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Review Article | DOI: https://doi.org/10.31579/2578-8868/256
1 Florida State University College of Medicine, Tallahassee, U.S.A.
2 Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, U.S.A.
*Corresponding Author: Brandon Lucke-Wold MD, PhD, MCTS, Department of Neurosurgery, University of Florida, Gainesville.
Citation: Annu L. Kurian, Brandon Lucke-Wold (2023). Update on Management of Symptomatic Carotid Stenosis. J. Neuroscience and Neurological Surgery. 13(1); DOI:10.31579/2578-8868/256
Copyright: © 2023 Brandon Lucke-Wold, This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 28 December 2022 | Accepted: 17 January 2023 | Published: 27 January 2023
Keywords: symptomatic carotid artery stenosis (CAS); carotid endarterectomy (CEA); carotid artery stenting; transcarotid artery revascularization (TCAR)
Carotid artery stenosis (CAS) is one of the leading causes of cerebral ischemia and stroke.7 When plaque builds up in the internal carotid artery, it blocks blood flow to the brain. Oftentimes, this condition only comes to light after a patient experiences a stroke or stroke-like symptoms. When this occurs, cholesterol-lowering medications and blood thinners can help to increase blood flow to the brain. However, if the plaque is so large that it severely narrows the lumen of the artery, surgery may be required to restore blood flow to the brain. Patients with severe stenosis can undergo procedures such as carotid endarterectomies (CEA), stenting, and transcarotid artery revascularization (TCAR) for this purpose. In this review, we discuss these procedures and which patients warrant which type of intervention. We look at the pathophysiology of internal carotid artery stenosis and current treatment options, while highlighting emerging treatment options. This review aims to increase understanding of the management of symptomatic carotid artery stenosis as well as provide a groundwork for more innovative treatments.
Carotid artery stenosis (CAS) is one of the leading causes of cerebral ischemia and stroke. [68] This stenosis may or may not be symptomatic. When it is symptomatic it can cause symptoms such as hemiplegia, dysphasia, amaurosis fugax, or vision loss. [7] As of now, one of the best ways to manage symptomatic carotid artery stenosis is by surgical interventions such as carotid endarterectomies (CEA) and transcarotid artery revascularization (TCAR). The other option is angioplasty with stent placement, which can manage symptoms. Lifestyle changes such as quitting smoking or medications such as statins, antiplatelet agents, and antihypertensives can also improve outcomes. [14]
Evidence Acquisition
Epidemiology of Carotid Artery Stenosis
The prevalence of carotid artery stenosis varies with the population being studied as well as the criteria that is used. When stenosis is less than 50% as measured by carotid ultrasound, the prevalence of carotid artery stenosis was 7% in women and 9% in men. [28] Prevalence of carotid artery stenosis was evaluated to be 11% in individuals with a high risk of atherosclerosis, 18% in those with a high risk of cardiac disease, and 60% in those with a high risk of acute stroke. [69,72] When stenosis is greater than 50%, the prevalence of carotid artery stenosis is 5.9% with coronary artery diseasec [82] When stenosis is greater than 70%, the prevalence of carotid artery stenosis is 2.1% with coronary artery disease. [82] The prevalence of coronary artery disease in patients with carotid stenosis can be as high as 77%. [85] The prevalence of carotid artery stenosis is higher in men than in women, at 8.8% and 5.0% respectively. [99] Additionally, the risk of carotid artery stenosis increased with age, a higher level of low-density lipoprotein cholesterol (LDL-C), a higher systolic blood pressure (SBP), and a higher fasting blood glucose. [99] Lastly, the risk of having a cerebrovascular event increased by 26% for every 10% increase in the degree of carotid stenosis. [56] This shows that coronary artery disease is a key factor in the development of carotid artery stenosis and it plays a vital role in the treatment of it as well.
Pathophysiology of Carotid Artery Stenosis
Carotid artery stenosis is caused by atherosclerosis, or an area of thickened plaque, on the arterial wall that causes the carotid artery to narrow over time. One of the biggest risk factors for this is hyperlipidemia. When there are increased levels of cholesterol in the plasma, there are changes in arterial endothelial permeability. [13] This leads to lipids, especially LDL-C, getting into the arterial wall. [13] Monocytes stick to the endothelial cells expressing adhesion molecules and move into the subendothelial space, where they transform into macrophages. [13] LDL particles then become chemoattractants, leading to more cholesterol buildup. [13] This eventually leads to plaque formation, which causes the vessel to narrow.
When this process occurs in the carotid artery, it can lead to serious complications. Even shear stress or disturbed flow through the artery can prompt the aforementioned endothelial cell changes and damage. These changes can be induced by hypertension, dyslipidemia, diabetes mellitus, and cigarette smoking. [40] Smoking is a big risk factor for stenosis. [37] For those who smoke and have diabetes mellitus, the risk is even greater for developing plaques. [38] Endothelial cell dysfunction leads to inflammatory cells accumulating, smooth muscle cells proliferating, and various cytokines and chemokines to be released, boosting the plaque and leading to further vessel narrowing. [98] Plaques in the carotid artery are typically composed of a fibrous cap covering a lipid core and inflammatory cells. [98] When this plaque ruptures or a thrombus forms from this plaque, it leads to cerebral infarction. These plaques can be stable and asymptomatic or they can be unstable, leading to acute coronary syndromes. If a plaque is prone to rupturing, it is known as an unstable or vulnerable plaque. Vulnerable plaques have active inflammation, substantial accumulation of macrophages, a thin fibrous cap with a large lipid core, denudation of the endothelium with platelet aggregation, and severe stenosis.[98] Vulnerable plaques also tend to be noncalcified whereas stable plaques tend to be calcified. [76] Stable, calcified plaques are more often associated with transient ischemic attacks (TIAs) whereas unstable, non-calcified plaques are more often associated with stroke. [90]
Most patients with carotid stenosis are asymptomatic until the artery severely narrows or a clot forms. This results in a decrease or even block of blood flow to the brain, so the patient will have symptoms of a transient ischemic attack. [26] The symptoms will look like a stroke and they can include weakness or numbness on one side of the body, aphasia, facial droop, and diplopia among other vision impairments.[54] However, these symptoms will resolve within 24 hours.
Risk factors for carotid artery stenosis include older age, hypertension, and smoking. Being older can lead to increased risk for CAS, possibly due to the increasing stiffness of the walls of blood vessels. [67] High blood pressure can lead to more cholesterol deposits in the arteries, increasing the risk of plaque formation and rupture. [80] Smoking harms the endothelium of blood vessels, which makes it easier for cholesterol to deposit and form a plaque. [80] Moreover, an individual who currently smokes or used to smoke has more than a 6-fold risk of developing atherosclerotic carotid stenosis than those who do not and have not smoked. [95]
Evidence Synthesis
Current Treatments for Symptomatic Carotid Artery Stenosis
Surgical interventions for symptomatic carotid artery stenosis are carotid endarterectomy (CEAs), carotid artery stenting, or transcarotid artery revascularization (TCAR). Carotid endarterectomy (CEA) is performed in order to decrease the risk of stroke in a patient with known cerebrovascular atherosclerotic disease. In CEAs, plaque and potential embolic material are removed from the carotid artery, which improves blood flow. [23] Afterwards, the artery is reconstructed. Carotid artery stenting involves guiding a catheter through the artery, then inserting a stent into the artery so that it keeps the artery from narrowing again. [74] Angioplasty involves inserting a catheter with an inflatable balloon through the artery and then inflating the balloon once it gets to the part of the artery that is too narrow.[18] By doing this, the atherosclerotic plaque is pushed against the wall, which improves blood flow to that area again. Carotid artery stenting and angioplasty are typically used for moderate stenosis and CEA for severe stenosis of the carotid artery. [91]
In 2014, the American Heart Association/American Stroke Association (AHA/ASA) released guidelines for the treatment of symptomatic carotid artery stenosis. [42] The recommendations read as follows: 42“For patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis as documented by noninvasive imaging, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6> Recommendations for Interventional Approaches for Patients with Carotid Artery Stenosis42Risk Factor Recommendations from the AHA/ASA Class/Level of Evidence Patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis as documented by noninvasive imaging CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6> Class I; Level of Evidence A Patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging with corroboration (eg, magnetic resonance angiogram or computed tomography angiogram) CEA is recommended depending on patient-specific factors, such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6> Class I; Level of Evidence B The degree of stenosis is <50> CEA and CAS are not recommended Class III; Level of Evidence A Symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the ICA is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is <6> CAS is indicated as an alternative to CEA Class IIa; Level of Evidence B Older patients (ie, older than ≈70 years), particularly when arterial anatomy is unfavorable for endovascular intervention CEA may be associated with improved outcome compared with CAS Class IIa; Level of Evidence B Younger patients CAS is equivalent to CEA Class IIa; Level of Evidence B Symptomatic severe stenosis (>70%) in whom anatomic or medical conditions are present that greatly increase the risk for surgery or when other specific circumstances exist such as radiation-induced stenosis or restenosis after CEA CAS is reasonable Class IIa; Level of Evidence B Patients with a recent (within 6 months) TIA or ischemic stroke ipsilateral to a stenosis or occlusion of the middle cerebral or carotid artery EC/IC bypass surgery is not recommended Class III; Level of Evidence A Patients with recurrent or progressive ischemic symptoms ipsilateral to a stenosis or occlusion of a distal (surgically inaccessible) carotid artery, or occlusion of a mid-cervical carotid artery after institution of optimal medical therapy EC/IC bypass usefulness is considered investigational Class IIb; Level of Evidence C All patients with carotid artery stenosis and a TIA or stroke Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification Class I; Level of Evidence A
Table I: Recommendations for Interventional Approaches for Patients with Carotid Artery Stenosis
Moreover, 94% of guidelines for symptomatic carotid artery stenosis endorsed CEA for individuals with about 50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 58% endorsed stenting, and 27% opposed stenting1,69. For individuals who are at a high risk for CEA due to comorbidities, vascular anatomy, or other reasons, 82% of guidelines endorsed stenting[1,69].
Approximately 15% of ischemic strokes are due to acute tandem occlusion in the proximal (cervical) internal carotid artery and concomitant thromboembolism involving the distal (intracranial) internal carotid artery or the ipsilateral middle cerebral artery.[70] This necessitates revascularization with balloon angioplasty and stenting followed by thromboembolectomy using an anterograde or retrograde approach. [70] Intracranial mechanical thromboembolectomy followed by angioplasty and/or stenting of the proximal occlusion, or vice versa, is often used3. Whether the extracranial or intracranial approach was done first, it was shown that there were no statistically significant differences in revascularization, intracranial hemorrhage, outcomes, or mortality within the first 90 days. [94]
This also raises the question as to whether angioplasty is enough or if stenting should be done as well. The problem here is that there is an increased risk of intracranial hemorrhage after stenting because dual antiplatelet therapy is the standard of care after the procedure. This was found to be the case as the risk of intracranial hemorrhage was higher in those after stenting versus after mechanical thromboembolectomy. [3] However, mono antiplatelet therapy was shown to increase the risk of transient ischemic attacks and strokes after stenting as compared to dual antiplatelet therapy. [10] Studies have also looked at the benefits of dual antiplatelet therapy with mono antiplatelet therapy and the results are summarized in table 2 below.
| Outcomes of Mono (MAPT) vs. Dual Antiplatelet Therapy (DAPT)32, 39, 100 | |||
| Medication | Name of Study (Year) | ICH Rate (% per week) (DAPT vs. MAPT) | Major Bleeding Rate (% per week) (DAPT vs. MAPT) |
| Aspirin + Clopidogrel100 | Zuo et al.100 | 0 vs. 0% | 0 vs. 0% |
| Aspirin + Cilostazol32 | CSPS.COM32 | 0 vs. 0% | 0 vs. 0% |
| Aspirin + Ticagrelor39 | THALES39 | 0.08 vs. 0.06% | 0.13 vs. 0.06% |
| ICH = intracranial hemorrhage | |||
Table II. Outcomes of Mono (MAPT) vs. Dual Antiplatelet Therapy (DAPT)
Antiplatelet therapy is a balancing act because it can reduce the risk of stroke but can also increase the risk of perioperative bleeding. [64] It was also suggested that stenting should be done with angioplasty itself was not effective enough. [48] Studies have shown that there is no statistically significant difference in patients who had stenting done versus those who only had angioplasties. [94] The studies seem to suggest that stenting can be delayed until it is deemed to be necessary. In this case, if the carotid artery becomes occluded again, it may require an emergent CEA.79 According to these studies, it seems probable that the best course of action may be to perform the angioplasty, then intracranial thromboembolectomy and only stent when necessary, along with emergent CEA for extracranial occlusions.
The Society for Vascular Surgery put forth their recommendations after looking at randomized controlled trials and came up with the following guidelines: “2(1) CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease.” They made their recommendations based on the GRADE (grades of recommendation assessment, development, and evaluation) approach. See Table 3 for more details on the recommendations from the Society for Vascular Surgery.
| Recommendations for Interventional Approaches for Patients with Carotid Artery Stenosis2 | ||
| Risk Factor | Recommendations from the Society for Vascular Surgery | Level/Quality of Evidence |
| Low surgical risk patients with asymptomatic carotid bifurcation atherosclerosis and stenosis of >70% (documented by validated duplex ultrasound or CTA/angiography) | CEA with best medical therapy instead of maximal medical therapy alone for the long-term prevention of stroke and death | Level of recommendation: grade 1 (strong); quality of evidence: B (moderate) |
| Low- and standard-risk patients with >50% symptomatic carotid artery stenosis | CEA over transfemoral carotid artery stenosis (TF-CAS) | Level of recommendation: grade 1 (strong); quality of evidence: A (high) |
| Patients with recent stable stroke (modified Rankin scale score 0-2) and >50% stenosis | Carotid revascularization to be performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days after the onset of symptoms | Level of recommendation: grade 1 (strong); quality of evidence: B (moderate) |
| Patients undergoing revascularization within the first 14 days after the onset of symptoms | CEA rather than carotid stenting | Level of recommendation: grade 1 (strong); quality of evidence: B (moderate) |
| Patients who experienced a disabling stroke, have a modified Rankin scale score of ≥3, whose area of infarction is >30% of the ipsilateral middle cerebral artery territory, or who have altered consciousness to minimize the risk of postoperative parenchymal hemorrhage | No revascularization, regardless of the extent of stenosis. These patients can be reevaluated for revascularization later if their neurologic recovery is satisfactory. | Level of recommendation: grade 1 (strong); quality of evidence: C (low) |
| Clinically asymptomatic carotid artery stenosis in individuals without cerebrovascular symptoms or significant risk factors for carotid artery disease | No routine screening | Level of recommendation: grade 1 (strong); quality of evidence: B (moderate) |
| Asymptomatic patients who are at an increased risk of carotid stenosis | Screening for clinically asymptomatic carotid artery stenosis, especially if patients are willing to consider carotid intervention if significant stenosis is discovered | Level of recommendation: grade 2 (weak); quality of evidence: B (moderate) |
| Asymptomatic patients who are undergoing screening for carotid artery stenosis | Duplex ultrasound performed in an accredited vascular laboratory as the imaging modality of choice instead of CTA, MRA, or other imaging modalities | Level of recommendation: grade 1 (strong); quality of evidence: B (moderate) |
| Patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and CABG | CEA before, or concomitant with, CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience. | Level of recommendation: grade 2 (weak); quality of evidence: C (low) |
| Patients with severe (70%-99%) bilateral asymptomatic carotid stenosis or severe asymptomatic stenosis and contralateral occlusion | CEA before, or concomitant with, CABG.
| Level of recommendation: grade 2 (weak); quality of evidence: C (low) |
| Patients requiring carotid intervention, staged or synchronous with coronary intervention | Decision between CEA and CAS is determined by the timing of procedure, the need for anticoagulation or antiplatelet therapy, patient anatomy, and patient characteristics. | Level of recommendation: grade 2 (weak); quality of evidence: B (moderate) |
Table III. Recommendations for Interventional Approaches for Patients with Carotid Artery Stenosis
Complications of Carotid Endarterectomy and Carotid Artery Stenting
Carotid endarterectomies are not without their risks either. Studies have shown that CEA increased the five-year risk of ischemic stroke in patients who had less than 30% stenosis of their carotid artery, had no statistically significant effect in patients with 30-49% stenosis, was beneficial in patients with 50-69% stenosis, was extremely beneficial in patients with 70-99% stenosis, and was not significantly beneficial to patients who had nearly occluded carotid arteries. [63] Both CAS and CEA are associated with high rates of failure and periprocedural stroke.51 When the carotid artery is nearly completely occluded, revascularization has not been shown to reduce the risk of stroke as compared to just medical treatment. [30] It has also been shown that long-term complications are less for CAS than for CEA. [46]
CEAs also come with operative complications to consider. [51,71] Wound bleeding after CEA was even more common than stroke or a myocardial infarction after CEA in patients in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) trial. [11] However, diagnosing patients with silent coronary ischemia and treating them with coronary revascularization after CEA has been shown to reduce the risk of cardiac death, myocardial infarction, and cardiovascular death compared to patients with CEA who only received the standard cardiac evaluation and care during a 3-year follow-up.43 Neck hematoma was also common after CEA, especially when treated with the antiplatelet clopidogrel after surgery. [9,59] Dual antiplatelet therapy was also associated with cranial nerve injury, although transient, following CEA. [19] CEA in patients with symptomatic carotid artery stenosis is also associated with cranial nerve palsy and access site hematoma with endarterectomy. [15] Stenting provides less risk of cranial nerve injury. [91] CEA can be done with either primary closure or patches.50 It was also shown that using synthetic, venous, or bovine pericardium patches did not have a significant decrease in the risk of future stroke or cranial nerve injury.88 CEA is performed to save patients with severely atherosclerotic carotid artery stenosis from stroke. [81] It was also shown that an emergent CEA had decreased rates of intracerebral hemorrhage and mortality than stenting.[79] Moreover, using smaller incisions hidden within the neck crease during CEA has been shown to have better outcomes. [77]
Many randomized controlled trials have been done and are currently underway to compare CEA to CAS when treating carotid artery stenosis. These studies show that CAS is often associated with periprocedural stroke and CEA is often associated with myocardial infarction. [16, 46, 47] It is risky to do CAS in patients who are older than 70 years of age.25 However, some studies have shown that this extra risk is mainly attributable to an increase in minor, non-disabling strokes occurring in patients who are more than 70 years of age. [61] Studies show that discontinuing antiplatelet therapy, resistance to antiplatelet therapy, and thrombotic disorders are the main culprits for post-CAS thrombosis.60 CAS also can lead to prolonged hypotension and bradycardia, especially in patients with increased narrowing of the carotid artery. [31] However, CAS is preferred when CEA is contraindicated. For example, patients who have a “hostile neck” from previous surgery or who do not tolerate anesthesia well may opt for CAS. [20] Regardless of whether the patient underwent a CAS or CEA, no statin use was associated with a higher risk of in-hospital stroke or death and 5-year mortality as compared to those who did use a statin afterwards. [6] Outside of the periprocedural period, carotid stenting was shown to be just as effective as CEA when it came to preventing future strokes. [61] What is even more interesting is that a recent study actually found that high hospital volume and high operator volume decreased the risk of procedural death and stroke after CEA and CAS. [66]
Restenosis
Restenosis is of the utmost importance to consider when looking at CEA versus CAS. In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) trial, restenosis was found to have a fourfold increase in the risk of having a stroke. [45] However, when looking at patients who had CAS or CEA, they both had similar incidences of 70% or greater restenosis. [45] Studies that looked at perioperative and 1-year outcomes between patients who received either CAS or CEA also showed no significant differences. [8] It is not an exact comparison though because CEA is typically done for those who are more critically ill than those who only need CAS. It was also found that those who underwent CAS after an unsuccessful CEA, ipsilateral neck surgery, or radiation had higher rates of restenosis. [58]
Transcarotid Artery Revascularization (TCAR)
TCAR is similar to CEA, but it can be done through a small incision at the neckline instead of a bigger incision at the neck. [49] A tube is then inserted into the carotid artery while diverting blood flow away from the brain so that plaque does not travel up to the brain while the procedure is going on. [96] Essentially, the flow reversal protects against embolism. [21, 33] This flow reversal helps make TCAR neuroprotective and unlike other stenting procedures. [84] The blood is then filtered and a stent is placed in the carotid artery to bolster its integrity and prevent future clot formation. This procedure is beneficial for those who have a higher risk of having a stroke. [92] TCAR is beneficial when stenting the cervical internal carotid artery, especially since this area tends to be stroke-prone. [65] That said, outcomes are best if flow reversal time is minimized as much as possible; studies suggest a clinical cutoff time of 10 minutes. [62] TCAR is not only less invasive, but it also can match the stroke hazard of CEA in standard risk populations. [53]
Moreover, the results of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial shows that the ENROUTE Transcarotid Neuroprotection System is safe and can prevent stroke during CAS, with a stroke rate of 1.4%, which is the lowest reported to date.44 Thirty days post-TCAR, no major stroke, myocardial infarction, or death occurred in a study that was done as well.5 However, more recent studies have shown that TCAR is better in the perioperative period for high-risk patients and that in the long-term, there were no significant differences in stroke or survival between groups of patients who had TCAR and CEA or TCAR and TFCAS.52 On the other hand, a study done in the United States and Europe showed that patients from ROADSTER-2 trial with risk factors such as re-stenosis or radiation injury had no perioperative myocardial infarction or stroke and that in the year following surgery, there was a low stroke and death rate. [41] TCAR is a safe and effective way to approach carotid artery stenosis. [17]
Another study also found no significant association between intolerance to flow reversal and comorbidities including “diabetes mellitus, hypertension, hyperlipidemia, congestive heart failure, prior myocardial infarction or angina, pre-operative CAS-related symptoms, prior stroke, prior CAS or CEA, prior neck radiation, tandem stenosis, high cervical stenosis, or hostile neck.”87 The same study found a significant association only with chronic obstructive pulmonary disease and contralateral carotid artery occlusion. This was corroborated by another study that found that TCAR in patients considered to have too hostile necks for CEA was not associated with increased intraoperative complexity or postoperative morbidity. [86] Studies have shown that TCAR led to a lower rate of stroke and death in the hospital after the procedure. [75] In addition to that, TCAR has been shown to be effective for older adults who are at a higher risk without perioperative cerebral ischemic event, MI, or death (Ghamraoui and Ricotta, 2020). The same finding held when looking at older adults 1 year after their TCAR procedure.57 Lastly, using somatosensory-evoked potential (SSEP) and electroencephalograms (EEG) during TCARs can improve clinical decision-making for thrombosis versus vasospasm after placing stents. [36] TCAR is a premier approach to carotid revascularization, especially for patients who are at a high risk for stroke, cranial nerve injury, or cardiovascular events. [21, 83]
Studies looking at the differences between males and females in outcomes when looking at ipsilateral stroke, in-stent thrombosis, conversion to CEA, and death after TCAR found no statistically significant difference among them.34 However, if a patient has already experienced a TIA or stroke, it was found that CEA resulted in lower rates of stroke post-operatively when compared to TCAR. [27] However, most studies overall have shown that TCAR is a safe and effective method to revascularization, substantially due to its low rates of periprocedural stroke and cranial nerve injury. [73]
Emerging Innovation
There are many novel ways of approaching carotid artery stenosis. A surgical technique that was recently tried was carotid endarterectomy (CEA) with auto-arterial remodeling of bifurcation of the common carotid artery (ARBCCA). The study looked at the difference between a classic CEA and ARBCCA and found that it does not have a significant difference in post-operative development of hypertension but the number of cases of restenosis greater than 50% during the 2-year follow-up was 4% for the ARBCCA group, compared to 12
Symptomatic carotid artery stenosis can be treated in many ways. The current literature vouches primarily for the use of CEA or TCAR for treatment, especially when the vessel has a greater degree of stenosis. TCAR and CEA have similar outcomes in terms of death or stroke 1 year after the respective procedure. [22] TCAR has a similar prognosis to CEA and can be performed without running the risk of myocardial infarction.[29] Here, we reviewed the literature on carotid artery stenosis, CAS, CEA, TCAR, as well as emerging innovation to provide support when making clinical decisions for treatment. For lesser degrees of stenosis, CAS is often performed and CEA is only done if the need arises. Most importantly, it is vital to always tailor treatment to each patient’s condition and their unique needs. Further studies regarding treatment for carotid artery stenosis need to be conducted before we can definitively outline a proper path for treatment.
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Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
