Age and sex-specific associations of carotid pulsatility with small vessel disease burden in transient ischemic attack and ischemic stroke

Background Although large artery stiffness has been implicated in the pathogenesis of cerebral small vessel disease, whether carotid pulsatility, a convenient surrogate marker of arterial stiffness, is similarly associated with global burden of small vessel disease is unknown.Aims To determine the age and sex-specific associations of carotid pulsatility with global burden of small vessel disease.Methods We studied consecutive patients with transient ischemic attack or non-disabling ischemic stroke from the Oxford Vascular Study who had a brain MRI and carotid duplex ultrasound during 2002-2014. We determined clinical correlates of common carotid artery (CCA) and internal carotid artery (ICA) pulsatility index (PI) and their associations with the total small vessel disease score on MRI, stratified by age (median=72).Results In 587 patients, correlates of CCA and ICA-PI were both independently associated with age, diabetes, and premorbid mean pulse pressure after adjustment for age, sex, and cardiovascular risk factors (all p0.05). No associations between CCA-PI with small vessel disease score were noted at any age. In 94 consecutive patients who also received transcranial Doppler ultrasound, strong associations between middle cerebral artery (MCA)-PI and an increasing small vessel disease score were noted (unadjusted OR-MCA: 4.26, 1.45-12.55, p=0.009; ICA: 2.37, 0.81-6.87, p=0.11; CCA: 1.33, 0.45-3.96, p=0.61).Conclusions ICA and MCA-PI are associated with global small vessel disease burden, especially in individuals aged<70 and may be causally related

Safety of carotid endarterectomy for symptomatic stenosis by age: meta-analysis with individual patient data

Background: There is uncertainty whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy. In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related. Few octogenarians were included in trials and there has been no systematic analysis of all study types. We aimed to evaluate the safety of carotid endarterectomy in symptomatic elderly patients, particularly in octogenarians. Methods: We did a systematic review and meta-analysis of studies (from January 1, 1980 through March 1, 2022) reporting post carotid endarterectomy risk of stroke, myocardial infarction, and death in patients with symptomatic carotid stenosis. We included observational studies and interventional arms of randomized trials if the outcome rates (or the raw data to calculate these) were provided. Individual patient data from 4 prospective cohorts enabled multivariate analysis. Results: Of 47 studies (107 587 patients), risk of perioperative stroke was 2.04% (1.94–2.14) in octogenarians (390 strokes/19 101 patients) and 1.85% (1.75–1.95) in nonoctogenarians (1395/75 537); P=0.046. Perioperative death was 1.09% (0.94–1.25) in octogenarians (203/18 702) and 0.53% (0.48–0.59) in nonoctogenarians (392/73 327); P<0.001. Per 5-year age increment, a linear increase in perioperative stroke, myocardial infarction, and death were observed; P=0.04 to 0.002. However, during the last 3 decades, perioperative stroke±death has declined significantly in octogenarians (7.78% [5.58–10.55] before year 2000 to 2.80% [2.56–3.04] after 2010); P<0.001. In Individual patient data multivariate-analysis (5111 patients), age ≥85 years was independently associated with perioperative stroke (P<0.001) and death (P=0.005). Yet, survival was similar for octogenarians versus nonoctogenarians at 1-year (95.0% [93.2–96.5] versus 97.5% [96.4–98.6]; P=0.08), as was 5-year stroke risk (11.93% [9.98–14.16]) versus 12.78% [11.65–13.61]; P=0.24). Conclusions: We found a modest increase in perioperative risk with age in symptomatic patients undergoing carotid endarterectomy. As stroke risk increases with age when on medical therapy alone, our findings support selective urgent intervention in symptomatic elderly patients

Supplemental material for Age and sex-specific associations of carotid pulsatility with small vessel disease burden in transient ischemic attack and ischemic stroke

<p>Supplemental material for Age and sex-specific associations of carotid pulsatility with small vessel disease burden in transient ischemic attack and ischemic stroke by Kui Kai Lau, Petra Pego, Sara Mazzucco, Linxin Li, Dominic PJ Howard, Wilhelm Küker and Peter M Rothwell in International Journal of Stroke</p

Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures

Objective: To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices.Methods: A physician initiated, multicentre, ambispective, observational registry (SUPERAXA -NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques.Results: Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 -79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 -12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 -9.6; p = .019) and introducer internal diameter &gt; 14 F (OR 6.6, 95% CI 2.1 -20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 -9.0; p = .013), vessel diameter &gt; 7 mm (OR 3.9, 95% CI 1.1 -13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 -31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p &lt; .001).Conclusion: AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

This editorial assembles endovascular specialists from diverse clinical backgrounds and nationalities with a global call to address key challenges to enhance revascularization in chronic limb-threatening ischemia (CLTI) patients.- Dedicated below-the-ankle (BTA) angiography and revascularization is underutilized in ischemic foot treatment. Existing guidelines do not address comprehensive BTA vessel analysis. CLTI trials also often lack data on in-line arterial flow to the ischemic lesion and BTA vessel evaluation, hindering outcome assessment.- Dedicated multi-planar angiographic evaluation of the distal microcirculation is key: Direct arterial flow or good-quality collaterals are crucial in influencing wound healing and need to be assessed diligently to the level of the distal ischemic wound territory, termed “woundosome.”- An important primary emphasis of future trials should be on validating technologies and strategies for assessing tissue perfusion before, during, and after revascularization undertaken to heal tissue loss in CLTI patients. This will allow determination of a potentially significant delta in tissue perfusion prior to and following intervention at the “woundosome” level. Once changes in arterial perfusion have been identified as positively correlated to wound healing, these could serve as a much-needed novel primary technical outcome measure for patients with tissue loss undergoing surgical, hybrid, or endovascular revascularization