Carotid Stenosis and Stroke: Medicines, Stents, Surgery—“Wait-and-See” or Protect?

Musiałek, Piotr; Rosenfield, Kenneth; Siddiqui, Adnan H.; Grunwald, Iris Q.

doi:10.1055/a-1952-1159

Cited by 7 publications

(8 citation statements)

References 132 publications

(476 reference statements)

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“…Despite a significant carotid reopening rate with balloon angioplasty alone (84%), the 90-day mRS £2 was only 39%. This is in contrast to the 91.7% in our treatment cohort (Figure 3), where sealing of the culprit lesion and lumen reconstruction was routinely performed novel micronet-covered stents to sequestrate the plaque and prevent further plaque-related events [4,25,28,37,38], suggesting that culprit lesion effective exclusion and optimal lumen reconstruction may be clinically fundamental in AIS-CA.…”

Section: E938549-7mentioning

confidence: 71%

“…Intracranial LVO MT [ 19 ] was performed in tandem lesions. The culprit CA lesion sequestration was performed using micronet-covered stents [ 4 , 25 , 28 , 37 , 38 ]. Functional status was routinely assessed at 90 days.…”

Section: Methodsmentioning

confidence: 99%

“…Carotid atherosclerotic disease is an important [1][2][3][4] yet underestimated [5] cause of ischemic stroke. Strokes of carotid bifurcation origin constitute at least 20% of ischemic strokes [1,6]; some of those present with a co-existing occlusion of the intracranial vessel(s) (tandem lesions) [7,8].…”

Section: Introductionmentioning

confidence: 99%

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Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

et al. 2022

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Background:Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. Material/Methods:We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. Results:Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% -endovascular, 6.7% -surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). Conclusions:In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

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Section: E938549-7mentioning

confidence: 71%

Section: Methodsmentioning

confidence: 99%

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Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

et al. 2022

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“…Note that carotid artery stenting or trans-carotid stent-assisted revascularization, with their inherent "final" confirmation of lesion severity by intra-arterial angiography (standard of reference), would probably have resulted in deferring any interventional management because in this study patient catheter quantitative angiography (cQA, NASCET method) revealed LICA stenosis severity of 47%. Medical therapy was maximized to reduce stroke risk [3,25,26], and the patient is monitored yearly in a certified DUS lab for potential stenosis progression [3,4,6] along with imaging and clinical observation for de novo presence of other increased stroke risk characteristics [3,4,6,25,26]. A documented increase in stenosis severity would trigger the NeuroVascular Team to re-consider recommended management, which would involve the patient's opinion (based on complete information on treatment options [26]) in the decision-making process showing the narrowest lumen diameter 3 measurements were performed and the average %DS was taken for further analysis.…”

Section: Intra-arterial Angiographymentioning

confidence: 99%

“…Medical therapy was maximized to reduce stroke risk [3,25,26], and the patient is monitored yearly in a certified DUS lab for potential stenosis progression [3,4,6] along with imaging and clinical observation for de novo presence of other increased stroke risk characteristics [3,4,6,25,26]. A documented increase in stenosis severity would trigger the NeuroVascular Team to re-consider recommended management, which would involve the patient's opinion (based on complete information on treatment options [26]) in the decision-making process showing the narrowest lumen diameter 3 measurements were performed and the average %DS was taken for further analysis.…”

Section: Intra-arterial Angiographymentioning

confidence: 99%

Misclassification of carotid stenosis severity with area stenosis-based evaluation by computed tomography angiography: impact on erroneous indication to revascularization or patient (lesion) migration to a higher guideline recommendation class as per ESC/ESVS/ESO/SVS and CMS-FDA thresholds

Tekieli¹,

Mazurek²,

Dzierwa³

et al. 2022

pwki

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Intoduction Despite a growing understanding of the role played by plaque morphology, the degree of carotid lumen reduction remains the principle parameter in decisions on revascularization in symptomatic and asymptomatic patients. Computed tomography angiography (CTA) is a widely used guideline-approved imaging modality, with “percent stenosis” commonly calculated as %area reduction (area stenosis – AS). Aim We evaluated the impact of the non-linear relationship between diameter stenosis (DS) and AS (area = π • (diameter/2) 2 , so that in concentric lesions 51%AS is 30%DS and 75%AS is 50%DS) on stenosis severity misclassification using calculation of area reduction. Material and methods CTA and catheter quantitative angiography (cQA) were performed in 300 consecutive patients referred to a tertiary vascular centre for potential carotid revascularization (age: 47–83 years, 33.7% symptomatic, 36% female; referral stenosis of ≥ “50%”). CTA-AS was determined by agreement of 2 experienced radiologists; cQA-DS (pivotal trials standard reference, NASCET method) was calculated by agreement of 2 corelab analysts. Results For symptomatic lesion thresholds, CTA-AS-based calculation reclassified 76% of “< 50%” cQA-DS measurements to the “50–69%” group, and 58% of “50–69%” measurements to the “≥ 70%” group. For asymptomatic lesion thresholds, 78% of “< 60%” cQA-DS measurements were reclassified to the “60–79%” group, whereas 42% of “60–79%” cQA measurements crossed to the “≥ 80%” class. Overall, employing CTA-AS instead of cQA-DS enlarged the “60–79%” and “≥ 80%” lesion severity classes 1.6- and 5.8-fold, respectively, whereas the “≥ 70%” class increased 4.15-fold. Conclusions Replacing the pivotal carotid trials reference standard cQA-DS “%stenosis” measurement with CTA-AS-based “%stenosis” results in a large-scale lesion/patient erroneous gain of an “indication” to revascularization or migration to a higher revascularization indication class. In consequence, unnecessary carotid procedures may be performed in the absence of cQA verification. Until guidelines rectify the “%stenosis” measurement methods with different guideline-approved imaging modalities (and, where needed, re-adjust decision thresholds), CTA-AS measurement should not be used as a basis for carotid revascularization.

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Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS)

Tekieli,

Kablak-Ziembicka,

Dabrowski

et al. 2023

Int J Cardiovasc Imaging

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Purpose Different non-invasive and invasive imaging modalities are used to determine carotid artery stenosis severity that remains a principal parameter in clinical decision-making. We compared stenosis degree obtained with different modalities against vascular imaging gold standard, intravascular ultrasound, IVUS. Methods 300 consecutive patients (age 47–83 years, 192 men, 64% asymptomatic) with carotid artery stenosis of “ ≥ 50%” referred for potential revascularization received as per study protocol (i) duplex ultrasound (DUS), (ii) computed tomography angiography (CTA), (iii) intraarterial quantitative angiography (iQA) and (iv) and (iv) IVUS. Correlation of measurements with IVUS (r), proportion of those concordant (within 10%) and proportion of under/overestimated were calculated along with recipient-operating-characteristics (ROC). Results For IVUS area stenosis (AS) and IVUS minimal lumen area (MLA), there was only a moderate correlation with DUS velocities (peak-systolic, PSV; end-diastolic, EDV; r values of 0.42–0.51, p < 0.001 for all). CTA systematically underestimated both reference area and MLA (80.4% and 92.3% cases) but CTA error was lesser for AS (proportion concordant-57.4%; CTA under/overestimation-12.5%/30.1%). iQA diameter stenosis (DS) was found concordant with IVUS in 41.1% measurements (iQA under/overestimation 7.9%/51.0%). By univariate model, PSV (ROC area-under-the-curve, AUC, 0.77, cutoff 2.6 m/s), EDV (AUC 0.72, cutoff 0.71 m/s) and CTA-DS (AUC 0.83, cutoff 59.6%) were predictors of ≥ 50% DS by IVUS (p < 0.001 for all). Best predictor, however, of ≥ 50% DS by IVUS was stenosis severity evaluation by automated contrast column density measurement on iQA (AUC 0.87, cutoff 68%, p < 0.001). Regarding non-invasive techniques, CTA was the only independent diagnostic modality against IVUS on multivariate model (p = 0.008). Conclusion IVUS validation shows significant imaging modality-dependent variations in carotid stenosis severity determination.

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Carotid Stenosis and Stroke: Medicines, Stents, Surgery—“Wait-and-See” or Protect?

Abstract: no abstract

Cited by 7 publications

References 132 publications

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

Misclassification of carotid stenosis severity with area stenosis-based evaluation by computed tomography angiography: impact on erroneous indication to revascularization or patient (lesion) migration to a higher guideline recommendation class as per ESC/ESVS/ESO/SVS and CMS-FDA thresholds

Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS)

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