The Role of New Generation Inflammatory Markers in Patients Undergoing Carotid Endarterectomy

The Role of New Generation Inflammatory Markers in Patients Undergoing Carotid Endarterectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of New Generation Inflammatory Markers in Patients Undergoing Carotid Endarterectomy Fehim Can Sevil, Halil Siner, Cem Korucu, Uğur Aksu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8506252/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract Objective This study aimed to evaluate the prognostic value of novel systemic inflammatory markers, particularly the Systemic Immune-Inflammation Index (SII), in predicting morbidity and mortality in patients undergoing carotid endarterectomy. Methods A retrospective analysis was conducted on 200 patients who underwent carotid endarterectomy. Patients were categorized into two groups based on their 1-year postoperative survival status (group-1:alive, group-2: dead). Inflammatory parameters including SII, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)were calculated. Demographic, clinical, echocardiographic, and angiographic data were analyzed. The association between inflammatory markers and outcomes was assessed using univariate and multivariate analyses. Results SII, NLR and PLR were significantly higher in the group-2 (p < 0.001). Patients with internal carotid artery tortuosity exhibited longer operation times (p = 0.002), and those with elevated SII levels had a higher risk of adverse outcomes. No significant difference was observed in echocardiographic parameters between the two groups. The presence of comorbidities such as hyperlipidemia and coronary artery disease was also more prevalent in the group-2. Conclusion Systemic inflammatory markers, particularly SII, may serve as useful predictors of postoperative mortality and procedural complexity in patients undergoing carotid endarterectomy. Incorporating these markers into preoperative risk assessment may improve clinical decision-making and patient outcomes. Carotid endarterectomy Systemic Immune-Inflammation Index (SII) Inflammatory biomarkers Mortality Carotid artery disease Figures Figure 1 Figure 2 Figure 3 Introduction Ischemic stroke is caused by atherosclerotic plaques in the carotid artery and is a major cause of morbidity and mortality in western societies. The North American Symptomatic Carotid Endarterectomy Trial stenosis classification (NASCET) is used to measure and classify the degree of carotid artery stenosis. This classification is used to guide treatment decisions in symptomatic and asymptomatic patients. The NASCET classification is considered the gold standard, especially in determining the indications for surgical treatment. Patients with carotid stenosis are considered to be at very high cardiovascular risk, and the prognosis is largely determined by the occurrence of adverse coronary events[ 1 ]. Inflammation is the main cause of carotid plaque susceptibility. The pathophysiology of atherosclerosis is considered to be a chronic, lipid-mediated inflammatory process initiated by endothelial dysfunction, followed by a series of cellular and molecular events that include activation of inflammatory pathways. The systemic immune-inflammation index (SII) is a simple and comprehensive biomarker based on the ratio of lymphocyte, neutrophil, and platelet counts, which has been widely investigated since its definition. Recent studies have shown that SII is a good marker for the assessment of the risk and prognosis of some solid cancers (e.g., gastroesophageal adenocarcinoma, hepatocellular carcinoma, and epithelial ovarian cancer), coronary artery disease, and is also a useful indicator for the follow-up of human immune and inflammatory status [ 2 , 3 ]. However, the number of studies showing the relationship between inflammatory status and carotid endarterectomy is limited. In this study, we investigated the predictive value of SII in morbidity and mortality in patients underwent carotid endarterectomy(CEA). Material and method Patients with carotid stenosis who underwent surgery in our clinic were included in the study. The study was designed and conducted retrospectively in accordance with the Declaration of Helsinki and the ethics committee approved the study. Between January 2018 and December 2023, a total of 250 consecutive patients who underwent CEA at our institution were retrospectively screened for eligibility. Patients with autoimmune diseases (n=10), active infection at the time of surgery (n=15), or a history of oncological disease (n=25) were excluded. The final study population consisted of 200 patients.(Figure1)All patients were divided into 2 groups according to whether they were alive or dead at the 1-year follow-up; group 1 was the living group and group 2 was the deceased group. Then, the demographic and clinical characteristics of the patients were examined. Those with autoimmune disease, active infection and oncological disease were excluded from the study. 2.1 Blood sampling Blood samples were taken from the patients for complete blood count analysis. Peripheral blood samples for CBC analysis were obtained from all patients within 24 hours before the surgical procedure.The patients' hemoglobin and hematocrit levels, platelet and white blood cell (WBC) counts and all routine biochemical tests were analyzed on an automatic biochemical analyzer (Biyo CE Cobas 8000, Roche Diagnostics, Basel, Switzerland). Total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C levels based on the Friedewald formula) were calculated. SII was calculated using the formula SII = (neutrophil count × platelet count)/lymphocyte count NLR, NLR = (neutrophil count/lymphocyte count) PLR = (platelet count/lymphocyte count). 2.2 Coronary angiography: Coronary angiography was performed on all patients using the Judkins method via the femoral route. Post-angiographic images were evaluated by 2 experienced cardiologists. Patients with lesions of 1.5 mm and above and 50% were included in the study. 2.3 Carotid artery evaluation: The severity of carotid artery disease and lesion characteristics were evaluated using the NASCET (North American Symptomatic Carotid Endarterectomy Trial) classification. 2.4 Primary &Secondary Endpoint Primary Endpoint: All-cause 1-year mortality. Secondary Endpoints: Perioperative stroke, myocardial infarction, Major Adverse Cardiovascular Events (MACE), operation time, in-hospital complications. 2.5 Statistical analysis Data were evaluated with SPSS (IBM) package program version 26 (SPSS Inc). Normally distributed variables were expressed with mean and standard deviation, and non-normally distributed variables were expressed with median and interquartile range. Categorical variables were expressed as percentages. T test was used for comparing normally distributed parameters, Man Whitney U test was used for comparing non-normally distributed parameters, and Chi-square test was used for comparing categorical variables. Parameters that were significant in univariate analysis were included in logistic regression analysis and mortality predictors were investigated P value < 0.05 was considered significant. Results A total of 200 patients were included in the study. The mean age of the patients was 69.57±4.51. While the mean age in the group-1 was 64.35±3.58, the mean age in the group-2 was higher at 69.64±4.01 and was statistically significant (p:0.05). 44.5% of the patients were male. 32% of the patients had HT, 40% had DM, and 27% had HL. CAD was present in 53.8% of the group-1, while this rate was 74.5% in the group-2 (p:0.064). There was statistical significance (p:0.05) between the two groups in HL patients, with 34.3% group-1 and 46.3% group-2. Baseline characteristics of the study population was shown in table-1. The mean operation time was 29.38±5.72 minutes, and no significant difference was found between the two groups (group-1: 23.38±5.7 min, group-2: 31.42±5.8 min). In univariate analysis; the inflammatory parameters NLR 4.21±1.84 (p:0.001), PLR 198.8±79.1 (p:0.001), SII 1481.03±578.32 (p:0.001), were found to be statistically significant in the group-2.(figure-2) In echocardiographic parameters, ejection fraction (EF) was 57.8% ± 4.6 in the group-1 vs. 58.4% ± 2.38 in the group-2, with no statistically significant difference found (p=0.698). Other echocardiographic assessments, no statistically significant differences were observed between the groups for LVDD (p=0.184), LVSD (p=0.875), or PASP (p=0.615). In subgroup analysis; Internal carotid arteries (ICA) tortuosity was present in 19,5% of all patients. While tortuosity was observed in 11.6% in the group-1, this rate was higher in the group-2 with 45.8% but it was not found to be statistically significant (p:0.059). The operation time of patients with ICA tortuosity (32.28±6.63) was found to be longer than those without tortuosity (28.68±5.56). This difference was statistically significant (p: 0.002). Moreover; A good correlation was observed between operation time and SII . The association between the systemic immune-inflammation index (SII) and mortality was assessed using univariate and multivariate logistic regression analyses. As shown in Table 2, univariate analysis identified age (OR: 1.05; 95% CI: 1.020–1.090; p = 0.05) and SII (OR: 1.010; 95% CI: 1.001-1.080; p = 0.001) as statistically significant factors. In multivariate analysis, only SII remained significant (OR: 1.008; 95% CI: 1.001-1.015; p = 0.026), whereas age and diabetes mellitus were not independently associated with mortalityNevertheless, comorbidities such as hypertension, diabetes mellitus, and chronic kidney disease are well-established independent risk factors for mortality in cardiovascular patients. Consequently, the observed association between SII and mortality may, at least in part, reflect the underlying risk contributed by these comorbidities rather than a truly independent predictive value of SII. To determine the optimal cut-off value of the systemic immune-inflammation index (SII) for predicting 1-year mortality, a receiver operating characteristic (ROC) curve analysis was performed. The area under the curve (AUC) was 0.812 (95% CI: 0.728–0.897, p < 0.001), and the best threshold for SII was identified as 1450, providing 77.8% sensitivity and 71.6% specificity for mortality prediction.(figüre -3) A post-hoc power analysis was conducted using G*Power version 3.1.9.7. Assuming an effect size (odds ratio) of 1.4 for SII based on the study by Niculescu et al., 2022 (Int J Environ Res Public Health) , a two-tailed α = 0.05, and a sample size of 200 patients (with 19 events), the achieved statistical power was 0.84 (84%), confirming that the sample size was sufficient to detect a significant effect at a power level exceeding the conventional 80% threshold. In regression analysis; SII was found to be an independent predictor of mortality in patient underwent endarterectomy(Table-2). Discussion In this study, we examined the effect of inflammatory parameters on the development of adverse events in patients underwent endarterectomy and showed that SII is closely related to mortality. Ischemic strokes mostly originate from the internal carotid artery and the middle cerebral artery. The general prevalence of carotid artery stenosis is 1.1%, the prevalence is 1.9% in men and 0.5% in women [ 4 , 5 ]. However, since routine carotid artery screening is not performed all over the world, it is thought that this rate is higher. Tortiosity of the carotid artery, histopathological structure of carotid plaques in the carotid artery, presence of ruptured plaques, and carotid stenosis rate are important risk factor for adverse events in patient with ischemic stroke. It is known that carotid atherosclerosis is clearly dominant in men. There are studies suggesting that this widely accepted model of reduced cardiovascular risk in women is due to the protective role of estrogens in endothelial function and lipid homeostasis [ 6 – 9 ]. In our study, no statistical significance was found between both genders. Since both coronary and carotid lesions develop on an atherosclerotic basis and cause stenosis after similar pathophysiology, the character of the lesions and their effects in the progression process are expected to be similar. Recent studies have shown that inflammatory factors can be used as predictors of lesion progression and adverse events in coronary atherosclerosis[ 10 , 11 ]. After these studies, the role of inflammation in coronary atherosclerosis has been better understood, but there are few studies on inflammation in carotid lesions. It has been suggested that inflammatory biomarkers can be used to predict adverse events in carotid diseases due to their similar pathophysiological structures [ 12 – 15 ]. Our findings are consistent with the growing body of evidence supporting the role of inflammation in carotid disease. King et al. [ 12 ] reported that NLR was associated with worse outcomes after CEA. Our study builds upon this evidence by specifically demonstrating the independent predictive value of SII, a more comprehensive index, for long-term mortality. The superiority of SII over NLR or PLR might be due to its incorporation of platelet count, which reflects both inflammatory and thrombotic pathways, both pivotal in atherosclerosis.In our study, NLR, PLR, SII, were found to be significant in the group-2 (p < 0.001). In multivariate analysis adjusting for diabetes mellitus, the systemic immune-inflammation index (SII) remained an independent predictor of mortality (OR: 1.008, 95% CI: 1.001–1.015, p = 0.026), while age lost statistical significance. This suggests that the inflammatory burden captured by SII may mediate some of the age-related mortality risk in patients undergoing carotid endarterectomy.The results of our study suggested that systemic inflammatory biomarkers can be used as a predictive marker for mortality in carotid artery disease. Similarly, the incidence of stroke was higher in patients with high inflammatory biomarkers at 1-year postoperative follow-up. In our study, we found that patients with high SII had longer operation times, suggesting that systemic inflammatory parameters may be predictive of many events that develop not only in acute but also in chronic background and affect the difficulty of the operation. Mild carotid artery tortuosity does not cause clinical symptoms and has a mild effect on cerebral blood flow under normal conditions, but severe tortuous arteries affect hemodynamics and blood pressure decreases after passing through these vessels, thus affecting cerebral perfusion [ 16 , 17 ]. Then, turbulent flow occurs as the blood passes through the tortuous carotid artery, which can lead to thrombosis and then cerebral infarction [ 18 ]. Non-invasive carotid anatomy examined preoperatively provides the operator with a predictive value for the treatment method. In tortuous vessels, the difficulty of the procedure increases, the operation time is prolonged, and the complications and even surgical failure rate increase significantly [ 19 , 20 ]. Patients planned for emergency mechanical thrombectomy require a longer surgical time and have a worse prognosis than those with carotid artery tortuosity [ 20 , 21 ]. In our study, the operation time in cases with tortuous vessels was found to be statistically significant, and we think that the factors mentioned above played a role in this significance. Limitations Our study has several limitations that should be considered when interpreting the results. First, the retrospective and single-center design may introduce selection bias and limit the generalizability of our findings. Second, the relatively small sample size, particularly the low number of events (only 19 deaths in Group 2), may reduce the statistical power of the analysis and increase the risk of overfitting in multivariate models. Finally, the measurement of inflammatory markers from blood samples taken at a single time point may not account for dynamic changes in these parameters over time, which could influence their predictive value. Conclusion In patients undergoing carotid endarterectomy, inflammatory parameters may provide useful insights for predicting adverse clinical outcomes. Specifically, patients with elevated SII values could benefit from closer monitoring, which may guide clinical decision-making and contribute to improved patient management. Abbreviations SII: Systemic Immune-Inflammation Index , NLR: Neutrophil-to-lymphocyte ratio, PLR: Platelet-to-lymphocyte ratio , NASCET: North American Symptomatic Carotid Endarterectomy Trial stenosis classification, MACE: Major Adverse Cardiovascular Events , CEA: carotid endarterectomy, ICA: Internal carotid arteries TC: Total cholesterol, TG: triglyceride, HDL-C: High-density lipoprotein cholesterol , LDL-C: low-density lipoprotein cholesterol, HT: Hypertension DM: Diabetes Mellitus HL: Hyperlipidemia EF: Ejection fraction LVDD: Left ventricular diastolic diameter LVSD: Left ventricular systolic diameter ROC: Receiver operating characteristic AUC: Area under the curve Declarations Ethics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee. Due to the retrospective design of the study, the requirement for written informed consent was waived by the ethics committee.(Afyonkarahisar Health Sciences University non-interventionist Scientific Researc Ethics Committee 07/03/2025 2025/4) Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are not publicly available due to ethical restrictions and patient confidentiality but are available from the corresponding author upon reasonable request. Conflicts of Interest: The authors declare no conflicts of interest Funding: This study received no financial support. Acknowledgements: The authors thank the healthcare professionals who contributed to patient management and data acquisition. Author Contribution Dr. FCS: Contributed to the study concept and design, collected patient data, performed statistical analyses, and drafted the initial version of the manuscript.Dr. HS: Conducted the literature review, contributed to the development of the methodology section, and participated in the interpretation of findings.Dr. CK: Responsible for data validation, verification of statistical results, and revisions of the discussion section.Dr. UA Author: Supervised the overall study process, contributed to the clinical interpretation of results, and finalized the manuscript for submission. References Go, C., et al., Long-term clinical outcomes and cardiovascular events after carotid endarterectomy. Ann Vasc Surg, 2015. 29 (6): p. 1265-71. Wang, B.L., et al., Dynamic change of the systemic immune inflammation index predicts the prognosis of patients with hepatocellular carcinoma after curative resection. Clin Chem Lab Med, 2016. 54 (12): p. 1963-1969. 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Giacomelli, E., et al., Sex-Related Outcomes in Asymptomatic Carotid Artery Stenosis Undergoing Carotid Endarterectomy. J Surg Res, 2025. 305 : p. 204-213. Li, Y., et al., The Systemic Immune Inflammatory Response Index Can Predict the Clinical Prognosis of Patients with Initially Diagnosed Coronary Artery Disease. J Inflamm Res, 2023. 16 : p. 5069-5082. Zhao, Z., et al., Prognostic value of systemic immune-inflammation index in CAD patients: Systematic review and meta-analyses. Eur J Clin Invest, 2024. 54 (2): p. e14100. King, A.H., et al., Elevated Neutrophil to Lymphocyte Ratio is Associated with Worse Outcomes after Carotid Endarterectomy in Asymptomatic Patients. J Stroke Cerebrovasc Dis, 2021. 30 (12): p. 106120. Niculescu, R., et al., Carotid Plaque Features and Inflammatory Biomarkers as Predictors of Restenosis and Mortality Following Carotid Endarterectomy. Int J Environ Res Public Health, 2022. 19 (21). 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Baseline clinical variables of the patients Group-1 (Alive) Group-2(Exitus) P Value Age,years 64,53±3,58 69,64±4,01 0,05 Male % 43,6 52,6 0,455 HT % 21,1 33,1 0,087 DM % 38,7 52,6 0,045 HL % 34,3 46,3 0,05 COPD % 9,4 15,8 0,378 Smoking history % 12,7 21,1 0,312 ACE-I use % 81.5 75,7 0,322 ARB use% 8.7 5.6 0,367 B-Bloker use% 89.3 87.7 0,728 Statin use % 27,8 5,3 <0,001 KREATIN (mg/dL) 0,79±0,22 0,99±0,18 0,072 LDL cholesterol(mg/dL) 119,3±38,1 127,8±45,3 0,053 TG (mg/dL) 153,7±75,2 170,1±86,8 0,124 ALT (U/L) 28,01±31,9 34,05±40,9 0,222 AST (U/L) 23,74±13,5 26,0±22,5 0,275 CRP (mg/dL) 10,46±4,6 12,1±7,8 0,073 HB (g/dL) 1,42±2,19 14,1±2,9 0,084 Neutrophil(10^3/uL) 6,08±2,34 6,47±2,98 0,284 Lymphocyte (10^3/uL) 2,01±1,02 1,62±1,18 <0,001 Platelet (10^3/uL) 235,6±79,02 222,5±89,1 0,182 Ejection fraction % 57,8±4,6 58,4±2,38 0,698 LVDD (mm) 44,75±3,4 43,79±2,9 0,184 LVSD (mm) 29,6±4,2 29,6±3,5 0,875 PABS (mmhg) 21,2±4,8 23,4±5,2 0,615 Coronary artery lesion% 53,8 74,5 0,064 Ica tortuosity % 11,6 45,8 0,059 Operation time 23,38±5,7 31,42±5,8 0,069 Lesion diameter >15mm% 11,6 15,9 0,248 NLR 2,13±1,07 4,21±1,84 <0,001 PLR 125,8±56,6 198,8±79,1 <0,001 SII 582,34±344,82 1481,03±578,32 <0,001 POST-OP STROKE 1,7 84,2 <0,001 POST-OP MI % 2,4 21,1 <0,001 HT: hypertension, DM: diabetes mellitus, HL: hyperlipidemia, COPD: chronic obstructive pulmonary disease, LDL: low-density lipoprotein TG: triglyceride, CRP: C-reactive protein, HB: hemoglobin, NT PRO-BNP: N-terminal pro B type non-uretic peptide, LVDD: left ventricular diastolic diamater, LVSD: left ventricular systolic diamater PABS: mean pulmonary artery pressure, SII: systemic inflammatory index, NLR:neutrophil lymphocyte ratio, PLR: platelet lymphocyte ratio Table-2: Mortality predictor of the study population Variables Univariate OR,95 CI% P Value Multivariate OR,95 CI% P Value Age 1,05(1,020-1,090) 0,05 1,030(1,000-1,065) 0,364 SII 1,010(1,001-1,080) 0,001 1,008(1,001-1,015) 0,026 DM 1,762(0,682-4,551) 0,067 1,966(0,734-5,265) 0,179 Additional Declarations No competing interests reported. Supplementary Files correlationgrafhoftheoptimeands.jpg Graphical abstract image : Correlation graph of the operation time and SII level Cite Share Download PDF Status: Published Journal Publication published 16 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 09 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 18 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers invited by journal 15 Jan, 2026 Editor assigned by journal 15 Jan, 2026 Editor invited by journal 14 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 13 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":227636,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection for the study.\u003c/p\u003e","description":"","filename":"figure1flowcart.png","url":"https://assets-eu.researchsquare.com/files/rs-8506252/v1/c3ff1cde73a454f7d14c751f.png"},{"id":100748106,"identity":"97b574af-3404-453b-a986-45fc76a4a24a","added_by":"auto","created_at":"2026-01-21 04:00:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22029,"visible":true,"origin":"","legend":"\u003cp\u003eBox graph of SII levels of the study population\u003c/p\u003e","description":"","filename":"figure2BoxgraphofSIIlevelsofthestudypopulation.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8506252/v1/a6a165e56a64a2ec39139495.jpg"},{"id":100748187,"identity":"93aecb0e-eb84-4a32-abb3-9b3cf86f9c09","added_by":"auto","created_at":"2026-01-21 04:01:06","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":405453,"visible":true,"origin":"","legend":"\u003cp\u003eROC Curve Analysis for Systemic Immune-Inflammation Index (SII)\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8506252/v1/cb5bd90c9ef36997f2b0d712.jpg"},{"id":105223569,"identity":"203e5944-5406-4b68-8419-45cbddd2bb03","added_by":"auto","created_at":"2026-03-23 16:08:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1463690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8506252/v1/049c7cde-42f6-4866-a850-1f4209f1d4cf.pdf"},{"id":100748163,"identity":"fe34b89e-4307-43a2-b8b9-f0f61299a2c3","added_by":"auto","created_at":"2026-01-21 04:00:59","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":120587,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical abstract image : Correlation graph of the operation time and SII level\u003c/p\u003e","description":"","filename":"correlationgrafhoftheoptimeands.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8506252/v1/bea14bb65d9b1c68ed4c08d9.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Role of New Generation Inflammatory Markers in Patients Undergoing Carotid Endarterectomy\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIschemic stroke is caused by atherosclerotic plaques in the carotid artery and is a major cause of morbidity and mortality in western societies. The North American Symptomatic Carotid Endarterectomy Trial stenosis classification (NASCET) is used to measure and classify the degree of carotid artery stenosis. This classification is used to guide treatment decisions in symptomatic and asymptomatic patients. The NASCET classification is considered the gold standard, especially in determining the indications for surgical treatment. Patients with carotid stenosis are considered to be at very high cardiovascular risk, and the prognosis is largely determined by the occurrence of adverse coronary events[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Inflammation is the main cause of carotid plaque susceptibility. The pathophysiology of atherosclerosis is considered to be a chronic, lipid-mediated inflammatory process initiated by endothelial dysfunction, followed by a series of cellular and molecular events that include activation of inflammatory pathways.\u003c/p\u003e \u003cp\u003eThe systemic immune-inflammation index (SII) is a simple and comprehensive biomarker based on the ratio of lymphocyte, neutrophil, and platelet counts, which has been widely investigated since its definition. Recent studies have shown that SII is a good marker for the assessment of the risk and prognosis of some solid cancers (e.g., gastroesophageal adenocarcinoma, hepatocellular carcinoma, and epithelial ovarian cancer), coronary artery disease, and is also a useful indicator for the follow-up of human immune and inflammatory status [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the number of studies showing the relationship between inflammatory status and carotid endarterectomy is limited. In this study, we investigated the predictive value of SII in morbidity and mortality in patients underwent carotid endarterectomy(CEA).\u003c/p\u003e"},{"header":"Material and method","content":"\u003cp\u003ePatients with carotid stenosis who underwent surgery in our clinic were included in the study. The study was designed and conducted retrospectively in accordance with the Declaration of Helsinki and the ethics committee approved the study. Between January 2018 and December 2023, a total of 250 consecutive patients who underwent CEA at our institution were retrospectively screened for eligibility. Patients with autoimmune diseases (n=10), active infection at the time of surgery (n=15), or a history of oncological disease (n=25) were excluded. The final study population consisted of 200 patients.(Figure1)All patients were divided into 2 groups according to whether they were alive or dead at the 1-year follow-up; group 1 was the living group and group 2 was the deceased group. Then, the demographic and clinical characteristics of the patients were examined. Those with autoimmune disease, active infection and oncological disease were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Blood sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBlood samples were taken from the patients for complete blood count analysis. Peripheral blood samples for CBC analysis were obtained from all patients within 24 hours before the surgical procedure.The patients\u0026apos; hemoglobin and hematocrit levels, platelet and white blood cell (WBC) counts and all routine biochemical tests were analyzed on an automatic biochemical analyzer (Biyo CE Cobas 8000, Roche Diagnostics, Basel, Switzerland). Total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C levels based on the Friedewald formula) were calculated. SII was calculated using the formula SII = (neutrophil count \u0026times; platelet count)/lymphocyte count NLR, NLR = (neutrophil count/lymphocyte count) PLR = (platelet count/lymphocyte count).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Coronary angiography:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCoronary angiography was performed on all patients using the Judkins method via the femoral route. Post-angiographic images were evaluated by 2 experienced cardiologists. Patients with lesions of 1.5 mm and above and 50% were included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Carotid artery evaluation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe severity of carotid artery disease and lesion characteristics were evaluated using the NASCET (North American Symptomatic Carotid Endarterectomy Trial) classification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Primary \u0026amp;Secondary Endpoint\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Endpoint:\u003c/strong\u003e All-cause 1-year mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Endpoints:\u003c/strong\u003e Perioperative stroke, myocardial infarction, Major Adverse Cardiovascular Events (MACE), operation time, in-hospital complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were evaluated with SPSS (IBM) package program version 26 (SPSS Inc). Normally distributed variables were expressed with mean and standard deviation, and non-normally distributed variables were expressed with median and interquartile range. Categorical variables were expressed as percentages. T test was used for comparing normally distributed parameters, Man Whitney U test was used for comparing non-normally distributed parameters, and Chi-square test was used for comparing categorical variables. Parameters that were significant in univariate analysis were included in logistic regression analysis and mortality predictors were investigated P value \u0026lt; 0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 200 patients were included in the study. The mean age of the patients was 69.57\u0026plusmn;4.51. While the mean age in the group-1 was 64.35\u0026plusmn;3.58, the mean age in the group-2 was higher at 69.64\u0026plusmn;4.01 and was statistically significant (p:0.05). 44.5% of the patients were male. 32% of the patients had HT, 40% had DM, and 27% had HL. CAD was present in 53.8% of the group-1, while this rate was 74.5% in the group-2 (p:0.064). \u0026nbsp;There was statistical significance (p:0.05) between the two groups in HL patients, with 34.3% group-1 \u0026nbsp;and 46.3% group-2. Baseline characteristics of the study population was \u0026nbsp;shown in table-1. \u0026nbsp;The mean operation time was 29.38\u0026plusmn;5.72 minutes, and no significant difference was found between the two groups (group-1: 23.38\u0026plusmn;5.7 min, group-2: 31.42\u0026plusmn;5.8 min).\u003c/p\u003e\n\u003cp\u003eIn univariate analysis; the inflammatory parameters NLR 4.21\u0026plusmn;1.84 (p:0.001), PLR 198.8\u0026plusmn;79.1 (p:0.001), SII 1481.03\u0026plusmn;578.32 (p:0.001), \u0026nbsp;were found to be statistically significant in the group-2.(figure-2)\u003c/p\u003e\n\u003cp\u003eIn echocardiographic parameters, ejection fraction (EF) was 57.8% \u0026plusmn; 4.6 in the group-1 vs. 58.4% \u0026plusmn; 2.38 in the \u0026nbsp;group-2, with no statistically significant difference found (p=0.698). Other echocardiographic assessments, no statistically significant differences were observed between the groups for LVDD (p=0.184), LVSD (p=0.875), or PASP (p=0.615).\u003c/p\u003e\n\u003cp\u003eIn subgroup analysis; Internal carotid arteries (ICA) tortuosity was present in 19,5% of all patients. While tortuosity was observed in 11.6% in the group-1, this rate was higher in the group-2 with 45.8% but it was not found to be statistically significant (p:0.059). The operation time of patients with ICA tortuosity (32.28\u0026plusmn;6.63) was found to be longer than those without tortuosity (28.68\u0026plusmn;5.56). This difference was statistically significant (p: 0.002). Moreover; A good correlation was observed between operation time and SII .\u003c/p\u003e\n\u003cp\u003eThe association between the systemic immune-inflammation index (SII) and mortality was assessed using univariate and multivariate logistic regression analyses. As shown in Table 2, univariate analysis identified age (OR: 1.05; 95% CI: 1.020\u0026ndash;1.090; p = 0.05) and SII (OR: 1.010; 95% CI: 1.001-1.080; p = 0.001) as statistically significant factors. In multivariate analysis, only SII remained significant (OR: 1.008; 95% CI: 1.001-1.015; p = 0.026), whereas age and diabetes mellitus were not independently associated with mortalityNevertheless, comorbidities such as hypertension, diabetes mellitus, and chronic kidney disease are well-established independent risk factors for mortality in cardiovascular patients.\u0026nbsp;Consequently, the observed association between SII and mortality may, at least in part, reflect the underlying risk contributed by these comorbidities rather than a truly independent predictive value of SII.\u003c/p\u003e\n\u003cp\u003eTo determine the optimal cut-off value of the systemic immune-inflammation index (SII) for predicting 1-year mortality, a receiver operating characteristic (ROC) curve analysis was performed. The area under the curve (AUC) was 0.812 (95% CI: 0.728\u0026ndash;0.897, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and the best threshold for SII was identified as 1450, providing 77.8% sensitivity and 71.6% specificity for mortality prediction.(fig\u0026uuml;re -3)\u003c/p\u003e\n\u003cp\u003eA post-hoc power analysis was conducted using G*Power version 3.1.9.7. Assuming an effect size (odds ratio) of 1.4 for SII based on the study by \u003cem\u003eNiculescu et al., 2022 (Int J Environ Res Public Health)\u003c/em\u003e, a two-tailed \u0026alpha; = 0.05, and a sample size of 200 patients (with 19 events), the achieved statistical power was 0.84 (84%), confirming that the sample size was sufficient to detect a significant effect at a power level exceeding the conventional 80% threshold.\u003c/p\u003e\n\u003cp\u003eIn regression analysis; SII was found to be an independent predictor of mortality in patient underwent endarterectomy(Table-2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we examined the effect of inflammatory parameters on the development of adverse events in patients underwent endarterectomy and showed that SII is closely related to mortality.\u003c/p\u003e \u003cp\u003eIschemic strokes mostly originate from the internal carotid artery and the middle cerebral artery. The general prevalence of carotid artery stenosis is 1.1%, the prevalence is 1.9% in men and 0.5% in women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, since routine carotid artery screening is not performed all over the world, it is thought that this rate is higher. Tortiosity of the carotid artery, histopathological structure of carotid plaques in the carotid artery, presence of ruptured plaques, and carotid stenosis rate are important risk factor for adverse events in patient with ischemic stroke. It is known that carotid atherosclerosis is clearly dominant in men. There are studies suggesting that this widely accepted model of reduced cardiovascular risk in women is due to the protective role of estrogens in endothelial function and lipid homeostasis [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, no statistical significance was found between both genders.\u003c/p\u003e \u003cp\u003eSince both coronary and carotid lesions develop on an atherosclerotic basis and cause stenosis after similar pathophysiology, the character of the lesions and their effects in the progression process are expected to be similar. Recent studies have shown that inflammatory factors can be used as predictors of lesion progression and adverse events in coronary atherosclerosis[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. After these studies, the role of inflammation in coronary atherosclerosis has been better understood, but there are few studies on inflammation in carotid lesions. It has been suggested that inflammatory biomarkers can be used to predict adverse events in carotid diseases due to their similar pathophysiological structures [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our findings are consistent with the growing body of evidence supporting the role of inflammation in carotid disease. King et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported that NLR was associated with worse outcomes after CEA. Our study builds upon this evidence by specifically demonstrating the independent predictive value of SII, a more comprehensive index, for long-term mortality. The superiority of SII over NLR or PLR might be due to its incorporation of platelet count, which reflects both inflammatory and thrombotic pathways, both pivotal in atherosclerosis.In our study, NLR, PLR, SII, were found to be significant in the group-2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In multivariate analysis adjusting for diabetes mellitus, the systemic immune-inflammation index (SII) remained an independent predictor of mortality (OR: 1.008, 95% CI: 1.001\u0026ndash;1.015, p\u0026thinsp;=\u0026thinsp;0.026), while age lost statistical significance. This suggests that the inflammatory burden captured by SII may mediate some of the age-related mortality risk in patients undergoing carotid endarterectomy.The results of our study suggested that systemic inflammatory biomarkers can be used as a predictive marker for mortality in carotid artery disease. Similarly, the incidence of stroke was higher in patients with high inflammatory biomarkers at 1-year postoperative follow-up. In our study, we found that patients with high SII had longer operation times, suggesting that systemic inflammatory parameters may be predictive of many events that develop not only in acute but also in chronic background and affect the difficulty of the operation.\u003c/p\u003e \u003cp\u003eMild carotid artery tortuosity does not cause clinical symptoms and has a mild effect on cerebral blood flow under normal conditions, but severe tortuous arteries affect hemodynamics and blood pressure decreases after passing through these vessels, thus affecting cerebral perfusion [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Then, turbulent flow occurs as the blood passes through the tortuous carotid artery, which can lead to thrombosis and then cerebral infarction [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Non-invasive carotid anatomy examined preoperatively provides the operator with a predictive value for the treatment method. In tortuous vessels, the difficulty of the procedure increases, the operation time is prolonged, and the complications and even surgical failure rate increase significantly [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Patients planned for emergency mechanical thrombectomy require a longer surgical time and have a worse prognosis than those with carotid artery tortuosity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, the operation time in cases with tortuous vessels was found to be statistically significant, and we think that the factors mentioned above played a role in this significance.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eOur study has several limitations that should be considered when interpreting the results. First, the retrospective and single-center design may introduce selection bias and limit the generalizability of our findings. Second, the relatively small sample size, particularly the low number of events (only 19 deaths in Group 2), may reduce the statistical power of the analysis and increase the risk of overfitting in multivariate models. Finally, the measurement of inflammatory markers from blood samples taken at a single time point may not account for dynamic changes in these parameters over time, which could influence their predictive value.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn patients undergoing carotid endarterectomy, inflammatory parameters may provide useful insights for predicting adverse clinical outcomes. Specifically, patients with elevated SII values could benefit from closer monitoring, which may guide clinical decision-making and contribute to improved patient management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSII: Systemic Immune-Inflammation Index ,\u003c/p\u003e\n\u003cp\u003eNLR: Neutrophil-to-lymphocyte ratio,\u003c/p\u003e\n\u003cp\u003ePLR: Platelet-to-lymphocyte ratio ,\u003c/p\u003e\n\u003cp\u003eNASCET: North American Symptomatic Carotid Endarterectomy Trial stenosis classification,\u003c/p\u003e\n\u003cp\u003eMACE: Major Adverse Cardiovascular Events ,\u003c/p\u003e\n\u003cp\u003eCEA: carotid endarterectomy,\u003c/p\u003e\n\u003cp\u003eICA: Internal carotid arteries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTC: Total cholesterol,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTG: triglyceride,\u003c/p\u003e\n\u003cp\u003eHDL-C: High-density lipoprotein cholesterol ,\u003c/p\u003e\n\u003cp\u003eLDL-C: low-density lipoprotein cholesterol,\u003c/p\u003e\n\u003cp\u003eHT: Hypertension\u003c/p\u003e\n\u003cp\u003eDM: Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eHL: Hyperlipidemia\u003c/p\u003e\n\u003cp\u003eEF: Ejection fraction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLVDD: Left ventricular diastolic diameter\u003c/p\u003e\n\u003cp\u003eLVSD: Left ventricular systolic diameter\u003c/p\u003e\n\u003cp\u003eROC: Receiver operating characteristic\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUC: Area under the curve\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee. Due to the retrospective design of the study, the requirement for written informed consent was waived by the ethics committee.(Afyonkarahisar Health Sciences University non-interventionist Scientific Researc Ethics Committee 07/03/2025 2025/4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are not publicly available due to ethical restrictions and patient confidentiality but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study received no financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors thank the healthcare professionals who contributed to patient management and data acquisition.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. FCS: Contributed to the study concept and design, collected patient data, performed statistical analyses, and drafted the initial version of the manuscript.Dr. HS: Conducted the literature review, contributed to the development of the methodology section, and participated in the interpretation of findings.Dr. CK: Responsible for data validation, verification of statistical results, and revisions of the discussion section.Dr. UA Author: Supervised the overall study process, contributed to the clinical interpretation of results, and finalized the manuscript for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGo, C., et al., \u003cem\u003eLong-term clinical outcomes and cardiovascular events after carotid endarterectomy.\u003c/em\u003e Ann Vasc Surg, 2015. \u003cstrong\u003e29\u003c/strong\u003e(6): p. 1265-71.\u003c/li\u003e\n\u003cli\u003eWang, B.L., et al., \u003cem\u003eDynamic change of the systemic immune inflammation index predicts the prognosis of patients with hepatocellular carcinoma after curative resection.\u003c/em\u003e Clin Chem Lab Med, 2016. \u003cstrong\u003e54\u003c/strong\u003e(12): p. 1963-1969.\u003c/li\u003e\n\u003cli\u003eBani Hani, D.A., et al., \u003cem\u003eLymphocyte-based inflammatory markers: Novel predictors of significant coronary artery disease(\u003c/em\u003e\u003cem\u003e✰\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e✰✰\u003c/em\u003e\u003cem\u003e).\u003c/em\u003e Heart Lung, 2025. \u003cstrong\u003e70\u003c/strong\u003e: p. 23-29.\u003c/li\u003e\n\u003cli\u003eCollaborators, G.B.D.S., \u003cem\u003eGlobal, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.\u003c/em\u003e Lancet Neurol, 2021. \u003cstrong\u003e20\u003c/strong\u003e(10): p. 795-820.\u003c/li\u003e\n\u003cli\u003eWoo, S.Y., et al., \u003cem\u003ePrevalence and risk factors for atherosclerotic carotid stenosis and plaque: A population-based screening study.\u003c/em\u003e Medicine (Baltimore), 2017. \u003cstrong\u003e96\u003c/strong\u003e(4): p. e5999.\u003c/li\u003e\n\u003cli\u003eKardys, I., et al., \u003cem\u003eThe female advantage in cardiovascular disease: do vascular beds contribute equally?\u003c/em\u003e Am J Epidemiol, 2007. \u003cstrong\u003e166\u003c/strong\u003e(4): p. 403-12.\u003c/li\u003e\n\u003cli\u003eSangiorgi, G., et al., \u003cem\u003eSex-related differences in carotid plaque features and inflammation.\u003c/em\u003e J Vasc Surg, 2013. \u003cstrong\u003e57\u003c/strong\u003e(2): p. 338-44.\u003c/li\u003e\n\u003cli\u003eBurke, A.P., et al., \u003cem\u003eEffect of menopause on plaque morphologic characteristics in coronary atherosclerosis.\u003c/em\u003e Am Heart J, 2001. \u003cstrong\u003e141\u003c/strong\u003e(2 Suppl): p. S58-62.\u003c/li\u003e\n\u003cli\u003eGiacomelli, E., et al., \u003cem\u003eSex-Related Outcomes in Asymptomatic Carotid Artery Stenosis Undergoing Carotid Endarterectomy.\u003c/em\u003e J Surg Res, 2025. \u003cstrong\u003e305\u003c/strong\u003e: p. 204-213.\u003c/li\u003e\n\u003cli\u003eLi, Y., et al., \u003cem\u003eThe Systemic Immune Inflammatory Response Index Can Predict the Clinical Prognosis of Patients with Initially Diagnosed Coronary Artery Disease.\u003c/em\u003e J Inflamm Res, 2023. \u003cstrong\u003e16\u003c/strong\u003e: p. 5069-5082.\u003c/li\u003e\n\u003cli\u003eZhao, Z., et al., \u003cem\u003ePrognostic value of systemic immune-inflammation index in CAD patients: Systematic review and meta-analyses.\u003c/em\u003e Eur J Clin Invest, 2024. \u003cstrong\u003e54\u003c/strong\u003e(2): p. e14100.\u003c/li\u003e\n\u003cli\u003eKing, A.H., et al., \u003cem\u003eElevated Neutrophil to Lymphocyte Ratio is Associated with Worse Outcomes after Carotid Endarterectomy in Asymptomatic Patients.\u003c/em\u003e J Stroke Cerebrovasc Dis, 2021. \u003cstrong\u003e30\u003c/strong\u003e(12): p. 106120.\u003c/li\u003e\n\u003cli\u003eNiculescu, R., et al., \u003cem\u003eCarotid Plaque Features and Inflammatory Biomarkers as Predictors of Restenosis and Mortality Following Carotid Endarterectomy.\u003c/em\u003e Int J Environ Res Public Health, 2022. \u003cstrong\u003e19\u003c/strong\u003e(21).\u003c/li\u003e\n\u003cli\u003eGoncalves, V.A., et al., \u003cem\u003eAssociation between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy.\u003c/em\u003e J Vasc Bras, 2023. \u003cstrong\u003e22\u003c/strong\u003e: p. e20220122.\u003c/li\u003e\n\u003cli\u003eMassiot, N., et al., \u003cem\u003eHigh Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio are Associated with Symptomatic Internal Carotid Artery Stenosis.\u003c/em\u003e J Stroke Cerebrovasc Dis, 2019. \u003cstrong\u003e28\u003c/strong\u003e(1): p. 76-83.\u003c/li\u003e\n\u003cli\u003eBrott, T.G., et al., \u003cem\u003e2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery.\u003c/em\u003e Circulation, 2011. \u003cstrong\u003e124\u003c/strong\u003e(4): p. 489-532.\u003c/li\u003e\n\u003cli\u003eMetz, H., et al., \u003cem\u003eKinking of the internal carotid artery.\u003c/em\u003e Lancet, 1961. \u003cstrong\u003e1\u003c/strong\u003e(7174): p. 424-6.\u003c/li\u003e\n\u003cli\u003eStanton, P.E., Jr., D.A. McClusky, Jr., and P.A. Lamis, \u003cem\u003eHemodynamic assessment and surgical correction of kinking of the internal carotid artery.\u003c/em\u003e Surgery, 1978. \u003cstrong\u003e84\u003c/strong\u003e(6): p. 793-802.\u003c/li\u003e\n\u003cli\u003eWang, L., et al., \u003cem\u003ePressure Drop in Tortuosity/Kinking of the Internal Carotid Artery: Simulation and Clinical Investigation.\u003c/em\u003e Biomed Res Int, 2016. \u003cstrong\u003e2016\u003c/strong\u003e: p. 2428970.\u003c/li\u003e\n\u003cli\u003eWang, Q., et al., \u003cem\u003eCorrelation of extracranial internal carotid artery tortuosity index and intraprocedural complications during carotid artery stenting.\u003c/em\u003e Eur Neurol, 2012. \u003cstrong\u003e68\u003c/strong\u003e(2): p. 65-72.\u003c/li\u003e\n\u003cli\u003eRosa, J.A., et al., \u003cem\u003eAortic and supra-aortic arterial tortuosity and access technique: Impact on time to device deployment in stroke thrombectomy.\u003c/em\u003e Interv Neuroradiol, 2021. \u003cstrong\u003e27\u003c/strong\u003e(3): p. 419-426.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 661px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Baseline clinical variables of the patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eGroup-1 (Alive)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eGroup-2(Exitus)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge,years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e64,53\u0026plusmn;3,58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e69,64\u0026plusmn;4,01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e43,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e52,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,455\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHT %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e21,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e33,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e38,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e52,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHL %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e34,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e46,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOPD %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e9,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e15,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,378\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking history %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e12,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e21,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,312\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACE-I use %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e81.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e75,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eARB use%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,367\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB-Bloker use%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e89.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e87.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,728\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatin use %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e27,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKREATIN (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0,79\u0026plusmn;0,22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0,99\u0026plusmn;0,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDL cholesterol(mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e119,3\u0026plusmn;38,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e127,8\u0026plusmn;45,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTG (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e153,7\u0026plusmn;75,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e170,1\u0026plusmn;86,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eALT (U/L)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e28,01\u0026plusmn;31,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e34,05\u0026plusmn;40,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAST (U/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e23,74\u0026plusmn;13,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e26,0\u0026plusmn;22,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e10,46\u0026plusmn;4,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e12,1\u0026plusmn;7,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHB (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e1,42\u0026plusmn;2,19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e14,1\u0026plusmn;2,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutrophil(10^3/uL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e6,08\u0026plusmn;2,34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e6,47\u0026plusmn;2,98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymphocyte (10^3/uL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2,01\u0026plusmn;1,02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1,62\u0026plusmn;1,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatelet (10^3/uL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e235,6\u0026plusmn;79,02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e222,5\u0026plusmn;89,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEjection fraction %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e57,8\u0026plusmn;4,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e58,4\u0026plusmn;2,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,698\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVDD (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e44,75\u0026plusmn;3,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e43,79\u0026plusmn;2,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,184\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVSD (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e29,6\u0026plusmn;4,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e29,6\u0026plusmn;3,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePABS (mmhg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e21,2\u0026plusmn;4,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e23,4\u0026plusmn;5,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,615\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronary artery lesion%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e53,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e74,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIca tortuosity %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e11,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e45,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e23,38\u0026plusmn;5,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e31,42\u0026plusmn;5,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLesion diameter \u0026gt;15mm%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e11,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e15,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0,248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNLR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2,13\u0026plusmn;1,07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4,21\u0026plusmn;1,84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePLR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e125,8\u0026plusmn;56,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e198,8\u0026plusmn;79,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e582,34\u0026plusmn;344,82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1481,03\u0026plusmn;578,32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOST-OP STROKE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e1,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e84,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOST-OP MI %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e21,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eHT: hypertension, DM: diabetes mellitus, HL: hyperlipidemia, COPD: chronic obstructive pulmonary disease, LDL: low-density lipoprotein TG: triglyceride, CRP: C-reactive protein, HB: hemoglobin, NT PRO-BNP: N-terminal pro B type non-uretic peptide, LVDD: left ventricular diastolic diamater, LVSD: left ventricular systolic diamater PABS: mean pulmonary artery pressure, SII: systemic inflammatory index, NLR:neutrophil lymphocyte ratio, PLR: platelet lymphocyte ratio\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable-2: Mortality predictor of the study population\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"587\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate OR,95 CI%\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate OR,95 CI%\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e1,05(1,020-1,090)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1,030(1,000-1,065)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0,364\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e1,010(1,001-1,080)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1,008(1,001-1,015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e1,762(0,682-4,551)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0,067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1,966(0,734-5,265)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0,179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Carotid endarterectomy, Systemic Immune-Inflammation Index (SII), Inflammatory biomarkers, Mortality, Carotid artery disease","lastPublishedDoi":"10.21203/rs.3.rs-8506252/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8506252/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the prognostic value of novel systemic inflammatory markers, particularly the Systemic Immune-Inflammation Index (SII), in predicting morbidity and mortality in patients undergoing carotid endarterectomy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 200 patients who underwent carotid endarterectomy. Patients were categorized into two groups based on their 1-year postoperative survival status (group-1:alive, group-2: dead). Inflammatory parameters including SII, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)were calculated. Demographic, clinical, echocardiographic, and angiographic data were analyzed. The association between inflammatory markers and outcomes was assessed using univariate and multivariate analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSII, NLR and PLR were significantly higher in the group-2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with internal carotid artery tortuosity exhibited longer operation times (p\u0026thinsp;=\u0026thinsp;0.002), and those with elevated SII levels had a higher risk of adverse outcomes. No significant difference was observed in echocardiographic parameters between the two groups. The presence of comorbidities such as hyperlipidemia and coronary artery disease was also more prevalent in the group-2.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSystemic inflammatory markers, particularly SII, may serve as useful predictors of postoperative mortality and procedural complexity in patients undergoing carotid endarterectomy. Incorporating these markers into preoperative risk assessment may improve clinical decision-making and patient outcomes.\u003c/p\u003e","manuscriptTitle":"The Role of New Generation Inflammatory Markers in Patients Undergoing Carotid Endarterectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 03:59:24","doi":"10.21203/rs.3.rs-8506252/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T07:38:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T05:31:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T22:44:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T05:33:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217980904840850248605145251973461013955","date":"2026-01-17T16:10:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65391512968209880960479011153705397227","date":"2026-01-17T01:00:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88068364189875030949715182185133651693","date":"2026-01-16T12:33:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-15T14:04:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-15T12:13:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-14T07:09:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T18:13:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-13T18:06:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0be5b152-8c2e-405a-96db-273ac2bb999a","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:05:36+00:00","versionOfRecord":{"articleIdentity":"rs-8506252","link":"https://doi.org/10.1186/s12893-026-03629-1","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-16 15:58:53","publishedOnDateReadable":"March 16th, 2026"},"versionCreatedAt":"2026-01-21 03:59:24","video":"","vorDoi":"10.1186/s12893-026-03629-1","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03629-1","workflowStages":[]},"version":"v1","identity":"rs-8506252","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8506252","identity":"rs-8506252","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}