Risk of MRI-detected cerebral infarction and vascular events after carotid endarterectomy and carotid stenting one decade apart Tomáš Hrbáč 1,2 , Martin Roubec 3,4 , Václav Procházka 5 , Tomáš Jonszta 5 , David Pakizer 4 , Tomáš Heryán 4 , Roman Herzig 6 and David Školoudík 3,4, * 1 Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic 2 Department of Neuroscience, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic 3 Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic 4 Centre for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic 5 Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic 6 Department of Neurology, Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic *Correspondence to: David Školoudík, Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, CZ-703 00 Ostrava, Czech Republic (e-mail: skoloudik@hotmail.com) Received: March 26, 2023. Accepted: April 11, 2023 © The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Dear Editor According to current recommendations, interventional treatment such as surgical carotid endarterectomy (CEA) or intraluminal carotid angioplasty with stenting (CAS) is indicated for selected patients with internal carotid artery (ICA) stenosis of 50 per cent or more 1,2 . It is anticipated that advances in both procedures can improve the prognosis of patients. In the present study, improvements over a decade were assessed by retrospective analysis of carotid interventions from a single hospital registry. Data from the first consecutive 50 symptomatic and 50 asymptomatic patients with ICA stenosis treated by CEA, and the first 50 symptomatic and 50 asymptomatic patients treated by CAS, over two periods (January 2008 to December 2012, P1; January 2018 to December 2022, P2) who met the following criteria were included in statistical analysis: ICA stenosis at least 70 per cent indicated for intervention; brain MRI available; and signed informed consent provided. During both observation periods, CEA was performed under general anaesthesia by an experienced neurosurgeon. During P2, a transverse skin incision was made instead of a longitudinal incision; individually predefined rather than universally defined systemic BP target values were determined by measurement of mean blood flow velocity in the ipsilateral middle cerebral artery using transcranial Doppler imaging; the anticoagulation strategy was changed from 10 000 to 7000 units heparin before operation for patients weighing 80 kg or more, and 5000 units for remaining patients; and protamine sulphate was not used. The CAS procedure was undertaken during both observation periods through the femoral approach by an experienced interventional radiologist. In P2, all patients were tested for antiplatelet resistance; the dose of unfractionated heparin was reduced from 10 000 to 5000 units for patients weighing less than 80 kg, and 7500 units in remaining patients; BP was controlled more accurately by continuous infusion of saline solution; and more advanced instrumentation, including a new double-layered stent (Roadsaver™ Carotid Artery Double-Layer Stent; Terumo, Tokyo, Japan), was used. MRI was carried out before operation and 24 ± 4 h after surgery using a 1.5-T Avanto system (Siemens, Erlangen, Germany). The MRI protocol was the same as described previously 3 . Physical and neurological examinations were performed by a board-certified neurologist 24 h and 30 days after the intervention. The study sample size calculations suggested that a minimum of 48 patients in each group would be required to achieve a significant difference with an α of 0.05 (two-tailed) and β of 0.8. Mann–Whitney U test and χ 2 test were used for statistical evaluations. Medical records for 400 patients (274 men, mean(s.d.) age 66.9(7.3) years) with carotid stenosis of at least 70 per cent (mean 80.7(9.1) per cent) receiving CEA (132 men, mean age 65.7(7.4) years) or CAS (142 men, mean age 68.0(7.0) years) during the two intervals were included in the statistical analysis. Demographic data and study results are summarized in Table 1. New ischaemic lesions on control postprocedure brain diffusion-weighted MRI were detected significantly less frequently in patients in the CEA group than the CAS group during both P1 (23 versus 49 per cent; P < 0.001) and P2 (15 versus 29 per cent; P = 0.017), in the CAS group during P2 compared with P1 (P = 0.004), and in the entire cohort during P2 compared with P1 (P = 0.002). Mean ischaemic lesion volume was larger in the CEA group than the CAS group, but the difference did not reach statistical significance (P > 0.050). The present results are consistent with a recently published systematic review and meta-analyses 4,5 concluding that new ischaemic lesions on brain MRI are more common after CAS than CEA, with an incidence ranging from 18 to 58 per cent. Patient safety continues to improve owing to advances in interventional techniques and perioperative care. BJS, 2023, 110, 987–988 https://doi.org/10.1093/bjs/znad116 Advance Access Publication Date: 29 April 2023 Research Letter