional therapy (CAS and CEA), as well as future directions.

Topics: Brain Ischemia; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Endovascular Procedures; Humans; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stents; Stroke; Treatment Outcome

This meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT).. The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized.. Overall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312-0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810-6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548-14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668-50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361-0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223-1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found.. CEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.

Topics: Aged; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Endovascular Procedures; Female; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Randomized Controlled Trials as Topic; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Medical therapy for asymptomatic carotid artery stenosis (ACAS) may obviate the carotid revascularization, according to recent literature reports, but many studies also considered moderate carotid artery stenosis (50-69% NASCET). This study reviews the most recent series of ACAS focusing on ipsilateral transient ischemic attack (TIA) stroke and annual risk of stroke in patients with ACAS ≥70%, thereby also evaluating the adherence to best medical therapy (BMT).. A systematic review consisting of all the series of patients with ACAS being treated medically was performed, which was published after 2005. The annual pooled risk of ipsilateral TIA-stroke and stroke in patients with ACAS ≥70% was calculated. A subgroup of studies with BMT defined as ≥90% of the patients in antiplatelet and statin therapy was performed.. Eleven studies, with the enrolling period from 1996 to 2009, were reviewed. Overall, 2185 patients were considered, with a follow-up from 2 to 13 years, for a total of 6834 patients/year. The pooled risk was 3.4%/year for ipsilateral TIA-stroke and 1.6%/year for stroke. Five studies, published from 2014, had BMT adherence, for a total of 1665 patients/year. The pooled risk was 3.5%/year for ipsilateral TIA-stroke and for stroke.. The most recent series of ACAS ≥70% and BMT had an overall stroke rate which is relatively low; however, the risk of developing symptoms is still relevant (3.4%/year).

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Databases, Factual; Endarterectomy, Carotid; Humans; Ischemic Attack, Transient; Medication Adherence

With modern intensive medical therapy, the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis (ACS) is now down to ∼0.5%. Despite this, there is a widespread practice of routine intervention in ACS with carotid endarterectomy (CEA) and stenting (CAS). This is being justified on the basis of much higher risks with medical therapy in trials conducted decades ago, compared with lower risks of intervention in recent trials with no medical arm. Such extrapolations are invalid. Although recent trials have shown that after subtracting periprocedural risks the outcomes with CEA and CAS are now comparable to medical therapy, the periprocedural risks still far outweigh the risks with medical therapy. In the asymptomatic carotid trial (ACT) 1 trial, the 30-day risk of stroke or death was 2.9% with CAS and 1.7% with CEA. In the CREST trial, the 30-day risk of stroke or death among asymptomatic patients was 2.5% for stenting and 1.4% for endarterectomy. Thus, intensive medical therapy is much safer than either CAS or CEA. The only patients with ACS who should receive intervention are those who can be identified as being at high risk. The best validated method is transcranial Doppler embolus detection. Other approaches in development for identifying vulnerable plaques include intraplaque haemorrhage on MRI, ulceration and plaque lucency on ultrasound, and plaque inflammation on positron emission tomography/CT. Intensive medical therapy for ACS includes smoking cessation, a Mediterranean diet, effective blood pressure control, antiplatelet therapy, intensive lipid-lowering therapy and treatment with B vitamins (with methylcobalamin instead of cyanocobalamin), particularly in patients with metabolic B

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Endovascular Procedures; Humans; Risk Assessment; Risk Factors; Stents; Treatment Outcome

To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS).. A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI).. Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis.. Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Cilostazol; Humans; Myocardial Infarction; Odds Ratio; Recurrence; Risk Assessment; Risk Factors; Stents; Stroke; Tetrazoles; Time Factors; Treatment Outcome

Described in the article is a rare case concerning spontaneous recanalization of the extracranial portion of the internal carotid artery (ICA) eleven months after occlusion. Only few publications have been dedicated to recanalization of ICA chronic occlusion. Spontaneous recanalization of the ICA is more common than it is generally understood. The authors have analysed all available articles about this problem from PubMed (1957 to 2013), reviewing the mechanisms of recanalization of the ICA, methods of diagnosis and treatment. The purpose of this case report is to emphasize the importance of ICA spontaneous recanalization and consequences thereof.

Topics: Angiography; Brain Ischemia; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Prognosis; Recovery of Function; Remission, Spontaneous; Tomography, X-Ray Computed; Ultrasonography, Doppler, Color; Vascular Patency

Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis.

Topics: Cardiovascular Agents; Carotid Stenosis; Evidence-Based Medicine; Humans; Patient Compliance; Risk Factors; Risk Reduction Behavior; Stroke; Treatment Outcome

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Topics: Amaurosis Fugax; Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Hemodynamics; Humans; Ischemic Attack, Transient; Patient Selection; Predictive Value of Tests; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people, the search for a patent foramen ovale (PFO) has become standard. In stroke of the elderly, atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO-related stroke over time is controversial and so is its prevention by device closure. The association of proximal aortic plaques in arteries subtending the brain and stroke is considered strong, ignoring that it is as putative as that of the PFO. Statins can prevent progression of such plaques. Antiplatelet agents in asymptomatic and surgical endarterectomy in symptomatic patients or highly ulcerated lesions are the treatment of choice. Stenting with protection devices was shown competitive in selected patients.

Topics: Anticoagulants; Aortic Diseases; Balloon Occlusion; Cardiovascular Agents; Carotid Stenosis; Foramen Ovale, Patent; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Plaque, Atherosclerotic; Platelet Aggregation Inhibitors; Prosthesis Design; Randomized Controlled Trials as Topic; Recurrence; Risk Factors; Secondary Prevention; Septal Occluder Device; Stents; Stroke

Medical treatment has a pivotal role in the treatment of patients with occlusive carotid artery disease. Large trials have provided the justification for operative treatment besides medical treatment in patients with recent significant carotid artery stenosis two decades ago. Since then, medical therapy has evolved tremendously. Next to aspirin, antiplatelet regimens acting on a different level in the modulation of platelet aggregation have made their entry. Moreover, statin therapy has been introduced. These changes among others in secondary stroke prevention, along with better understanding in life-style adjustments and perioperative medical management, have led to a decrease in stroke recurrence. Secondary prevention is therefore now the most important pillar of medical therapy. It consists of antiplatelet therapy, statins and blood pressure lowering agents in all patients. Small adjustments are recommended for those patients referred for invasive treatment. Moreover, long-term medical treatment is imperative. In this article, we summarize current evidence in literature regarding medical management in patients with previous stroke or TIA.

Topics: Antihypertensive Agents; Cardiovascular Agents; Carotid Stenosis; Drug Therapy, Combination; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Secondary Prevention; Stroke; Time Factors; Treatment Outcome

Stroke is a leading cause of morbidity and mortality in the developed world. Although the rates of stroke have decreased in North America, there are significant areas of risk stratification and management that can be improved. Hypertension is the most significant and perhaps most modifiable risk factor for stroke. Carotid atherosclerotic disease is associated with 15% of ischemic strokes. Although carotid endarterectomy (CEA) remains a recommendation for significant symptomatic carotid stenosis, controversy continues in the management of asymptomatic and recurrent carotid stenosis. Medical management options and effectiveness has significantly improved since the early CEA trials were published. Optimal medical management now must incorporate aggressive risk factor reduction measures, particularly with antihyperlipidemic therapy. Improved understanding of the natural history of carotid atherosclerosis is necessary to improve the application of management strategies.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Evidence-Based Medicine; Humans; Recurrence; Risk Assessment; Risk Factors; Risk Reduction Behavior; Smoking Cessation; Stroke; Treatment Outcome

Despite randomized controlled trials demonstrating the superiority of carotid endarterectomy over medical management in the prevention of stroke in asymptomatic patients with severe carotid artery stenosis, considerable controversy remains with regard to selecting the appropriate asymptomatic patient for carotid intervention. Adding to the complexity of this issue is the fact that the extensive existing literature on this topic is heterogeneous, with trials having used varying definitions of high-grade stenosis, inclusion criteria for patients, and outcome measurements. The current article will review the existing randomized controlled trials on this topic, data regarding the risk of stroke in asymptomatic patients with severe stenosis, data regarding subsets of asymptomatic patients that may be at a higher-than-average risk of future stroke, and data regarding the efficacy of current medical therapy on the risk of stroke in asymptomatic patients with high-grade stenosis. Ultimately, the challenge for clinicians is to ensure that asymptomatic patients with the highest risk of future stroke are offered carotid revascularization and that the intervention is performed with the lowest possible complication rate, in order to maintain the benefit of prophylactic treatment.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Carotid endarterectomy (CEA) has long been considered the "gold standard" in the treatment of patients with symptomatic or asymptomatic carotid stenosis. However, the utility of this treatment modality in medical or surgical "high-risk" patients remains in question. Numerous clinical trials have demonstrated that carotid angioplasty and stenting (CAS) is not inferior to CEA. Furthermore, there are also increasing data that show that best medical therapy is becoming more effective in preventing strokes and in a more cost-effective manner than carotid interventions. With this in mind, there is now ample evidence to suggest that in a certain subgroup of patients, CEA may not be indicated, and in fact, CAS or observation with best medical therapy is preferred.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Stents; Stroke; Treatment Outcome

In the past, management of symptomatic carotid stenosis was uncertain. The results of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) in 1991 demonstrated a significant advantage of Carotid Endarterectomy (CEA) compared to medical management with Aspirin (ASA). Since the publishing of the NASCET results, there have been advances in both the medical management of patients with peripheral arterial disease as well as the introduction and improvement of the technique of minimally invasive carotid angioplasty and stenting. With this progress, the question has to be raised about what is the most appropriate treatment option for patients with symptomatic carotid artery stenosis. A review of the prospective clinical trials regarding the medical, surgical and endovascular management will help to elucidate the optimal therapy for symptomatic carotid stenosis.

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Clinical Trials as Topic; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Practice Guidelines as Topic; Risk Assessment; Severity of Illness Index; Stents; Treatment Outcome

Topics: Cardiovascular Agents; Carotid Stenosis; Disease Management; Endarterectomy, Carotid; Humans; Postoperative Complications; Risk Factors

Arterial disease in women will become a major issue in the near future.. A systemic review of existing literature was retrospectively conducted to collect information on the three most common entities of vascular disease: carotid atherosclerotic, abdominal aortic aneurismal, and lower extremity arterial occlusive disease.. Vascular disease is either underdiagnosed or undertreated in women. Whether regarding cerebrovascular disease, aortic aneurysmal disease, or atherosclerosis affecting the lower extremities, natural history, clinical and physiologic patterns are different in women vs men. Current biomedical devices create challenges in endovascular procedures performed in women. Furthermore, indications for treatment of vascular disease are derived from large studies where women are often underrepresented; and, thus, may not be applicable in female vascular patients.. Better understanding of the gender differences in vascular disease with focused randomized trials, biomedical research, and identification of gender specific medical and social risk factors will improve the clinical outcomes in female patients.

Topics: Aortic Aneurysm; Arterial Occlusive Diseases; Cardiovascular Agents; Carotid Stenosis; Estrogen Replacement Therapy; Female; Healthcare Disparities; Humans; Lower Extremity; Peripheral Vascular Diseases; Sex Factors; Vascular Surgical Procedures; Women's Health

Stroke is an important cause of morbidity and mortality, and is an economic burden. Diabetes and obesity are two important modifiable risk factors for stroke. Patients with diabetes have a higher incidence of stroke and a poorer prognosis after stroke. Risk-factor modification is the most important aspect of prevention of stroke in diabetes and obesity. This includes lifestyle modifications and different therapeutic modalities to control conditions, such as diabetes, hypertension, dyslipidemia and arrhythmia. Recent landmark studies have shown the beneficial effects of statins in diabetic patients even with close to normal or normal low-density lipoprotein cholesterol. Obesity, which is a risk factor for diabetes, hypertension and hyperlipidemia has been shown to be an independent risk factor for stroke. Increased leptin, dysregulation of adipocyte proteins, increased insulin resistance and C-reactive protein may be factors involved in the increased incidence of cardiovascular morbidity and mortality directly related to obesity. Visceral fat is a much bigger health risk than subcutaneous fat. Lifestyle interventions and pharmacotherapeutic agents have been used to manage obesity. In morbidly obese patients, surgical intervention seems to be the best method of treatment with a long-lasting favorable metabolic outcome. In the 21st Century, with the advanced medical knowledge and the therapeutic modalities available, it should be possible to reduce the incidence of stroke associated with diabetes and obesity.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Atrial Fibrillation; Blood Glucose; Cardiovascular Agents; Carotid Stenosis; Diabetes Mellitus; Diabetic Angiopathies; Diabetic Nephropathies; Diabetic Retinopathy; Dyslipidemias; Humans; Hypertension; Insulin Resistance; Ischemic Attack, Transient; Leptin; Life Style; Lipoproteins; Obesity; Plasminogen Activator Inhibitor 1; Risk Factors; Smoking; Stroke

The clinical manifestations of arteriosclerosis (cardiovascular, stroke and peripheral artery diseases) represent the leading causes of morbidity and mortality in industrialized countries. The early in vivo diagnosis and follow up of subclinical progression of arteriosclerosis is important for the evaluation of efficient preventive and therapeutic interventions. The carotid artery intima-media thickness (IMT) is a reliable surrogate marker of the arteriosclerosis and could be easily investigated with high resolution B-mode sonography. Due to its good reproducibility, the IMT measurement is optimal for tracking the progression or regression of atherosclerotic disease. The increase of IMT is influenced by numerous vascular risk factors (age, smoking, hypertension, dyslipidemia, alcohol etc.) and positively associated with the incidence of vascular events in the arterial vasculature (stroke, myocardial infarct). Studies with lipid-lowering, antihypertensive, antidiabetic drugs, hormones confirmed, that modifying of vascular risk factors significantly reduces the progression of IMT. It is probable, that reduced progression of IMT is also accompanied with the decrease of future vascular events.

Topics: Antihypertensive Agents; Ascorbic Acid; Cardiovascular Agents; Carotid Arteries; Carotid Stenosis; Disease Progression; Estradiol; Humans; Hypolipidemic Agents; Risk Factors; Tunica Intima; Tunica Media; Ultrasonography; Vitamin E

Prior clinical trials produced evidence-based treatment recommendations for patients with asymptomatic carotid stenosis that may not be appropriate for clinical decision-making today. High-quality patient outcomes data to allow informed decision making regarding the optimal management of high-grade asymptomatic internal carotid artery stenosis is lacking. The results of the Asymptomatic Carotid Atherosclerosis Study were published in 1995 based on a randomized patient enrollment in the 1990s. Outcomes after endarterectomy, stenting, and medical treatment for these patients have all improved in the subsequent 2 decades. Therefore, the time has come to test whether contemporary intensive medical therapy is an acceptable alternative to contemporary endarterectomy or stenting and is the rationale for the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST-2) trial. This National Institute of Neurological Disorders and Stroke-sponsored prospective, multicenter clinical trial has the investigators, study teams, asymptomatic patients, and robust study design needed to provide these answers. Two randomized clinical trials are planned: carotid revascularization and intensive medical management versus medical management alone in patients with asymptomatic high-grade carotid stenosis randomize in a 1:1 ratio; the other trial will randomize patients in a 1:1 ratio to carotid stenting with embolic protection versus no stenting. ClinicalTrials.gov Identifier: NCT02089217.

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Diffusion of Innovation; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Prospective Studies; Research Design; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome

Patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion with haemodynamic insufficiency are at high risk for recurrent stroke when treated medically.. The Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS) trial is an ongoing, government-funded, prospective, multicentre, randomised controlled trial. The CMOSS will recruit 330 patients with symptomatic ICA or MCA occlusion (parallel design, 1:1 allocation ratio) and haemodynamic insufficiency. Participants will be allocated to best medical treatment alone or best medicine plus extracranial-intracranial (EC-IC) bypass surgery. The primary outcome events are all strokes or deaths occurring between randomisation and 30 days post operation or post randomisation and ipsilateral ischaemic stroke within 2 years. Recruitment will be finished by December 2016. All the patients will be followed for at least 2 years. The trial is scheduled to complete in 2019.. The CMOSS will test the hypothesis that EC-IC bypass surgery plus best medical therapy reduces subsequent ipsilateral ischaemic stroke in patients with symptomatic ICA or MCA occlusion and haemodynamic cerebral ischaemia. This manuscript outlines the rationale and the design of the study. CMOSS will allow for more critical reappraisal of the EC-IC bypass for selected patients in China.. NCT01758614 with ClinicalTrials.gov. Registered on 24 December 2012.

Topics: Adolescent; Adult; Aged; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Cerebral Revascularization; Cerebrovascular Circulation; China; Clinical Protocols; Collateral Circulation; Combined Modality Therapy; Female; Hemodynamics; Humans; Infarction, Middle Cerebral Artery; Male; Middle Aged; Prospective Studies; Recurrence; Research Design; Risk Factors; Risk Reduction Behavior; Time Factors; Treatment Outcome; Young Adult

ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization.. Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012.. A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%.. Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions.. ISRCTN21144362.

Topics: Aged; Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Male; Middle Aged; Myocardial Infarction; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome

Asymptomatic carotid artery stenosis may be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS) or with best medical treatment (BMT) only. Definitive and evidence-based treatment recommendations for one of these options are currently not possible. Studies showing an advantage of CEA over BMT alone do not meet current standards from a pharmacological point of view. On the other hand, more recent data point to a further stroke risk reduction using BMT according to current standards. Studies on carotid artery stenting as a third alternative treatment are partially insufficient, especially when comparing CAS with BMT. Initiated in 2009, the randomized, controlled, multicenter SPACE-2 trial is intended to answer the question about the best treatment option of asymptomatic carotid artery stenosis; however, to increase recruitment rates as a condition for the successful completion of this important study, the trial design had to be modified.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Carotid Stenosis; Cause of Death; Endarterectomy, Carotid; Europe; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Practice Guidelines as Topic; Recurrence; Risk Factors; Risk Reduction Behavior; Stents; Survival Rate

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion.. From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months.. There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B.. Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Topics: Aged; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Chi-Square Distribution; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Patient Selection; Prospective Studies; Recurrence; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Fully absorbable polymeric scaffolds, as a potential alternative to permanent metallic stents, are entering the clinical field. The aim of this study is to assess the in vivo biocompatibility of a novel Sirolimus-eluting (SIR) absorbable scaffold based on poly(L-lactide) (PLLA) and poly(4-hydroxybutyrate) (P4HB) for interventional application.. Absorbable PLLA/P4HB scaffolds either loaded with SIR coating or unloaded scaffolds were implanted interventionally into common carotid arteries of 14 female. Bare metal stents (BMS) served as control. Peroral dual anti-platelet therapy was administered throughout the study. Stented common carotid arteries segments were explanted after 4 weeks, and assessed histomorphometrically.. The absorbable scaffolds showed a decreased residual lumen area and higher stenosis after 4 weeks (PLLA/P4HB: 6.56 ± 0.41 mm² and 37.56 ± 4.67%; SIR-PLLA/P4HB: 6.90 ± 0.58 mm² and 35.60 ± 3.15%) as compared to BMS (15.29 ± 1.86 mm² and 7.65 ± 2.27%). Incorporation of SIR reduced the significantly higher inflammation of unloaded scaffolds however not to a level compared to bare metal stent (PLLA/P4HB: 1.20 ± 0.19; SIR-PLLA/P4HB: 0.96 ± 0.24; BMS: 0.54 ± 0.12). In contrast, the BMS showed a slightly elevated vascular injury score (0.74 ± 0.15), as compared to the PLLA/P4HB (0.54 ± 0.20) and the SIR-PLLA/P4HB (0.48 ± 0.15) groups.. In this preclinical model, the new absorbable polymeric (SIR-) scaffolds showed similar technical feasability and safety for vascular application as the permanent metal stents. The higher inflammatory propensity of the polymeric scaffolds was slightly reduced by SIR-coating. A smaller strut thickness of the polymeric scaffolds might have been a positive effect on tissue ingrowth between the struts and needs to be addressed in future work on the stent design.

Topics: Absorbable Implants; Angioplasty, Balloon; Animals; Cardiovascular Agents; Carotid Artery, Common; Carotid Stenosis; Inflammation; Materials Testing; Models, Animal; Polyesters; Prosthesis Design; Sirolimus; Sus scrofa; Time Factors

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Treatment Outcome

Topics: Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Consensus; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Practice Guidelines as Topic; Treatment Outcome

Background Activation of the YAP (Yes-associated protein) pathway has been demonstrated to be related to smooth muscle cells (SMCs) phenotypic modulation and vessel restenosis. The aim of this study was to illustrate the molecular mechanisms that regulate the expression of YAP during the process of SMCs phenotypic switch. Whether the molecular basis identified in the study could be a potential therapeutic target for drug-eluting stents is further tested. Methods and Results In cell culture and in rat carotid arterial injury models, Sp-1 (specificity protein 1) expression was significantly induced, and correlated with SMCs proliferative phenotype. Overexpression of Sp-1 promoted SMCs proliferation and migration. Conversely, siSp-1 transfection or Sp-1 inhibitor Mithramycin A treatment attenuates SMC proliferation and migration. Through gain- and loss-function assays, we demonstrated that YAP was involved in Sp-1-mediated SMC phenotypic switch. Mechanistically, activated Sp-1 regulated YAP transcriptional expression through binding to its promoter. Moreover, we fabricated a Sp-1 inhibitor Mithramycin A-eluting stent and further tested it. In the rabbit carotid model, Mithramycin A-eluting stent inhibited YAP transcription and attenuated in-stent restenosis through regulating YAP-mediated SMC phenotypic switch. Conclusions Sp-1 controls phenotypic modulation of SMC by regulating transcription factor YAP. Drug-eluting stent targeting Sp-1 might represent a novel therapeutic strategy to prevent in-stent restenosis.

Topics: Angioplasty, Balloon; Animals; Apoptosis Regulatory Proteins; Cardiovascular Agents; Carotid Arteries; Carotid Artery Injuries; Carotid Stenosis; Cell Movement; Cell Plasticity; Cell Proliferation; Cells, Cultured; Disease Models, Animal; Drug-Eluting Stents; Male; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Phenotype; Plicamycin; Prosthesis Design; Rabbits; Rats; Signal Transduction; Sp1 Transcription Factor; YAP-Signaling Proteins

Topics: Aged; Angioplasty, Balloon; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Drug-Eluting Stents; Humans; Male; Plaque, Atherosclerotic; Prosthesis Design; Severity of Illness Index; Sirolimus; Treatment Outcome

Carotid endarterectomy (CEA), carotid artery stenting (CAS) and best medical therapy (BMT) are the major treatments used for significant asymptomatic carotid artery stenosis (ACAS, ≥50%). However, the widespread use of lipid-lowering drugs in this century has improved BMT outcomes. This study aims to compare the treatment efficacy of current BMT, CEA+BMT and CAS+BMT in patients with significant ACAS.. This protocol was designed based on the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Publication time for studies will be set from 1 January 2000 to 1 June 2020. We will search three databases: PubMed, EMBASE and The Cochrane Library. Suitable randomised controlled studies will be screened. The primary outcomes will include short-term and long-term mortality, stroke and myocardial infarction. OR and HR for dichotomous data and time-to-event data with 95% CIs will be calculated. Treatment effects among different therapies will be ranked according to the surface under the cumulative ranking curve and mean rank. A comprehensive evaluation of the risk of bias, heterogeneity and transitivity will be performed before data synthesis. Consistency and evidence quality will also be assessed.. There will be no need for ethics approval as this systematic review is a summary and analysis of existing literature. Final results may be presented in international conferences or a peer-reviewed journal.. CRD42019138942.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Endovascular Procedures; Humans; Meta-Analysis as Topic; Stents; Systematic Reviews as Topic; Treatment Outcome

A 27-year-old male patient suffering from dizziness and right amaurosis was diagnosed with Takayasu arteritis (TA). Computed tomography angiography showed that all the supra-aortic arteries were occluded except an aberrant right subclavian artery. The patient underwent drug-coated balloon dilatation at the lesion of the right common carotid artery and performed well after the procedure. Six months later, the patient's symptoms have not recurred and computed tomography angiography showed the right carotid artery remains patency. The supra-aortic artery lesions in TA may be a potential novel indication for a drug-coated balloon.

Topics: Adult; Angioplasty, Balloon; Cardiovascular Agents; Carotid Artery, Common; Carotid Stenosis; Humans; Male; Paclitaxel; Takayasu Arteritis; Treatment Outcome; Vascular Access Devices; Vascular Patency

Vascular smooth muscle cell (SMC) phenotypic modulation contributes to the development of restenosis. A sorafenib-eluting stent was specifically designed to target SMC phenotypic modulation to inhibit in-stent restenosis in the present study. SMC contractile protein from the freshly isolated rat aorta was expressed at a high level, but its expression was dramatically reduced after SMCs were cultured in 10% FBS for 1 wk. After sorafenib treatment, SMC contractile protein expression was markedly upregulated. We further observed that Yes-associated protein (YAP) expression was attenuated after sorafenib treatment in a dose-dependent manner. Overexpression of YAP by lentivirus reversed the expression of sorafenib-induced SMC contractile protein and increased the expression of cyclin D. Mechanistically, sorafenib regulated the serum response factor-myocardin (SRF-Myocd) complex through competitive binding of YAP to Myocd and increased SRF binding to CArG-containing regions of SMC-specific contractile genes within intact chromatin, thereby controlling the activity of smooth muscle-specific gene transcription. In a rabbit carotid model, the sorafenib-eluting stent (SFES) dramatically inhibited in-stent restenosis and upregulated SMC contractile protein expression. Overexpression of YAP blocked the antirestenosis effect of SFES and repressed contractile smooth muscle-specific genes in vivo, indicating that SFES attenuated in-stent restenosis through YAP-mediated SMC phenotypic modulation. We demonstrated that SFES attenuated in-stent restenosis through YAP-mediated SMC phenotypic modulation. Targeting SMC phenotypic modulation by drug-eluting stent represents an attractive therapeutic approach for the treatment of occlusive vascular diseases.

Topics: Animals; Aorta; Apoptosis Regulatory Proteins; Cardiovascular Agents; Carotid Arteries; Carotid Stenosis; Cell Proliferation; Cells, Cultured; Drug-Eluting Stents; Male; Models, Animal; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Nuclear Proteins; Phenotype; Prosthesis Design; Prosthesis Implantation; Rabbits; Rats; Serum Response Factor; Signal Transduction; Sorafenib; Trans-Activators; YAP-Signaling Proteins

Recent advances in best medical therapy (BMT) has been associated with reduced risk of stroke similar to that observed following surgical carotid revascularization (CR). Thus, it remains uncertain which subset(s) of patients would benefit from prophylactic CR+BMT for asymptomatic carotid stenosis (ACS) over BMT alone. The purpose of this study was to analyze the contemporary experience in the management of >70% ACS in an academic institution, to compare the short- and long-term outcomes of BMT alone against CR+BMT, and to identify risk factors for the development of future cerebrovascular events.. A retrospective review of all patients with severe ACS between January 2005 and December 2012 at Loyola University Medical Center and its affiliated Edward Hines Jr. Veterans Administration Hospital was conducted. Baseline patient characteristics, medications, and follow-up data were collected from electronic medical records, and treatment outcomes were compared. The random forest method was performed to select potential important variables for the development of late stroke. The recursive partitioning regression analysis (RPRA) was performed to identify the patient subgroup at increased risk of future stroke.. Of 409 patients identified; 247 were treated with CR and 162 with BMT. Between these groups with CR+BMT and BMT alone, the mean age was 69.1±8.2 versus 75.5±9.0, respectively (P<0.01). Mean follow-up was 60.7±37.5 months. Early (30-day) outcomes of stroke, acute myocardial infarction or mortality did not differ between the treatment modalities (2.0% CR vs. 0.6% BMT, P=0.41). Probability of freedom from ipsilateral stroke, and any stroke at 1- and 5-year follow-up were also comparable between CR+BMT and BMT alone. However, random forest method and RPRA demonstrated that patients with history of diabetes and remote stroke treated with BMT alone were at a high risk for future stroke (36.4% in total, 7.2% per year). The diabetics with contralateral carotid stenosis >50% who are active smokers are at the highest risk for stroke after CR (20.0% in total, 4.0% per year).. Prophylactic CR+BMT does not provide overall late stroke prevention compared with BMT alone. Diabetics with a history of stroke, in particular, are at an increased risk of stroke despite BMT. Timely CR+BMT for high-risk patients is still indicated.

Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Illinois; Male; Middle Aged; Myocardial Infarction; Regression Analysis; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Evidence-Based Medicine; Humans

Early in-stent restenosis after stent-protected angioplasty of the carotid artery (SPAC) is an infrequent, but potentially harmful condition for patients with carotid artery disease.. In our retrospective single-center analysis of 176 patients with carotid artery stenting between 2009 and 2015, using duplex ultrasound, we detected 9 patients with high-grade carotid artery in-stent restenosis. All restenosis patients were treated with a drug-eluting balloon (DEB) to prevent recurrent neointimal hyperplasia. One patient had bilateral carotid artery disease with bilateral in-stent restenosis, and 1 patient needed repeated DEB treatment 19 months after the first DEB intervention, so 11 DEB procedures, in total, were performed.. The median time-interval between primary carotid artery stenting and first DEB-treatment was 9 months. In 3 of the 11 interventions, the DEB treatment was assisted by an additional stent. One repeat DEB treatment was necessary, and three DEB treatments were followed by a secondary stent. No peri-interventional complications (TIA, stroke, or death) were observed during or after DEB intervention. Therefore, in the entire group, the 1y event-free survival (EFS) was 100%, and the 2y/3y/5y EFS was 83%.. DEB intervention seems to be an effective and safe treatment for patients with high-grade in-stent restenosis after SPAC.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Endovascular Procedures; Female; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Recurrence; Retrospective Studies; Treatment Outcome; Ultrasonography, Doppler, Duplex

Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high-sensitivity C-reactive protein [hs-CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA).. A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs-CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An "inflammatory score" was also created, which consisted of six predictive values of inflammatory markers (hs-CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow-up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done.. Our results showed an increased risk of early CR within 1 year in patients with increased hs-CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins.. Increased hs-CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

Topics: Aged; Algorithms; Aspirin; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Complement C3; Computed Tomography Angiography; Databases, Factual; Decision Support Techniques; Endarterectomy, Carotid; Female; Fibrinogen; Humans; Inflammation Mediators; Male; Middle Aged; Predictive Value of Tests; Recurrence; Retrospective Studies; Risk Assessment; Risk Factors; Sex Factors; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Color

To report long-term results of stent placement and medical therapy for symptomatic and asymptomatic patients, respectively, with carotid artery near-occlusion with full collapse.. Between January 2008 and December 2010, 204 carotid arteries diagnosed by duplex scanning as exhibiting complete occlusion were re-examined with CT angiography; 46 arteries in 46 patients were patent with threadlike lumens and were reclassified as exhibiting near-occlusion with full collapse. Asymptomatic patients (n = 22) received best medical therapy (BMT) alone, and symptomatic patients (n = 24) were referred for carotid artery stent (CAS) placement plus BMT. Patients underwent clinical follow-up for 63.9 months ± 23.6 and duplex surveillance.. None of the 22 asymptomatic patients treated with BMT alone experienced neurologic events during the follow-up interval. Four died of unrelated causes, resulting in a cumulative survival rate of 81.8%. Technical failure occurred in 5 of 24 symptomatic patients, but none had perioperative complications related to inability to cross the near-occlusion. Of the 19 patients with procedural success, 1 developed immediate upper limb monoparesis; none had periprocedural myocardial infarction, and none died. At 60-month follow-up, patients who underwent successful CAS placement had neurologic event-free and cumulative survival rates of 89.4% and 89.4%; patients with failed recanalization had neurologic event-free and cumulative survival rates of 0% and 40.0% (P = .01).. Asymptomatic patients with carotid near-occlusion with full collapse experienced good outcomes with BMT alone. Symptomatic patients who underwent CAS placement demonstrated long-term survival and freedom from neurologic event rates comparable to those of asymptomatic patients.

Topics: Adult; Aged; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Computed Tomography Angiography; Disease-Free Survival; Endovascular Procedures; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Prospective Studies; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Risk Assessment; Risk Factors; Stroke; Treatment Outcome

The clinical spectrum of internal carotid artery occlusion ranges from being a completely asymptomatic occlusion to a devastating stroke or death. The prevalence of asymptomatic internal carotid artery occlusion is unknown, particularly for bilateral occlusion. The distal branches of the external carotid artery anastomose with distal branches of the internal carotid artery provide important sources of collateral circulation to the brain. Stenosis of the external carotid artery with ipsilateral/bilateral internal occlusion may result in ischemic sequelae. Coiling or kinking of the vertebral artery is a rare morphological entity that is infrequently reported because it remains asymptomatic and has no clinical relevance. Currently, there is little evidence to support management strategies for this disease entity and no official recommendations for asymptomatic bilateral carotid artery occlusion. We present a case of a 62-year-old female with asymptomatic bilateral internal carotid artery occlusion, bilateral external carotid artery stenoses, and bilateral kinking of the vertebral artery at the V2 segment, who has been successfully managed conservatively for over 5 years. An individualized approach to management of patients with bilateral internal carotid artery occlusion, especially in combination with external carotid artery stenosis and elongation malformations of the vertebral artery is key to a successful strategy.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Artery, External; Carotid Artery, Internal; Carotid Stenosis; Computed Tomography Angiography; Diet; Female; Humans; Middle Aged; Risk Reduction Behavior; Smoking Cessation; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Color; Vertebral Artery

Whether improvement of cognitive function can be maintained remains controversial.. This study aimed to investigate cognitive changes between before carotid endarterectomy (CEA) or carotid artery stenting (CAS) and 1 year after intervention using cognitive evaluation tools.. Patients suspected as having carotid stenosis were prospectively registered for evaluation of cognitive function from October 2011 to December 2013 in the Department of Neurosurgery, Fukuoka University Hospital. Cognitive evaluation by the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were performed before and 1 year after CEA or CAS. Cognitive changes were evaluated using the Wilcoxon signed rank test, whereas the subscores of MoCA and MMSE were also compared.. The MoCA score was significantly ameliorated from 21 to 23 at 1 year after CEA (P = .003), but the MMSE score did not significantly change (24 to 25, P = .56). Additionally, the MoCA score was improved 1 year after CAS (P = .04), but it was unchanged in those who were treated medically (P = .15). Regarding the analyses of subscores, patients who had CEA improved in the areas of executive and memory functions, whereas those with medical treatment only showed improvement in memory. CAS did not improve any subscores. There was no significant improvement in the subscores of the MMSE in patients with CEA, CAS, or medical treatment 1 year after treatment compared with before treatment.. CEA or CAS may be significantly associated with cognitive improvement as evaluated by the MoCA. However, patients treated medically do not show improvement in cognitive performance.

Topics: Aged; Cardiovascular Agents; Carotid Stenosis; Cognition; Cognition Disorders; Endarterectomy, Carotid; Endovascular Procedures; Executive Function; Female; Hospitals, University; Humans; Japan; Male; Memory; Mental Status and Dementia Tests; Middle Aged; Prospective Studies; Recovery of Function; Registries; Risk Factors; Stents; Time Factors; Treatment Outcome

In recent trials, after deducting the risks in the 30-day periprocedural period, the long-term risk of stroke or death was similar with carotid stenting (CAS) and endarterectomy (CEA) for asymptomatic carotid stenosis (ACS) - approximately 0.5% per year. These findings may exacerbate the problem of inappropriate routine intervention in ACS, being justified on the basis of an invalid comparison of the risks in the medical arms of clinical trials conducted decades ago (˜ 2% per year) to the risks in modern trials of CAS vs. CEA with no medical arm. Intervention is regarded as justified if it can be carried out with a risk below 3%. The annual risk of ipsilateral stroke or death in ACS with intensive medical therapy is now ˜ 0.5% - similar to the long-term risk after the periprocedural period in recent trials of intervention. However, periprocedural risk was ˜ 3% for CAS and 1.7% for CEA. Thus with modern CAS and CEA, the risk remains much higher than with modern medical therapy, even with careful vetting of the surgeons and interventionalists. In real world practice, documented in registries, the risks are much higher. National differences - 90% of carotid intervention for ACS in the US vs. 0% in Denmark - bring into question the advisability and ethics of routine intervention. A moratorium on routine intervention for ACS should be respected except in ongoing randomized trials comparing CAS, CEA and modern intensive medical therapy. Patients with high-risk ACS can be identified for appropriate intervention.

Topics: Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Risk; Stents; Stroke

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone.. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period.. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65).. CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Topics: Age Factors; Aged, 80 and over; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Diagnostic Imaging; Disease Progression; Disease-Free Survival; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Patient Selection; Recurrence; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

Several guidelines recommend carotid endarterectomy for patients with severe asymptomatic carotid stenosis to reduce the risk of a future cerebrovascular event, as long as the perioperative stroke/death rate is <3%. Based on improvements in best medical treatment, it was argued that currently best medical treatment alone should comprise the treatment-of-choice for asymptomatic carotid stenosis patients and that no intervention is warranted in these individuals. While it is true that best medical treatment should be used for the management of all asymptomatic carotid stenosis patients, emerging evidence suggests that best medical treatment alone may not prevent disease progression and the development of symptoms in some asymptomatic carotid stenosis patient subgroups. This article analyzes the results of two recent independent studies demonstrating that medical therapy alone may not be adequate for stroke prevention in some asymptomatic carotid stenosis patient subgroups. These results suggest that besides best medical treatment, additional carotid endarterectomy should be considered for specific asymptomatic carotid stenosis patients.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Combined Modality Therapy; Disease Progression; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

The aim of the study was to evaluate the effect of the nutritional supplements Pycnogenol® and total triterpenic fraction of Centella asiatica (TTFCA) on atherosclerosis progression in low-risk asymptomatic subjects with carotid or femoral stenosing plaques.. This was an observational pilot, substudy of the San Valentino epidemiological cardiovascular study. The study included 824 subjects aged 45-60 without any conventional risk factors who had a stenosing atherosclerotic plaque (>50-60%) in at least one carotid or common femoral bifurcation, allocated into 6 groups: Group 1 (Controls): management was based on education, exercise, diet and lifestyle changes. This same management plan was used in all other groups; group 2: Pycnogenol® 50 mg/day; group 3: Pycnogenol® 100 mg/day; group 4: Aspirin® 100 mg/day or ticlopidine 250 mg/day if intolerant to aspirin; group 5: Aspirin® 100 mg/day and Pycnogenol® 100 mg/day; group 6: Pycnogenol® 100 mg/day plus TTFCA 100 mg/day. The follow-up lasted 42 months. Plaque progression was assessed using the ultrasonic arterial score based on the arterial wall morphology and the number of plaques that progressed and on the number of subjects that had cardiovascular events. A secondary endpoint was to evaluate the changes in oxidative stress at baseline and at 42 months.. The ultrasonic score increased significantly in groups 1, 2, and 4 (>1%) but not in groups 3, 5 and 6 (<1%) suggesting a beneficial effect of Pycnogenol® 100 mg. Considering the percent of patients that progressed from class V (asymptomatic) to VI (symptomatic) there was a progression of plaques in 48.09% of controls. In the Pycnogenol® 100 (group 3, 10.4%) and in the Aspirin®+ Pycnogenol® (group 5, 10.68%) progression was half of what observed with antiplatelet agent (group 4, 20.93%); in the TTFCA+ Pycnogenol®group (group 6) progression was 7.4 times lower than in controls; 3.22 times lower than in the antiplatelet agents group (4). Events (hospital admission, specialized care) were observed in 16.03% of controls; there were 8.83% of subjects with events with Pycnogenol® 50 mg and 8% in group 3 (Pycnogenol® 100 mg). In group 4 (antiplatelets), 8.52% of subjects had events; in group 5, 6.87% of subjects had events and in group 6 (TTFCA+ Pycnogenol®) only 4.41% had events (this was the lowest event rate; P<0.05). All treatment groups had a significantly lower event rate (P<0.05) in comparison with controls. Considering treatments groups 2, 3, 5, 6 had a lower number (P<0.05) of subjects in need of cardiovascular management in comparison with controls. The need for risk factor management was higher in controls and lower in group 6 (P<0.05). In groups 2 to 6 the need for risk factor management was lower than in controls (P<0.05). Including all events (hospital admission, need for treatment or for risk management) 51.9% of controls were involved. In the other groups there was a reduction (from a -9.28% reduction in group 2 to a -26% in group 6) (P<0.002). The most important reduction (higher that in all groups; P<0.05) was in group 6. At 42 months, oxidative stress in all the Pycnogenol® groups was less than in the control group. In the combined group of Pycnogenol® and TTFCA the oxidative stress was less than with Pycnogenol® alone (P<0.001).. Pycnogenol® and the combination of Pycnogenol® +TTFCA appear to reduce the progression of subclinical arterial plaques and the progression to clinical stages. The reduction in plaque and clinical progression was associated with a reduction in oxidative stress. The results justify a large, randomized, controlled study to demonstrate the efficacy of the combined Pycnogenol® and TTFCA prophylactic therapy in preclinical atherosclerosis.

Topics: Asymptomatic Diseases; Cardiovascular Agents; Carotid Arteries; Carotid Stenosis; Centella; Combined Modality Therapy; Dietary Supplements; Disease Progression; Drug Therapy, Combination; Female; Femoral Artery; Flavonoids; Humans; Male; Middle Aged; Oxidative Stress; Peripheral Arterial Disease; Pilot Projects; Plant Extracts; Plaque, Atherosclerotic; Platelet Aggregation Inhibitors; Registries; Risk Reduction Behavior; Rupture, Spontaneous; Time Factors; Treatment Outcome; Triterpenes; Ultrasonography

To investigate if drug-coated balloon (DCB) predilation may improve the efficacy of carotid artery stenting (CAS) for restenosis after carotid endarterectomy (CEA).. Eighteen consecutive patients (11 men; median age 75 years) with significant restenosis within 24 months of CEA were treated with a paclitaxel-coated DCB prior to CAS. Clinical outcomes and stent patency were systematically appraised.. All patients were successfully treated according to this clinical protocol. The only complication occurred in a patient who had a transient ischemic attack during prolonged DCB inflation. At a median follow-up of 18 months, no >50% restenosis was observed on duplex ultrasound scans; however, moderate hyperplasia at the proximal stent edge was found in 4 patients. One patient died at 9 months from a myocardial infarction.. Despite the small sample size and in keeping with the historically high risk of recurrent restenosis after CAS for CEA restenosis, this case series suggests that DCB dilation followed by CAS for postsurgical restenosis is feasible, safe, and may be associated with favorable clinical outcomes at midterm follow-up.

Topics: Aged; Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Coated Materials, Biocompatible; Endarterectomy, Carotid; Equipment Design; Female; Humans; Italy; Male; Paclitaxel; Recurrence; Retrospective Studies; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Duplex; Vascular Access Devices; Vascular Patency

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Coated Materials, Biocompatible; Endarterectomy, Carotid; Female; Humans; Male; Paclitaxel; Vascular Access Devices

The aim of this study is to evaluate the rate of progression of stenosis and development of symptoms in patients with asymptomatic carotid artery stenosis (aCAS) treated with contemporary medical therapy over a prolonged time interval.. This study is a retrospective review of consecutive patients diagnosed with moderate or severe aCAS at our institution between 2000 and 2001. Data were gathered from both carotid arteries for each patient excluding vessels operated within 1 year of diagnosis and occlusions. Multivariate analysis was performed to analyze factors associated with ipsilateral transient ischemic attack (TIA)/stroke.. We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Degree of stenosis was severe (>70%) upon diagnosis in 92 (26.4%) vessels. Median length of follow-up was 13 years (interquartile range 10-14), and mean number of time points for follow-up imaging were 8.1 ± 3.9. Progression of stenosis was observed in 237 (67.9%) vessels, and 72 (20.6%) patients developed symptoms ipsilateral to the stenosis (TIA in 14.4%, non-disabling stroke in 4%, disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). On multivariate analysis, degree of baseline stenosis, intracranial stenosis >50%, plaque ulceration, silent infarction and previous history of TIA/stroke were associated with ipsilateral TIA/stroke, but progression of stenosis was not.. There was a substantial rate of progression of stenosis in patients with aCAS over time despite adequate medical therapy, but progression of stenosis did not increase the risk of ipsilateral TIA/stroke. Over long-term follow-up, 1 in 5 patients with aCAS developed ipsilateral TIA/stroke, though most events were either transient or non-disabling.

Topics: Aged; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Cerebral Infarction; Comorbidity; Disease Progression; Endarterectomy, Carotid; Female; Follow-Up Studies; Humans; Ischemic Attack, Transient; Male; Middle Aged; Retrospective Studies; Risk; Risk Factors; Stents

Topics: Aspirin; Cardiovascular Agents; Carotid Stenosis; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Platelet Aggregation Inhibitors

Topics: Aspirin; Cardiovascular Agents; Carotid Stenosis; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Platelet Aggregation Inhibitors

Intimal hyperplasia produces restenosis (re-narrowing) of the vessel lumen following vascular intervention. Drugs that inhibit intimal hyperplasia have been developed, however there is currently no clinical method of perivascular drug-delivery to prevent restenosis following open surgical procedures. Here we report a poly(ε-caprolactone) (PCL) sheath that is highly effective in preventing intimal hyperplasia through perivascular delivery of rapamycin. We first screened a series of bioresorbable polymers, i.e., poly(lactide-co-glycolide) (PLGA), poly(lactic acid) (PLLA), PCL, and their blends, to identify desired release kinetics and sheath physical properties. Both PLGA and PLLA sheaths produced minimal (<30%) rapamycin release within 50days in PBS buffer. In contrast, PCL sheaths exhibited more rapid and near-linear release kinetics, as well as durable integrity (>90days) as evidenced in both scanning electron microscopy and subcutaneous embedding experiments. Moreover, a PCL sheath deployed around balloon-injured rat carotid arteries was associated with a minimum rate of thrombosis compared to PLGA and PLLA. Morphometric analysis and immunohistochemistry revealed that rapamycin-loaded perivascular PCL sheaths produced pronounced (85%) inhibition of intimal hyperplasia (0.15±0.05 vs 1.01±0.16), without impairment of the luminal endothelium, the vessel's anti-thrombotic layer. Our data collectively show that a rapamycin-loaded PCL delivery system produces substantial mitigation of neointima, likely due to its favorable physical properties leading to a stable yet flexible perivascular sheath and steady and prolonged release kinetics. Thus, a PCL sheath may provide useful scaffolding for devising effective perivascular drug delivery particularly suited for preventing restenosis following open vascular surgery.

Topics: Animals; Cardiovascular Agents; Carotid Artery Injuries; Carotid Stenosis; Cell Proliferation; Chemistry, Pharmaceutical; Delayed-Action Preparations; Disease Models, Animal; Drug Carriers; Hyperplasia; Kinetics; Linear Models; Male; Neointima; Polyesters; Rats; Rats, Sprague-Dawley; Sirolimus; Solubility; Technology, Pharmaceutical

Although level 1 evidence supports carotid endarterectomy (CEA) for stroke prevention in patients with asymptomatic severe carotid artery stenosis (ASCAS; >70%), medical therapy alone has been promulgated by some as equally effective. The goal of this study was to determine the natural history of medically treated patients with ASCAS.. Patients with ASCAS from 2005 to 2006 were identified in a health network database. Patients were included if the initial therapeutic plan involved medical therapy alone (usually because of comorbidities or patient preference). Study end points included: ipsilateral neurologic symptoms (INS) of transient ischemic attack and/or stroke, death, and INS and/or death.. There were 126 carotid arteries identified in 115 patients. Using standard duplex velocity criteria, 88 (70%) had severe (70%-89%) and 38 (30%) had very severe stenoses (VSS; 90%-99%). The average age was 73.5 years, demographic characteristics included: 66% hypertension, 64% coronary artery disease, 30% diabetes, 5% chronic kidney disease (CKD), and 86% were taking a statin drug (28% had a low-density lipoprotein level <100 mg/dL). There were 31 patients (24.6%) who developed INS during a mean follow-up of 27 months; most (23 of 31; 74%) occurred within 12 months of the initial duplex ultrasound examination; 14 (45%) were strokes. The 5-year actuarial freedom from INS was 70.1 ± 5%. Multivariate predictors of INS included: VSS (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.56-6.76; P = .002), CKD (HR, 6.25; 95% CI, 2.05-19.2; P = .001), and age (HR, 0.94; 95% CI, 0.91-0.98; P = .001). There were 41 patients (33%) who underwent eventual carotid revascularization (32 CEA, nine stent); 23 of 41 (56%) were performed for INS and 18 (44%) for plaque progression. Overall 5-year actuarial survival was 69.8% ± 4.1%. Multivariate predictors of death included: age (HR, 1.06; 95% CI, 1.03-1.1; P = .0001), chronic obstructive pulmonary disease (HR, 1.92; 95% CI, 1.08-3.41; P = .03), and diabetes (HR, 5.08; 95% CI, 2.86-9.01; P < .0001). The 5-year actuarial freedom from INS and/or death was 54 ± 4.4%. Multivariate predictors of INS and/or death were: VSS (HR, 1.98; 95% CI, 1.22-3.23; P = .006), CKD (HR, 5.46; 95% CI, 2.12-14.08; P = .0004), and diabetes (HR, 2.6; 95% CI, 1.59-4.24; P = .0001). Statin use was not protective against INS or death in this cohort.. Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.

Topics: Aged; Aspirin; Asymptomatic Diseases; Blood Flow Velocity; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Comorbidity; Disease Progression; Disease-Free Survival; Female; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Registries; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Cardiovascular Agents; Carotid Stenosis; Female; Humans; Male

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Endovascular Procedures; Female; Humans; Male; Paclitaxel; Stents

To evaluate the potential role, safety, and efficacy of paclitaxel-eluting balloon angioplasty for treatment of recurrent carotid in-stent restenosis (ISR).. Among 856 consecutive patients who underwent carotid artery stenting from May 2002 to January 2008, 41 patients had a significant ISR (>80% stenosis). Of these, 9 patients (7 women; mean age 78.1±5.6 years) had recurrent ISR despite multiple endovascular treatments (3.4±0.9 interventions) within a short period of time (2-5 months). These patients were treated with drug-eluting balloon (DEB) angioplasty for neointimal hyperplasia. Imaging (ultrasound or computed tomographic angiography) was performed at 1, 3, and 6 months and yearly thereafter.. Technical success was obtained in 100% of cases, with angiographic stenosis decreasing from 87%±4% to 6%±4% post treatment. Peak systolic velocity decreased significantly from 4.7±1.5 m/s to 0.6.±0.3 m/s after the procedure. Over a mean follow-up of 36.6±2.7 months, ultrasound imaging indicated recurrent ISR in only 3 patients at 18, 25, and 32 months after DEB angioplasty, respectively. The target vessel revascularization rate was 33.3% at 36 months. No neurological or myocardial events were recorded during follow-up. One patient died at 3 months.. DEB may have a potential role improving outcomes of those patients treated for early recurrent carotid ISR.

Topics: Aged; Angioplasty, Balloon; Blood Flow Velocity; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Endovascular Procedures; Female; Humans; Hyperplasia; Male; Middle Aged; Neointima; Paclitaxel; Prosthesis Design; Recurrence; Regional Blood Flow; Retreatment; Risk Factors; Stents; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler; Vascular Patency

Triglyceride (TG) accumulation in arterial tissue is associated with the development of cardiovascular disease; however, the underlying mechanism remains unclear. Cilostazol (CLZ), a selective inhibitor of phosphodiesterase 3, has antiplatelet and vasodilating effects and may decrease serum TG levels. We examined the effect of CLZ on TG accumulation in the arterial tissue of a rat model of carotid artery ligation.. Rats were fed normal chow with 0.1% CLZ (CLZ group) or without CLZ (control group) for 4 weeks after unilateral carotid artery ligation near the carotid bifurcation.. At the end of this period, the control group showed 3.3-fold higher TG levels in the ligated carotid artery than in the contralateral artery; however, compared with the contralateral artery, the ligated artery in the CLZ group showed significantly lower levels of TG accumulation but similar serum levels of TG, total cholesterol, and high-density lipoprotein cholesterol. Furthermore, matrix-assisted laser desorption/ionization imaging mass spectrometry revealed that the ligated carotid artery in both groups had ubiquitous accumulation of TG in the intima, media, and adventitia, along with decreased heme B signals, which was indicative of ischemia. However, heme B signals were less reduced in the CLZ group than in the control group.. Our results indicate that CLZ can inhibit the ubiquitous accumulation of TG in arterial tissues, possibly by ameliorating tissue ischemia. CLZ may be useful in improving arterial tissue hemodynamics and lipid metabolism.

Topics: Animals; Cardiovascular Agents; Carotid Artery, Common; Carotid Stenosis; Cholesterol, HDL; Cilostazol; Disease Models, Animal; Heme; Hemodynamics; Ligation; Male; Phosphodiesterase 3 Inhibitors; Rats; Rats, Sprague-Dawley; Regional Blood Flow; Tetrazoles; Time Factors; Triglycerides

We report an unusual case of a patient whose whole cerebral circulation was supported by poor vicariate collaterals and a severely atherosclerotic right vertebral artery, with no brain perfusion abnormalities. Our belief is that despite the brain imaging and the absence of symptoms, because of his critical vascular disease and the paucity of data from large randomised clinical trials on vertebra-basilar revascularisation, the case required an extremely cautious approach regarding any kind of revascularisation. An accurate imaging analysis together with clinical features allowed us to decide on a strategy based on optimal medical therapy and careful clinical monitoring.

Topics: Atherosclerosis; Cardiovascular Agents; Carotid Stenosis; Cerebrovascular Circulation; Collateral Circulation; Drug Therapy, Combination; Humans; Magnetic Resonance Angiography; Male; Middle Aged; Perfusion Imaging; Predictive Value of Tests; Subclavian Steal Syndrome; Treatment Outcome; Vertebrobasilar Insufficiency

Despite level 1 evidence in support of carotid endarterectomy vs medical therapy in selected asymptomatic patients, an alternative posture is that optimal medical therapy (OMT) has not been adequately studied and that such OMT has reduced stroke risk in asymptomatic patients to levels wherein carotid endarterectomy is no longer justified. The goal of this study was to determine the natural history of patients with asymptomatic moderate (50%-69%) carotid artery stenosis (AMCAS) in a contemporary cohort as a function of their associated medical therapy.. Patients with AMCAS determined by duplex ultrasound (DUS) from 2005-2006 were identified in our hospital database. Patients were included in the cohort if they had at least one additional DUS during the 6-year follow-up interval. Patient characteristics including medication history and lipid levels were collected. Patients were considered to have OMT if they were on aspirin and a statin with a low-density lipoprotein level that was always <100 mg/dL. Study end points included progression of carotid disease by DUS to severe stenosis (70%-100%), development of ipsilateral neurologic symptoms (INS) such as stroke or transient ischemic attack, and death.. There were 900 carotid arteries in 794 patients in the study cohort. The average age was 72.5 years, 77.2% had hypertension, 59.6% had coronary artery disease, and 87.1% were on a statin throughout the study. The low-density lipoprotein cholesterol level was always normal (<100 mg/dL) in 37.8% and accordingly, 241 (30.3%) had OMT as defined above. The 5-year actuarial survival was 81.9% ± 1.3% with no advantage seen with OMT. Multivariate analysis of survival showed statins were protective (hazard ratio [HR], 0.50; confidence interval [CI], 0.34-0.73; P = .0004). The 5-year freedom from plaque progression was 61.2% ± 2.1% with no benefit from OMT vs the control group. Multivariate predictors of plaque progression were chronic kidney disease (HR, 2.1; CI, 1.2-3.7; P = .009), aspirin use (HR, 1.9; CI, 1.2-3.0; P = .01), and the use of calcium channel blockers (HR, 1.4; CI, 1.1-1.8; P = .007). There were 90 (11.3%) patients who developed INS during follow-up (58% of these were strokes), and the 5-year freedom from INS was 88.4% ± 1.5%. Multivariate predictors of INS were diabetes (HR, 2.3; CI, 1.5-3.6; P = .0002) and warfarin use (HR, 1.9; CI, 1.2-2.9; P = .009); while statin use (HR, 0.37; CI, 0.22-0.65; P = .0005) was protective against symptom development.. At the 5-year of follow-up, OMT failed to prevent carotid disease progression or development of ipsilateral symptoms in 45% of patients with AMCAS.

Topics: Aged; Aged, 80 and over; Aspirin; Asymptomatic Diseases; Biomarkers; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Cholesterol, LDL; Comorbidity; Disease Progression; Drug Therapy, Combination; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Humans; Sirolimus

Topics: Angioplasty, Balloon; Brain; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Endarterectomy, Carotid; Humans; Stroke

The A(2B) adenosine receptor (A(2B)R) is highly expressed in macrophages and vascular smooth muscle cells and has been established as an important regulator of inflammation and vascular adhesion. Recently, it has been demonstrated that A(2B)R deficiency enhances neointimal lesion formation after vascular injury. Therefore, we hypothesize that A(2B)R agonism protects against injury-induced intimal hyperplasia.. Apolipoprotein E-deficient mice were fed a Western-type diet for 1 week, after which the left common carotid artery was denuded. Mice were treated with the A(2B) receptor agonist BAY60-6583 or vehicle control for 18 days. Interestingly, lumen stenosis as defined by the neointima/lumen ratio was inhibited by treatment with the A(2B) receptor agonist, caused by reduced smooth muscle cell proliferation. Collagen content was significantly increased in the BAY60-6583-treated mice, whereas macrophage content remained unchanged. In vitro, vascular smooth muscle cell proliferation decreased dose dependently whereas collagen content of cultured smooth muscle cells was increased by BAY60-6583.. Our data show that activation of the adenosine A(2B) receptor protects against vascular injury, while it also enhances plaque stability as indicated by increased collagen content. These outcomes thus point to A(2B) receptor agonism as a new therapeutic approach in the prevention of restenosis.

Topics: Adenosine A2 Receptor Agonists; Aminopyridines; Animals; Apolipoproteins E; Cardiovascular Agents; Carotid Artery Injuries; Carotid Artery, Common; Carotid Stenosis; Cell Adhesion; Cell Proliferation; CHO Cells; Collagen; Cricetinae; Cricetulus; Dietary Fats; Disease Models, Animal; Dose-Response Relationship, Drug; Endothelium, Vascular; Female; HEK293 Cells; Humans; Mice; Mice, Knockout; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Neointima; Neutrophil Activation; Neutrophils; Platelet Activation; Receptor, Adenosine A2B; Time Factors; Transfection

To evaluate the safety and efficacy of a balloon-mounted drug-eluting stent (DES) for recurrent carotid in-stent stenosis (ISS).. As part of our targeted carotid artery stenting (TARGET-CAS) protocol, neurological and ultrasound evaluations have been performed at 3, 6, and 12 months and then annually since 2001 in all carotid stent patients. For angiographically-confirmed >70% ISS, balloon angioplasty was performed as a first-line treatment. Recurrent ISS was treated with a 4.0-mm zotarolimus-eluting coronary stent (ZES) that was postdilated according to intravascular ultrasound imaging. Among the 1350 neuroprotected CAS procedures performed between January 2001 and March 2011, there were 7 (0.52%) patients (5 men; ages 51-72 years), all neurologically asymptomatic, with >70% recurrent ISS that occurred at 5 to 11 months after the initial balloon angioplasty treatment for ISS.. ZES implantation under distal embolic protection was technically successful and uncomplicated. Angiographic stenosis was reduced from 84.6%±7.5% to 10.7%±3.6% (p<0.01). In 5 patients with ZES implanted fully within the self-expanding carotid stent, duplex ultrasound follow-up (mean 17 months, range 6-36) revealed no evidence of restenosis or stent fracture/deformation. In the 2 other patients, the ZES had been implanted for distal edge ISS such that the ZES protruded beyond the original carotid stent. This protruding segment of the ZES demonstrated deformation/kinking in both; in one, this led to symptomatic stent occlusion.. The use of coronary ZES in the treatment of recurrent carotid ISS is feasible and appears effective provided the ZES is placed entirely within the original stent. Placement of a coronary ZES outside the carotid stent scaffold should be avoided.

Topics: Aged; Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Embolic Protection Devices; Female; Humans; Male; Middle Aged; Poland; Prosthesis Design; Recurrence; Severity of Illness Index; Sirolimus; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex; Ultrasonography, Interventional

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Female; Humans; Male; Sirolimus

Effects of carotid artery stenting (CAS) on patients with chronic internal carotid artery occlusion are unknown.. This study included 21 patients who underwent successful CAS treatment and 41 patients who received optimal medical therapy. Modified Rankin Scale (mRS) and cardiocerebral vascular events were compared between CAS and medical therapy group.. The mRS in CAS group was lower than in control group during a 2-year follow up (P<0.05 or 0.01). The combined cerebrovascular events and mortality in study group was lower than in the control group (33.4% vs. 56.1%, P=0.045), but there was no statistically significant difference in the cerebrovascular event (28.6% vs. 46.3%, P=0.088) or mortality rate (4.8% vs. 9.8%, P=0.247) between the two groups. Cox regression analysis revealed that smoking (RR=3.189, 95% CI 1.020-9.968, P=0.046), diabetes (RR=2.717, 95% CI 1.113-6.631, P=0.028), and baseline National Institute of Health stroke scale (RR=2.984, 95% CI 1.049-8.485, P=0.040) were independent risk factors for major cerebrovascular events following CAS.. CAS was superior to drug therapy in achieving better functional outcomes in patients with chronic internal carotid artery occlusion. However, CAS was not associated with a statistically significant reduction in cerebrovascular events or mortality. Larger and randomized clinical trials are required to ascertain the long-term benefits of CAS in patients with chronic internal carotid artery occlusion.

Topics: Aged; Analysis of Variance; Angioplasty; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Case-Control Studies; Cerebrovascular Disorders; Chi-Square Distribution; China; Chronic Disease; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Proportional Hazards Models; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome

To report midterm results of 3 cases in which drug-eluting balloons (DEBs) were successfully used for the management of carotid in-stent restenosis (ISR).. Two women aged 68 and 70 years and a 68-year-old man were referred to our institution for asymptomatic severe stenosis [>80% with peak systolic velocity (PSV) >300 cm/s by Doppler ultrasound assessment] of individual Carotid Wallstents implanted in the proximal left internal carotid artery (ICA). In the angiosuite, the left ICA was engaged in a telescopic fashion with a triple coaxial system formed by a 6-F long sheath and a preloaded 5-F, 125-cm diagnostic catheter over a 0.035-inch soft hydrophilic guidewire. Under distal filter protection, the lesions were predilated using a 3.5 × 20-mm coronary balloon and then treated with two 1-minute inflations of a 4 × 40-mm Amphirion In.Pact paclitaxel-eluting balloon, followed by 3 months of dual antiplatelet therapy. At 12, 22, and 36 months, respectively, the patients are still asymptomatic, with duplex-documented stent patency at 6, 12, and 24 months, respectively.. DEBs are an emerging strategy for carotid ISR, with encouraging midterm results in these patients. Further experience in larger cohorts is needed to confirm these preliminary observations.

Topics: Aged; Angiography, Digital Subtraction; Angioplasty, Balloon; Cardiovascular Agents; Carotid Arteries; Carotid Stenosis; Catheters; Coated Materials, Biocompatible; Drug Therapy, Combination; Equipment Design; Female; Humans; Male; Paclitaxel; Platelet Aggregation Inhibitors; Recurrence; Severity of Illness Index; Stents; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex; Ultrasonography, Interventional; Vascular Patency

To evaluate the safety and efficacy of drug-eluting balloons (DEB) for the treatment of in-stent restenosis (ISR) after carotid artery stenting (CAS).. Among 830 consecutive patients undergoing CAS between November 2001 and June 2012, significant ISR (>80% stenosis) occurred in 10 (1.2%) asymptomatic patients. Angioplasty with DEB treatment was performed in 7 patients (6 internal and 1 common carotid arteries) at a mean of 20.9 ± 19.4 months (median 12.1) after CAS. Intravascular ultrasound (IVUS)-guided predilation with distal cerebral protection was carried out with a cutting balloon followed by inflation of a DEB with a 1:1 stent-to-balloon size ratio.. Technical/procedural success was achieved in all cases. Angiographic stenosis decreased from 83%± 5% to 18%± 6%. At IVUS evaluation, minimal lumen area increased from 3.19 ± 1.73 to 12.78 ± 1.97 mm(2) (p=0.0001), stent area was unchanged (from 17.36 ± 4.36 to 17.52 ± 4.34 mm(2), p=0.70), and the restenosis area decreased from 13.58 ± 5.27 to 4.71 ± 3.06 mm(2) (p=0.0005). At a mean follow-up of 13.7 ± 1.5 months (median 13.7), 1 patient had a minor stroke ipsilateral to the ISR vessel 2 months after DEB treatment; the stent was widely patent on duplex ultrasound and angiographic images. Overall, the average PSV decreased from 4.0 ± 1.0 to 0.9 ± 0.1 m/s (p=0.0001). At 6 and 12 months, PSVs after DEB treatment were significantly lower compared to those assessed at comparable intervals after CAS.. The use of DEBs to treat ISR after CAS shows promising acute and midterm results.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon; Cardiovascular Agents; Carotid Artery, Common; Carotid Artery, Internal; Carotid Stenosis; Catheters; Coated Materials, Biocompatible; Equipment Design; Female; Humans; Male; Middle Aged; Paclitaxel; Recurrence; Severity of Illness Index; Stents; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Duplex; Ultrasonography, Interventional; Vascular Patency

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Arteries; Carotid Artery, Common; Carotid Stenosis; Catheters; Coated Materials, Biocompatible; Female; Humans; Male; Paclitaxel; Stents

The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis.. In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2).. In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switched to a more conservative treatment. Younger physicians suggested a more conservative approach (P<0.014).. Different medical specialties prefer different treatments for asymptomatic carotid stenosis. Also, younger physicians seem more conservative. We elaborate on the different reasons that could explain these findings.

Topics: Adult; Age Factors; Aged; Angioplasty; Asymptomatic Diseases; Belgium; Cardiology; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Endarterectomy, Carotid; Female; Health Care Surveys; Health Knowledge, Attitudes, Practice; Humans; Internet; Male; Medicine; Middle Aged; Neurology; Odds Ratio; Patient Selection; Practice Patterns, Physicians'; Referral and Consultation; Severity of Illness Index; Stents; Vascular Surgical Procedures

The purpose of this study was to clarify the clinical impact of endovascular treatment (EVT) on acute cerebral large vessel occlusion using a nationwide survey of Japan conducted in 2009.. Patients admitted within 24 h after stroke onset were registered retrospectively. Treatment selection, methods, and clinical results were analyzed.. A total of 1,963 patients (855 women, 1,108 men) treated in 2008 were registered from 68 medical centers in Japan. Mean age on admission was 74.1 ± 12.2 years (range 7-100 years). The first treatment was conservative therapy in 68%, intravenous tissue plasminogen activator (IV-tPA) in 21%, EVT in 9%, and combined IV-tPA + EVT in 2%. EVT mainly comprised angioplasty, intra-arterial thrombolysis and/or the combination of both. Patients treated ≤3 h after onset (1,286 cases) showed better clinical outcomes with combined IV-tPA + EVT than with conservative therapy, and significant differences in outcomes were seen for patients with occlusion of the basilar artery (p < 0.01) or middle cerebral artery (p < 0.01), but not the internal carotid artery. At >3 h after onset (677 patients), no IV-tPA was performed, and EVT was performed in 11%. Among the patients treated by EVT, there were significant differences in clinical outcome between complete recanalization (TIMI grade 3) and partial/no recanalization (TIMI grade 0-2) (p < 0.001; OR 5.98; 95% CI 3.27-10.96) and between any recanalization (TIMI grade 1-3) and no recanalization (TIMI grade 0) (p < 0.001; OR 36.15; 95% CI 4.88-267.53).. This nationwide survey showed the efficacy of EVT with IV-tPA in patients with occlusion of the basilar or middle cerebral artery, but not of the internal carotid artery. The effects of new endovascular devices should be clarified in the near future.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Carotid Stenosis; Chi-Square Distribution; Child; Combined Modality Therapy; Endovascular Procedures; Female; Health Care Surveys; Humans; Infarction, Middle Cerebral Artery; Japan; Male; Middle Aged; Odds Ratio; Patient Selection; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Thrombolytic Therapy; Time Factors; Treatment Outcome; Vertebrobasilar Insufficiency; Young Adult

To evaluate the development of neointimal hyperplasia after implantation of drug-eluting stents (paclitaxel) compared to bare metal stents in porcine internal carotid arteries (ICAs).. While drug-eluting stents have effectively reduced neointimal proliferation in porcine external carotid arteries, the porcine internal carotid artery (ICA) is more sensitive to shear stress and altered flow conditions. Thus, a study was conducted to evaluate bare vs. drug-eluting stents in porcine ICAs. Under general anesthesia, 18 domestic pigs were implanted with paclitaxel-eluting (n = 18) and bare (n = 18) stents in the left and right ICAs, respectively. After 1 and 3 months, control carotid angiography was performed, followed by histopathological and histomorphometric analyses of the stented ICA.. Histopathological results (fibrin deposition, necrosis, inflammation) were similar in the groups at 1 and 3 months. Moreover, the injury score and rate of endothelialization did not differ between the groups. Histomorphometric analysis after 1 month revealed significantly (p<0.05) less neointimal hyperplasia after implantation of paclitaxel-eluting stents. The antiproliferative effect of paclitaxel-eluting stents were maintained during the 3-month follow-up: the neointimal area was 0.7 ± 0.5 vs. 1.2 ± 0.6 mm(2) (p<0.01), the area stenosis was 23.5% ± 13.9% vs. 37.8% ± 14.4% (p<0.01), the maximal neointimal thickness was 0.2 ± 0.1 vs. 0.2 ± 0.9 mm (p<0.05) in paclitaxel-eluting vs. bare stents, respectively. Implantation of paclitaxel-eluting and bare stents did not lead to edge restenosis or vessel remodeling in porcine ICAs at 1 or 3 months.. Compared to bare metal stents, drug-eluting stents implanted in the porcine ICA produced significantly less neointimal hyperplasia.

Topics: Angioplasty, Balloon; Animals; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Cell Proliferation; Drug-Eluting Stents; Hyperplasia; Metals; Paclitaxel; Platelet Aggregation Inhibitors; Prosthesis Design; Radiography; Stents; Sus scrofa; Time Factors; Tunica Intima

Vascular surgery has matured to the point that there exists robust bodies of literature exploring many of our therapies. However, this evidence is but one of the factors that dictate medical practice. Others include local patient demographics, the practical implications of healthcare delivery, and an individual surgeon's interpretation of this evidence, which can be somewhat subjective. As a result, there are numerous examples of vascular specialists' practice patterns differing depending on their geographic location. Recognizing this, the Editors of the Journal of Vascular Surgery and the European Journal of Vascular and Endovascular Surgery have developed a series of Trans-Atlantic Debates to explore these instances. The inaugural debate explores the controversial question of how best to manage asymptomatic carotid artery stenoses. Our debators, Peter Schneider and Ross Naylor, offer reasoned and passionate arguments to defend their differing approaches. We trust that this addition to our journals will prove enlightening and, perhaps, entertaining.

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Combined Modality Therapy; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Practice Patterns, Physicians'; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Treatment Outcome

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Combined Modality Therapy; Endarterectomy, Carotid; Evidence-Based Medicine; Humans; Patient Selection; Practice Patterns, Physicians'; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Recurrence; Risk Assessment; Risk Factors; Stents; Stroke; Therapeutic Equipoise; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Topics: Angioplasty; Asymptomatic Diseases; Cardiovascular Agents; Carotid Stenosis; Endarterectomy, Carotid; Humans; Patient Selection; Risk Assessment; Risk Factors; Stents; Stroke; Treatment Outcome

Although there is level I evidence supporting the role of carotid endarterectomy (CEA) in patients with asymptomatic disease, opinion remains polarised regarding what constitutes optimal management, especially as carotid artery stenting (CAS) has emerged as a less invasive alternative. Reasons for this lack of consensus amongst surgeons, interventionists, neurologists and stroke physicians include our continued inability to identify 'high risk for stroke' patients in whom to target costly therapies. For example, recent data from the USA suggest that up to $21 billion is being spent each year on ultimately 'unnecessary' interventions. Second, is growing evidence that improvements in what now constitutes modern 'best medical therapy' has significantly reduced the risk of stroke compared to that observed in ACAS and ACST. If true, this will compromise risk:benefit analyses used in national and international guidelines. At a time when evidence suggests that up to 94% of interventions may not benefit the patient, the authors urge that at least one of the randomised trials comparing CEA with CAS in asymptomatic patients includes an adequately powered third limb for BMT. Timely investment now could optimise patient care and resource utilisation for all of us in the future.

Topics: Angioplasty; Cardiovascular Agents; Carotid Stenosis; Cost-Benefit Analysis; Endarterectomy, Carotid; Evidence-Based Medicine; Health Care Costs; Humans; Patient Selection; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Research Support as Topic; Risk Assessment; Stents; Stroke; Treatment Outcome; Unnecessary Procedures

Topics: Animals; Cardiovascular Agents; Carotid Stenosis; Cell Proliferation; Coronary Restenosis; Drug-Eluting Stents; Enzyme Activation; Enzyme Activators; Humans; Hyperplasia; Muscle, Smooth, Vascular; NAD(P)H Dehydrogenase (Quinone); Naphthoquinones; Secondary Prevention; Tunica Intima

Intimal hyperplasia is a major cause of restenosis after the interventional or surgical treatment of occlusive arterial disease. We investigated the effects of clopidogrel, calcium dobesilate, nebivolol, and atorvastatin on the development of intimal hyperplasia in rabbits after carotid venous bypass surgery. We divided 40 male New Zealand rabbits into 4 study groups and 1 control group. After occluding the carotid arteries of the rabbits, we constructed jugular venous grafts between the proximal and the distal segments of the occluded artery. Thereafter, group 1 (control) received no medication. We administered daily oral doses of clopidogrel to group 2, calcium dobesilate to group 3, nebivolol to group 4, and atorvastatin to group 5. The rabbits were killed 28 days postoperatively. The arterialized jugular venous grafts were extracted for histopathologic examination. Intimal thicknesses were 42.87 +/- 6.95 microm (group 2), 46.5 +/- 9.02 microm (group 3), 34.12 +/- 5.64 microm (group 4), and 48.37 +/- 6.16 microm (group 5), all significantly less than the 95.12 +/- 9.93 microm in group 1 (all P < 0.001). Medial thicknesses were 94 +/- 6 microm (group 2), 101.5 +/- 13.52 microm (group 3), 90.5 +/- 9.69 microm (group 4), and 101.37 +/- 7.99 microm (group 5), all significantly thinner than the 126.62 +/- 13.53 microm in group 1 (all P < 0.001). In our experimental model of carotid venous bypass grafting in rabbits, clopidogrel, calcium dobesilate, nebivolol, and atorvastatin each effectively reduced the development of intimal hyperplasia. Herein, we discuss our findings and review the medical literature.

Topics: Administration, Oral; Animals; Atorvastatin; Benzopyrans; Calcium Dobesilate; Cardiovascular Agents; Carotid Stenosis; Clopidogrel; Disease Models, Animal; Ethanolamines; Graft Occlusion, Vascular; Heptanoic Acids; Hyperplasia; Jugular Veins; Male; Nebivolol; Pyrroles; Rabbits; Ticlopidine; Tunica Intima; Vascular Surgical Procedures

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Female; Humans; Middle Aged; Recurrence; Sirolimus; Treatment Outcome

Baicalein (5,6,7-trioxyflavone-7-O-beta-D-glucuronide) derived from the Chinese herb Scutellaria baicalensis is well known as a lipoxygenase inhibitor. We investigated baicalein-mediated inhibitory effects on vascular smooth-muscle cell (VSMC) proliferation and intimal hyperplasia by balloon angioplasty in the rat. In vascular injury studies, baicalein significantly suppressed intimal hyperplasia by balloon angioplasty. Baicalein significantly inhibited cell proliferation via a lipoxygenase-independent pathway using [(3)H]thymidine incorporation, 3-(4,5-dimethylthiazol-2-yl)2,5-diphenyltetrazolium bromide (MTT), and flow cytometry assays. At the concentrations used, no cytotoxic effect on cell culture was found. Baicalein blocks cell-cycle progression in S/G2/M phase, consistent with the cell-cycle effects, baicalein significant inhibited cyclin D1, p42/44 mitogen-activated protein kinase (MAPK), and Akt phosphorylation without change in the other cell-cycle regulatory proteins. Furthermore, baicalein attenuated serum-induced deoxyribonucleic acid (DNA) binding activity of nuclear factor kappa B (NF-kappaB). These results show that baicalein blocks cell proliferation via blocking cell-cycle progression and proliferating events, including p42/44 MAPK and Akt activations as well as NF-kappaB activation. It also inhibits intimal hyperplasia after balloon vascular injury in the rat, indicating the therapeutic potential for treating restenosis after arterial injury.

Topics: Animals; Apoptosis; Cardiovascular Agents; Carotid Stenosis; Catheterization; Cell Cycle; Cell Proliferation; Extracellular Signal-Regulated MAP Kinases; Flavanones; Hyperplasia; Muscle, Smooth, Vascular; NF-kappa B; Phosphorylation; Proto-Oncogene Proteins c-akt; Rats; Rats, Wistar; Signal Transduction; Tunica Intima

Most studies that have reported on the progression of ipsilateral and/or contralateral internal carotid artery (ICA) stenosis are restricted to a few years.. Based on a single-center carotid endarterectomy (CEA) registry, we sought all patients with CEA for symptomatic high-grade ICA stenosis between 1970 and 2002. 361 CEA patients (mean age 66 years, 73% male) with annual carotid ultrasound and clinical follow-up were identified. Kaplan-Meier analysis was used to estimate the occurrence of (i) progressive ICA stenosis or restenosis of either the operated or contralateral side, and (ii) cerebrovascular events over time of either the operated or contralateral side.. Progressive ICA disease was more likely on the contralateral than on the ipsilateral ICA (hazard ratio 2.71; CI 1.8-4.1, p < 0.001). After 5 years, the probability for progressive ICA disease was 5.2% for the ipsilateral versus 15.8% for the contralateral ICA. After 15 years, the likelihood was 37% for both sides. In the presence of progressive restenosis of the ipsilateral ICA, the 20-year probability of further ischemic cerebrovascular events was 50% compared to 18% in patients without ICA disease progression. For the contralateral ICA, the probability of further ischemic events was 24.5% in patients with ICA disease progression compared to 9.6% without ICA disease progression (15 years).. 15 years after CEA, one third of the patients can be expected to develop progressive ICA disease. While ICA disease progression seems to be more prominent on the contralateral ICA within the first years, this difference fades out after 15 years. One out of 2 patients with ipsilateral ICA disease progression can be expected to have a recurrent cerebral ischemic event within 15 years. It remains to be determined whether consequent application of high-dose statins, optimal blood pressure management and antithrombotic therapy can reduce this rate.

Topics: Adult; Aged; Aged, 80 and over; Brain Ischemia; Cardiovascular Agents; Carotid Stenosis; Comorbidity; Disease Progression; Endarterectomy, Carotid; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Recurrence; Registries; Risk Factors; Switzerland; Time Factors; Ultrasonography, Doppler, Color

Topics: Angioplasty, Balloon; Cardiovascular Agents; Carotid Stenosis; Drug-Eluting Stents; Humans; Patient Selection; Recurrence; Sirolimus; Treatment Outcome; Ultrasonography, Doppler, Color

The goal of this study was to evaluate the ability of recombinant human thrombomodulin (rTM) to inhibit neointimal hyperplasia when bound to expanded polytetrafluoroethylene (ePTFE) stent grafts placed in a porcine balloon injured carotid artery model.. The left carotid artery of male pigs, weighing 25 to 30 Kg, was injured with an angioplasty balloon. Two weeks later either a non-coated standard ePTFE stent graft (Viabahn, 6 x 25 mm, W. L. Gore & Associates) or a rTM coated stent graft was implanted into the balloon-injured segment using an endovascular technique. Carotid angiography was performed at the time of the balloon injury, two weeks later and then at 4 weeks to assess the degree of luminal stenosis. One month after stent graft deployment, the grafts were explanted following in situ perfusion fixation for histological analysis. The specimens were then cross-sectioned into proximal, middle and distal segments, and the residual arterial lumen and intimal to media (I/M) ratios were calculated with computerized planimetry.. rTM binding onto ePTFE-grafts was confirmed by functional activation of protein C and histopathology with immuno-scanning electron microscopy, backscatter electron emission imaging and x-ray microanalysis. All seven of the rTM coated stent grafts and six of the seven uncoated stent grafts were patent at the time of explantation. The mean luminal diameter of the rTM coated stents was 93% +/- 2.0% of the original diameter, compared with 67% +/- 23% (P = .006) in the control group. Histological analysis demonstrated that the area obliterated by intimal hyperplasia at the proximal portion of the rTM stent was -27% compared with the control group: (2.73 +/- 0.69 mm(2), vs 3.47 +/- 0.67 mm(2), P <.05).. Neointimal hyperplasia is significantly inhibited in ePTFE stent grafts coated with rTM compared with uncoated grafts, as documented by improved luminal diameter by angiography and by computerized planimetry measurements of residual lumen area. These findings suggest that binding of recombinant human thrombomodulin onto ePTFE grafts may improve the long-term patency of covered stents grafts.. Decrease of neointimal hyperplasia of the magnitude observed in this study could significantly improve blood flow and patency of small caliber prosthetic grafts. If the durability of these results can be confirmed by long-term studies, this technique may prove useful in preventing graft stenosis and arterial thrombosis following angioplasty or vascular bypass procedures.

Topics: Angioplasty, Balloon; Animals; Cardiovascular Agents; Carotid Artery Injuries; Carotid Stenosis; Coated Materials, Biocompatible; Disease Models, Animal; Drug-Eluting Stents; Feasibility Studies; Humans; Hyperplasia; Male; Polytetrafluoroethylene; Prosthesis Design; Radiography; Recombinant Proteins; Swine; Thrombomodulin; Time Factors

Drug-eluting stents are increasingly used to reduce in-stent restenosis and adverse cardiac events after percutaneous coronary interventions. However, the race for the ideal drug-eluting stent is still on, with special regard to the best stent-coating system and the most effective and less toxic drug. Fludarabine, a nucleoside analog, has both anti-inflammatory and antiproliferative cellular effects. The aim of the present study was to assess the cellular and molecular effects of fludarabine on vascular smooth muscle cell (VSMC) growth in vitro and in vivo and the feasibility and efficacy of a fludarabine-eluting stent. To study the biomolecular effects of fludarabine on VSMC proliferation in vitro, rat VSMCs were grown in the presence of 50 microM fludarabine or in the absence of the same. To evaluate the in vivo effect of this drug, male Wistar rats underwent balloon injury of the carotid artery, and fludarabine was locally delivered at the time of injury. Finally, fludarabine-eluting stents were in-laboratory manufactured and tested in a rabbit model of in-stent restenosis. Fludarabine markedly inhibited VSMC proliferation in cell culture. Furthermore, fludarabine reduced neointimal formation after balloon angioplasty in a dose-dependent manner, and fludarabine-eluting stents reduced neointimal hyperplasia by approximately 50%. These in vitro and in vivo cellular effects were specifically associated with the molecular switch-off of signal transducer and activator of transcription (STAT)-1 activation, without affecting other STAT proteins. Fludarabine abolishes VSMC proliferation in vitro and reduces neointimal formation after balloon injury in vivo through specific inhibition of STAT-1 activation. Fludarabine-eluting stents are feasible and effective in reducing in-stent restenosis in rabbits.

Topics: Angioplasty, Balloon; Animals; Aorta; Cardiovascular Agents; Carotid Artery Injuries; Carotid Stenosis; Cell Proliferation; Cells, Cultured; Disease Models, Animal; Dose-Response Relationship, Drug; Feasibility Studies; Hyperplasia; Janus Kinase 2; Male; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Phosphorylation; Prosthesis Design; Rabbits; Rats; Rats, Wistar; RNA, Antisense; STAT1 Transcription Factor; Stents; Time Factors; Transfection; Tunica Intima; Vidarabine

Topics: Aged; Aspirin; Cardiovascular Agents; Carotid Artery, Internal; Carotid Stenosis; Clopidogrel; Endarterectomy, Carotid; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Platelet Aggregation Inhibitors; Stents; Stroke; Ticlopidine

Topics: Alcohol Drinking; Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Surgical Procedures; Carotid Stenosis; Clinical Trials as Topic; Combined Modality Therapy; Diabetes Complications; Diabetes Mellitus; Epidemiologic Studies; Evidence-Based Medicine; Hormone Replacement Therapy; Humans; Hypercholesterolemia; Hypertension; Life Style; Smoking; Stroke