Trends and controversies in carotid artery stenosis treatment

Lalla, Rakhee; Raghavan, Prashant

doi:10.12688/f1000research.25922.1

Cited by 6 publications

(5 citation statements)

References 30 publications

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“…Scientific research and technological advancements have allowed a significant improvement in diagnostic methods. However, the diagnostic process may differ amongst symptomatic and asymptomatic patients [ 41 ]. Digital subtraction angiography (DSA) has been the gold standard for verification of the severity of stenosis.…”

Section: Reviewmentioning

confidence: 99%

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Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Ismail¹,

Ravipati²,

Gonzalez‐Hernandez³

et al. 2023

Cureus

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Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.

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Section: Reviewmentioning

confidence: 99%

Section: Diagnostic Modalitiesmentioning

confidence: 99%

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Ismail¹,

Ravipati²,

Gonzalez‐Hernandez³

et al. 2023

Cureus

View full text Add to dashboard Cite

show abstract

“…Despite some integral technical limitations, such as being time-consuming, showing artifacts, and contrast-induced artifacts, MRI can assess non-invasively statin-induced changes in carotid plaque morphology [23,30]. A recent systematic review [31] included seven prospective studies (a total of 361 patients with carotid atherosclerotic disease) and examined changes in LRNC volumes and lumen volumes after statin therapy for at least one year.…”

Section: Effects Of Statins On Mri-based Carotid Plaque Vulnerabilitymentioning

confidence: 99%

A new approach of statin therapy in carotid atherosclerosis: Targeting indices of plaque vulnerability on the top of lipid-lowering. A narrative review

et al. 2022

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Novel imaging techniques and biomarkers have emerged as surrogate markers of carotid plaque vulnerability. In parallel, statin administration in patients with established carotid atherosclerosis not requiring revascularization has reduced the number of consequent cerebrovascular events. This reduction is not only attributed to the lipid-lowering properties of statins but also to their pleiotropic actions. The present literature review aimed to summarize the stabilizing effects of statins on carotid plaques based on imaging modalities and biomarkers and propose an alternative approach to their implementation. Moreover, we assessed the perioperative use of statins in patients undergoing carotid revascularization and the impact of aggressive vs. conventional statin therapy. Recent studies using: (1) ultrasound indices of plaque echogenicity; (2) fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scans for plaque inflammation assessment; or (3) magnetic resonance imaging (MRI) scans quantifying intraplaque hemorrhage, and lipid-rich necrotic core (LRNC) have shown quite promising results in evaluation of carotid plaque vulnerability. Based on those imaging modalities, a growing number of studies have demonstrated a very modest carotid plaque regression due to/induced by statins, while their stabilizing impact is disproportionally higher. Other studies assaying several biomarkers (e.g. inflammation, etc.) have confirmed a statin-induced carotid plaque stabilization. All the aforementioned benefits followed a dose-dependent pattern of statins, on top of the low-density lipoprotein cholesterol (LDL-C) target in current guidelines. In the case of symptomatic patients with carotid atherosclerosis suitable for revascularization, robust evidence implicates a significant statin-related reduction of perioperative cardiovascular risk only in patients undergoing endarterectomy.

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“…Carotid artery stenosis (CAS) is a leading cause of stroke, accounting for 10-15% of ischemic strokes (1,2).…”

Section: Introductionmentioning

confidence: 99%

“…Carotid artery stenosis (CAS) is a leading cause of stroke, accounting for 10–15% of ischemic strokes ( 1 , 2 ). Management of patients with CAS relies on assessment of the percentage of stenosis, which does not evaluate factors important in stroke pathophysiology such as plaque composition, the patency of cerebral collaterals, or the cerebral vascular flow reserve ( 3 - 5 ).…”

Section: Introductionmentioning

confidence: 99%

A magnetic resonance imaging-based computational analysis of cerebral hemodynamics in patients with carotid artery stenosis

Schollenberger¹,

Braet²,

Hernandez‐García³

et al. 2023

Quant Imaging Med Surg

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Management of asymptomatic carotid artery stenosis (CAS) relies on measuring the percentage of stenosis. The aim of this study was to investigate the impact of CAS on cerebral hemodynamics using magnetic resonance imaging (MRI)-informed computational fluid dynamics (CFD) and to provide novel hemodynamic metrics that may improve the understanding of stroke risk. CFD analysis was performed in two patients with similar degrees of asymptomatic high-grade CAS. Three-dimensional anatomical-based computational models of cervical and cerebral blood flow were constructed and calibrated patient-specifically using phase-contrast MRI flow and arterial spin labeling perfusion data. Differences in cerebral hemodynamics were assessed in preoperative and postoperative models. Preoperatively, patient 1 demonstrated large flow and pressure reductions in the stenosed internal carotid artery, while patient 2 demonstrated only minor reductions. Patient 1 exhibited a large amount of flow compensation between hemispheres (80.31%), whereas patient 2 exhibited only a small amount of collateral flow (20.05%). There were significant differences in the mean pressure gradient over the stenosis between patients preoperatively (26.3 vs. 1.8 mmHg). Carotid endarterectomy resulted in only minor hemodynamic changes in patient 2. MRI-informed CFD analysis of two patients with similar clinical classifications of stenosis revealed significant differences in hemodynamics which were not apparent from anatomical assessment alone. Moreover, revascularization of CAS might not always result in hemodynamic improvements. Further studies are needed to investigate the clinical impact of hemodynamic differences and how they pertain to stroke risk and clinical management.

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Trends and controversies in carotid artery stenosis treatment

Cited by 6 publications

References 30 publications

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

A new approach of statin therapy in carotid atherosclerosis: Targeting indices of plaque vulnerability on the top of lipid-lowering. A narrative review

A magnetic resonance imaging-based computational analysis of cerebral hemodynamics in patients with carotid artery stenosis

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