The impact of carotid plaque presence and morphology on mortality outcome in cardiological patients

BACKGROUND: Carotid plaque severity and morphology can affect cardiovascular prognosis. We evaluate both the importance of echographically assessed carotid artery plaque geometry and morphology as predictors of death in hospitalised cardiological patients. METHODS: 541 hospitalised patients admitted in a cardiological division (age = 66 ± 11 years, 411 men), have been studied through ultrasound Duplex carotid scan and successively followed-up for a median of 34 months. Echo evaluation assessed plaque severity and morphology (presence of heterogeneity and profile). RESULTS: 361 patients showed carotid stenosis (67% with <50% stenosis, 18% with 50–69% stenosis, 9% with >70% stenosis, 4% with near occlusion and 2% with total occlusion). During the follow-up period, there were 83 all-cause deaths (15% of the total population). Using Cox's proportional hazard model, age (RR 1.06, 95% CI 1.03–1.09, p = 0.000), ejection fraction > 50% (RR = 0.62, 95% CI 0.4–0.96, p = 0.03), treatment with statins (RR = 0.52, 95% CI 0.29–0.95, p = 0.34) and the presence of a heterogeneous plaque (RR 1.6; 95% CI, 1.2 to 2.14, p = 0.002) were independent predictors of death. Kaplan – Meier survival estimates have shown the best outcome in patients without plaque, intermediate in patients with homogeneous plaques and the worst outcome in patients with heterogeneous plaques (90% vs 79% vs 73%, p = 0.0001). CONCLUSION: In hospitalised cardiological patients, carotid plaque presence and morphology assessed by ultrasound are independent predictors of death

Poststent ballooning during transcarotid artery revascularization

BACKGROUND: Post-stent ballooning/angioplasty (post-SB) have been shown to increase the risk of stroke risk after Transfemoral CAS. With the advancement of TransCarotid Artery Revascularization (TCAR) with dynamic cerebral blood flow reversal, we aimed to study the impact of post-SB during TCAR. METHODS: Patients undergoing TCAR in the Vascular Quality Initiative between September 2016 and May 2019 were included and were divided into 3 groups: those who received pre-stent deployment angioplasty only (pre-SB, reference group), those who received post-stent deployment ballooning only (post-SB), and those who received both pre-stent and post-stent deployment ballooning (prepost-SB). Patients who did not receive any angioplasty during their procedure (n=367, 6.7%) were excluded as these represent a different group of patients with less complex lesions than those requiring angioplasty. Primary outcome was in-hospital stroke/death. Analysis was performed using univariable and multivariable logistic regression models. RESULTS: Out of 5,161 patients undergoing TCAR, 34.7% had pre-SB only, 25% had post-SB only and 40.3% had both (prepost-SB). No differences in the rates of in-hospital and 30-day stroke, death and stroke/death were observed among the three groups; in-hospital stroke/death in the pre-SB group was 1.4% (n=25), post-SB: 1.2% (n=16), and prepost-SB: 1.4% (n=29), p=0.92. However, patients undergoing post-SB and prepost-SB had higher rates of in-hospital transient ischemic attacks (TIA) (post-SB:0.9%, prepost-SB: 1% vs. pre-SB: 0.2%, p<0.01) and post-procedural hypotension (16.6% and 16.8% vs. 13.1%, respectively; p<0.001). Post-stent ballooning also had longer operative times, as well as flow reversal and fluoroscopy times. On multivariable analysis, no association was seen between post-stent ballooning and the primary outcome of in-hospital stroke/death [OR (95%CI): post-SB: 0.88 (0.44, 1.73), prepost-SB: 0.98 (0.57, 1.70)]. Similarly, no significant differences were noted in terms of post-procedural hemodynamic instability and 30-day outcomes. However, post-SB and prepost-SB were associated with four times the odds of in-hospital TIA compared to pre-SB alone [OR (95%CI): post-SB: 4.24 (1.51, 11.8); prepost-SB: 4.76 (1.53, 14.79), p=.01]. Symptomatic patients had higher rates of in-hospital stroke/death compared to their asymptomatic counterparts, however, there was no significant interaction between symptomatic status and ballooning in predicting the primary outcome. CONCLUSION: Post-stent ballooning was used in 65.3% of TCAR patients. This maneuver seems to be safe without an increase in the odds of post-operative in-hospital stroke/death. However, the increased rates of TIA associated with post-SB requires further investigation