BACKGROUND: Stenoses of the internal carotid artery (ICA) with a ≥ 50% degree of stenosis are common in the German population with a prevalence of approx. 4.2%. Furthermore, about 15% of ischemic strokes are due to stenosis or occlusion of the ICA. There are currently three approaches to the treatment of ICA stenoses: conventional therapy, endovascular treatment and surgical treatment.
METHODS: Summary of the S3 guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3 February 2020.
RESULTS: Color-coded duplex sonography, computed tomography (CT) angiography and magnetic resonance (MR) angiography and, in exceptional cases, diagnostic subtraction angiography can be used to diagnose ICA stenoses, including the stenosis grade. The classification is into symptomatic and asymptomatic ICA stenoses. ICA stenoses can be treated conservatively, endovascularly with stenting or surgically by carotid endarterectomy. Invasive treatment should be carried out under inpatient conditions, whereby the hospital stay should be kept as short as possible. Color-coded duplex sonography should be performed regularly before discharge and at regular intervals thereafter to detect recurrent stenosis at an early stage and, if necessary, to initiate further invasive therapy.
CONCLUSIONS: When choosing the treatment modality, particular attention must be paid to whether the stenosis is symptomatic or asymptomatic and the degree of stenosis. The S3 guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3 February 2020 provides guidance here.
UNASSIGNED: HINTERGRUND: Engstellen der A. carotis interna (ACI), die einen Stenosegrad von ≥ 50 % aufweisen, sind mit einer Prävalenz von ca. 4,2 % häufig in der deutschen Bevölkerung zu finden. Etwa 15 % der ischämischen Schlaganfälle sind auf Stenosen oder Verschlüsse der ACI zurückzuführen. Gegenwärtig gibt es 3 Behandlungsansätze für ACI-Stenosen: das konventionelle Therapieregime, die endovaskuläre und die chirurgische Versorgung.
UNASSIGNED: Zusammenfassung der S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der extrakraniellen Karotisstenose vom 03.02.2020.
UNASSIGNED: Zur Diagnostik von ACI-Stenosen inklusive deren Gradeinteilung können die farbkodierte Duplexsonographie, die Computertomographie(CT)-Angiographie und die Magnetresonanz(MR)-Angiographie sowie in Ausnahmefällen die diagnostische Subtraktionsangiographie durchgeführt werden. Die Einteilung erfolgt in symptomatische und asymptomatische ACI-Stenosen. ACI-Stenosen können konservativ, endovaskulär mit Stent oder chirurgisch durch Karotis-Endarteriektomie behandelt werden. Eine invasive Versorgung sollte unter stationären Bedingungen durchgeführt werden, wobei der Krankenhausaufenthalt so kurz wie möglich gehalten werden sollte. Vor Entlassung und im Verlauf sollten regelmäßig farbkodierte Duplexsonographien durchgeführt werden, um eine Rezidivstenose frühzeitig zu erkennen und ggf. eine erneute invasive Therapie einzuleiten.
UNASSIGNED: Bei der Wahl der Behandlungsmodalität ist besonders zu beachten, ob es sich um eine symptomatische oder asymptomatische Stenose handelt und wie hoch der Stenosegrad ist. Die S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der extrakraniellen Karotisstenose aus dem Jahr 2020 stellt hier eine Orientierungshilfe dar.

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OBJECTIVE: Patients with asymptomatic carotid artery stenosis currently account for the majority of carotid interventions performed in the United States; therefore, the following article will review the 2022 Society for Vascular Surgery (SVS) clinical practice guidelines perspective in treating patient with asymptomatic carotid stenosis.
METHODS: A systemic review and meta-analysis were conducted by the evidence practice center of the Mayo Clinic using a specified population, intervention, comparison, outcome (PICO) framework.
RESULTS: Based on published randomized trials and related supporting evidence, the following were noted: the SVS recommends that patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke, provided the patient has a life expectancy of 3 to 5 years with risk of perioperative stroke and death not exceeding 3%. The type of carotid intervention should be based on the presence or absence of high-risk criteria for each specified intervention. Data from CREST, ACT, and the Vascular Quality Initiative suggest that certain properly selected asymptomatic patients can be treated with carotid stenting with equivalent outcome to CEA in the hands of experienced interventionalists. The institutions and operator performing carotid stenting must exhibit expertise sufficient to meet the established American Heart Association guidelines for treatment of patient with asymptomatic carotid stenosis (ie, combined stroke/death rate of less than 3%).
CONCLUSIONS: SVS recommends that low surgical risk patients with asymptomatic carotid stenosis of ≥70% to be treated with CEA with best medical therapy over medical therapy alone for the long-term prevention of stroke/death (GRADE 1B). Carotid intervention should also be based on the presence or absence of high-risk criteria for each specified intervention (ie, CEA, TCAR, and TFCAS).

OBJECTIVE:  According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke.
METHODS:  Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay.
RESULTS:  The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006).
CONCLUSIONS:  Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance.
CONCLUSIONS: · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared..
UNASSIGNED: · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2024; 196: 471 - 481.
UNASSIGNED:  Nach der Evidenz aus randomisierten Studien und aktuellen Leitlinien wird das elektive Carotis-Stenting (CAS) gegenüber der Carotisendarteriektomie (CEA) immer noch als Zweitlinientherapie angesehen. Die Publikation der randomisierten Vergleichsstudien für Patienten mit symptomatischen Stenosen erfolgte allerdings vor deutlich mehr als 10 Jahren. Angesichts von Problemen der deutschen Qualitätssicherung bei der sauberen Trennung zwischen elektiven und Notfalleingriffen und geringen Fallzahlen für die CAS-Nischenindikationen erschien es sinnvoll, neurologisch kontrollierte CAS-Ergebnisse darzustellen, und zu untersuchen, ob elektives CAS die strengen Qualitätskriterien durchgängig erfüllt und welche Unterschiede zu notfälligen CAS-Eingriffen beim akuten ischämischen Schlaganfall bestehen.
METHODS:  Zwischen 01/2012 und 07/2022 wurden 141 elektive CAS-Eingriffe zur Behandlung von Patienten mit symptomatischen (n = 123) und asymptomatisch (n = 18) Stenosen durchgeführt. Bei 134 dieser elektiven Eingriffe (95 %) konnte eine Protektion durch ein Filtersystem erfolgen. Im gleichen Zeitraum wurden 158 Patienten im Rahmen eines akuten Schlaganfalles mittels Carotis-Stent behandelt. Die Komplikationsrate wurde anhand neurologisch kontrollierter Daten ermittelt. Bei den Notfall-Eingriffen wurden CAS-bezogene Komplikationen (Stent-Thrombosen, Stent-assoziierte Gefäßschäden, Thrombembolien und symptomatische Blutungen) extrahiert und das klinische Outcome (NIHSS-Verlauf) während des stationären Aufenthalts ermittelt.
UNASSIGNED:  Die während des stationären Aufenthalts für elektive symptomatische Patienten ermittelte Rate an Schlaganfällen und Todesfällen lag bei 0,8 %. Eine frühe Behandlung innerhalb der ersten 7 Tage nach dem Indexereignis, Alter > 70 Jahre und Erfahrung des Operateurs waren keine signifikanten Risikofaktoren für das Auftreten von Komplikationen. Nach CAS-asymptomatischer Stenosen wurden keine Komplikationen beobachtet. Die prozedurbezogene Komplikationsrate bei Notfalleingriffen lag bei 7,8 % und war damit erwartungsgemäß signifikant höher als nach elektivem CAS (p < 0,006).
UNASSIGNED:  Auch bei begrenzter Indikationsstellung und eingeschränkter Fallzahl ist die Einhaltung der strengen Qualitätskriterien der aktuellen S3-Leitlienie 2022 für elektive CAS-Eingriffe sowohl bei symptomatischen als auch bei asymptomatischen Stenosen in einem erfahrenen Zentrum möglich. Notfall-CAS-Eingriffe haben bei anderen Voraussetzungen signifikant höhere Komplikationsraten und müssen bezüglich der Qualitätssicherung separat betrachtet werden.
UNASSIGNED: · Elektives Carotis-Stenting erfüllt die strengen Qualitätskriterien der aktuellen S3-Leitlinie 2022.. · Notfälliges Carotis-Stenting weist signifikant höhere Komplikationsraten auf als elektive Eingriffe.. · Elektives und notfälliges Carotis-Stenting sind nicht sinnvoll vergleichbar..
UNASSIGNED: · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2024; 196: 471 – 481.

OBJECTIVE: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear.
METHODS: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response.
RESULTS: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered \"recently symptomatic\" should be reduced from the current definition of \"6 months\" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence.
CONCLUSIONS: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.

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BACKGROUND: There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA.
METHODS: We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke was assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cut points were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke.
RESULTS: We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3 (interquartile range: 12.3-51.7) and the median hospital volume was 67 (interquartile range: 36.3-119.3). The surgeon volume cut point was 3 and the hospital volume cut point was 6 cases per year. There were 756 (2.3%) procedures performed by surgeons with a volume < 3 and 560 (1.7%) procedures performed by hospitals with a volume < 6. Perioperative stroke and death rates were 2.0% (95% confidence interval [CI]: 1.8-2.1) and 3.8% (95% CI: 2.6-5.5) for an average yearly surgeon volume ≥ 3 and < 3 (P = 0.070), respectively. The combined stroke and death rate was 2.0% (95% CI: 1.8-2.1) and 4.8% (95% CI: 3.2-7.0) for an average yearly center volume ≥ 6 and < 6 (P = 0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low-volume procedures did not meet previously proposed American Heart Association and Society for Vascular Surgery quality measures.
CONCLUSIONS: These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcome relationships in asymptomatic CEA.

Carotid duplex ultrasound (CDUS) examination is used in the long-term surveillance after transcarotid artery revascularization (TCAR). The objective of this study was to evaluate the usefulness and cost effectiveness of post-TCAR CDUS surveillance regimens in monitoring for in-stent restenosis (ISR) and associated stroke risk at a single-center community institution.
CDUS data were collected retrospectively from patients who had undergone TCAR between January 2017 and January 2023. ISR >50% was defined as a peak systolic velocity (PSV) of >220 cm/s and an internal carotid artery (ICA) to common carotid velocity ratio of >2.7. ISR >80% was defined as a PSV of >340 cm/s and an ICA/common carotid artery ratio of >4.15. Study outcomes included incidences of ISR, reintervention, transient ischemic attacks (TIAs), strokes, and mortality. A Kaplan-Meier survival analysis was done to calculate the rates of freedom from ISR.
During the study period, 108 TCAR stents were deployed in 104 patients. Eight patients were excluded in analysis or lost to follow-up. Preoperatively, 62% of patients had >80% stenosis, and 39% were symptomatic. No intraprocedural complications were noted. One patient suffered an immediate postoperative dissection. Eight stents (8%) experienced ISR progression from <50% to >50%. Three of the eight had further ISR progression to >80%. One patient had high-grade ISR and a contralateral ICA occlusion that warranted reintervention. There were no occurrences of postoperative TIAs, strokes, or TCAR-related deaths. Rates of freedom from ISR progression from <50% to >50% were 97.4%, 95.9%, 90.9%, 88.2%, and 88.2% at 6, 12, 24, 36, and 42 months, respectively. Rates of freedom from ISR >80% were 100%, 100%, 98.5%, 95.5%, and 95.5% at the same time points. Patients with >50% ISR tended to be females with hyperlipidemia. In addition, they had higher average lesion lengths and lower rates of postdilation balloon angioplasty. The 5-year estimated surveillance cost in this cohort using the Society for Vascular Surgery 2022, and 2018 guidelines, as well as our current protocol would be $113,853, $221,382, and $193,207, respectively.
This study revealed a low incidence of ISR progression, as well as no TIA, stroke, or TCAR-related deaths, highlighting the safety and efficacy of TCAR. Post-TCAR CDUS examination using the updated Society for Vascular Surgery guidelines are safe and cost effective. Patients with contralateral occlusion or stenosis, or who have significant risk factors, should have more frequent surveillance regimens.