Management strategies in asymptomatic carotid artery stenosis are largely centered on intensive medical management, with carotid revascularization via endarterectomy or carotid artery stenting being reserved for select patients. This decision may be based on stenosis severity, perioperative risk, and patient preference. Current guidelines emphasize shared decision-making for patients with severe (>70%) stenosis, informed by prior trial data that does not demonstrate superiority of revascularization over independent medical therapy. Other studies more specifically recommend carotid endarterectomy over carotid artery stenting for asymptomatic patients with >60% stenosis. However, these studies are limited by poor statistical power. Recent findings in the CREST-2 trial have challenged this discussion of medical management as an independent primary course of action. The carotid artery stenting arm demonstrated significant long-term reduction in ipsilateral ischemic stroke compared to medical therapy alone. In this perspective, we argue that this new evidence supports a renewed role for carotid artery stenting in carefully selected patients with severe asymptomatic carotid artery stenting.

BACKGROUND AND OBJECTIVES: Cerebral aneurysms are the major cause of spontaneous subarachnoid hemorrhage, and a common treatment is endovascular embolization. Aneurysmal recurrence after embolization is frequent, and clinical follow-up to monitor for this is critical to prevent subarachnoid hemorrhage. Herein, we assess demographic and socioeconomic factors associated with poor clinical follow-up to determine which patients are at high risk of loss to follow-up. METHODS: A retrospective analysis was performed of 937 patients who underwent endovascular treatment of cerebral aneurysms at a single center from 2006 to 2017. Attendance at follow-up visits for 5 years after treatment was correlated with various demographic and socioeconomic factors. Follow-up for patients who initially presented with unruptured vs ruptured aneurysms was also compared. RESULTS: The most significant factors associated with poor follow-up were lack of insurance and non–English-speaking status. Noninsured patients had significantly less follow-up in both mean number of follow-up visits (2.5 ± 1.7 visits for insured patients and 1.0 ± 1.2 visits for noninsured, P < .0001), and in time until lost to follow-up (2.9 ± 1.9 years for insured and 1.1 ± 1.4 years for non-insured, P < .0001). Non–English-speaking patients had less follow-up visits (2.3 ± 1.7 visits for English-speaking and 0.74 ± 1.0 visits for non–English-speaking, P < .0001) and were more quickly lost to follow-up (2.6 ± 1.9 years for English-speaking and 0.82 ± 1.2 years for non–English-speaking, P < .0001). CONCLUSION: Demographics and socioeconomic factors, particularly lack of insurance and non–English-speaking status, are correlated with poor clinical follow-up after endovascular treatment of cerebral aneurysms. Patients at high risk of loss to follow-up should be counseled before treatment about risk of aneurysm recurrence.

Objective: The AXS Vecta 46 intermediate catheter (Stryker) features a large inner diameter, enabling effective aspiration, combined with a small outer diameter and soft distal-tip flexibility, which allows for safe tracking through more tortuous and smaller arterial segments to target medium vessel occlusions non-traumatically. The efficacy of the Vecta 46 in the spectrum of large and medium vessel occlusions has not been well elucidated in the literature. Methods: This retrospective cohort study included patients who underwent MT for acute ischemic stroke at our institution between July 2022 and June 2024. The outcomes of patients treated with Vecta 46 were compared to those of all other catheters used at the institution. Results: The distribution of aspiration and stent retriever attempts in Vecta 46 procedures versus non-Vecta 46 procedures was significantly different (p = 0.00325). Aspiration was attempted 1.66 ± 0.936 times in the Vecta 46 group and 1.12 ± 0.650 times in the non-Vecta 46 group (p = 0.00135). More mechanical thrombectomies with the Vecta 46 included aspiration of a secondary thrombus (p = 0.0314), despite no difference in the distribution of the primary or secondary occlusion location. There were no statistically significant differences in recanalization success (p = 0.800), recanalization time (p = 0.245), procedure duration (p = 0.580), discharge modified Rankin Score (p = 0.875), or intracranial hemorrhage rate (p = 0.720) between non-Vecta 46 and Vecta 46 procedures. Conclusions: Vecta 46 has similar safety and functional outcomes compared to other endovascular treatment options despite procedural differences.