Timing of carotid surgery after acute stroke

Carotid endarterectomy (CEA) has been proven to reduce the risk of stroke and death in both asymptomatic and symptomatic patients with carotid occlusive disease. Stroke is the third leading cause of death in the USA. Since up to one-third of stroke patients have a stroke secondary to carotid occlusive disease, it is important to offer CEA to this subgroup of patients that meet indications for surgery. Historically, literature has suggested that the optimal timing to perform CEA is approximately 6 weeks after an acute stroke. This was concluded owing to high perioperative morbidity and mortality if CEA was performed too early. However, data are increasingly showing that some patients do benefit from CEA earlier than 6 weeks after an acute stroke. This article discusses mid-20th Century literature and focuses on more recent 21st Century literature discussing the timing of CEA after acute stroke. Although there are data to support delayed CEA, it is reasonable to perform early CEA in select stroke patient populations. Candidates for early CEA should have complete or near resolution of symptoms, small infarcts on imaging and ipsilateral carotid stenosis.     

Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting

Carotid endarterectomy (CEA) has been used for the past several decades in patients with carotid occlusive disease. Large randomized controlled trials have documented that CEA is a highly effective stroke preventive among patients with carotid stenosis and recent transient ischemic attack or cerebral infarction. In asymptomatic patients with carotid stenosis, clinical trial data suggest that the degree of stroke prevention from CEA is less than among symptomatic patients. However, otherwise healthy men and women with an asymptomatic carotid stenosis of 60% or greater have a lower risk of future cerebral infarction, including disabling cerebral infarction, if treated with CEA compared with those treated with medical management alone. More recently, carotid artery stenting has been performed Increasingly for patients with carotid occlusive disease. As technology has improved, procedural risks have declined and are approaching those reported for CEA. The benefits and durability of CEA compared with carotid artery stenting are still unclear and are being studied in ongoing randomized controlled trials.     

Vascular surgery for peripheral arterial disease

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) confirmed that carotid endarterectomy (CEA) can significantly cut the risk of stroke in patients with moderate and severe blockage. The standard today is that patients who have internal carotid artery stenosis > 70% with associated symptoms and who are appropriate surgical candidates should be offered CEA. Aneurysmal disease, a growing public health concern, poses the threat of death from rupture, and lower extremity arterial occlusive disease poses a significant risk of critical leg ischemia and limb loss. Both conditions involve surgical options. In treating their patients, primary care physicians should become familiar with the benefits and risks of vascular surgery to manage the various aspects of peripheral arterial disease.     

Patient outcomes beyond hospitalization: carotid endarterectomy surgical patient outcomes after a rapid recovery program

Improved surgical techniques for carotid endarterectomy (CEA) surgical patients have resulted in improved postoperative hemodynamic stability of patients and reduced lengths of hospitalization. The purpose of this pilot project was to determine CEA patient outcomes after a rapid recovery hospitalization program. Thirty-nine patients were enrolled in the study and contacted at 1 month after CEA surgery to examine carotid occlusive disease clinical symptoms, functional status, atherosclerotic disease risk-factor reduction, and patient satisfaction. Findings of the pilot study demonstrated that CEA surgical patients were able to resume physical and psychosocial functioning by 1 month after surgery at levels comparable to preoperative functioning. Subjects reported relief of carotid artery occlusive disease symptoms and reported high levels of independent functioning and satisfaction with CEA surgery. Men in the study had significantly higher levels of reported independence in functioning compared with the women, using a "0" to "10" scale to rate level of functioning independence. Findings from the pilot study will be used to develop an early recovery and atherosclerotic disease risk-factor modification program for CEA surgical patients.     

Time is brain: an update

The ‘6-month’ threshold for treating symptomatic patients is obsolete. There is compelling evidence that the highest-risk period for stroke (after suffering a transient ischemic attack) is the first 2 weeks, especially the first few days, and that carotid endarterectomy (CEA) confers maximal benefit when performed early. Despite well-documented anxieties, there is increasing evidence that CEA can be performed safely within the first 7 days after onset of symptoms, although risks may be higher when performed within 48 h. The role for carotid artery stenting in the hyperacute period remains uncertain. Centers performing carotid artery stenting within 14 days of symptom onset with risks equivalent to CEA should be encouraged to continue and help others to achieve similar outcomes. For the majority, however, CEA will probably remain the safer option. ‘Best medical therapy’ and risk factor modification should be started as soon as a transient ischemic attack is suspected, while the early introduction of dual antiplatelet therapy may reduce recurrent events prior to CEA, without increasing perioperative bleeding complications.     

颈动脉狭窄引起短暂性脑缺血的外科治疗

目的 探讨颈动脉内膜剥脱术的适应证及围手术期处理。方法 回顾性总结11例因短暂性脑缺血(TIA)伴有颈动脉硬化狭窄患而行颈动脉内膜剥脱术(CEA)的临床资料。结果 除1例术后第二天发生脑梗塞死亡外，其余患TIA表现消失，4例慢性脑缺血症状也得到明显的改善。术后未出现偏瘫或脑出血等严重的并发症。结论 对于TIA病人，经多普勒超声或动脉血管造影(DSA)或磁共振血管造影(MRA)检查发现一侧或双侧颈总动脉或颈内动脉狭窄大于50％，可以考虑行颈动脉内膜剥脱术。对于双侧颈动脉狭窄，分期手术治疗较为安全。做好围手术期处理。有助于减少手术并发症。     

Should statins be given routinely before carotid endarterectomy?

Statins belong to a class of drugs known to inhibit 3-hydroxy 3-methylglutaryl coenzyme A (HMG CoA) reductase, and block hepatic cholesterol synthesis. Statins have been found to be highly effective in primary and secondary stroke prevention among medically managed patients with cardiovascular disease, and it appears that this benefit is largely owing to the non-cholesterol-lowering, so called pleiotropic, effects of statins. Over the past decade, agents such as beta-blockers, aspirin, or other antiplatelet medications have proven to reduce the incidence of adverse postoperative outcomes among vascular surgical patients and have rightfully assumed a place in our overall therapeutic armamentarium. There is growing evidence that statins may be especially effective in reducing cardiovascular morbidity and improving outcome following major vascular surgery. A recent study from Johns Hopkins Hospital demonstrated a threefold reduction in the rate of perioperative stroke (P < .05) and fivefold reduction of perioperative mortality (P < .05) among 1566 patients undergoing carotid endarterectomy (CEA). This benefit was confirmed in a series of 3360 CEAs performed at multiple hospitals throughout western Canada. Statin use was independently associated with a 75% reduction (OR: 0.25; 95%CI: 0.07-0.90) in the odds of death and a 45% reduction (OR: 0.55; 95% CI: 0.32-0.95) in the odds of ischemic stroke or death among patients with symptomatic carotid disease. A number of the pleiotropic effects of statin medications may be responsible for these clinical observations. Further work is necessary to better elucidate these mechanisms, as well as to determine the optimal agents, dosing, and timing of drug administration among patients undergoing carotid interventions. Nevertheless, in light of these data a strong case can be made to start patients on statin medications prior to CEA if time permits.     

Comparison of Carotid Artery Stenting and Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Single Center Study

Introduction

Carotid artery stenting (CAS) is believed to be an alternative to carotid endarterectomy (CEA); however, recent studies have demonstrated an increase of complications with stenting that does not reflect our experience. We thus wanted to compare the periprocedural and 1-year follow-up outcomes of CAS with those of CEA among patients with symptomatic extracranial carotid stenosis in a population from eastern Turkey.

Methods

The hospital records of all patients who underwent carotid artery revascularization were retrospectively reviewed. Patients were divided into two groups based on the type of carotid revascularization performed, namely CEA or CAS. Comparisons were made with respect to 30-day and 1-year outcomes of transient ischemic attack (TIA), myocardial infarction (MI), stroke, and all-cause death rates. Composite endpoints for both groups were also analyzed.

Results

Thirty-two CEA and 33 CAS procedures were performed for symptomatic occlusive carotid disease. Baseline characteristics were similar between both groups except for the incidence of diabetes mellitus. No significant differences were found with respect to 30-day mortality, MI, and neurologic morbidity endpoints for CEA and CAS procedures. In the postprocedural 1-year follow-up, only TIA was observed to be significantly higher in the CAS group; the other endpoints did not differ significantly. One-year composite endpoints did not differ between both groups (log-rank P = 0.300).

Conclusion

In our trial of patients with symptomatic carotid artery stenosis, no significant difference could be shown in periprocedural outcomes, postprocedural outcomes except TIA, and in composite endpoints between the CEA and CAS groups. CAS is a safe and efficacious alternative for the treatment of symptomatic carotid artery stenosis.     

Carotid artery stenting versus carotid endarterectomy in the treatment of symptomatic and asymptomatic carotid stenosis: a systematic review and meta-analysis

Purpose: To evaluate the short-term and intermediate- to long-term efficacy and safety of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA).Materials and Methods: The published literature was electronically searched for randomized controlled trials (RCTs) between CAS and CEA for the treatment of carotid stenosis performed from January 2000 to January 2017. The short-term and intermediate- to long-term outcomes were evaluated.Results: We identified 10 RCTs including 7,183 participants with symptomatic or asymptomatic carotid stenosis. Our meta-analysis found different results between the patients with and those without symptoms. In patients with symptomatic carotid stenosis, the total stroke incidence in the CAS group was significantly higher than that in the CEA group within the 30-day periprocedural period (p<0.001); however, the myocardial infarction incidence in the CAS group was significantly lower than that in the CEA group (p<0.05). There was no significant difference between the two groups in the mortality within 30 days post-procedure, but the intermediate- to long-term incidence of stroke or death in the CAS group was higher than that of the CEA group (p<0.05). In contrast, for asymptomatic patients, there were no significant differences between the CAS and CEA groups in the short- and intermediate- to long-term outcomes.Conclusion: For patients with symptomatic carotid stenosis, CEA is associated with an increased risk of myocardial infarction, whereas CAS is correlated with an increased risk of procedurally related strokes. However, for patients with asymptomatic carotid stenosis, no significant difference was found in the efficacy or safety between CAS and CEA.     

The Natural History of Asymptomatic Extracranial Arterial Disease

The natural history of a group of 76 patients without neurologicalsymptoms, but with untreated extracranial arterial disease demonstratedby angiography 10 years ago, was studied. During this period46 patients died, and coronary artery disease was the most commoncause of death (n = 25). Six patients suffered a lethal stroke,five patients had a stroke before they died from other causesand five of the six surviving patients, who became symptomaticdeveloped TIAs, followed by a stroke in two cases, leaving onlyone who suffered a sudden stroke without premonitory warningsymptoms. Although the overall cumulative stroke rate (18 percent) was three times higher than normal, the cerebrovascularterritories affected corresponded only twice with the originalextracranial carotid lesion. Therefore, early carotid endarterectomyis inadvisable for the majority of asymptomatic patients andrepetitive non-invasive prospective study of these patientsis favoured for selection of more appropriate timing for individualtreatment.     

Carotid artery stenting will replace carotid endarterectomy

Stroke is the third leading cause of death in the United States. Carotid artery stenosis represents one of the most common etiologies of stroke. The current treatment modalities available for the treatment of carotid artery stenosis are carotid endarterectomy (CEA) and carotid artery stenting (CAS). Several clinical trials comparing CEA with medical management showed superiority of the surgical arm; however, the applicability of these results to the general population is limited by the fact that the patients and surgeons enrolled in these trials were carefully selected, and the optimal medical therapy used does not meet the current treatment standards. Carotid artery stenting has emerged as a treatment alternative to CEA, as shown in randomized trials comparing the 2 treatment modalities. Recent data from large-volume CAS registries indicate that percutaneous treatment of carotid artery stenosis compares favorably to CEA. Furthermore, the CAS trial designs make these results more applicable to the community standards. These data suggest that CAS will become the treatment of choice in patients with carotid artery stenosis.     

The natural history of asymptomatic extracranial arterial disease

The natural history of a group of 76 patients without neurological symptoms, but with untreated extracranial arterial disease demonstrated by angiography 10 years ago, was studied. During this period 46 patients died, and coronary artery disease was the most common cause of death (n = 25). Six patients suffered a lethal stroke, five patients had a stroke before they died from other causes and five of the six surviving patients, who became symptomatic developed TIAs, followed by a stroke in two cases, leaving only one who suffered a sudden stroke without premonitory warning symptoms. Although the overall cumulative stroke rate (18 per cent) was three times higher than normal, the cerebrovascular territories affected corresponded only twice with the original extracranial carotid lesion. Therefore, early carotid endarterectomy is inadvisable for the majority of asymptomatic patients and repetitive non-invasive prospective study of these patients is favoured for selection of more appropriate timing for individual treatment.     

The need for wider and appropriate utilization of aspirin and statins in the treatment and prevention of cardiovascular disease

There is an increasing burden of occlusive cardiovascular disease (CVD) in developed, as well as in developing, countries. In fact, the WHO has projected that CVD will become the leading cause of death in the world in the next 10 years. The proximate cause of virtually all occlusive vascular events is thrombosis and the principal underlying cause is atherosclerosis. Aspirin, which inhibits platelet-dependent cyclooxygenase for the entire life of the platelet, has clinically important antithrombotic effects. Statins, which principally decrease low-density lipoprotein cholesterol, triglycerides and increase high-density lipoprotein cholesterol, have clinically important antiatherogenic effects. In secondary prevention, in a wide range of patients who have survived a prior myocardial infarction (MI), occlusive stroke, transient ischemic attack, as well as other high-risk conditions, long-term use of aspirin confers statistically significant and clinically important reductions in MI, stroke and CVD death. In addition, aspirin confers similar benefits when administered during acute MI or acute occlusive stroke. In primary prevention, aspirin confers a statistically significant and clinically important reduction in risk of a first MI but the data on stroke and CVD death remain inconclusive, so aspirin should be prescribed on an individual basis by the healthcare provider who weighs this clear benefit against long-term side effects. In a meta-analysis of 14 randomized trials of 90,056 subjects treated for 5 years, statins confer statistically significant and clinically important reductions in MI, stroke, CVD death and total mortality. In a meta-analysis of randomized trials of statins, in which aspirin was used in varying frequencies, the combination of aspirin and statins conferred greater clinical benefits than either agent alone on MI, occlusive stroke and CVD death. At present, the wider and more appropriate use of aspirin and statins will reduce premature MI, stroke and CVD death.     

Carotid endarterectomy in the UK: acceptable risks but unacceptable delays

Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe carotid stenosis, provided surgical morbidity and mortality are acceptably low. To assess the current performance of CEA in the UK, an interim analysis of 30-day postoperative outcome data, blinded to anaesthetic allocation, from the first 1,001 UK patients randomised in the GALA Trial (multicentre randomised trial of general versus local anaesthesia for CEA) took place and the time from last symptomatic event to surgery was recorded. The 30-day risk of stroke was 5.3%, myocardial infarction (MI) 0.4%, death 1.7%, and stroke, MI or death 6.4%. Median delay between symptoms and surgery was 82 days. These risks are similar to those reported in the large randomised trials of CEA, but current delays to surgery are excessive and must have substantially reduced the benefit of endarterectomy.     

Combined carotid and transcranial color-coded sonography in acute ischemic stroke.

The objective of this study is to clarify whether the combination of carotid duplex sonography (CD) and transcranial color-coded sonography (TCCS) can accurately detect occlusive lesions in extra and intracranial brain arteries in acute stroke patients, using angiography as the standard. Just before angiography, we performed CD and TCCS in 40 consecutive patients within 24 h after stroke onset. We assessed 320 vessels in total, bilateral internal carotid arteries, vertebral arteries, M1 segments of middle cerebral arteries (MCAs), and P2 segments of posterior cerebral arteries (PCAs). Out of all vessels, 250 (78.1%) could be evaluated by neurosonography because 32 MCAs and 38 PCAs were excluded due to inadequate acoustic windows for TCCS. Significant occlusive lesions (>50%) were observed in 21 out of 250 vessels by neurosonography. Angiography confirmed 20 occlusive lesions as revealed by neurosonography. In the remaining 229 neurosonographically normal vessels, angiography showed no significant lesions except M2 occlusions. The accuracy, sensitivity, and specificity of neurosonography for the detection of occlusive vessels were 99.6, 100 and 99.6%, respectively. Occlusive lesions were observed in 20 of all patients by neurosonography. Nineteen of them were confirmed by angiography. The combination of CD and TCCS can make an accurate diagnosis for significant occlusive lesions in brain arteries in acute stroke patients.     

Carotid stenting vs endarterectomy: new results in perspective

Carotid artery stenosis is a major risk factor for stroke, and treatments for this condition to decrease the risk of stroke include medical therapy, carotid endarterectomy (CEA), and, more recently, carotid angioplasty and stenting (CAS). Randomized controlled trials comparing the efficacy of CEA vs medical therapy showed a clear benefit for CEA in patients with symptomatic carotid artery stenosis of greater than 70% and a lesser benefit in patients with 50% to 69% stenosis. Treatments have evolved in the ensuing 20 years, and a new method, CAS, has emerged as a possible alternative to CEA. In early results, CAS proved feasible but did not compare favorably with CEA. Later and larger-scale studies comparing CAS to CEA failed to reach conclusions regarding a clear neurologic outcome advantage of one method over the other. This subject was of sufficient interest that 2 larger-scale randomized controlled trials comparing CAS and CEA, the Carotid Revascularization Endarterectomy vs Stenting Trial and the International Carotid Stenting Study, were undertaken to further explore this issue. This brief review places the new data arising from these studies in the context of prior efforts to address the problem of carotid artery stenosis and explores further opportunities for improvement and patient recommendations in light of these new findings.     

Contemporary management of carotid stenosis: carotid endarterectomy is here to stay

Thromboembolic complications from atherosclerotic disease of the carotid bifurcation are a common etiology of ischemic stroke, which has a significant morbidity and mortality. Carotid artery angioplasty and stenting (CAS) has been proposed as an alternative therapy for patients requiring treatment of carotid artery stenosis as opposed to the "gold standard" surgical intervention, carotid endarterectomy (CEA). Intense debate regarding these 2 therapeutic approaches has centered on their respective safety profiles. To date, despite multiple studies, no convincing evidence demonstrates the superiority or even equality of CAS to the proven safety, efficacy, and durability of CEA. This chapter reviews in detail the available evidence for CAS and CEA and provides a rationale that, given the available data, CEA remains the preferred therapy for the majority of patients who require treatment of carotid artery stenosis.     

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.     

Positron emission tomography of the vulnerable atherosclerotic plaque in man – a contemporary review

Atherosclerosis is the primary underlying cause of cardiovascular disease (CVD). It is the leading cause of morbidity and mortality in the Western world today and is set to become the prevailing disease and major cause of death worldwide by 2020. In the 1950s surgical intervention was introduced to treat symptomatic patients with high‐grade carotid artery stenosis due to atherosclerosis – a procedure known as carotid endarterectomy (CEA). By removing the atherosclerotic plaque from the affected carotid artery of these patients, CEA is beneficial by preventing subsequent ipsilateral ischemic stroke. However, it is known that patients with low to intermediate artery stenosis may still experience ischemic events, leading clinicians to consider plaque composition as an important feature of atherosclerosis. Today molecular imaging can be used for characterization, visualization and quantification of cellular and subcellular physiological processes as they take place in vivo; using this technology we can obtain valuable information on atherosclerostic plaque composition. Applying molecular imaging clinically to atherosclerotic disease therefore has the potential to identify atherosclerotic plaques vulnerable to rupture. This could prove to be an important tool for the selection of patients for CEA surgery in a health system increasingly focused on individualized treatment. This review focuses on current advances and future developments of in vivo atherosclerosis PET imaging in man.     

A refined angioplasty and stenting technique may offer an alternative to carotid endarterectomy

Strokes are the third leading cause of death in the United States. Carotid artery occlusive disease accounts for about 20% to 30% of all strokes. Carotid endarterectomy has been the traditional standard treatment for patients with significant carotid artery disease. However, surgical therapy is associated with significant complications. Carotid angioplasty and stenting offers an attractive alternative to surgery. There have been significant advances in this field including the use of embolic protection devices. In this article, we review the current literature addressing the role of endovascular interventions in the management of patients with significant carotid stenosis.