The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

echolucent plaques are associated with a higher neurological risk. In homogenous plaques the absence of an echogenic cap and disruption of the plaque surface also correlates with symptoms. In heterogenous plaques, juxtaluminal location of the echolucent region is an additional marker of increased risk.

Background and Purpose-Many processes involved in the pathogenesis of atherosclerosis result in modifications of the extracellular matrix. These changes not only determine the mechanical stability of atherosclerotic lesions but can directly or indirectly influence further development of the lesions. The purpose of the present study was to compare the matrix composition of human carotid plaques from symptomatic patients with those obtained from patients without symptoms. Furthermore, matrix changes related to age were studied. Methods-Thirty atherosclerotic carotid plaques were removed by endarterectomy from 27 patients and divided into 2 groups on the basis of the presence of ipsilateral symptoms. The plaques were homogenized, and the total levels of the major components of the extracellular matrix were determined. Results-Plaques associated with symptoms were characterized by increased levels of elastin (1.58Ϯ0.46 versus 1.24Ϯ0.40 mg/g wet wt; Pϭ0.03) and decreased levels of hydroxyapatite (45.1Ϯ46.3 versus 131.4Ϯ111.7 mg/g wet wt; Pϭ0.02) compared with asymptomatic plaques. The increase in elastin in plaques from symptomatic patients was due to elevated levels of an intermediate-size fraction, as determined by liquid chromatography. Collagen and sulfated glycosaminoglycans were present in equal amounts in both groups. Elastin content in carotid plaques decreased with age. Conclusions-Carotid plaques from symptomatic patients have lower levels of hydroxyapatite than those from asymptomatic patients. The present study also raises the possibility that non-cross-linked forms of elastin, increased in plaques associated with symptoms, could be a marker of plaque vulnerability and/or directly induce harmful cellular activities or increase lipoprotein retention in the vascular wall.

In the case of carotid atherosclerosis, to avoid unnecessary surgeries in asymptomatic patients, it is necessary to develop a technique to effectively differentiate symptomatic and asymptomatic plaques. In this paper, we have presented a data mining framework that characterizes the textural differences in these two classes using several grayscale features based on a novel combination of trace transform and fuzzy texture. The features extracted from the delineated plaque regions in B-mode ultrasound images were used to train several classifiers in order to prepare them for classification of new test plaques. Our CAD system was evaluated using two different databases consisting of 146 (44 symptomatic to 102 asymptomatic) and 346 (196 symptomatic and 150 asymptomatic) images. Both these databases differ in the way the ground truth was determined. We obtained classification accuracies of 93.1 and 85.3 %, respectively. The techniques are low cost, easily implementable, objective, and non-invasive. For more objective analysis, we have also developed novel integrated indices using a combination of significant features.

Herein, we present the European Society for Vascular Surgery Guidelines pertinent to the secondary prevention of cerebrovascular events in patients with carotid artery stenosis including lipid lowering therapy, antiplatelet therapy and other risk factor modification. These recommendations are based on current evidence from clinical trials. There is a need for aggressive prevention treatment in patients with carotid artery disease. We also discuss the diagnosis and grading of carotid artery stenosis.