Introducing the JVS Special Issue “Critical Issues and Controversies in Carotid Artery Stenosis”

"Innovation distinguishes between a leader and a follower"Steve Jobs (1955-2011) Progress in medicine is possible only through inventions and innovations. This is particularly true for the specialty of Vascular Surgery, which has witnessed the endovascular revolution in the 1990s and has transformed completely over the past three decades.1Gloviczki P. Lawrence P.F. The road to medical innovations.J Vasc Surg. 2020; 71: 1Google Scholar The Journal of Vascular Surgery has been one of the most influential and leading Journals in the field, constantly advancing and transforming to follow the continuous progress in the specialty of Vascular Surgery.2Gloviczki P. Lawrence P.F. Evolution and transformation of JVS journals.J Vasc Surg. 2021; 74: 1775-1782Google Scholar,3Forbes T.L. Dalman R.L. Building the team.J Vasc Surg. 2023; 77: 317-318Google Scholar Several important initiatives and innovations have been introduced over the last few years, paving the way for the Journal of Vascular Surgery publications to flourish, namely The Journal of Vascular Surgery; The Journal of Vascular Surgery: Cases, Innovations, and Techniques; The Journal of Vascular Surgery: Venous and Lymphatic Disorders; The Journal of Vascular Surgery - Vascular Science; and the newest Member of the Family of the Journal of Vascular Surgery publications launched in January 2023, The Journal of Vascular Surgery - Vascular Insights.4Gloviczki P. Lawrence P.F. The increasing number and impact of Journal of Vascular Surgery publications.J Vasc Surg. 2019; 70: 1731-1736Google Scholar, 5Gloviczki P. Lawrence R.F. Publish and flourish.J Vasc Surg. 2020; 72: 775-776Google Scholar, 6Dalman R.L. Forbes T.L. Bush R.L. Smeds M.R. Dardik A. Traditions and transitions.J Vasc Surg. 2022; 76: 1-2Google Scholar In this constantly evolving environment, a new feature introduced in 2023 is Virtual Special Issues. The first Special Issue on "Aneurysms" was introduced in mid-2023 in The Journal of Vascular Surgery - Vascular Science7Vorp D.A. Introduction to the JVS-VS special issue, "Aneurysms".JVS Vasc Sci. 2023; 4100110Google Scholar (available at: https://jvsvs.org/aneurysms). The first Special Issue to be published in The Journal of Vascular Surgery is on "Critical Issues and Controversies in Carotid Artery Stenosis." This Special Issue discusses several unresolved topics in the management of patients with both symptomatic and asymptomatic carotid artery stenosis. An international, multi-disciplinary team of eminent experts including Vascular Surgeons, Vascular Medicine Specialists, Stroke Physicians, Neurologists, and Interventional Radiologists/Cardiologists from the United States of America and Europe (Germany, the United Kingdom, France, Italy, The Netherlands, Slovenia, Russia, Ireland, Austria, Poland, Portugal, and Greece) addressed these issues and attempted to resolve the conflicting views in the various topics. An international, multispecialty expert-based (n = 61) Delphi Consensus document addresses several controversial issues in the management of patients with symptomatic and asymptomatic carotid stenosis.8Paraskevas K.I. Mikhailidis D.P. Ringleb P.A. et al.An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis.J Vasc Surg. 2024; 79: 420-435Google Scholar Some of the topics discussed include: (1) whether shunting should be used routinely, selectively, or never; (2) whether the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with symptomatic and from 3% to 2% for patients with asymptomatic carotid stenosis; (3) whether the threshold for a patient being considered 'recently symptomatic' should be reduced from the current definition of '6 months;' and (4) whether 80% to 99% asymptomatic carotid stenosis carries a higher risk of stroke compared with 60% to 79% carotid stenosis, and others.8Paraskevas K.I. Mikhailidis D.P. Ringleb P.A. et al.An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis.J Vasc Surg. 2024; 79: 420-435Google Scholar A second article of this Virtual Special Issue addresses a number of recent advances in the management of patients with asymptomatic carotid stenosis.9Paraskevas K.I. Brown M.M. Lal B.K. et al.Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis.J Vasc Surg. 2024; 79: 695-703Google Scholar Some examples include: (1) the role of technological advances in surgical/endovascular skills/techniques and outcomes; (2) the various risk factors, the clinical/imaging characteristics, and the risk prediction models for the identification of asymptomatic patient subgroups at high risk for future stroke; (3) the improvements in the constituents of best medical treatment for carotid patients and the declining stroke risk; and (4) the association between cognitive dysfunction and asymptomatic carotid stenosis, and others.9Paraskevas K.I. Brown M.M. Lal B.K. et al.Recent advances and controversial issues in the optimal management of asymptomatic carotid stenosis.J Vasc Surg. 2024; 79: 695-703Google Scholar Dr Ali AbuRahma discusses the implications of the 2022 Society for Vascular Surgery clinical practice guidelines for the treatment of patients with asymptomatic carotid stenosis.10AbuRahma A. An analysis of the recommendations of the 2022 Society for Vascular Surgery clinical practice guidelines for patients with asymptomatic carotid stenosis.J Vasc Surg. 2024; 79: 1235-1239Google Scholar Dr AbuRahma puts into perspective the recommendations for the invasive treatment of asymptomatic carotid patients and explains the rationale supporting selection of carotid endarterectomy, transcarotid artery revascularization, or transfemoral carotid stenting in different patient subgroups.10AbuRahma A. An analysis of the recommendations of the 2022 Society for Vascular Surgery clinical practice guidelines for patients with asymptomatic carotid stenosis.J Vasc Surg. 2024; 79: 1235-1239Google Scholar Saba et al discuss cryptogenic strokes, which is a subtype of ischemic stroke that poses a considerable challenge for both neurologists/stroke physicians and vascular surgeons.11Saba L. Cau R. Spinato G. et al.Carotid stenosis and cryptogenic stroke.J Vasc Surg. 2024; 79: 1119-1131Google Scholar Plaque vulnerability is an emerging risk factor for carotid artery plaques that do not cause a significant (ie, >50%) luminal stenosis to comprise an underlying cause of ischemic stroke.11Saba L. Cau R. Spinato G. et al.Carotid stenosis and cryptogenic stroke.J Vasc Surg. 2024; 79: 1119-1131Google Scholar Schaller et al12Schaller M.S. Rinaldo L. Benzon J.C. et al.Non-stenotic symptomatic internal carotid artery plaques: epidemiology, pathophysiology and treatment.JVS Vasc Insights. 2024; Google Scholar extend the article of Saba et al11Saba L. Cau R. Spinato G. et al.Carotid stenosis and cryptogenic stroke.J Vasc Surg. 2024; 79: 1119-1131Google Scholar and provide a comprehensive and complementary analysis on the topic by discussing the epidemiology, pathophysiology, and treatment of patients with cerebrovascular ischemic neurologic symptoms secondary to non-stenotic carotid plaques.12Schaller M.S. Rinaldo L. Benzon J.C. et al.Non-stenotic symptomatic internal carotid artery plaques: epidemiology, pathophysiology and treatment.JVS Vasc Insights. 2024; Google Scholar Pini et al performed a systematic review and meta-analysis of studies (n = 6 prospective; n = 22 retrospective) focusing on the treatment of carotid artery dissection.13Pini R. Faggioli G. Lodato M. et al.Medical and interventional outcome of dissection of the cervical arteries. Systematic review and meta-analysis.J Vasc Surg. 2024; Google Scholar The effect of antiplatelet and oral anticoagulant therapy for carotid artery dissection is discussed, as well as an evaluation of the role of stenting in these patients.13Pini R. Faggioli G. Lodato M. et al.Medical and interventional outcome of dissection of the cervical arteries. Systematic review and meta-analysis.J Vasc Surg. 2024; Google Scholar Stilo et al review the role and effectiveness of different methods of intraoperative neuro-monitoring during carotid endarterectomy.14Among others, the benefits and the drawbacks of regional anesthesia are analyzed, as well as the role of near-infrared spectroscopy and shunting.14Stilo F. Montelione N. Paolini J. et al.Current status of brain monitorind during carotid endarterectomy.JVS Vasc Insights. 2024; 2100060Google Scholar Finally, Myrcha et al review the effect of the anatomy of the circle of Willis and the cerebral circulation on outcomes in patients undergoing carotid cross-clamping during carotid endarterectomy.15Myrcha P. Pinheiro F. Rocha-Neves J. Myrcha J. Gloviczki P. The effect of the collateral cerebrovascular circulation on tolerance to carotid artery cross-clamping and on early outcome after carotid endarterectomy.J Vasc Surg. 2024; Google Scholar Furthermore, they analyze the effect of variations in the circle of Willis and contralateral carotid stenosis >70% or occlusion on the results of the positive awake test.15Myrcha P. Pinheiro F. Rocha-Neves J. Myrcha J. Gloviczki P. The effect of the collateral cerebrovascular circulation on tolerance to carotid artery cross-clamping and on early outcome after carotid endarterectomy.J Vasc Surg. 2024; Google Scholar Hopefully, the readers of The Journal of Vascular Surgery will find the articles of this Special Issue educational and useful. None.