New System May Cut Unneeded Stroke Prevention Surgeries

 I still don't understand why you would medically need to stent a carotid artery or do an endarterectomy at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

Didn't your competent? doctor tell you of these possible complications of endarterectomy? NO? So, your doctor isn't competent?

Possible problems:

Cognitive Dysfunction and Mortality After Carotid Endarterectomy

Carotid Interventions for Women: The Hazards and Benefits

Female Gender Increases Risk of Stroke and Readmission after CEA(Carotid endarterectomy) and CAS(carotid artery stenting)

Ticagrelor Induced Angioedema Following Carotid Artery Stenting

Cognitive Dysfunction and Mortality After Carotid Endarterectomy

Here is why your doctor needs to GUARANTEE NO complications from stenting!

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

New System May Cut Unneeded Stroke Prevention Surgeries

University College London

Researchers at UCL have tested a new scoring system to measure the risk of stroke in patients with narrowed arteries due to atherosclerosis, which could prevent unnecessary surgeries and stents.

Atherosclerosis is a condition where the blood vessels become narrowed and hardened due to the buildup of plaque, including in the carotid arteries, which carry blood from the heart to the brain. Atherosclerosis can lead to serious health problems like strokes and heart attacks.

Atherosclerosis is a very common condition that can affect anyone, particularly those over the age of 65, smokers and people with a high cholesterol, hypertension or family history of heart or circulatory diseases. It is estimated that atherosclerosis affecting the carotid artery causes up to 20% of strokes.

Currently, many patients undergo surgery or stenting to prevent strokes resulting from atherosclerosis. However, these procedures also carry risks of causing strokes and other serious complications at the time of the intervention.

In the new study, published in The Lancet Neurology and in collaboration with colleagues at the Amsterdam University Medical Centre and the University of Basel, researchers found that using the Carotid Artery Risk (CAR) scoring system can offer a safer alternative, by identifying patients who can be effectively treated with a combination of medications and lifestyle changes tailored to their individual risk factors (otherwise known as optimised medical therapy).

The CAR system was developed by researchers at UCL and the University of Oxford.

Senior author, Emeritus Professor Martin Brown (UCL Queen Square Institute of Neurology), said: "While further follow-up and additional trials are needed to confirm these findings, we recommend using the CAR score to identify patients with carotid narrowing who can be managed with optimised medical therapy alone.

"This approach emphasises personal assessment and intensive treatment of vascular risk factors, potentially sparing many patients from the discomfort and risks of carotid surgery or stenting.

"Additionally, this method could lead to substantial cost savings for health services."

The new research paper, which was partly funded by the Stroke Association, evaluated the effectiveness of the CAR score by testing it in a randomised clinical trial involving 428 patients across 30 centres in the UK, Europe and Canada.

All patients involved in the trial were over the age of 18 and had a significant narrowing of their carotid arteries, which was picked up before it had caused symptoms or after it had caused a minor stroke.

Those with symptoms were selected using their CAR score – which takes into account factors such as the percentage of narrowing in the carotid artery and medical history – to determine who had a low to intermediate risk of stroke over the next five years and could be included in the trial. Patients with a high score were not suitable for the trial and were recommended immediate surgery or stenting.

The patients in the trial were then divided into two groups, with one group receiving optimised medical therapy alone, and the other group receiving both optimised medical therapy and additional carotid surgery or stenting.

Optimised medical therapy included a low cholesterol diet, target-adjusted cholesterol-lowering medication, treatment to lower blood pressure, antithrombotic therapy (a treatment that helps prevent blood clots from forming or growing), and regular checks to adjust the medication as necessary.

The patients were monitored through regular visits, telephone calls, and brain scans to detect strokes.

The researchers found that, over the first two years, patients in the trial who were treated with optimised medical therapy alone had very low rates of recurrent strokes and heart attacks. Those who underwent additional surgery or stenting did not experience significant benefits, considering the associated risks of these procedures.

Dr Louise Flanagan, Head of Research at the Stroke Association, said: "Atherosclerosis is a common condition, and a major risk factor for heart disease and stroke. Whilst medical therapy is the first line of treatment, many of those who have medical therapy then need surgery or stenting which can lead to complications including an increased risk of stroke, and other unpleasant side effects.

"The CAR risk score offers the opportunity to take away the downsides of surgery and stenting by using medical therapy alone as well as combining medical therapy with surgery. The Stroke Association is pleased to have funded this trial which indicates that some people with atherosclerosis could see the same benefits from medication and lifestyle changes that previously required surgery.

"The medical therapies used to reduce the risk of stroke from atherosclerosis work by treating risk factors for stroke, including high cholesterol and raised blood pressure, which we are putting at the heart of our recommendations for the Government's 10 Year Health Plan .

"Whilst we welcome the results of this study, we note the need for more research to confirm or refute these findings, so we look forward to further developments."

The research was funded in the UK by the National Institute for Health and Care Research (NIHR), the Stroke Association and the Leeds Neurology Foundation, and in Europe by the Swiss National Science Foundation and the Dutch Organisation for Knowledge and Innovation in Health, Healthcare and Well-Being.

/Public Release. This material from the originating organization/author(s) might be of the point-in-time nature, and edited for clarity, style and length. Mirage.News does not take institutional positions or sides, and all views, positions, and conclusions expressed herein are solely those of the author(s).View in full here.           

FDA grants premarket approval to carotid stenting system for stroke

 

 Why are you stenting at all? Verify that the Circle of Willis is complete, close up the offending artery and you won't have to deal with all these complications!

My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

Ask your competent? doctor if this guarantees NO complications from stenting!

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

The latest here:

FDA grants premarket approval to carotid stenting system for stroke

The FDA has granted premarket approval to the Neuroguard IEP System, a novel stenting system intended to ease the process for individuals with stroke, according to the manufacturer.

Contego Medical said in a press release that the system, which is comprised of a high-performance stent, integrated dilation balloon and integrated filters, aims to reduce the steps necessary to place the stent, ensuring greater safety by embolic capture(Will your doctor guarantee NO complications?NO! Then it's not safe enough!)

The FDA granted premarket approval to a novel carotid stent implementation system intended to make the placement process safer and quicker. Image: Adobe Stock

"The idea for the Neuroguard IEP System started with a fundamental question: How can we improve outcomes and reduce procedural complexity for patients undergoing carotid revascularization?,” Contego Medical founder and CEO Ravish Sachar, MD, told Healio in an email.

According to data cited in the release, use of the Neuroguard IEP in the PERFORMANCE I and PERFORMANCE II IDE clinical trials resulted in significantly low event rates related to the carotid arteries; there were no major strokes or neurologic deaths, as well as no record of stent thrombosis at both 30 days and 1 year.

“The key discovery that drove the innovation is that the greatest risk is procedural, particularly during balloon dilation and stenting,” Sachar told Healio. “With the approval, we are ready for more physicians to have access to this standard of care-changing technology.”

Sources/Disclosures

Collapse

Source:

Press Release

Transradial Access Versus Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta‐Analysis

 Why are you stenting at all? Verify that the Circle of Willis is complete, close up the offending artery and you won't have to deal with all these complications!

My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

None of the outcomes in the diagram are zero! Here is why your doctor needs to guarantee NO complications from stenting!

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

Transradial Access Versus Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta‐Analysis

Aaron Rodriguez‐Calienes,

Fabian A. Chavez‐Ecos,

David Espinosa‐Martinez,

Diego Bustamante‐Paytan,

Juan Vivanco‐Suarez,

Nagheli Fernanda Borjas‐Calderón,

… See all authors

Originally published27 Dec 2023https://doi.org/10.1161/SVIN.123.001156Stroke: Vascular and Interventional Neurology. 2024;4:e001156

• Other version(s) of this article

Abstract

Background

Carotid artery stenting (CAS) has emerged as a viable alternative to carotid endarterectomy for managing carotid artery stenosis in high‐risk patients. Although transfemoral arterial access remains the preferred method, it is associated with inherent limitations and potential complications. Consequently, exploring transradial artery access as a potential option becomes crucial in optimizing patient outcomes and procedural success rates. There are limited data comparing the outcomes of the transradial with the transfemoral approach for CAS. This study aimed to systematically review and meta‐analyze the outcomes and complication rates between transradial and transfemoral access for CAS.

Methods

A systematic electronic search was conducted in 4 databases. Studies with randomized or nonrandomized designs, involving CAS by the transradial or transfemoral approach, were included. Outcomes of interest were stroke, transient ischemic attack, death, myocardial infarction, and access site complications. A meta‐analysis was performed, analyzing pooled odds ratios (ORs) and 95% CIs to assess the effect size.

Results

Six studies with a total of 6917 patients were included, of whom 602 (8.7%) underwent the transradial approach and 6315 (91.3%) the transfemoral approach. The meta‐analysis showed no significant difference in stroke occurrence between the transradial and transfemoral groups (transradial:1.7% versus transfemoral:1.9%; OR = 0.98 [95% CI, 0.49–1.96]; I² = 0%). Similarly, no significant difference was found in death (TR:1% versus transfemoral:0.9%; OR = 0.95 [95% CI, 0.38–2.37]; I² = 0%), myocardial infarction (transradial:0.2% versus transfemoral:0.3%; OR = 1.53 [95% CI, 0.20–11.61]; I² = 0%), transient ischemic attack (transradial:0.4% versus transfemoral:1%; OR = 0.46 [95% CI, 0.11–1.95]; I² = 0%), or access site complications (transradial:2.2% versus transfemoral:1%; OR = 0.97 [95% CI, 0.48–1.98]; I² = 0%).

Conclusion

No significant differences were observed in stroke, death, myocardial infarction, transient ischemic attack, or access site complications on comparing thetransradial and transfemoral approaches for CAS. The transradial approach shows promise as an alternative method for CAS, offering potential benefits without increased risk of complications. However, further studies are needed to confirm these findings.

• Download figure

Relationship between in-stent restenosis following carotid artery stenting and platelet reactivity to clopidogrel

Stents were never the permanent solution, they do nothing to address the inflammation in your arteries that creates plaque. And why would you want to put inflexible stents in flexible arteries?  I still don't understand why you would medically need to stent a carotid artery at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

Here is why your doctor needs to guarantee NO complications from stenting!

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

 

 

Restenosis is a gradual re-narrowing of the stented segment that occurs mostly between 3 to 12 months after stent placement. 

So by not solving the inflammation problem you get this! Stents don't solve the underlying problem, why the fuck is your doctor prescribing them? Money?

 Relationship between in-stent restenosis following carotid artery stenting and platelet reactivity to clopidogrel

1. http://orcid.org/0000-0002-4474-1295Min-Yong Kwon1,
2. http://orcid.org/0000-0001-5508-7172Sang Hyo Lee2,
3. Yongjae Lee2,
4. Young Deok Kim2,
5. Si Un Lee2,
6. Jae Seung Bang2,
7. O-Ki Kwon2,3,
8. Chang Wan Oh2,3,
9. http://orcid.org/0000-0002-7774-0467Seung Pil Ban2,3

1. Correspondence to Dr Seung Pil Ban, Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea (the Republic of); neurosurgeryban@gmail.com

Abstract

Objective To analyze the relationship between in-stent restenosis (ISR) following carotid artery stenting (CAS) and platelet clopidogrel reactivity confirmed by the P2Y12 reaction unit (PRU) and inhibition rate (IR).

Methods We retrospectively analyzed 171 patients who underwent CAS with extracranial carotid stenosis from January 2016 to December 2019. Dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel was started ≥5 days before CAS. Clopidogrel resistance was measured with the PRU and IR the day before CAS. The ISR degree was classified into R1, R2, and R3 (moderate to severe luminal stenosis of ≥50% or occlusion) by carotid CT angiography after 24–30 months. The degree of quantitative association between platelet reactivity and ISR R3 was determined by the receiver operating characteristic curve method. The optimal cut-off values of PRU and IR were derived using the maximum Youden index.

Results There were 33 R3 degrees of ISR (19.3%) and nine ipsilateral ischemic strokes (5.3%). The PRU and IR were different between R1+R2 degrees (176.4±50.1, 27.5±18.7%) and R3 degree (247.5±55.0, 10.3±13.4%) (P<0.001). The areas under the curves of PRU and IR were 0.841 and 0.781, and the optimal cut-off values were 220.0 and 14.5%, respectively. Multivariate logistic regression analysis showed that PRU ≥220 and IR ≤14.5% were significant predictive factors for ISR R3 (P<0.001 and P=0.017, respectively). ISR R3 was independently associated with ipsilateral ischemic stroke after CAS (P=0.012).

Conclusions High PRU (≥220) and low IR (≤14.5%) are related to ISR R3 following CAS, which may cause ipsilateral ischemic stroke.

Data availability statement

No data are available.

https://doi.org/10.1136/jnis-2024-021445

Statistics from Altmetric.com

Stenting Hits Another Wall in Intracranial Stenosis Stroke

 

Why would you want to put inflexible metal stents in flexible arteries? Don't listen to me, but ask your doctor plenty of questions.   Ask for a guarantee of no stroke due to any procedure.   

But I'd rather my doctor told me how much watermelon juice to drink.

Watermelon juice reverses hardening of the arteries  Nov. 2011

I'm not medically trained so nothing here should be brought to your doctor's attention because they being completely up-to-date will already know about it.

The latest here:

 

Stenting Hits Another Wall in Intracranial Stenosis Stroke

Trial disappoints, but another hints at benefit for tirofiban in this stroke population

by Nicole Lou, Senior Staff Writer, MedPage Today August 9, 2022

Intracranial angioplasty again failed for less severe intracranial atherosclerotic stenosis (ICAS) strokes in a Chinese trial. However, a separate analysis did leave a glimmer of hope that IV antiplatelet therapy prior to thrombectomy helped eligible candidates with ICAS.

Echoing the results of prior trials, patients in the CASSISS trial presenting with transient ischemic attack (TIA) or nondisabling stroke gained no benefit in terms of prevention of future events, reported Liqun Jiao, MD, of China's Xuanwu Hospital and Capital Medical University in Beijing, and colleagues.

Adding stenting to medical therapy didn't reduce the primary outcome of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year (8.0% vs 7.2% after medical therapy alone, HR 1.10, 95% CI 0.52-2.35).

ICAS is a major cause of stroke that disproportionately affects Black, Asian, and Hispanic people at relatively younger ages. Stroke survivors with ICAS are at greater risk of recurrent events, so the 380-person CASSISS trial, published in JAMA, had been designed to improve stenting's chances of succeeding in this population.

"Despite efforts to reduce perioperative complication rates by vetting of surgeons and sites and refining patient selection, the findings nonetheless demonstrated no clinical benefit from the addition of stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis," Jiao's group concluded.

This conclusion was bolstered by similarly neutral findings in secondary endpoints, including stroke in the qualifying artery territory at 2 years and 3 years. What's more, mortality rates at 3 years even put the stenting group at a numerical disadvantage, albeit not statistically significant (4.4% vs 1.3%, HR 3.75, 95% CI 0.77-18.13).

Negative results also came from the RESCUE BT trial of IV tirofiban (Aggrastat) given right before endovascular therapy for large vessel occlusion, according to findings previously presented at the International Stroke Conference and now published in JAMA as well.

In the trial, also from China, tirofiban didn't reduce disability at 90 days by modified Rankin Scale score compared with placebo. Nor was there any advantage for the highly selective nonpeptide platelet glycoprotein IIb/IIIa inhibitor on any secondary endpoints after thrombectomy, reported Qingwu Yang, MD, PhD, of Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University of Chongqing, China, and colleagues.

The investigators said their findings do not support IV tirofiban before endovascular thrombectomy for acute ischemic stroke with one possible exception.

"In subgroup analyses, the point estimates for tirofiban vs placebo raise the possibility that tirofiban might be associated with lower disability level among patients with stroke due to large artery atherosclerosis, although the test for interaction did not reach statistical significance," according to Yang and colleagues. They said a confirmatory trial is merited in this population.

An accompanying editorial led by Craig Anderson, MD, PhD, of The George Institute for Global Health in Sydney, Australia, observed that most of the RESCUE BT cohort with large artery atherosclerosis had ICAS.

"[A]ny further investigation of targeted approaches with tirofiban, or other potent antiplatelet agent(s), in ICAS would benefit from a better understanding of the interactions between atherosclerosis and thrombosis, the importance of thrombus composition ... and the relation of blood flow to vascular occlusion in the progression of large vessel occlusion in acute ischemic stroke," Anderson's group wrote.

Tirofiban is currently FDA approved only for the treatment of acute coronary syndrome. In stroke, the antiplatelet has a mixed body of evidence. Yang's team noted that yet another Chinese trial, the ongoing RESCUE BT 2, is investigating the outcomes of tirofiban in non-large-vessel occlusive stroke.

Both Jiao and Yang's groups cautioned that their respective studies may have limited generalizability to populations outside China.

Yet the editorialists suggested this may not be the case.

"Despite relatively long workflow times and low use of intravenous thrombolysis, outcomes from endovascular procedures in China are comparable to Western countries. Although the prognosis from ICAS will vary according to age, background risk factors, and the effectiveness of medical management, the evidence generated from these two trials are broadly generalizable," Anderson and colleagues argued.

CASSISS had 358 people eligible for the main analysis (mean age 56.3 years, 73.5% men). Eligible people had TIA or nondisabling, nonperforator territory ischemic stroke attributed to severe intracranial stenosis (70%-99% occlusion). Excluded were patients with ischemic symptoms within 3 weeks of study enrollment. Randomization resulted in well-balanced stenting and control group characteristics.

RESCUE BT included 948 thrombectomy candidates randomized after presenting within 24 hours of time last known well (mean age 67 years, 41.2% women). Tirofiban and placebo recipient characteristics were well balanced. The tirofiban group received the study drug as a bolus dose of 10 μg/kg, followed by continuous infusion of 0.15 μg/kg/min for up to 24 hours.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

CASSISS was supported by a grant from the National Health Commission of the People's Republic of China as well as supplemental funding from Stryker Neurovascular.

Jiao disclosed grants from China's Ministry of Science and Technology and Stryker Neurovascular.

RESCUE BT was supported by Lunan Pharmaceutical Group, the National Natural Science Foundation of China, and the Army Medical University Clinical Medical Research Talent Training Program.

RESCUE BT coauthors reported multiple ties with industry.

Yang and Anderson had no disclosures.

Primary Source

JAMA

Source Reference: Gao P, et al "Effect of stenting plus medical therapy vs medical therapy alone on risk of stroke and death in patients with symptomatic intracranial stenosis: The CASSISS randomized clinical trial" JAMA 2022; DOI: 10.1001/jama.2022.12000.

Secondary Source

JAMA

Source Reference: RESCUE BT trial investigators "Effect of intravenous tirofiban vs placebo before endovascular thrombectomy on functional outcomes in large vessel occlusion stroke: the RESCUE BT randomized clinical trial" JAMA 2022; DOI: 10.1001/jama.2022.12584.

Additional Source

JAMA

Source Reference: Anderson CS, et al "Therapeutic strategies for intracranial atherosclerosis" JAMA 2022; DOI: 10.1001/jama.2022.11525.

AAN Issues Guidance on Preventing Second Stroke in Those with Plaque in Brain Arteries

But stent placement brings in money for the doctors and hospital.

AAN Issues Guidance on Preventing Second Stroke in Those with Plaque in Brain Arteries

MINNEAPOLIS, March 21, 2022 /PRNewswire/ -- The use of medications and exercise is more beneficial in preventing a second stroke in people with intracranial atherosclerosis than placing a stent in the blood vessel, according to a new practice advisory issued by the American Academy of Neurology (AAN). The practice advisory is published in the March 21, 2022, online issue of Neurology^®, the medical journal of the AAN, and is endorsed by the American Heart Association/American Stroke Association, Neurocritical Care Society and Society of Vascular and Interventional Neurology.

Intracranial atherosclerosis is a buildup of cholesterol plaque in the arteries in the brain. This buildup can occur over time causing a narrowing of the blood vessels. It is associated with high blood pressure, high cholesterol, diabetes and smoking.

The practice advisory looked at all available research on preventing a second stroke or death for people who had a first stroke due to intracranial atherosclerosis. It is one of the most common causes of stroke worldwide and is associated with a high risk of having another stroke.

"People who have had this type of stroke should first be started on medications to prevent blood clots, reduce blood pressure and cholesterol and safely start increasing their physical activity as recommended by their doctors to decrease the risk of another stroke," said practice advisory author Tanya Turan, MD, MSCR, of the Medical University of South Carolina in Charleston and a Fellow of the American Academy of Neurology. "Having a stent placed in the blood vessel of the brain should not be the first option of care for most people."

Turan said that medical management through medication and exercise and placing a stent have been the two approaches developed for preventing a second stroke for people with narrowing of the brain arteries. A stent is a device used to open the narrowing of the blood vessel.

"Reviewing all of the evidence that has accumulated over the last two decades, we found that the research shows that medical management is more beneficial for people as an initial treatment," she said.

The practice advisory recommends the use of aspirin for long-term prevention of second stroke and death. If the narrowing of the arteries is severe, the drug clopidogrel can be used in addition to aspirin for up to 90 days. The practice advisory recommends: the use of statins to achieve the goal of low-density lipoprotein cholesterol of less than 70 mg/dL; a long-term blood pressure target of less than 140/90 mm Hg; and at least moderate physical activity for people who can safely exercise.

Learn more about stroke at BrainandLife.org, home of the American Academy of Neurology's free patient and caregiver magazine focused on the intersection of neurologic disease and brain health. Follow Brain & Life^® on Facebook, Twitter and Instagram.

The American Academy of Neurology is the world's largest association of neurologists and neuroscience professionals, with over 38,000 members. The AAN is dedicated to promoting the highest quality patient-centered neurologic care. A neurologist is a doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system such as Alzheimer's disease, stroke, migraine, multiple sclerosis, concussion, Parkinson's disease and epilepsy.

For more information about the American Academy of Neurology, visit AAN.com or find us on Facebook, Twitter, Instagram, LinkedIn and YouTube.

View original content:https://www.prnewswire.com/news-releases/aan-issues-guidance-on-preventing-second-stroke-in-those-with-plaque-in-brain-arteries-301507092.html

SOURCE American Academy of Neurology; Neurology

Long-Term Risk Factors for Intracranial In-Stent Restenosis From a Multicenter Trial of Stenting for Symptomatic Intracranial Artery Stenosis Registry in China

 I'm sure there is something important here but beyond my pay grade of understanding.

Long-Term Risk Factors for Intracranial In-Stent Restenosis From a Multicenter Trial of Stenting for Symptomatic Intracranial Artery Stenosis Registry in China

Xu Guo^†, Ning Ma, Feng Gao, Da-Peng Mo, Gang Luo and Zhong-Rong Miao^*

• Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Background: For patients with symptomatic intracranial artery stenosis (sICAS), endovascular treatment has been shown to be feasible and safe in recent studies. However, in-stent restenosis (ISR) risks the recurrence of ischemic stroke. We attempt to elucidate the risk factors for ISR.

Methods: We retrospectively analyzed 97 patients with sICAS from a prospective registry trial that included 20 centers from September 2013 to January 2015. Cases were classified into the ISR≥ 50% group or the ISR < 50% group. The baseline characteristics and long-term follow-up were compared between the two groups. Binary logistic regression analyses were identified as an association between ISR and endovascular technique factors.

Results: According to whether ISR was detected by CT angiography, 97 patients were divided into the ISR group (n = 24) and the non-ISR group (n = 73). The admission baseline features and lesion angiography characteristics were similar, while plasma hs-CRP (mg/L) was higher in the ISR≥ 50% group at admission (8.2 ± 11.4 vs. 2.8 ± 4.1, p = 0.032). Binary logistic regression analysis identified the longer stents (adjusted OR 0.816, 95% CI 0.699–0.953; p = 0.010), balloon-mounted stents (adjusted OR 5.748, 95% CI 1.533–21.546; p = 0.009), and local anesthesia (adjusted OR 6.000, 95% CI 1.693–21.262; p = 0.006) as predictors of ISR at the 1-year follow-up.

Conclusions: The longer stents, balloon-mounted stents implanted in the intracranial vertebral or basilar artery, and local anesthesia were significantly associated with in-stent restenosis. Further studies are required to identify accurate biomarkers or image markers associated with ISR in ICAS patients.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01968122.

Introduction

The prevalence of intracranial atherosclerotic stenosis (ICAS) in Chinese patients was up to 46.6% in symptomatic ischemic stroke patients (1). Symptomatic ICAS (sICAS) is associated with recurrent ischemic stroke (2). SAMMPRIS and VISSIT trials have shown that aggressive medical management has been more effective and safer than endovascular therapy in the past decade (3, 4). However, a recent Wingspan Stent System Post Market Surveillance Study (WEAVE) indicated that the perioperative complication rate is quite low for on-label patients (2.6%). Patients enrolled in this study, including patients with symptomatic and severe ICAS lesions, had suffered at least two ischemic strokes (5). It is obvious that patients with sICAS who failed the best medical treatment would benefit from endovascular therapy.

As we reported, the 30-days rate of primary endpoints, including stroke, transient ischemic attack, and death, was 4.3% in a multicenter prospective registry study of stenting for sICAS in China (6). The incidence of the composite endpoint in this study at 1 year was 8.1%, and restenosis ≥50% was found in 27.6% of patients at the 12-months follow-up. Although the majority of patients (78.9%) were asymptomatic (7), restenosis would be a risk factor for ischemic stroke, causing acute large vessel occlusion or transient ischemic attack (TIA) (2). Therefore, in the present study, according to the inflammatory index (hs-CRP), features of the lesion in angiography, and characteristics of the stent in the operation procedure, we aimed to identify risk factors for in-stent restenosis of endovascular treatment in intracranial atherosclerotic stenosis in a 12-months follow-up.

More at link.

 

Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance

I can see massive problems with stenting your carotid artery. Why do it if your Circle of Willis is complete?

1. Occlusion

2. Trying to snake mechanical thrombectomy thru that stent to get to a clot in the brain.

3. Tying to pull a grabbed clot back thru the stent without ripping the artery completely open. 

I'm not medically trained, don't listen to me. But have your doctor GUARANTEE NO COMPLICATIONS EVER!

Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance

• Arturo Renú ¹
• Jordi Blasco ¹
• Carlos Laredo
• 
  
• José David Guio
• Sergio Amaro
• Angel Chamorro
• Show all authors
• Show footnotes

Published:September 10, 2020DOI:https://doi.org/10.1016/j.atherosclerosis.2020.09.002

PlumX Metrics

Highlights

• •
  Stent thrombosis occurs in one fifth of the patients treated with acute stenting.
• •
  Stent thrombosis is associated with specific procedural variables.
• •
  Stent thrombosis is associated with poor clinical outcome.
• •
  Further investigation of strategies aimed to prevent stent occlusion is needed.

Abstract

Background and aims

Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy.

Methods

We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression.

Results

Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49–50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38–3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97–92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3–11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8–22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033).

Conclusions

Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.

Graphical abstract

• View Large Image
• Figure Viewer
• Download Hi-res image
• Download (PPT)

Study: Polymer-Free Stents Don't Deliver Long Term

Stents were never the solution, they do nothing to address the inflammation in your arteries that creates plaque. And why would you want to put inflexible stents in flexible arteries? 

Study: Polymer-Free Stents Don't Deliver Long Term

— 10-year ISAR-TEST-5 results suggest the future isn't about coatings

by Nicole Lou, Staff Writer, MedPage Today July 6, 2020

Long-term adverse outcomes were similar for polymer-free and durable-polymer drug-eluting stents (DES) in the ISAR-TEST-5 study, suggesting that stent innovations might have reached their limit for improving coronary artery disease treatment.
Patients who were randomized to the polymer-free, sirolimus- and probucol-eluting Isar DES fared similarly over 10 years compared to peers who got durable-polymer, zotarolimus-eluting Endeavor Resolute DES, reported Sebastian Kufner, MD, of Deutsches Herzzentrum München, Germany, and colleagues in the July 14 issue of the Journal of the American College of Cardiology. That was true for the following endpoints:

• The device-oriented composite of cardiac death, target vessel-related MI, or target lesion revascularization (43.8% vs 43.0%, HR 1.01, 95% CI 0.89-1.14)
• The patient-oriented composite of all-cause death, any MI, or any revascularization (66.2% vs 67.7%, HR 0.94, 95% CI 0.86-1.04)
• Individual components of those composite measures
• Stent thrombosis (1.6% vs 1.9%, HR 0.85, 95% CI 0.46-1.54)

Notably, on landmark analysis of stent thrombosis events occurring more than a year after stent implantation, such late events were similarly low between groups (0.5% vs 0.7%, HR 0.69, 95% CI 0.22-2.16) -- suggesting that dual antiplatelet therapy duration may not have to depend on the presence or absence of polymer, according to the researchers.
"The benefit of stents without polymer is expected to accrue with time. However, in many respects, the failure to detect a late advantage with the polymer-free stent -- despite following a large number of patients out to 10 years -- calls this hypothesis into question," the group concluded.
On face value, that lack of long-term advantage may be the main lesson, commented Ori Ben-Yehuda, MD, of the Cardiovascular Research Foundation in New York City and the University of California San Diego, "There are, however, additional, perhaps more important takeaways."
"The most important is the linear and relentless accumulation of events over the 10 years of the trial, including a high mortality, 35.0% versus 37.3% in the polymer-free and durable polymer stents, respectively, with 60% of the deaths deemed cardiovascular," Ben-Yehuda pointed out in his editorial accompanying the paper.
In the future, choice of stent will be less important in the holistic approach to long-term care for coronary artery disease, he predicted.
"Stent technology has undoubtedly improved and will continue to evolve, but coronary atherosclerosis, the underlying process which drives coronary events, is a diffuse disease. Short of a full metal jacket (with its own set of issues!), stenting, as currently practiced, only addresses ischemia-producing lesions, leaving behind potentially vulnerable plaques as well as lesions that may progress over time," he said.
ISAR-TEST-5 was a trial in which 3,002 patients were randomized 2:1 to polymer-free Isar Vivo stents or durable-polymer Endeavor Resolute stents. A total of 4,391 lesions were treated in 2008-2009.
Median age was 67.8 years, and women comprised less than 24% of the cohort. More than 40% of patients had presented with an acute coronary syndrome.
One limitation of the trial was that 14.9% of patients were missing 10-year data. Device assignment was also not blinded to patients or physicians, and the two stents differed in various aspects (not just the presence or absence of polymer coating), Kufner and colleagues noted.
Moreover, LDL cholesterol levels were not reported in ISAR-TEST-5, so one could only speculate whether better secondary prevention efforts might have improved outcomes for these patients, Ben-Yehuda noted.

• 
  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The study was funded in part by the Bavarian Research Foundation and the European Union under the Seventh Frame Work Programme.
Kufner disclosed receiving speaker fees from AstraZeneca and Bristol-Myers Squibb.
Ben-Yehuda reported institutional grants from Medinol, Abbott Vascular, Medtronic, SMT, Concept Medical, Biosensors International, and OrbusNeich.

Primary Source

Journal of the American College of Cardiology

Source Reference: Kufner S, et al "10-year outcomes from a randomized Trial of polymer-free versus durable polymer drug-eluting coronary stents" J Am Coll Cardiol 2020; DOI: 10.1016/j.jacc.2020.05.026.

Secondary Source

Journal of the American College of Cardiology

Source Reference: Ben-Yehuda O "Long-term outcomes with drug-eluting stents: beyond stent choice" J Am Coll Cardiol 2020; DOI: 10.1016/j.jacc.2020.05.050.

Severe Neovascular Glaucoma Exacerbation as a Complication of Carotid Artery Stenting: A Case Report

I can see almost zero use for stenting a carotid artery if the Circle of Willis is complete, you would have three arteries still feeding the brain.  If fact I would have the artery closed in that case to prevent the chance of plaque breaking loose and causing  a stroke. 

Don't listen to what I have to say, I'm not medically trained.

I guess this is why gluing is not done for brain work:
FDA issues warning about Covidien brain device that has killed nine - Onyx glue

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries. Don't listen to me, but ask your doctor plenty of questions.   Ask for a guarantee of no stroke due to any procedure.  

Instead of doing a carotid endarterectomy with its attendant risks, why not glue it up or close it some other way?

1. Verify that the Circle of Willis is complete. Mine obviously is since one carotid artery is completely blocked and I am having no cognitive issues(arrogance is not one of my issues).

2. Glue the offending artery shut, No risky surgery.

You need to know where the blockage is, above or below the split to the face.

The latest here:

Severe Neovascular Glaucoma Exacerbation as a Complication of Carotid Artery Stenting: A Case Report

Show all authors

Sishir Mannava, MD, Luis F. Torres, MD, Keith G. DeSousa, MD, ...

First Published May 22, 2020 Case Report

https://doi.org/10.1177/1941874420923914

Article information

Abstract

Introduction:

Neovascular glaucoma (NVG) has been rarely reported as an acute complication of carotid endarterectomy, but there is scant literature available regarding this potential condition following carotid artery stenting (CAS). We present a case of severe worsening of NVG occurring after bilateral CAS with progressive deterioration of vision ultimately leading to blindness.

Case Description:

A 66-year-old male with multiple stroke risk factors, bilateral cataract extraction, proliferative diabetic retinopathy of left eye, and nonproliferative diabetic retinopathy of right eye, and prior left eye pars plana vitrectomy presented with episodes of transient right eye vision loss in context of bilateral high-grade internal carotid artery stenoses. He underwent right CAS with subsequent elevation of bilateral intraocular pressures (IOPs) concerning for acute NVG. Over time, the patient had some interval improvement in IOPs and underwent planned left CAS. After the procedure, he again developed elevated IOPs, concerning for acute NVG which eventually led to right eye pars plana vitrectomy for vitreous hemorrhage and refractory IOP elevation. At 6-month follow-up from initial stenting, the patient was blind in both eyes.

Discussion:

We present a case of recurrent IOP elevations following CAS eventually resulting in bilateral eye blindness. This case is important not only as an illustration of an underrecognized postprocedural CAS complication but also as a demonstration of likely elevated risk of NVG following CAS for patients with other predisposing risk factors for ocular hypertension such as glaucoma, proliferative diabetic retinopathy, prior cataract extraction, and prior pars plana vitrectomy.

Keywords carotid artery stenting, endovascular therapy, neovascular glaucoma

Access Options

Atherosclerosis Progresses Rapidly in Healthy People From the Age of 40

At age 50 despite being extremely healthy my right carotid artery got to 80% closure, which is not a problem except that the plaque tore, clotted and sent that clot to the brain. I would never have stented that because the risk from stenting is too great and ideally my doctors would have tested for a complete Circle of Willis.  For 10 years that artery was completely closed which was great, now I guess collaterals have formed around it.  My coronary arteries are pretty good though.  What is your doctor doing to clear that plaque?  Stenting doesn't clear anything.

Do you want the lawnmower?
Lawnmower For Clogged Arteries
Or Drano? I would be worried about this, sloughing off chunks
Drano For Clogged Arteries
Or conventional?
9 Complications With Coronary Artery Bypass Surgery

Or this?

Israeli study uses gold particles to ‘seek and destroy’ artery blockages

But I'd rather my doctor told me how much watermelon juice to drink.

Watermelon juice reverses hardening of the arteries  Nov. 2011

I'm not medically trained so nothing here should be brought to your doctor's attention because they being completely up-to-date will already know about it.

The latest here:

Atherosclerosis Progresses Rapidly in Healthy People From the Age of 40

Atheroma plaques extend rapidly through the arteries of 40% of asymptomatic individuals aged 40 to 50 years, according to a study published in the Journal of American College of Cardiology.

“The key finding of the study is that over a short follow-up of just 3 years, 40% of individuals aged 40 to 50 years showed major progression of atherosclerosis in distinct locations, including the carotid, femoral, and coronary arteries,” said Beatriz López-Melgar, MD, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain. “This rapid disease progression could make these individuals more vulnerable to developing symptoms or having clinical events such as a myocardial infarction or stroke.”

The Progression of Early Subclinical Atherosclerosis (PESA) study has been monitoring 4,200 healthy middle-aged men and women with noninvasive imaging technology, such as 2D or 3D ultrasound, for more than 10 years.

“[Noninvasive technology] allows us to identify the progression of the disease earlier than is possible with classical markers, such as the presence of coronary calcium detected by computed tomography, thus allowing us to identify individuals at higher risk who could benefit from early intervention,” said Valentín Fuster, MD, CNIC.

“This study is the first to analyse the progression of atherosclerosis at frequent intervals,” added Borja Ibañez, MD, CNIC. “The previous view was that the disease progressed very slowly throughout life. However, the new results show that the disease progressed very rapidly in 40% of the individuals analysed.”

The researchers conclude that the findings, while they await validation from the occurrence of events in the PESA cohort in the future, will be of great value for the identification of strategies to stall the epidemic of cardiovascular disease.

“Future data from the PESA study will show whether this progression is associated with subsequent cardiovascular events,” said Dr. Ibañez. “Until now, the speed of atherosclerosis progression has not been a factor in assessing individual risk.”

Reference: http://www.onlinejacc.org/content/75/14/1617

SOURCE: Centro Nacional de Investigaciones Cardiovasculares Carlos III

Does the Type of Carotid Stent, Cerebral Protection Matter During Carotid Artery Stenting in High-Risk Patients?

I still don't understand why you would medically need to stent a carotid artery at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery has been closed for the past 10 years and I cognitively function quite well with no episodes of fainting. But I'm not medically trained and thus can't even ask these simple questions. 

And this problem:

Plaque Protrusion Tied to Stroke in Carotid Stenting 3% rate

 

Does the Type of Carotid Stent, Cerebral Protection Matter During Carotid Artery Stenting in High-Risk Patients?

MILAN, Italy -- May 28, 2019 -- In patients with high-risk lipid-rich plaque undergoing carotid artery stenting, using the Use the MoMa ultra proximal cerebral protection device plus the double-mesh Roadsaver (RS) stent seems to be a promising tool in limiting embolic risks, and outperforms the single-mesh Carotid Wallstents (CW), according to a study presented here at the 5th European Stroke Organisation Conference (ESOC).

“The role of the stent type during carotid artery stenting is unclear,” said Luigi Caputi, MD, Fondazione IRCCS ‘C. Besta’ Neurological Institute, Milan, Italy. However, “the newer double-mesh carotid stents might reduce embolic complication.”

The researchers compared the safety and efficacy of RS and CW stents during carotid artery stenting in 104 patients with lipid-rich plaques. All patients in the study had unilateral de-novo carotid artery stenosis (symptomatic or asymptomatic) with high lipid-plaque composition.

Both stents were randomly tested with FilterWire and MO.MA cerebral protection, and patients were randomised to stenting with MoMa plus CW (n = 25), MoMa plus RS (n = 27), FilterWire plus RS (n = 27) or FilterWire plus CW (n = 25).

The primary endpoint was the number of microembolic signals (MES) by transcranial Doppler ultrasound.

When comparing the FilterWire with MoMa, MoMa significantly reduced MES (P < .0001) during target vessel cannulation, lesion wiring, lesion stent crossing, stent deployment, and stent dilation.

When comparing RS with CW, MES were significantly lower with RS during stent deployment, stent dilation, device retrieval/deflation (P = .031).

MoMa plus RS performed significantly better than MoMa plus CW (P = .043).

There were no significant differences for in-hospital and 30-day major adverse cardiac and cerebrovascular events and vascular complications, which included 1 retinal embolism, 1 minor stroke (premature opening of MoMa balloon [operator error]), and 1 death (acute rupture of iliac aneurysm).

“There were no significant differences in restenosis rates,” said Dr. Caputi.

[Presentation title: Randomized Study Comparing the Type of Carotid Stent and Cerebral Protection During Carotid Artery Stenting in Patients With High-Risk Plaque]