An algorithmic approach to patient-specific treatment: medical management, carotid endarterectomy, carotid artery stenting and transcarotid artery revascularization.

The treatment of asymptomatic carotid artery stenosis (AsxCS) has been controversial over the past three decades. In this article an algorithmic approach to patient-specific treatment is described whether medical management or a carotid intervention is considered, including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and/or transcarotid artery revascularization (TCAR). This article will summarize the commonly-quoted randomized controlled trials for both TFCAS and CEA which were published over the past two decades for both symptomatic (SxCS) and AsxCS, and create an algorithmic approach to patient-specific treatment according to risk stratification.

Late neuro events in asymptomatic vs symptomatic isolated subclavian steal.

Objective: Natural history of subclavian steal (SS) is not well defined. This is the largest study to date, to analyze late neuro events of patients with asymptomatic (asx) vs symptomatic (sx) isolated SS in an over 5-year period.

Methods: SS detected during 11,762 routine carotid duplex ultrasound exams (CDUEs) done over a 2-year period were analyzed.

The future in the management of patients with asymptomatic carotid artery stenosis.

Introduction: The optimal management of patients with asymptomatic (AsxCS) and symptomatic carotid stenosis (SxCS) is still debatable. The present article will discuss emerging technological advances for the diagnosis and management of patients with AsxCS.

Evidence Acquisition: PubMed/MedLine was searched until December 31, 2024 for studies in English discussing emerging technological advances in the diagnosis and management of patients with AsxCS.

An International, Expert-Based Delphi Consensus Document on Controversial Issues about TransCarotid Artery Revascularization (TCAR).

Background: Transcarotid artery revascularization (TCAR) has emerged as an alternative therapeutic modality to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) for the management of patients with carotid artery stenosis. However, certain issues regarding the indications and contraindications of TCAR remain unanswered or unresolved. The aim of this international, expert-based Delphi consensus document was to attempt to provide some guidance on these topics.

Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report.

Introduction: Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program.

Implications of the Centers for Medicare and Medicaid Services decision to expand indications for carotid artery stenting.

Objective: On October 11, 2023, the Centers for Medicare and Medicaid Services (CMS) expanded the indications for carotid artery stenting (CAS) to include patients with ≥50% symptomatic or ≥70% asymptomatic carotid stenosis. The aim of this article was to investigate the implications of this decision.

Methods: The reasons behind the increased coverage for CAS are analyzed and discussed, as well as the various Societies supporting or opposing the expansion of indications for CAS.

Clinical outcomes of transcarotid artery revascularization vs carotid endarterectomy from a large single-center experience.

Background: Transcarotid artery revascularization (TCAR) has been practiced as an alternative for both carotid endarterectomy (CEA) and transfemoral carotid artery stenting, specifically in high-risk patients. More recently, the Centers for Medicare and Medicaid Services expanded coverage for TCAR in standard surgical risk patients if done within the Society for Vascular Surgery Vascular Quality Initiative TCAR surveillance project. A few registry studies (primarily from the Society for Vascular Surgery Vascular Quality Initiative) compared the early and up to 1-year outcomes of TCAR vs CEA or transfemoral carotid artery stenting.

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease.

Objectives: Compliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes.

Methods: The 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data.

Primary versus patching versus eversion as carotid endarterectomy closure.

The type of closure after carotid endarterectomy (CEA), whether with patching primary closure or eversion resulting optimal results, remains somewhat controversial. We conducted a PubMed literature review search comparing CEA with patching versus CEA with primary closure versus eversion CEA over the past four decades with emphasis on randomized controlled trials and systematic/meta-analysis and large single center or multicenter studies. The data showed that routine carotid patching can be recommended over primary closure (level 1 evidence); however, CEA with primary closure can be used for large internal carotid arteries (ICAs)>6 mm.

Thirty-Day Perioperative Clinical Outcomes of Transcarotid Artery Revascularization vs Carotid Endarterectomy in a Single-Center Experience.

Background: Transcarotid artery revascularization (TCAR) has been proposed as a alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting in high-risk patients. Recently Centers for Medicare and Medicaid Services expanded coverage for TCAR to include standard surgical risk patients within the Society of Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project. Few single centers compared the clinical outcome of TCAR with CEA.

Rates of progression of carotid in-stent stenosis and clinical outcomes.

Background: We previously reported the incidence of ≥50% and ≥80% carotid in-stent stenosis. In the present study, we analyzed the rate of progression of in-stent stenosis and clinical outcomes with longer follow-up.

Methods: We performed a retrospective analysis of prospectively collected data for 450 patients who had undergone transfemoral carotid artery stenting with longer follow-up (mean, 70 months).

Critical analysis of vertebral artery flow patterns/subclavian steal detected by cerebrovascular duplex ultrasound examinations and its clinical implications.

Background: The prevalence of subclavian steal (defined as retrograde/bidirectional vertebral artery flow) in the general population and in patients undergoing cerebrovascular duplex ultrasound (CDUS) examinations is variable. This is the largest study to date to analyze the incidence of duplex-suggested subclavian steal in 5615 CDUS examinations over a 1-year period and to examine its clinical implications.

Patient Population And Methods: All consecutive CDUS examinations performed over a 1-year period were analyzed for the presence of subclavian steal.

A single-center experience of 30-day perioperative and one year clinical outcomes of transcarotid artery revascularization in 100 consecutive patients.

Background: Transcarotid Artery Revascularization (TCAR) using the ENROUTE system (Silk Road) has been proposed as a safe and effective alternative to both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Two large registries (ROADSTER 1 and ROADSTER 2) have shown that TCAR has acceptable/low rates of perioperative stroke/death. This study will analyze the 30-day perioperative and 1-year clinical outcomes from a single-center.

Clinical Outcome of Drug-Eluted Stenting (Zilver PTX) in Patients With Femoropopliteal Occlusive Disease a Single Center Experience.

Background: Few industry sponsored trials reported satisfactory outcomes in the use of drug-eluting stents (DES) for treatment of femoropopliteal arterial disease. This study analyzed the early/late clinical outcome from a real world single center.

Patient Populations/methods: A total of 115 limbs treated with Zilver PTX were analyzed for: major adverse limb event (MALE: above ankle limb amputation/major intervention at 1 year), major adverse events (MAEs; death, amputation, and target lesion thrombosis/reintervention), primary patency (based on duplex ultrasound ± ankle brachial indexes), limb salvage, and amputation free survival rates (AFS) at 1 and 2 years.

Use of drug-eluting stents in patients with critical limb ischemia and infrapopliteal arterial disease: a real-world single-center experience.

Background: Although no drug-eluting stent (DES) has been approved by the Food and Drug Administration to treat infrapopliteal arterial disease, several industry-sponsored trials have reported the outcomes with the use of paclitaxel or sirolimus DESs. To the best of our knowledge, only one study to date has reported on the use of everolimus DESs for infrapopliteal arterial disease. In the present study, we analyzed the clinical outcomes with everolimus DESs in our real-world, single-center experience.