Manuel Matas

High-sensitivity C-reactive protein in high-grade carotid stenosis: risk marker for unstable carotid plaque

OBJECTIVES Increasing evidence points to the inflammatory character of atherosclerosis, and several parameters of inflammation have been proposed as cardiovascular risk markers. We analyzed associations among serum high-sensitivity C-reactive protein (hs-CRP) concentrations, carotid plaque structure, and immunocytology, and neurologic symptoms in patients with high-grade carotid stenosis. METHODS This was a cross-sectional study in a referral center and institutional practice in hospitalized patients. The study included 62 patients with greater than 70% carotid stenosis treated surgically; 58% of patients had symptoms, and 42% did not. Serum hs-CRP concentrations were determined 48 hours before surgery; levels greater than 10 mg/L were considered pathologic. Histopathologic analysis (stable or unstable) and immunohistochemistry (macrophage count, T lymphocytes, activated T lymphocytes) were carried out on the atherosclerotic plaques. RESULTS Median hs-CRP values were 7.6 mg/L (range, 0-165 mg/L). Median hs-CRP concentrations were higher in patients with unstable plaque (53.2%) than in patients with stable plaque (46.7%): 27.1 mg/L (range, 1.8-165 mg/L) versus 4.1 mg/L (range, 0.3-56 mg/L) (P <.001). Among patients with symptomatic disease, 81% had CRP concentrations significantly higher than CRP concentrations in patients with asymptomatic disease (P <.001). A statistically significant association was found between hs-CRP levels and the presence of macrophages (Spearman rank correlation [rho], 0.61, P <.001) and T lymphocytes in the plaque (Spearman rank correlation [rho], 0.52, P <.001). At logistic regression analysis, neurologic event and macrophages in the plaque were independently associated with unstable plaque. CONCLUSIONS Increased hs-CRP levels may be related to the presence of macrophages and T lymphocytes in plaque, which is associated with the phenomena of instability that can lead to development of an ischemic event. Thus determination of circulating hs-CRP levels may be a useful additional marker of risk in patients with high-grade carotid stenosis.

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years.

BACKGROUND Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA. METHODS Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures. RESULTS The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years. CONCLUSIONS In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.

Asymptomatic Carotid Stenosis and Cognitive Improvement using Transcervical Stenting with Protective Flow Reversal Technique

OBJECTIVES The relationship between carotid artery stenosis and cognitive function in individuals without a history of stroke is not clear. The possible pathomechanisms of cognitive impairment include silent embolization and hypoperfusion. In this study the aim was to assess cognitive changes after transcervical carotid artery stenting with proximal cerebral protection by flow reversal in patients with asymptomatic carotid stenosis, a novel technique that has been proved to decrease the number intraoperative emboli. METHODS 25 consecutive patients were assessed, of which 22 were men (88%) mean age of 74 years with severe asymptomatic carotid stenosis who underwent revascularization by carotid artery stenting (CAS) with flow reversal. Patients were evaluated 1 day before and 6 months after the procedure using a standardized neuropsychological battery. Test scores were adjusted according to age, sex, education level and were standardized (0-100). The mean of all the cognitive function scores yielded the global cognitive score (GCS). RESULTS There were no neurological complications during the procedure or during hospitalization in any patient. No deaths or cardiac complications occurred in any patient. The pre-procedure neuropsychological study showed cognitive impairment in: information processing speed in 15 patients (62.5%), visuospatial function in 14 (56.0%), memory in 18 (72.0%), executive functions in 14 (56.0%), language in three (12.0%), attention in 10 (40.0%), and global cognitive performance in eight (32.0%). Comparison of these scores with those obtained 6-month post-procedure showed significant improvement in GCS in all patients (p = .002), with a particularly marked gain in information processing speed (p = .018). Although significant improvement was not found for the remaining cognitive functions assessed, some gain was documented, and there was no deterioration. CONCLUSIONS Revascularization by transcervical CAS with flow reversal for cerebral protection results in improved neurocognitive performance in asymptomatic elderly patients with severe carotid artery stenosis.

Antiplatelet Therapy in Endovascular Surgery: The RENDOVASC Study

BACKGROUND Antiplatelet treatment prevents cardiovascular events and thrombosis during the endovascular surgery procedure. The aim of this study is to analyze the different antiplatelet treatment used in endovascular procedures in Spain. METHODS In this investigation we included observational, retrospective, and multicenter study patients who underwent arterial endovascular therapy in 2006 or in the first 3 months of 2007, and follow-up of at least 1 year. The following data were collected: the usual epidemiologic variables, history of cardiovascular disease (coronary, cerebrovascular, or peripheral artery disease), risk factors, endovascular procedure performed, blood pressure, ethiology of arterial disease, the pre-operative antiaggregant treatment, and antiplatelet therapy used at 1 month and 1 year after the procedure. RESULTS A total of 1,557 patients were evaluated, of whom 84.3% were male. In addition 72.1% were hypertensive, 53.1% dyslipidemic, and 43.3% diabetic. From these patients, 32.6% presented with ischemic cardiomyopathy, 17.9% had a cerebral vascular history, and 35.3% had peripheral arterial disease. The most common etiology was occlusive disease (76.9%), the most commonly treated arterial sector was iliac (33.4%), and the most frequent procedure was stent angioplasty (46.9%). In the preoperative period, 75.1% of the patients were given antiplatelet therapy (89% simple antiplatelet treatment), 62.9% in the perioperative period, and 93.8% at 1 month after surgery (37.3% double antiaggregation). Antiplatelet treatment was administered previously to 86.2% of patients with history of cerebrovascular disease and to 88% of those with coronary disease. In the femoropopliteal sector 76.1% patients were receiving antiaggregation treatment before the procedure (11.1% double). However, 1 month later, double antiaggregation therapy was increased (45.3%), especially in the angioplasty and stent. In the iliac sector, 43.1% of patients with arterial stenosis and 38.2% of patients with complete arterial occlusion treated with angioplasty and stent continued receiving double antiaggregation 1 month after the procedure. In the carotid territory, 65.7% of patients treated with stent were receiving double antiplatelet treatment 1 month after the procedure. CONCLUSIONS We believe it is necessary to create consensus committees to perform clinical practice evidence-based guidelines to formalize antiaggregation treatment in endovascular procedures.

Relationship Between Plasma Homocysteine and the Morphological and Immunohistochemical Study of Carotid Plaques in Patients With Carotid Stenosis Over 70

BACKGROUND Several clinical and epidemiological studies describe hyperhomocysteinemia as an independent cardiovascular risk factor. Implication of cellular immunity in atherosclerosis also seems clear. This study aimed to analyze the association among plasma hyperhomocysteinemia, neurological clinical events, and the morphology and immunocytology of carotid plaques in patients with carotid stenosis >70% receiving surgical treatment. METHODS Sixty-two patients with carotid stenosis >70% receiving surgical treatment were studied; 58% had a history of stroke in the ipsilateral carotid territory. Plasma homocysteine concentrations were determined by considering pathological values >12.4 μmol/L. Histopathological (stable and unstable plaques) and immunohistochemical (macrophages, T lymphocytes, and active T lymphocytes counts) studies were performed. Hyperhomocysteinemia prevalence was calculated in this population, as were the possible relationships between homocysteine plasma concentrations, and the carotid plaque type and the cell types in it. The relationship between this risk factor and the presence of a neurological event relating to carotid stenosis was also investigated. RESULTS Hyperhomocysteinemia prevalence was 43.5%, with a mean value of 11.8 μmol/L (median; range = 2-41.8 μmol/L). No significant differences were found between homocysteine levels and the plaques morphological characteristics, or between the cell types analyzed. Elevated concentrations of homocysteine were not significantly higher in patients with a history of stroke. CONCLUSION The present study confirms high hyperhomocysteinemia prevalence in patients with extracranial cerebrovascular disease, although no relationship between plaque complication phenomena and this cardiovascular risk factor was observed.