Carotid artery stenosis in asymptomatic patients: when and what should be done?

Department of Cardiology and Interventional Radiology, Montevergine Clinic, Mercogliano, Italy, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Introduction: La sténose asymptomatique de l’artère carotide se réfère à la présence des lésions sténosées ou occlusives impliquant une artère carotide interne ou une bifurcation carotidienne chez des patients sans symptômes cliniques de maladie cérébrovasculaire. Elle survient habituellement chez les patients atteints d’athérosclérose systémique et les lésions coexistent dans plus d’un système artériel. En effet, chez la plupart des patients, les artères carotides sont atteintes quelques années plus tard que les artères coronaires. Comme les lésions carotidiennes peuvent être associées à des événements ischémiques non identifiés dans la circulation cérébrale, leur prise en charge chez des patients asymptomatiques pose de nombreux défis. Contenu: La conférence aborde diverses modalités et critères utilisés pour identifier les patients à haut risque présentant une sténose de l’artère carotide asymptomatique pouvant nécessiter des interventions. Celles-ci concernent la détection des plaques athérosclérotiques instables à l’échographie carotidienne, la détection des microembolies par Doppler transcrânien, la réduction de la réserve cérébrale sanguine, la détection des infarctus cérébraux emboliques silencieux à l’examen tomodensitométrique ou IRM, l’identification hémorragique de la plaque athéromateuse à l’IRM ou la progression de la sténose de l’artère carotide. Une brève revue de la littérature est également fournie. Conclusions: La plupart des recommandations indiquent une revascularisation chez les patients asymptomatiques présentant une sténose de l’artère carotide de 60% à 99%, à condition que le risque périopératoire d’accident vasculaire cérébral, d’infarctus du myocarde ou de décès soit inférieur à 3%. L’évaluation du risque est effectuée sur une base individuelle et comprend généralement une variété de facteurs, y compris la sévérité de la sténose carotidienne et sa progression, les caractéristiques morphologiques de la plaque sténosée, la présence d’emboles asymptomatiques, l’évaluation de la réserve cérébrale et les comorbidités du patient.Background: Asymptomatic carotid artery stenosis refers to the presence of stenotic or occlusive lesions involving internal carotid artery or carotid bifurcation in patients without clinical symptoms of cerebrovascular disease. It usually occurs in patients with systemic atherosclerosis and the lesions coexist in more than one arterial system. As a matter of fact, in most patients the carotid arteries become affected a few years later than the coronary arteries. As the carotid lesions may be associated with unheralded ischemic events in the cerebral circulation, their management in asymptomatic patients is posing a variety of challenges. Content: The lecture discusses various modalities and criteria used to identify high risk patients with asymptomatic carotid artery stenosis that may require interventions. These refer to detection of unstable atherosclerotic plaques on carotid ultrasound exam, detection of microemboli by transcranial Doppler, reduced cerebral blood flow reserve, detection of silent embolic cerebral infarctions on CT or MRI exam, hemorrhage identification within the atherosclerotic plaque on MRI exam or progression of the carotid artery stenosis. A brief literature review is also provided. Conclusions: Most guidelines recommend revascularization in asymptomatic patients with carotid artery stenosis from 60% to 99%, provided the perioperative risk of stroke, myocardial infarction or death is less than 3%. The risk evaluation is performed on individual basis and commonly includes a variety of factors, including the severity of carotid artery stenosis and its progression, morphologic characteristics of the stenotic plaque, presence of asymptomatic emboli, cerebral blood flow reserve assessment and patient’s comorbidities

Heparin versus bivalirudin for carotid artery stenting using proximal endovascular clamping for neuroprotection: Results from a prospective randomized study

BackgroundGeneral recommendations indicate that, during a carotid artery stenting (CAS), sufficient unfractionated heparin (UFH) has to be given to maintain the activated clotting time between 250 to 300 seconds. Bivalirudin use is able to reduce postprocedural bleedings in percutaneous interventions when compared with UFH. The study purpose was to evaluate, in a randomized study, the safety and efficacy of bivalirudin versus heparin during CAS, using proximal endovascular occlusion (PEO) as a distal protection device.MethodsFrom January 2006 to December 2009, 220 patients undergoing CAS using PEO have been randomly assigned to one of the study arms (control arm: 100 UI/kg UFH or bivalirudin arm: 0.75 mg/kg intravenous bolus and intraprocedural infusion at 1.75 mg/kg/h).ResultsProcedural success was achieved in all the patients. No episodes of intraprocedural thrombosis occurred. One major stroke occurred in the bivalirudin arm, and two minor strokes occurred, one in each group. A significant difference in the incidence of postprocedural bleedings was observed between the study groups; bivalirudin use was associated with reduced number of bleedings according to Thrombolysis In Myocardial Infarction criteria.ConclusionsThe use of bivalirudin should be considered a safe and effective anticoagulation regimen during CAS, using PEO as a distal protection device. Bivalirudin use is associated with a reduced incidence of bleedings

Drug-Eluting Balloon for Treatment of Superficial Femoral Artery In-Stent Restenosis

ObjectivesThe purpose of this prospective registry was to evaluate the safety and efficacy, at 1 year, of the use of drug-eluting balloons (DEB) for the treatment of superficial femoral artery (SFA) in-stent restenosis (ISR).BackgroundThe use of the self-expanding nitinol stent has improved the patency rate of SFA after percutaneous transluminal angioplasty (PTA). As the population with SFA stenting continues to increase, occurrence of ISR has become a serious problem. The use of DEB has showed promising results in reducing restenosis recurrence in coronary stents.MethodsFrom December 2009 to December 2010, 39 consecutive patients underwent PTA of SFA-ISR in our institution. All patients underwent conventional SFA PTA and final post-dilation with paclitaxel-eluting balloons (IN.PACT, Medtronic, Minneapolis, Minnesota). Patients were evaluated up to 12 months.ResultsTechnical and procedural success was achieved in every patient. No in-hospital major adverse cardiac and cerebrovascular events occurred. At 1 year, 1 patient died due to heart failure. Primary endpoint, primary patency rate at 12 months, was obtained in 92.1% (35 patients). At 1 year, patients were asymptomatic for claudication, and duplex assessment demonstrated lack of recurrent restenosis (100% rate of Secondary patency). The presence of an occlusive restenosis at the time of treatment was not associated with an increased restenosis rate, when compared with non-occlusive restenosis, at 1 year.ConclusionsThe data suggest that adjunctive use of DEB for the treatment of SFA-ISR represents a potentially safe and effective therapeutic strategy. These data should be considered hypothesis-generating to design a randomized trial

Carotid Artery Stenting Using Five-French Distal Radial Vascular Access

Carotid artery stenting (CAS) is usually performed through a femoral vascular access using 6–9 Fr guiding catheters. We investigated whether a systematic distal radial approach using 5 Fr guiding sheaths was a safe and effective alternative to transfemoral approach for CAS. From July 2020 to October 2022, two operators at our center systematically performed CAS using a 5 Fr distal radial approach in consecutive patients. The main endpoints of the study were procedural success via distal radial and via proximal or distal radial access. The learning curve was evaluated by comparing the first half of patients versus the second half of patients enrolled. Procedural data and 30-day clinical outcomes were collected. Fifty-one patients were prospectively enrolled. CAS was effectively performed via distal radial access in 45 patients (88%). Overall radial artery success was 92%. Distal radial CAS was successfully performed in 20 out of the first 25 patients enrolled (80%), and in 25 of the last 26 patients enrolled (96%; p = 0.07). Significantly less contrast was administered in the last 26 patients compared to the first 25 enrolled (110 (70, 140) mL vs. 120 (107, 150) mL; p = 0.045). Radial artery occlusion was reported in 1 patient (2%). Only 1 minor stroke (2%) was reported in-hospital and at 30-day follow-up. In conclusion, distal radial CAS using 5 Fr catheters was a safe procedure with a high success rate. The procedure had a relatively short learning curve in operators familiar with transfemoral CAS

Combined therapy with rotational atherectomy and drug coated balloon for superficial femoral artery in-stent restenosis: safety, efficacy, and two-year results of a single center experience

Background: The primary patency rate of superficial femoral artery (SFA) after percutaneous transluminal angioplasty (PTA) has improved with the use of self-expanding stents. However, occurrence of in-stent restenosis (ISR) still represents a frequent problem. Despite different studies have assessed the role of atherectomy and drug coated balloons (DCBs), no long-term data exist about combined use. The aim of this study was to evaluate safety and efficacy of combined treatment with Jetstream (Boston Scientific Corp., Marlborough, MA, USA) atherectomy and DCB for SFA intrastent restenosis (ISR) at 2-year follow-up. Methods: 30 patients treated with PTA from November 2018 to September 2019 at Montevergine Clinic (Mercogliano, Avellino, Italy) were included in this analysis. All patients underwent PTA of SFA-ISR with Jetstream Atherectomy System followed by paclitaxel eluting balloon treatment. Patients were evaluated at 30 days, and every 3 months up to 24. Results: Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiac and cerebrovascular events occurred. No acute and sub-acute(in-hospital) procedure related complications occurred. During follow-up, 1 patient died due to stroke. Primary patency rate at 12 months was 93.4%. Primary patency rate at 24 months was 83.4%. Secondary patency rate at 24 months was 96.7%. One minor amputation, planned before treatment, was performed in the first 30 days. Conclusions: Our data suggest that combined therapy with Rotational Atherectomy and DCBs for SFA-ISR represents a safe and effective procedure with a high rate of primary patency at 2-year follow-up

Stress Hyperglycemia Drives the Risk of Hospitalization for Chest Pain in Patients With Ischemia and Nonobstructive Coronary Arteries (INOCA)

Objective: Ischemia with nonobstructive coronary arteries (INOCA) is a prevailing finding in patients with angina. However, the main factors underlying the risk of being rehospitalized for chest pain in patients with INOCA remain mostly unknown. Research design and methods: We evaluated INOCA patients referred to the "Casa di Cura Montevergine" in Mercogliano (Avellino), Italy, from January 2016 to January 2021 for percutaneous coronary intervention (PCI). In these subjects, we assessed the impact of the stress hyperglycemia ratio (SHR), defined as the ratio of mmol/L blood glucose and % HbA1c, on the risk of rehospitalization for chest pain. Results: A total of 2,874 patients with INOCA successfully completed the study. At the 1-year follow-up, the risk of rehospitalization for chest pain was significantly higher (P 1 compared to patients with SHR ≤1. These findings were confirmed by multivariable analyses (adjusting for potential confounders, including age, BMI, blood pressure, heart rate, chronic kidney disease, and cholesterol), propensity score matching, and inverse probability of treatment weighting. Conclusions: Our data indicate, to our knowledge for the first time, that SHR on hospital admission significantly and independently increases the risk of rehospitalization for chest pain in INOCA patients