Carotid Stenosis

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Multifocal atherosclerosis and cardiovascular outcomes

Preclinical atherosclerosis of carotid arteries and future cardiovascular events
Pavel Poredos (Slovenia)

An increase in intima-media thickness, the earliest structural marker of vascular damage, is associated with the extent and severity of atherosclerosis in different arterial beds, and it can predict cardiovascular events. The increase in intima-media thickness is related to vascular risk factors, the adequate treatment of which may prevent its progression or even induce its regression. Consequently, intima-media thickness can be very useful clinically to assess the harmful effects of vascular risk factors on the vessel wall, determine the risk for cardiovascular events, and identify high-risk individuals for cardiovascular incidents. An increase in intima-media thickness clearly constitutes an independent risk factor for cardiovascular events.

The connection between carotid and coronary arteries
Salvatore Novo (Italy)

Patients with an acute myocardial infarction and patients with acute or chronic coronary heart disease have a very high frequency of asymptomatic atherosclerosis in carotid and peripheral territories and an enhanced atherosclerosis progression. In addition, multifocal atherosclerosis worsens the outcomes for these patients. Consequently, a strong secondary prevention and intensive follow-up are mandatory for these patients.

Ankle brachial index and the prediction of future events
Denis Clement (Belgium)

Ankle brachial index has been used as a numerical value to define peripheral arterial disease. Meanwhile, ankle brachial index measurements have several problems and limitations; in fact, according to the peripheral arterial disease guidelines from the ESC, ankle brachial index has a specificity of 96%, but a sensitivity of only 79%. Diabetic patients have increased arterial wall stiffness, which leads to an abovenormal ankle brachial index, resulting in misleading normal ankle brachial index values and underestimating peripheral arterial disease. Therefore, in these situations, toe brachial index, which assesses skin perfusion, should be used. Additionally, ankle brachial index is operator dependent and has additional questions to be answered (ie, what decrease in ankle brachial index should be considered clinically relevant, is the risk for future events clearly graded, or what is its relevance in the long term). Furthermore, in addition to its more common use to predict long-term prognosis (local and systemic cardiovascular morbidity and mortality), it can be used to evaluate the functional status, and it is related to specific genetic characteristics. In fact, there is a relationship between ankle brachial index and functional impairment (crosssectional), and ankle brachial index predicts the evolution of functional impairment over time (longitudinal).

Asymptomatic aortic abdominal aneurysm and future cardiovascular events
Philippe Lacroix (France)

Patients with an abdominal aortic aneurysm are multivascular patients, and the rate of myocardial infarction and stroke before and after surgery is greater for these patients than in an age- and sex-matched general population. Antiplatelet therapy is recommended not only for patients with an abdominal aortic aneurysm who have a preexisting cardiovascular disease (or who are at high risk), but rather for all patients with an abdominal aortic aneurysm. Statin therapy should be initiated in all patients with an abdominal aortic aneurysm and maintained for life after that. In addition, in the presence of hypertension, ACE inhibitors should be considered. Finally, these patients have higher rates of cancer-related mortality.

Progress in the interventional therapy of carotid and peripheral arterial disease
José Fernandes e Fernandes (Portugal)

Remarkable developments have been made in carotid stenting with low-profile devices (eg, guide wires, balloons), better stent designs (closed vs open cells), safer cerebral protection devices, flow-reversal systems, and a cervical approach (vs the standard femoral access). However, the results of carotid stenting are still associated with early neurological deficits in symptomatic patients and worse results during early interventions. The early results of carotid stenting in asymptomatic patients, even in high-volume centers, are not superior to carotid endarterectomy. However, long-term durability and stroke-free survival rates appear comparable with carotid endarterectomy in both symptomatic and asymptomatic patients. In addition, the selective use of carotid stenting is advised for carotid bifurcation disease, and carotid endarterectomy should be reserved for restenosis (early), radiation arteritis, hostile necks, and high surgical risk patients.