Faculty Bibliography

OBJECTIVE:To validate the carotid web (CW) risk stratification assessment described in previous works within a larger cohort of patients with symptomatic and incidentally found asymptomatic CWs. METHODS:A retrospective analysis of our institution's electronic medical records identified all patients with a diagnosis of CW from 2017 to 2024. We included symptomatic patients and those with asymptomatic CWs, that is, incidentally found webs without history of stroke or transient ischemic attack. Patient charts were reviewed for demographics, imaging, comorbidities, and a diagnosis of stroke after diagnosis of asymptomatic CW. All angles were measured as described in previous work on a sagittal reconstruction of neck CT angiography in which the common carotid artery (CCA), external carotid artery, and internal carotid artery (ICA) were well visualized, together with the CW itself. Principal component analysis and logistic regression were performed to evaluate the association between high-risk angles and stroke risk.  RESULTS: Twenty-six symptomatic and 26 asymptomatic patients were identified. Of note, the number of patients with hypertension, hyperlipidemia, and smoking history was 17 (65.0%), 16 (62.0%), and 8 (31.0%) for symptomatic patients and 18 (69.0%), 17 (65.0%), and 15 (58.0%) for asymptomatic patients. All angular measurements showed statistically significant associations with stroke status. The CCA-web-pouch angle showed the strongest association (p=2.07×10⁻⁴), followed by the CCA-pouch-tip angle (p=3.23×10⁻⁴), ICA-web-pouch angle (p=0.004), and ICA-pouch-tip angle (p=0.005). Each additional high-risk angle increased the odds of stroke by 9.47-fold (p<0.0001). The associated probability of stroke increased from 6.3% with no high-risk angles to 39.1% with one high-risk angle and further to 85.9% with two high-risk angles. The model demonstrated high sensitivity, correctly identifying 84.6% of positive cases, and high specificity, correctly identifying 88.5% of negative cases. The F1 score was 0.863, indicating good overall model performance.  CONCLUSION: Given this successful stratification of CWs into high- and low-risk groups, the utilization of geometric CW parameters may play a role in improving patient selection for intervention in the setting of incidentally diagnosed CW. .

OBJECTIVE:This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR). METHODS:Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network (VQI VISION) database who underwent elective carotid revascularization 2016-2020 were included. Patients were analyzed by group based upon whether they underwent cardiac stress testing within two years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or MI). Outcomes of interest were postoperative MI/neurologic events, 90-day re-admission rates, as well as long-term mortality. RESULTS:We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). While comorbidities were significantly higher amongst patients undergoing CEA with preoperative stress test compared to those without stress testing, the overall prevalence of co-morbidities was higher amongst patients undergoing TF-CAS or TCAR irrespective of preoperative stress test status. Compared to patients with a negative stress test, patients with positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day re-admission rates (CEA 19.6% vs 15.8%, p=0.003; CAS 33.3% vs. 18.6%, p<0.001; TCAR 25% vs. 17.5%, p=0.04). No group demonstrated a difference in the incidence of in-hospital postoperative neurologic events or CHF, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital post-operative MI (1.7% vs 0.6%, p<0.001). In 3-year follow-up, those with a positive compared to negative stress test were more likely to undergo CABG/PCI in the CEA (adjusted HR 1.87 [1.42-2.27], p<0.0001) and CAS groups (adjusted HR 3.89 [1.77-8.57], p<0.01), but not the TCAR cohort. Notably those undergoing CEA with a positive compared to negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR 1.28 [1.03-1.58], p=0.03) at 3 years. Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in mortality at 3 years (adjusted HR 0.86 [0.76-0.98], p=0.02); this mortality difference was not observed in similar stress test cohort undergoing TF-CAS or TCAR. CONCLUSIONS:Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be preferentially offered optimal medical management and/or stenting.

Typical carotid webs are nonatherosclerotic shelf-like projections of fibromyxoid tissue extending from the posterior wall of the proximal internal carotid artery (ICA). Carotid webs may precipitate acute embolic stroke, especially in younger patients. We describe our experience with pathology-proven carotid webs of atypical appearance, or atypical carotid webs (ACWs), a subset of carotid webs exhibiting abnormal location, morphology, or association with atherosclerotic changes. Our electronic medical record database was queried for all imaging impressions containing "carotid web," "shelf," or "protrusion" from 2018-2024. Imaging was reviewed by an experienced neuroradiologist and neurosurgeon. Patients with typical carotid webs or those with different diagnoses (e.g. dissection/thrombus) were excluded. Twenty-seven patients were treated for typical carotid webs; 24 were treated with carotid endarterectomy (CEA) and had pathology-confirmed webs. Five patients (three male) were identified to have ACWs and included in this report. Mean age was 43.6 years. All ACWs were identified by computed tomography angiography (CTA). All patients presented with acute ischemic stroke or transient ischemic attack (TIA). One web was located on the anterior ICA wall, three were of abnormal morphology different from a "shelf-like" projection, and one was associated with atherosclerotic change. No patients experienced a further stroke or TIA following CEA. ACWs may precipitate ischemic stroke and can be treated and definitively diagnosed with CEA. Due to their unusual appearance, ACWs may evade radiographic identification or be misdiagnosed. As ACWs have not been previously reported in the literature, awareness of their existence must be raised to increase their detection and treatment.