Spontaneous improvement of peristent ulceration after carotid artery stenting
Shinya KohyamaKiyoshi KazekawaMinoru IkoHiroshi AikawaMasahiro TsutsumiY. GoShunichi NagataTomonobu KodamaKouhei NiiShinichi MatsubaraAkira Tanaka
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BACKGROUND AND PURPOSE: Because carotid plaque ulceration is associated with an increased risk of cerebral embolism, residual carotid plaque ulceration directly around a stent (peristent ulceration) after carotid angioplasty and stent placement (CAS) could still be a risk factor for a stroke. The purpose of this study is to understand the morphologic and clinical prognosis of peristent ulceration. PATIENTS AND TECHNIQUES: CAS was attempted on 91 consecutive stenotic lesions (80 patients). Of these, 54 lesions (48 patients) had ulceration before CAS. Angiograms were evaluated immediately after the procedure. Peristent ulceration was found in 34 lesions (30 patients). The mean depth and length of peristent ulcers were 2.1 mm (range, 1–4.7 mm) and 8.9 mm (range, 1.5–22 mm), respectively. All patients with peristent ulceration were followed with antiplatelet therapy. RESULTS: No ischemic event due to the lesions occurred during the mean follow-up period of 25.5 months (range, 3–48 months). Angiography on 25 lesions (21 patients) at a mean of 5.8 months (range, 1–21 months) after CAS showed that peristent ulceration disappeared in 12 lesions (48%), improved in 11 lesions (44%), and remained unchanged in 2 lesions (8%). Nine lesions (36%) showed restenosis, which were ≤30% and did not require any additional intervention. New ischemic lesions were not detected in any of the 14 patients (17 lesions) who underwent follow-up MR imaging at a mean of 9 months (range, 1–32 months) after CAS. CONCLUSION: We conclude that peristent ulceration after CAS improves spontaneously and is not a risk factor for cerebral embolism.Keywords:
Stroke
Target lesion
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The first choice of treatment for neck cancer is often radiotherapy. Therefore, we aimed to investigate the microinflammation after radiotherapy of the neck and the incidence of carotid stenosis. This study reports on patients treated with radiotherapy as part of the treatment for laryngeal cancer in the Department of Radiation Oncology, The Second Hospital of Jilin University, Changchun, P.R. China. Sixty-two males and nine females were treated with radiotherapy between 2006 and 3012. The carotid diameter was determined by measuring carotid intima-media thickness (IMT) in the common, external and internal carotid artery. Microinflammatory conditions were assessed by high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6) and tumor necrosis factoralpha (TNF-α). Other studied risk factors included age, treatment modalities, radiation dose and energy, the height of the radiation field, and follow-up time. Carotid stenosis was detected in all of the 71 patients. It was mainly clinically unsuspected; 19 patients had sustained a vascular event (14 TIA, 5 CVI) at a median of 3.11 years (range 2.35.6 years) following RT. In four of five CVI patients, CVI occurred on the side of the irradiation. Eleven patients who suffered vascular incident had severe stenosis of the carotid artery and 6 had moderate (31-49% of the lumen). Only two patients with mild stenosis on the irradiated side suffered TIAs. Serum hs-CRP levels in carotid stenosis were 9.4 (±SD=5.97) mg/ml, IL-6 = 12.8 (±SD=2.62) pg/ml and TNF-α = 15.4 (±SD=4.49) ng/ml. The clinical detection of asymptomatic carotid stenosis is challenging, and current recommendations regarding the follow-up period should be scrutinized.
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Cervical radiation for head and neck cancer has been associated with an increased incidence of carotid arterial stenosis. Modern radiation therapy delivers higher doses with increasing long-term survival. In our study 50 patients with head and neck malignancies treated with radiotherapy are analized with colour Doppler ultrasonographic scanning of the carotid arteries. These patients were compared with a population of asymptomatic historical controls (40) These findings suggest that radiation has an adverse effect on large vessels. Colour Doppler follow-up may be indicated for patients receiving head and neck radiation therapy.50-70 Gy is the local dose that all patients received. during a period of about 8 weeks. The ecodoppler scan of carotid arteries was performed in all patients with estimation of Common and internal carotid artery's intimal medial thickness (IMT). Stenosis grade were divided into low (0-30%), moderate (31-49 %) and severe (= >50%). In add we considered ematochimics and flogosys parameters. Patients recruited from a hospital Radiation-oncology-surgery department from April 2007 to September 2011, 90 consecutive head and neck cancer patients were enrolled in this study. 50 of these patients had previously undergone RT (RT group) and 40 had no RT (control group). All patients were screened with bilateral carotid arterial duplex ultrasonography. We defined disease as "normal or mild" if the carotid stenosis was <50%, and "significant" if >50%. The relationship between standard demographic risk factors and screening outcomes was then analyzed.We found that severe carotid stenosis (= >50% ) was higher (41%) in patients who underwent to radiotherapy than in control group. The Eco Doppler examination demonstrated that the most affected site was Internal Carotid Arthery 's fork . There were no differences in age or gender between the two groups. The RT group had a significantly higher plaque score than the non-irradiated group. Bilateral plaque score was significantly correlated with age, hyperlipidemia, and RT. This analysis showed that in RT patients > 50 years old, age was inversely correlated with plaque score; however, in RT patients 50%). In aggiunta abbiamo considerato parametri ematochimici e di flogosi. I pazienti sono stati reclutati da un Dipartimento ospedaliero di radiaterapia, oncologia e chirurgia dal mese di aprile 2007 a settembre 2011. Sono stati arruolati in questo studio 90 pazienti con cancro di testa e collo. Di questi pazienti, 50 erano stati precedentemente sottoposti a RT (gruppo RT) e 40 senza RT (gruppo di controllo). Tutti i pazienti sono stati sottoposti a screening con Ecografia Doppler delle Arterie Carotidee bilateralmente. Abbiamo definito la malattia come “normale o lieve” se la stenosi carotidea è stata <50%, e “significativa“, se> 50%. La relazione tra i fattori di rischio demografici e gli esiti di screening è stata poi analizzata.Abbiamo trovato che la stenosi carotidea grave (=>50%) è stata superiore (41%) nei pazienti sottoposti a radioterapia rispetto al gruppo di controllo. L’esame Eco Doppler ha dimostrato che il luogo più colpito è la biforcazione della Arteria Carotide Interna . Non ci sono state differenze di età o di genere tra i due gruppi. Il gruppo RT aveva un Punteggio di Placca significativamente più alto rispetto al gruppo non irradiato. Punteggio di Placca bilaterale è risultato significativamente correlato con l’età, iperlipidemia, e RT. Questa analisi ha mostrato che nei pazienti con RT> 50 anni, l’età è risultata inversamente correlata con il Punteggio di Placca, tuttavia, nei pazienti RT con età minore o uguale a 41 anni, l’età era positivamente correlata con il Punteggio di Placca.Le evidenze nella letteratura su questo argomento sono poche e simili alla nostra. Moritz et all hanno trovato una grave stenosi carotidea nel 30% dei pazienti irradiati e del 5,6% nel gruppo di controllo. Lam ha trovato una stenosi carotidea nel 78,9% dei pazienti irradiati e del 21,6% nel gruppo di controllo. Si può concludere che la radioterapia è in grado di indurre lesioni aterosclerotiche solo nei siti inclusi nel campo di radiazione.Dovrebbe essere importante effettuare una Ecografia color-Doppler delle arterie Carotidee pre e post radioterapia carotidea nei pazienti in procinto di sottoporsi a radioterapia della testa e del collo. La prevalenza della malattia arteriosa carotidea in pazienti con precedente radioterapia cervicale è clinicamente significativa e garantisce lo screening aggressivo come parte della routine e del trattamento pre e post radiazione. Lo screening mirato di questa popolazione ad alto rischio può essere efficace e medicalmente vantaggioso in termini di modificazione dei fattori di rischio e prevenzione dell’ictus.
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Carotid artery disease
Endarterectomy
Duplex scanning
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Lethargy
Endarterectomy
Depression
Carotid artery disease
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Subclinical infection
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Aging is considered to cause atherosclerotic changes in the carotid artery, but few studies have evaluated this relationship. In this study, we used carotid plaques removed from patients with carotid artery stenosis and investigated how aging contributes to carotid plaque morphology and symptoms.A total of 60 patients(55 men, 5 women; mean age, 70.5 years; range, 53-85 years) treated at our hospital between January 2009 and April 2012 were enrolled in this study. All patients underwent carotid endarterectomy; their carotid plaques were stained with hematoxylin-eosin and/or Elastica-Masson stain and examined by a pathologist. Using these data, the carotid systolic velocity and plaque morphology were analyzed considering the age by decade as well as the symptomatology.Of the 60 patients, 29 were symptomatic(transient ischemic attack (TIA) in 8 patients; infarction in 20;and amaurosis in 1). Symptoms were less common as patient age increased. The incidence of TIA also tended to decrease with an increase in age, although the opposite trend was seen with infarction. In plaque morphology, the presence of active plaque, macrophage, inflammatory infiltration, and capillary angiogenesis decreased as age increased, while the presence of degenerative plaques, decrease in smooth muscle cell number, and calcification inversely increased. Active, degenerative, and combined (active/degenerative) lesions are statistically unrelated to symptoms as well as systolic velocity (cm/sec) at the carotid stenosis. The rates of hemorrhagic lesions were similar among decades, but the lesion statistically contributed to increasing symptoms (p=0.0045) and increasing systolic velocity (p=0.031).Increasing age contributes to morphological changes in carotid plaques and symptoms. When hemorrhagic lesions are suspected in carotid plaques, patients will be symptomatic and may require surgery.
Amaurosis fugax
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Clinical and angiographic characteristics of renovascular hypertension were studied in 95 patients. The patients were divided into 3 groups: 55 cases with aortic arteritis (group AA), 27 with fibromuscular dysplasia (group FMD) and 9 with atherosclerosis (group AS). The patients in group AS were significantly older in age and had longer history of hypertension. Abdominal bruit was heard significantly more often in group AA and serum potassium was significantly lower in group FMD. Angiographic data showed that in group AA lesions in thoracic aorta and abdominal aorta was found in 81.4% and those involving both renal arteries in 52.5%. In group FMD, 82.5% of patients had lesion in renal artery on one side and none had lesion in thoracic and abdominal aorta. In group AS, lesions were found mainly in thoracic and abdominal aorta, accounting for 77.7% and lesions in renal arteries were mainly unilateral. In group AA, lesions were found in 90 renal arteries altogether. Among them, 58.9% was in the proximal part of the renal artery; the lesion was either localized stenosis (67.8%) or obstruction (17.7%). In group FMD, lesions were found in 33 renal arteries altogether. Among them, 48.5% was in the middle or distal part of the renal artery and 27.3% resembled string of beads. In group AS, a total of 10 renal arteries were involved with 4 (40%) of ostial stenosis and 4 (40%) total obstruction.
Abdominal aorta
Renovascular Hypertension
Fibromuscular Dysplasia
Thoracic aorta
Renal Artery Obstruction
Right Renal Artery
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Introduction: New diffusion weighted imaging (DWI) lesions are very common after cardiothoracic surgery. However, most of these lesions are asymptomatic and what determines whether a lesion would be symptomatic or not remains unclear. Hypothesis: New ischemic lesions are more likely to be symptomatic if large and if affecting primary motor areas. Methods: Patients over 65 years undergoing surgical aortic valve replacement (AVR) for calcific stenosis were prospectively recruited (n=196). All patients underwent neurological evaluation on post-op days 1, 3, and 7, and MRI scans on planned post-op day 5. Among those with new post-op DWI lesions, we compared baseline characteristics, surgery, and imaging data between subjects who were symptomatic and asymptomatic. Results: Of the 129 patients who completed a post-surgical MRI, 79 (61%) had new DWI lesions and 17 of those (22%) had new neurological symptoms. New symptoms were associated with longer times on bypass (132±43 vs. 103±36 min, p=0.006), smaller intra-operative drops in arterial pressures (28±2 vs. 40±15 mm Hg, p=0.001), and more concomitant procedures (59% vs. 29%, p=0.047). Symptomatic patients had a greater number of new DWI lesions (5±8 vs. 3±3, p=0.012), higher DWI total lesion volumes (7±15 vs. 1±14 mL, p=0.002), and higher old lesion burden on FLAIR (11±11 vs. 5±7 mL, p=0.028). Symptomatic lesions more frequently involved the frontal (92% vs 62%, p=0.043) and parietal white matter (67% vs 29%, p=0.020) and were more common in right hemispheric lesions (100% vs.58%, p=0.005). Conclusions: New DWI lesions are common after AVR, but most are asymptomatic. Patients are more likely to have symptoms with right frontal and parietal involvement, with larger absolute DWI lesion count and volumes, and with longer bypass durations, complicated surgeries, and higher pre-existing lesion burdens.
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Carotid-artery stenting and carotid endarterectomy are both options for treating carotid-artery stenosis, an important cause of stroke.
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Carotid stenting
Endarterectomy
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