الفهرس 
Dedication
Anatomy of the cerebrovascular systemOnly 14 pages are availabe for public view
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Abstract
from January 2017 to July 2019 we conducted a prospective study comprising 728 patients who underwent carotid artery stenting for atherosclerotic stenosis of extracranial carotid artery. Both symptomatic (150 patients) and Asymptomatic (578 patients) were included in the study. Symptomatic patients included in the study when they were high risk for surgery, or hostile neck and anatomically challenging lesions. Otherwise carotid total occlusion, lesions due to other causes like fibromuscular dysplasia, and recent stroke (within 2 weeks) were excluded from our study. The patients were evaluated by full history taking, clinical examination, laboratory especially renal function and imaging investigations especially duplex scan. The following criteria were studied: Age and sex, risk factors, contralateral carotid status, clinical presentation, and lesion characteristics (namely side, degree of stenosis, plaque length, plaque echogenicity, pervious CEA). Primary end points were the 30-day composite of death, any stroke, or myocardial infarction (major adverse cardiac or cerebrovascular event [MACCE]) plus long-term (beyond 30 days) ipsilateral stroke. Secondary endpoints were the occurrence HI, stent patency rate, and the need for reintervention. Male gender was found in 479 (65.8%), while 34.2% (n=249) were females. The mean age of our study patients was 71.00 ± 7.40 years (range; 51 - 79). Hypertension was the most prevalent risk factor (79.8%) in our patients. Other risk factors were diabetes in (29.7%), smoking in (52.9%), dyslipidemia in (36.1%), coronary artery diseases in (26.2%) and chronic obstructive pulmonary disease (18.5%).The indications of treatment were: symptomatic carotid stenosis of ≥50% in 20.6% of patients and asymptomatic carotid stenosis of ≥ 60 % in 79.4% of patients. There were different clinical presentations in our symptomatic patients most of them presented with TIA in 124 (17%). The other smaller proportion presented by stroke in 26 patients (3.6%).Patients were followed up for 12 months using clinical examination, and duplex scanning. In patients with abnormal DUS (direct sign: > 300 cm/s peak systolic velocity within or at the ends of the CCA), significant (>70%) ISR was suspected Stent occlusion was diagnosed when neither color nor Doppler signal was detected in the stent. The presence of significant ISR/stent occlusion was confirmed by CTA or DSA. Technical success and patency rate: This study revealed an overall successful rate of 95.9%. There was no statistical significance difference in stroke rate between symptomatic and asymptomatic subtypes of patients (p=0.461). There was no statistically significant association between stroke rate and age, sex and risk factors. Also Relation of hemodynamic instability to stroke rate was studied and revealed non significance correlation between HI and stroke rate. We found a statistical significant difference between severity of the lesion and stroke rate (p=0.007). Patients with stenosis <70%, 70-90%, and>90% had incidence of stroke 16%, 36%, and 48%, respectively. Similarly, lengthy plaque was associated with significant increase of stroke (p=0.012).Other lesion characteristics did not have any significant association with stroke rate. In this study, 250 patients (34.3%) experienced complications from the 728 procedures. Different types of Complications encountered in our patients including: neurological, cardiovascular, access site–related and other complications. Fifty patients (6.9%) developed neurologic events in the first 30 days after CAS, including 23 (3.1%) transient ischemic events, 6(0.8%) disabling strokes, and 21(2.9%) non disabling strokes. Most events occurred during or within 6 hours after the procedure. Immediate survival rate in our study was 99% with 6 deaths occurred in the first 30 days post-procedure. The most frequent cardiovascular complications encountered in our series were symptomatic hypotension that occurred in 29.9% of patients. The overall incidence of HI was 227 (31.2%). Hypotension occurred in 218 (29.9%) and isolated bradycardia without hypotension in 101 (13.9%). A systole occurred in 58 (8%) patients. Adjunctive atropine or vasopressor treatment was required in 69.4% of patients developing HI. A multivariate logistic regression model was constructed to determine possible predictors of HI during and after CAS. The presence of hypertension (OR, 2.037; 95% CI, 1.292 - 3.211; p= 0.0022), symptomatic carotid lesions (OR, 1.704; 95% CI, 1.057 - 2.747; p= 0.0287), right sided lesions (OR, 3.090; 95% CI, 1.934 - 4.935; p= <0.0001), hyperechoic/calcified plaques (OR, 2.195; 95% CI, 1.458 - 3.304; p= 0.0002), and longer lesions (OR, 1.043; 95% CI, 1.012 - 1.076; p= 0.0072) were significant predictable factors for the occurrence of HI. On the other hand, smoking was significantly associated with a 48.1% decrease in risk of development of HI (OR, 0.519; 95% CI, 0.358 - 0.754; p= 0.0006). The primary patency rate at 6 months and at 12 month was 95% (644 patients) and 90.8% (616 patients), respectively. Significant (≥ 70%) ISR developed in 62 patients (9.2%). Immediate survival rate in our study was 99% with 6 deaths occurred in the first 30 days post-procedure. Survival rate of patients had CAS at 6 and 12 months was 95% and 93%, respectively. During the whole study period, 91strokesoccurred in our patients including the 50 strokes documented at peri-procedureperiod. The cumulative percentage of freedom of stroke in our study at 1, 6 , and 12 months was 92.8% , 88.5%, and 84%, respectively. Testing known different patient clinical and risk factors as regard primary stent patency revealed no significant relationship between these factors and the primary stent patency except for hyperlipidemia (p=.001). Patients with hyperlipidemia are more risky for the development of ISR.