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Techniques for Optimizing Results in Carotid Stenting
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Carotid angioplasty and stenting (CAS) has emerged as a feasible and safe alternative for the management of extracranial carotid occlusive disease. The appropriate clinical setting, indications and techniques to maximize the benefit of this new approach are in constant evolution. The success of CAS relies not only on technique, device selection and management of complications but, maybe more importantly, on patient selection, peri-operative medical management and pre-procedural imaging and planning. The purpose of this review is to describe the peri-procedural and technical steps that can optimize the results of CAS.
KeywordsCarotid Angioplasty Stenting Technique Outcome optimization Patient selection Carotid stenosis Antiplatelet therapy Ultrasound Angioplasty
Since the initial US Food and Drug Administration approval of the first interventional carotid artery stenting (CAS) device system for use in high-risk patients in 2004 [1], multiple trials have been conducted. The most recent of these is the multicenter randomized CREST trial, with its results published in July 2010 [2•].
The initial randomized trials and registries data not only confirmed the safety and efficacy of CAS, but also identified a set of high risk criteria describing cases in which an endovascular intervention might harbor higher risks for adverse events. The results of these trials have also confirmed carotid endarterectomy (CEA) as the current standard of care for most patients with carotid stenosis, mainly because of the uniformly reported lower rate of neurologic adverse events when compared to CAS. Among the objectives of this review, we attempt to identify high risk situations for CAS in order to address and optimize the peri-procedural factors that impact its results. This review will describe the pre-procedural workup, intra-procedural details and post-procedural factors that are known to impact outcomes of CAS.
Patient Selection
The indications for treatment for extracranial carotid occlusive disease are regarded to be the same whether CEA or CAS is contemplated. However, it is a constant matter of debate if the patient selection criteria for surgery can be applied to CAS. It is important to note that the benefit of CEA is based on its potential for decreasing the risk of stroke occurrence 3–5 years after the procedure [3]. In general, any condition that limits life expectancy will negate the benefit of revascularization of an asymptomatic carotid stenosis with either approach.
Patient selection for CEA or CAS may often be biased by provider or patient preferences. It is well accepted, nevertheless, that certain risk factors, such as prior neck irradiation, re-operative surgical fields and high lesions, may make CEA technically challenging and complicated, thus favoring CAS as a better option [4, 5]. In addition, congestive heart failure (III–V), multi-vessel coronary artery disease, LVEF <30 %, unstable angina, recent MI, renal failure on dialysis and liver failure have been described as physiologic variables conferring a high risk for complications after carotid endarterectomy [6]. CAS, therefore, may be desirable in this last patient population, keeping in mind that the benefit of revascularization for asymptomatic carotid disease in the setting of disabling medical comorbidities is questionable.
On the other hand, certain characteristics, which are described below, can make CAS a high risk procedure. A careful evaluation of the benefits and risks of either approach should be individualized to every patient. Proper selection of candidates for CAS is crucial to avoid complications and optimize outcomes.
Symptomatic Carotid Stenosis
Results from several trials have consistently shown worse outcomes in symptomatic patients treated with CAS as compared to CEA. As early as 2004, subgroup analysis in the SAPPHIRE trial showed that among patients treated with CAS, a greater cumulative incidence of the primary neurologic endpoint was observed in the symptomatic patients (16.8 %) compared to the asymptomatic (9.9 %) [7]. In the EVA-3S, among symptomatic patients the incidence of any non-fatal strokes within 30 days was significantly higher in the CAS compared to the CEA group (8.8 vs. 2.7 %); this trial was terminated early for safety and futility reasons. The SPACE trial in 2006 also failed to show CAS non-inferiority when compared to CEA, showing a slightly higher rate of ipsilateral ischemic stroke and death at 30 days in symptomatic patients undergoing CAS [8]. The CAPTURE registry publication of predictors of outcomes in 2007 concluded that CAS is safe in high-risk patients with severe stenosis. However, when compared with the asymptomatic cohort, symptomatic patients treated with CAS had a sobering statistically significant higher risk of death or stroke (10.6 vs. 4.9 %) and death or major stroke (6.2 vs. 2.4 %) at 30 days. More recently, the CREST trial showed slightly higher but not significant incidence of stroke and death in the stenting group compared to the endarterectomy group among symptomatic patients (6.7 vs. 5.4 %; hazard ratio for stenting, 1.26; 95 % CI, 0.81 to 1.96) and an almost equal incidence of the primary endpoints among asymptomatic patients (3.5 vs. 3.6 %; hazard ratio, 1.02; 95 % CI, 0.55 to 1.86). These results suggest poorer outcomes for CAS in symptomatic patients compared to asymptomatic patients, thus advocating the cautious use of CAS in this patient population, primarily in the presence of other anatomic or medical high risk criteria. Symptomatic patients from a high grade carotid stenosis should be preferentially treated with CEA by current guidelines and recommendations [9•, 10•, 11].
Of special importance is the subset of patients older than 80 years. Numerous studies have demonstrated that patients older than 75–80 years are perfectly suitable candidates for CEA [12, 13]. In addition, investigators in the recent CREST lead in trial results and other trials found increased rate of death and stroke in this group of patients (12 % in octogenarians vs. 3.23 % in non-octogenarians) after CAS. This observation has been repeated with such alarming regularity in other trials that age older than 80 years should be considered at least a relative contraindication to CAS [14, 15]. It should be noted, however, that increased risk with age actually starts at 75 years and accelerates beyond the age of 80 [5]. The etiology of the poor outcome in these patients remains to be elucidated. Factors such as arch elongation, arch calcification, and vessel tortuosity, seem to be more prevalent in the elderly and have been associated anecdotally with increased risk of CAS even in the younger patients. In addition, increased plaque thrombogenicity and vulnerability noted in elderly symptomatic patients may explain the increased rate of neurologic complications with CAS [16, 17].
Increased risk of stroke after CEA in women was first reported in the ACAS trial [18]. On the other hand ACST [19], NASCET [20] and CAVATAS demonstrated no difference by sex detected in the primary endpoint of the trials. Recently, according to a subgroup analysis of the CREST trial the peri-procedural risk of events seems to be higher in women who undergo CAS instead of CEA [21]. Peri-procedural events were observed in 31 (6.8 %) of 455 women assigned to carotid artery stenting compared with 16 (3.8 %) of 417 assigned to carotid endarterectomy (p = 0.064), whereas there was no significant difference among men. These results suggest a trend for higher peri-procedural stroke in women, and should be taken into account when choosing the treatment modality.
The number of intra-procedural micro emboli detected with trans-cranial Doppler scans [22] and the incidence of new embolic lesions detected by diffusion weighted MRI [23] show a higher incidence of embolic events in CAS when compared to patients undergoing CEA. This could be particularly important in the setting of adverse plaque characteristics. Long stenotic lesions (>15 mm) and involvement of the internal carotid ostium seem to be associated with increased incidence of peri-operative complications, especially when CAS is performed in elderly patients [24]. In addition, plaque characteristics have received some attention as a predictors of CAS outcomes, with some evidence that soft plaques with low echogenicity scores may be associated with significant neurologic adverse events [25]. Thus, anatomical characteristics should be considered in the treatment algorithm of carotid revascularization, recognizing the higher incidence of adverse events with long and ostial lesions, as well as vulnerable carotid plaques. Until further validation of these findings, caution should be exercised in stenting lesions in this particular subset of patients.
Medical Therapy
The most recent multi-society guidelines on the management of patients with extra-cranial carotid and vertebral artery disease (ECVD) describe the current keystones on the medical management of these patients [9•]. Medical therapy, regardless of any surgical or endovascular intervention, focuses on the specific management of hypertension, hyperlipidemia and diabetes. Smoking cessation is strongly recommended to reduce the risk of atherosclerosis progression and stroke. Furthermore, although no specific recommendations are made, the importance of obesity, lack of physical activity and the metabolic syndrome as potential risk factors for carotid disease and stroke is highlighted.
It is important to note that since the publication of trials comparing carotid revascularization to medical therapy with aspirin only, the non-operative intervention or medical management has been continuously refined and redefined. The current medical management of carotid occlusive disease (which entails the routine use of antiplatelet therapy, lipid lowering agents, angiotensin inhibitors and beta blockers) might have altered the natural history of the disease. This is supported by recent data suggesting a stroke risk of less than 1 % per year for asymptomatic carotid stenosis treated with best medical treatment (BMT) alone [26, 27].
Antiplatelet Therapy
Intimal injury during CAS releases pro-coagulants and exposes sub-endothelial platelet adhesive proteins, thus leading to rapid formation of thrombus and potential embolization. Most of the information on stent thrombosis is from extrapolation of the literature on the coronary bed [28, 29].
Aspirin (ASA) is an effective and safe antiplatelet agent, extensively investigated, and constitutes the mainstay of antithrombotic therapy. However, it shows marked inter-patient variability and some vasculopath patients appear to be resistant to its action [30]. Clopidogrel, an oral thienopyridine of the same family as ticlopidine but better tolerated, irreversively inhibits a chemoreceptor on platelet membranes, thus impairing adhesion. Dual therapy with clopidogrel and ASA has been able to demonstrate reduction in silent microemboli detected by TCD among patients with recent symptomatic carotid stenosis [31].
There is consensus among interventionalists to treat patients undergoing CAS in a similar fashion to those receiving coronary stents, thus a regimen consisting of ASA 81–325 mg/day and clopidogrel 75 mg/day to be started 4 days prior to the procedure is advocated. Alternatively a loading dose of 300 mg can be administered 4–6 h before the procedure followed by 75 mg daily [9•, 10•].
Regarding the duration of the antiplatelet therapy, most practitioners recommend 4 weeks of therapy to prevent acute and sub-acute thrombosis, documented to occur up to 30 days after stenting [32].
Over the last few years special attention has been devoted to the reported "resistance" to antiplatelet therapies in specific patients. "Resistance" has been described as the occurrence of occlusive cardiovascular disease events despite regular intake of these agents at recommended doses [33]. The frequency of this phenomenon has been reported to range from 1 to 45 % for aspirin and/or clopidogrel [34]. The mechanisms or resistance are poorly understood and multifactorial, thus despite the variety of tests available, no consensus exists regarding the reference standard for measuring platelet activation [35]. Several explanations can account for Clopidogrel resistance or treatment failure, including non-compliance, variable platelet response, genetic variability of cytochrome P450 enzymes, and interaction with several classes of medications (statins, proton pump inhibitors, calcium channel blockers). The failure of antiplatelet therapy will likely result in an adverse clinical outcome, however, there is no clear strategy for the management of this problem, an initial approach would be to correct clinical factors that may cause therapeutic resistance. Physicians must ensure proper patient compliance while also minimizing drug–drug interactions. Although testing for Clopidogrel resistance is not routinely recommended, given the current evidence, it should be selectively entertained in patients suspected of having recurrent failure of antiplatelet therapy prior to CAS. In addition, optimal control of glucose levels and cholesterol levels can reduce platelet reactivity and should be actively pursued.
Antihypertensive Therapy
Hypertension increases the risk of stroke. For each 10-mmHg increase in blood pressure, the risk of stroke increases by 30 to 45 % [36]. A meta-analysis of more than 40 trials and 188,000 patients found a 33 % decreased risk of stroke for each 10-mmHg reduction in systolic blood pressure [37]. A large body of literature is available to support the reduction of recurrent strokes by antihypertensive therapy regardless of the agent used [38]. In patients who had experienced ischemic stroke, administration of a combination of angiotensin converting enzyme inhibitors and a diuretic significantly reduced the risk of recurrent ischemic events compared with placebo [39].
Patients with ischemic stroke or TIA, regardless of the source, should receive anti-hypertensive treatment beyond the hyper-acute period [26]. According to the American Heart Association guidelines for the management of extracranial carotid disease, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic extracranial carotid or vertebral atherosclerosis. However, the benefit of treatment to a specific target blood pressure (e.g., below 140/90 mmHg) has not been established in relation to the risk of exacerbating cerebral ischemia [9•, 10•].
Of note, symptomatic patients with severe carotid artery stenosis represent a challenging situation since it is not known whether antihypertensive therapy is beneficial or harmful by reducing cerebral perfusion. The Seventh Report of the Joint National Committee for the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) offers no specific recommendation for treatment of hypertension in patients with severe ECVD [40].
It is instrumental to establish a patient targeted antihypertensive regimen to control blood pressure before and after CAS in order to maximize its outcomes [9•, 10•].
Statins belong to a class of drugs known to inhibit 3-hydroxy 3-methylglutaryl coenzyme A reductase, and block hepatic cholesterol synthesis. They became the gold standard for treatment of hypercholesterolemia since their FDA approval in 1987. They have proven to successfully reduce the incidence of stroke among patients at increased risk for cardiovascular disease; the Stroke Prevention Aggressive Reduction of Cholesterol Levels (SPARCL) [27] showed that the use of atorvastatin reduced the overall incidence of stroke and of cardiovascular events. Furthermore, statin use was independently associated with a 75 % reduction in the odds of death and 45 % reduction in the odds of ischemic stroke or death among patients with symptomatic carotid disease. There are data indicating that statin use may reduce long-term incidence of restenosis following CEA [41] and a similar benefit of reducing neurologic morbidity among patients undergoing carotid angioplasty and stent procedures has been documented [42]. The precise mechanism underlying the "pleiotropic" favorable effects of the drug on platelet adhesion, thrombosis, plaque stability, and inflammation is unclear; however, statins given peri-operatively may not only lower lipid levels but might stabilize the arterial wall as well. The use of statins (pravastatin, simvastatin, lovastatin or cervistatin) for at least 1 week prior to the procedure has been shown to reduce the incidence of stroke, myocardial infarction, and death within 30 days after CAS [43]. Magnetic resonance imaging (MRI) using ultra-small super-paramagnetic iron oxide (USPIO) particles has been shown to identify inflammatory changes by monitoring macrophage uptake, a major component of high-risk (vulnerable) plaques [44]. The ATHEROMA trial (Atorvastatin Therapy: Effects on Reduction of Macrophage Activity) used this new MRI technology to compare the effects of a low (10 mg) vs. a high (80 mg) atorvastatin daily dose in the carotid plaque. It concluded that aggressive lipid-lowering therapy over a 3-month period is associated with significant reduction in USPIO-defined inflammation [45]. The use of aggressive statin therapy is therefore likely to improve the outcomes of CAS by reducing adverse neurologic and myocardial events through different mechanistic effects.
Determination of degree of carotid artery stenosis is of critical importance when deciding whether a patient warrants intervention. Physicians rely heavily in diagnostic imaging to make this decision. The fast evolution pace of current non-invasive imaging, as well as their continuously increasing accuracy and resolution has relegated purely diagnostic cerebral angiography to a second plane.
Plaque characterization in US and also in CTA and MRA may have special relevance in the era of carotid stenting, since identification of a high-risk vulnerable plaque may be useful when deciding whether to perform a stent procedure or an endarterectomy.
The near future might bring the ability to create a computer model and perform a simulated procedure to test the operator, the devices and to prove the feasibility of CAS for a given patient [46, 47].
Currently, physicians most commonly rely on Duplex ultrasound when planning an operative intervention for carotid stenosis. The current guidelines advocate for the use of US in the initial evaluation of any patient that presents with acute, focal ischemic neurological symptoms corresponding to the territory supplied by the carotid arteries. Ultrasound is a non-invasive and relatively inexpensive diagnostic method capable of detecting and quantifying the degree of stenosis based on velocity measurement and Doppler waveform analysis. B-mode imaging is also able to evaluate specific additional characteristics of the carotid plaque that might make it high risk for embolization: a hyperechoic, echodense or bright plaque is indicative of an indurated, relatively stable, calcified plaque. On the other hand a hypoechoic, echolucent or dark plaque is indicative of blood or lipid rich plaque, which is likely prone to embolize during CAS [48]. Ultrasound, however, is operator dependent, is limited in highly calcified lesions and the criteria for grading stenosis may differ among different institutions. Furthermore, CAS requires full understanding and precise knowledge of the specific anatomy of the intra- and extra-cranial vascular tree, and current generation US does not provide an adequate and reliable road-map to help in device selection and plan a detailed intervention.
CTA and MRA
Computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) have gained a prominent role in CAS planning in recent years. Detailed imaging and understanding of the anatomy and quality of the aortic arch, neck and cerebral vasculature is necessary to be aware of potential difficulties during the procedure such as tortuosity of the vessels. Severe arch atherosclerosis (eggshell aorta), arch irregularities (shaggy aorta), diffuse common carotid artery disease, eccentric stenoses, severe angulations of the bifurcation and kinking or disease of the distal internal carotid artery should raise a red flag, since they might represent relative contraindications for an endovascular procedure. CT and MR imaging also provide documentation of pre-procedural pathologic changes in the brain and serve as a platform for measuring and sizing the arteries in order to choose the most appropriate devices to use during the intervention.
The current American guidelines recommend the use of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in patients with acute, focal ischemic neurological symptoms when sonography either cannot be obtained or yields equivocal or otherwise non-diagnostic results. In general and in asymptomatic patients, when initial noninvasive images are inconclusive, additional examination by use of another imaging method is reasonable.
Magnetic resonance angiography without contrast is reasonable for assessing the extent of disease in patients with symptomatic carotid atherosclerosis and renal insufficiency or extensive vascular calcification. CTA, on the other hand, is reasonable for evaluation of patients with clinically suspected significant carotid atherosclerosis who are not suitable candidates for MRA because of claustrophobia, implanted pacemakers, or other incompatible devices [9•].
The use of axial imaging before CAS can therefore help improve CAS outcomes by providing an anatomic roadmap and by allowing the operator to anticipate high risk anatomic situations and procedural events.
Catheter Based Contrast Angiography
Conventional angiography was once considered the standard against which other methods of vascular imaging were compared; however, its use as a screening modality has been abandoned due to its high risk and cost. Currently, its use is of particular importance in situations where adequate delineation of the disease cannot be obtained by other methods or when imaging studies have yielded discordant results [10•].
The most feared complication is stroke, initially reported as high as 1.2 % in the ACAS trial [49], however the incidence of which should be <1 % when performed by experienced physicians, according to more recent trials [50, 51, 52].
The selective utilization of angiography to rule out significant disease is rarely indicated, thus the operator should ideally be prepared to perform an intervention if needed.
Intravascular Ultrasound (IVUS)
Intravascular ultrasound technology, which has been gaining acceptance in the coronary and peripheral arterial fields, allows the operator to gather intra-procedural detailed information about the diameter of the vascular lumen, extent of atherosclerosis, and degree of calcification. It is also used to evaluate the outcome of an intervention (i.e., detect arterial dissection after angioplasty and plaque and stent configuration after deployment) [53, 54].
The incorporation of IVUS during CAS has been addressed in a few studies and has focused mainly on the safety of the technique and its potential contribution to the success of carotid revascularization [55].
Although there is some evidence showing that incomplete stent expansion or small post-procedural stent diameter may be associated with a greater risk of restenosis [56], there are limited data regarding the impact that IVUS completion imaging might have in preventing re-stenosis, reducing strokes or improving overall outcomes.
Although used safely in small series of patients, more evidence is needed before the incremental risk associated with the additional catheter manipulation required to traverse stenotic lesions can be justified.
Device Selection
Selection of the appropriate equipment is of paramount importance. Devices able to negotiate the aortic arch and carotid system tortuosity with adequate support and minimal trauma are ideal. The operator should be familiar with a set of devices for both routine and complex CAS, and should use them on a regular basis to achieve proficiency. Adopting routine CAS steps and familiarity of the operator and staff with a set of devices and tools ensure the smooth flow of the procedure.
Sheaths and Guiding Catheters
The anticipated stent size required to perform the procedure should be placed at the time of initial access, usually a 6 or 7 Fr sheath. Following femoral access, systemic anticoagulation is indicated prior to device manipulation in the aortic arch. This can help minimize thromboembolic complications.
Selecting Catheters
Multiple selective catheters are available. These are generally available in 100–125 cm length. The selective catheters can be grouped in two major categories:
Simple curve catheters have a primary angled tip. Such catheters are placed in the arch proximal to the ostium of the target artery and rotated toward the orifice as the catheter is being withdrawn. Among these catheters are the angled-taper Glidecath, the H1 headhunter, The JB 1 and the vertebral catheter (Angiodynamics, Latham, NY).
Complex curve catheters have, in addition to a primary angle tip, a secondary curve and must be reshaped in the aorta to their original configuration to achieve cannulation. The two or more curves are useful in complex arterial configuration. The catheter head is positioned near the branch vessel and advanced or withdrawn to select the target vessel. Among these catheters we have the H3 headhunter, the Simmons 1, 2 and 3, JB 2 and the VTK catheters (Angiodynamics, Latham, NY).
Placement of the sheath or the guiding catheter into the CCA requires a relatively stiff 0.035-inch 260 cm long wire. The wire is advanced into the ECA in order to obtain enough purchase to advance the sheath or guiding catheter into the CCA. This allows adequate guidewire length placed beyond the carotid bifurcation for the subsequent placement of the carotid sheath. Passage of the stiff exchange guidewire into the small external carotid artery branches must be performed with caution to avoid injury or perforation to these small branches, especially avoiding the lingual and ophthalmic branches. To minimize thromboembolic complications, the target lesion is not manipulated at this stage of the procedure.
Embolic Protection Devices (EPD)
Pharmacologic strategies to minimize platelet aggregation and thrombus formation are not sufficient to prevent cerebral embolization during CAS. Previous studies have demonstrated the embolization of clot and plaque components during carotid manipulation [57, 58]. Two types of cerebral protection strategies are currently widely used: distal filtration and reversal of flow.
Distal filtration is the most widely used type of cerebral protection, its principle being to trap particulate debris while maintaining blood flow during the procedure. Most of the devices are calibrated to filter particles >100 u (70–140u). Filters are typically mounted on a 0.014 wire in a monorail or over the wire (OTW) configuration and are recaptured after CAS with a dedicated retrieval system. The AcuNet filter (Abbott, Illinois) was the first of these to obtain FDA approval. The Spider RX (ev3 Inc., Minneapolis, MN), the AngioGuard XP (Cordis, Warren, NJ), the FilterWire EZ (Boston Scientic, Natic, MA), the EmboShield Pro (Abbott, Illinois) are some of the filters also available in the USA.
The disadvantages of the filters are similar to previously utilized cerebral protection balloons; they cross the lesion without protection and pose the potential risk of arterial injury during deployment. In addition, suboptimal apposition can cause distal embolization and the filter itself can fill with debris due to its limited volumetric capacity [59, 60]. However, the main advantage of these devices is their ability to perform the procedure without interruption of cerebral blood flow.
Flow reversal (proximal occlusion) devices, on the other hand, can provide cerebral protection prior to crossing the target lesion. A reversal of flow in the ICA is achieved by occlusion of the CCA and ECA by a compliant balloon and either active syringe aspiration (Mo.Ma system, Invatec, Italy) through a side arm [61] or by continuous arterio-venous shunt from the ICA to the femoral vein (Gore Neuro protection system or Parodi anti-embolic device, Gore & Associates, Flagstaff, AZ) [62]. These devices could be useful for the treatment of friable and tight lesions in tortuous arteries where placement of filters or balloons might prove to be difficult or risky. Proximal occlusion devices require larger introducers and are technically complex. Intolerance to flow blockage is also encountered in 5.7–7.6 % of the patients [63] and could be dangerous in those with contralateral carotid occlusion. Nevertheless, this type of cerebral protection has been reported to be safe and effective in recent series, with a low rate of procedural adverse events [64]. Recent studies suggest that the differential in adverse neurologic event rates in CAS between symptomatic and asymptomatic patients may be ameliorated by the use of flow reversal embolic protection strategies in symptomatic patients.
Flow reversal with transcervical access has been recently described as minimizing the neurologic complications of CAS. It eliminates some of the complications associated with the transfemoral route, which include the hazards of wire and catheter manipulation in the aortic arch. In this setting, Criado et al described in 2004 a technique for transcervical CAS with flow reversal protection [65]. Although the experience is still small and prospective trials are needed, the short-term and long-term outcomes are also good and appear comparable with the reported results for carotid revascularization by endarterectomy [66, 67]. This technique promises to improve the neurologic outcomes of CAS as it has been associated with a lower incidence of new ischemic brain infarcts on diffusion-perfusion magnetic resonance imaging when compared to transfemoral CAS with a distal filter [68].
Angioplasty Balloons and Stents
Multiple low profile balloons are available for carotid angioplasty. A rapid exchange (monorail) system is instrumental and mandatory, as it minimizes manipulation across the lesion. The diameters range from 2 and 4 mm for pre-dilatation purposes to 4–6 for mm for post-stenting dilatation. After the lesion has been crossed and the filter deployed, it is common to pre-dilate the lesion with a 3 or 4 mm rapid exchange balloon. Some operators routinely administer small doses of atropine (0.25–0.5 mg) before balloon dilatation, except in patients with a recurrent stenosis.
Post-stenting balloon angioplasty should be focal and judiciously utilized to gently mold the stent at the site of lesion, which allows for future remodeling. Aggressive large balloon angioplasty should be avoided to minimize thromboembolic complications. The stent provides continuous expansible energy after the procedure, and the urge to disrupt the lesion more than necessary should be avoided. The balloon should also be maintained within the stent to avoid dissection during post-dilatation.
All carotid stents are self-expandable and they are all constructed from nitinol (nickel-titanium alloy) except the Wallstent (Boston Scientific, Natik, MA), which is a braided-mesh frame constructed from stainless steel (a cobalt alloy). There are 3 types of carotid stent designs: open cell, closed cell and hybrid.
Open cell stent designs have a bigger free cell area and lighter scaffolding, which allows some individual segments of the stent to move more freely. Open-cell stents are able to conform to more tortuous anatomy without significant kinking. On the other hand, they might show decreased ability to trap plaque and thrombus. The Precise stent (Cordis Endovascular Inc, Warren, NJ), Acculink stent (Abbott, Abbott Park, IL) and the Protegé (ev3 Inc. Minneapolis, MN) are examples of FDA approved open cell stents.
Closed-cell stents have a smaller free cell area and denser scaffolding, providing greater radial force, greater rigidity, and potentially improved ability to trap plaque or thrombus between the outside of the stent and the vessel wall. The higher rigidity of these stents, however, might make them prone to fracture and also more likely to deform the vessel in which they are placed, creating kinking of the vessel and poor wall apposition. The Xact carotid stent (Guidant/Abbott Vascular) and the Carotid Wallstent Monorail (Boston Scientific, Natik, MA) are among these kind of stents.
Recently, a hybrid stent, the Cristallo Ideale stent (Invatec/Medtronic, Roncadelle, ITA), became available for use in Europe. This stent has been designed with an open cell configuration in the proximal and distal ends to maximize conformability, and closed cell configuration in the middle portion of the stent to prevent plaque prolapse through the stent struts. This stent platform seems to be safe and effective in the peri-procedural period [69].
Stent tapering is advantageous when the common carotid artery (CCA) and internal carotid artery (ICA) differ significantly in size. There is evidence of decrease in the rate of re-stenosis with the use of tapered stents in this situation [70]. The Wallstent self-tapers, however, and because of its woven design, it substantially foreshortens with larger diameters. The Precise stent also tolerates mismatch in size owing to a relatively small number of connecting bridges. Specifically designed tapered stents include the Acculink Xact (Abbott, Abbott Park, IL) and the Protegé (ev3 Inc. Minneapolis, MN).
Given the differences in stent design and behavior, stent choice should be carefully tailored to the carotid anatomy and the plaque characteristics. Adequate sizing of the device is of utmost importance and should be guided by pre- and intra-procedural measurements, aiming for slight oversizing and complete lesion coverage, typically spanning the carotid bifurcation.
Intraprocedural Technical Considerations
In patients requiring an initial arch arteriogram, a 30°–45° left anterior oblique (LAO) projection generally provides the best visualization ("open up") of the brachio-cephalic arteries' take off. Of note, the best projection for evaluating the right innominate bifurcation is the right anterior oblique (RAO). When diffuse or shaggy disease is observed at the level of the aortic arch, compromising the take off of the brachiocephalic arteries, selective catheterization should be cautiously done or even avoided.
Heparin to achieve ACT >250 s should be given prior to selective catheterization of the aortic branches. Careful monitoring of ACT is recommended to avoid excessive anticoagulation. Bivalrudin has also been proven to be a safe and efficient anticoagulation strategy for CAS and could be considered as an alternative to heparin [71, 72].
During catheter exchange and manipulation, extra care should be taken to avoid potential embolization of debris, thrombus and air bubbles. Use of a manifold system is helpful in that regard.
Once the ostium of the common carotid artery has been negotiated, it is not recommended to advance the wire to the ICA, but rather to park it in the CCA or the ECA; the wire should provide enough purchase to avoid loss of access from the CCA while advancing the catheter. The operator should also avoid tension accumulation while advancing the catheter, since this might cause a sudden jump of the wire-catheter complex and inadvertent forward movement into the bifurcation or the ICA.
Once the catheter is placed at the level of the common carotid artery, an angiogram to visualize the carotid bifurcation, as well as the cerebral vessels in the Townes and lateral projection, is often obtained. Detailed and specific knowledge of the brain vascularization is instrumental in identifying and delineating collateral pathways and the pre-interventional cerebral perfusion configuration.
Baro-reflex responses such as bradycardia, hypotension, and vasovagal reactions occur in 5–10 % of cases, but have been reported in as many as 33 % of patients undergoing CAS [73, 74]. Most are transient and do not require ongoing treatment after the procedure. Asystole during balloon inflation is transient and responds to balloon deflation. Pre-treatment with atropine or glycopirrolate prior to angioplasty is often used to prevent bradycardia or asystole during carotid angioplasty and stent placement [75, 76]. The operator should be aware that patients on pre-operative beta-blockers might not respond well to atropine.
Complications and Bailout Techniques
Cerebral embolization might result from the dislodging of an organized clot from the surface of the plaque, debris, plaque fragments and a mixture of fibrin, cholesterol clefts, red and white cell aggregates [57].
The prevention of micro-embolization depends on optimization of pharmacological treatment outlined above and on gentle technique.
The primary role of the EPDs is the capture of macro-emboli. Unfortunately, embolism still occurs, either due to insufficient EPD seal, distal embolization caused by the deployment of the EPD itself, dislodged thrombus prior to proper placement of the device or simply by the lack of its use. Embolization can also occur after the completion of the procedure through the stent struts. Acute emboli lodging in the middle cerebral artery can be fragmented using balloon angioplasty or by guide wire manipulation under the risk of further distal embolization [77]; this could be particularly helpful in cases where the embolic material is plaque-like, and not effectively dissolved by thrombolytic agents.
Recombinant TPA are commonly used thrombolytic agents. These are delivered through super-selectively placed micro-catheters. Recombinant TPA may be given as a 5-mg bolus, followed by slow-infusion (maximum dose 20 mg). Control angiography at regular intervals (e.g. every 15 min) should be performed and continued for 1 h or until recanalization has been achieved [78]. Other techniques for neurorescue involve the use of intra-cerebral clot retrieval devices such as the Merci (Stryker; Kalamazoo, MI, USA) or the Solitaire (Covidien/ev3; Dublin, Ireland). If the operator is not familiar with neurorescue techniques and maneuvers, it is imperative to identify someone at the same institution who is, in the rare event such interventions are needed.
Acute in-stent thrombosis in CAS is a potentially fatal complication. With a rare incidence of 0.5–2 % [79], this life threatening complication seems to be related to the lack of treatment with combination antiplatelet therapy [80]. Treatment consists of intra-arterial thrombolysis at dose regimens described above for embolism. Treatment with intra-carotid administration of 0.25 mg/kg of abciximab intra-arterially, followed by a continuous intravenous infusion (9 μg/min for 12 h), has also been reported [81].
Thrombosis occurring during the procedure itself seems to be associated with the use of EPD [82], likely due to dislodgement and accumulation of debris and thrombus in the device. There are reports of thrombosis arising on the wire of the filter system [83]. Treatment consists of local administration of abciximab or aspiration of thrombus followed by retrieval of the filter device using the guiding catheter or sheath already in place.
Spasm can occur during any procedure in the carotid artery. It seems to occur more frequently in cases where embolic protection devices are used [84]. Treatment is necessary in cases of flow-limiting spasm, and consists of the local administration of vasodilators, either nitroglycerin or papaverin [85]. In cases where the embolic protection device seems to be the cause of the spasm, advancement of the device may be useful.
Dissection is a rare complication during carotid artery stenting. If flow reduction is not hemodynamically significant, expectant management could be advocated; however, if the flow impairment is judged to be significant, treatment consists of either insertion of a second stent, or urgent surgical repair [86].
Post-operative Care and Follow-up after CAS
Patients are monitored in the hospital overnight. It is not uncommon for patients to respond to carotid sinus distension with bradycardia and hypotension [76]. Hypotension may last from hours to days, depending on the sensitivity of the baroreceptors. Occasionally, 24–48 h of inotropic support is required before the carotid sinus adapts to the radial force of the self-expanding stents. The presence of significant hypotension in the absence of bradycardia is unusual in the immediate post procedure period; it is worth emphasizing that other causes (e.g. retroperitoneal bleed, myocardial infarction) should also be excluded.
In hypertensive patients and in patients with critical stenosis, a transient post-procedural confusional state with headaches and transient localized symptoms not associated with angiographic changes has been reported by Vitek et al. CT scan imaging will demonstrate mild hemispheric swelling and effacement of sulci, suggesting adequate or improved perfusion. These symptoms resolve over 24 h with good control of blood pressure [87].
Cerebral hyperperfusion syndrome (HPS), is a potentially life threatening neurological syndrome characterized by the triad of: (1) unilateral headache, (2) seizures and (3) focal neurological deficit. In its extreme form it can present as intracerebral hemorrhage. Originally, HPS was described in patients undergoing carotid endarterectomy for severe carotid stenosis; more recently however, it is a well documented complication of CAS. It is believed to result from hyperperfusion of blood into an unprotected or damaged brain parenchyma, resulting in maximal dilatation of intra-parenchymal arterioles and impaired cerebral autoregulation. The incidence of HPS after CEA has been reported to be around 3 and 7 % after carotid stenting [88]. This is particularly prominent in patients with severe stenosis and poor cerebro-vascular reserve [89]. Post-procedurally, tight blood pressure control is mandatory and the systolic blood pressure should be maintained between 100 and 140 mmHg. A combination of short acting IV beta-blockers and nitroglycerine is the initial therapy to control severe hypertension. HPS occurs mainly within the first 2 weeks after CAS and may be triggered by poorly controlled hypertension. In current practice, patients typically are discharged home the day after the procedure, so it is important to be conscious of this complication since it can occur in the outpatient setting. Continuous blood pressure monitoring after discharge is important since the patient's anti-hypertensive medications might have been stopped in the hospital after a transient reduction in blood pressure post-procedurally.
Prior to discharge, NIH stroke scale classification should be recorded. Follow-up includes 1 month, 6 month, and yearly clinical evaluation and duplex examination.
Carotid artery stenting is an effective treatment for carotid stenosis in the appropriate setting and for the appropriate patient population.
Patient selection is the cornerstone to secure optimal outcomes, it requires thorough imaging, detailed diagnostic evaluation and a cautious decision making. Patients at high risk for stroke with CAS such as symptomatic patients and octogenarians should be treated only selectively with CAS to minimize the risk of neurologic adverse events.
Peri-procedural medical management is of utmost importance to optimize the results of CAS. Blood pressure control, hyperlipidemia management and adequate antiplatelet therapy are mandatory. In addition, overall management of comorbidities such as diabetes, concurrent CAD and pulmonary issues by a multispecialty team is also necessary.
Optimal results will likely derive from putting institutional protocols in place that allow careful patient selection, best medical management, and integration of a highly skilled interventional team.
Rolando Celis and Rabih A. Chaer declare that they have no conflicts of interest.
Papers of particular interest, published recently, have been highlighted as: • Of importance
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An excerpt from www.HouseOfNames.com archives copyright © 2000 - 2018
Wales. This old, proud name derives from the personal name Meuric, which is the Welsh form of Maurice. The surname Merock is ultimately derived from the Latin personal name Mauritius, which means "dark." In Britain, Maurice was the learned form of the name, while Morice was the common form.
Merock Early Origins
Anglesey (Welsh: Ynys Môn), a Welsh-speaking island, and present day County of Isle of Anglesey, located at the northwestern extremity of Wales, where they held a family seat from early times and their first records appeared on the early census rolls taken by the early Kings of Britain to determine the rate of taxation of their subjects.
Merock Early History
Merock Early History
This web page shows only a small excerpt of our Merock research. Another 235 words (17 lines of text) covering the years 1190, 1505, 1566, 1538, 1599, 1576, 1599, 1556, 1601, 1563, 1640, 1636, 1713, 1674, 1712, 1714, 1666 and 1660 are included under the topic Early Merock History in all our PDF Extended History products and printed products wherever possible.
Merock Spelling Variations
Merock Spelling Variations
There are relatively few surnames native to Wales, but they have an inordinately large number of spelling variations. Early variations of Welsh surnames can be explained by the fact that very few people in the early Middle Ages were literate. Priests and the few other literate people were responsible for recording names in official documents. And because most people could not specific how to properly record their names it was up to the individual recorder of that time to determine how a spoken name should be recorded. Variations due to the imprecise or improper recording of a name continued later in history when names originally composed in the Brythonic Celtic, language of Wales, known by natives as Cymraeg, were transliterated into English. Welsh names that were documented in English often changed dramatically since the native language of Wales, which was highly inflected, did not copy well. Occasionally, however, spelling variations were carried out according to an individual's specific design: a branch loyalty within the family, a religious adherence, or even patriotic affiliations could be indicated by minor variations. The spelling variations of the name Merock have included Merrick, Merick, Meyrick, Meynik and others.
Merock Early Notables (pre 1700)
Merock Early Notables (pre 1700)
Prominent amongst the family during the late Middle Ages was Rowland Meyrick (1505-1566), born at Bodargan in the parish of Llangadwaladr, Anglesey, a Welsh bishop of Bangor; John Meyrick (or Merick, Mericke, or Merrick), M.A. (1538-1599), an Anglican clergyman who served in the Church of England as the Bishop of Sodor...
Another 81 words (6 lines of text) are included under the topic Early Merock Notables in all our PDF Extended History products and printed products wherever possible.
Merock In Ireland
Merock In Ireland
Some of the Merock family moved to Ireland, but this topic is not covered in this excerpt. Another 61 words (4 lines of text) about their life in Ireland is included in all our PDF Extended History products and printed products wherever possible.
The Great Migration
The Great Migration
Many Welsh families joined their Scottish and Irish neighbors during the late 1800s and early 1900s in seeking refuge in North America. Like the Irish and Scottish, many Welsh anxiously awaited the work, freedom, and opportunities that they believed lay in North America. Those who did journey over to the United States and what became known as Canada often realized those dreams, but only through much toil and perseverance. Whenever and however these Welsh immigrants arrived in North America, they were instrumental in the creation of the industry, commerce, and cultural heritage within those two developing nations. In the immigration and passenger lists a number of early immigrants bearing the name Merock were found: Henry Merrick, who settled in Virginia in 1635; Francis Merrick, who settled in Virginia in 1654; John Merrick, who arrived in Barbados in 1680 with his servants.
Merock Family Crest Products
Merock Family Crest Products
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Recognized implant dentistry program in the country
Spread over 8 sessions; 3 days / month, 180 Hours of Implant Education
Starting from Sept 19, 2014 and ending on Sept 11, 2015 at 'MQI' Lahore
Galvanize the rapidly emerging field of Implantology by harvesting the
Unique Training from the 20-Year Experience of the
Internationally Recognized Implant Mentor & Expert Dr. MQ
This is the 23rd One Year Program in Succession
This archetypal program, comprising of lectures, table clinics, laboratory exercises, surgical demonstrations and participant-supervised Live Patient Surgical Sessions is designed to develop skills for each procedure, thus covering almost every aspect of implant dentistry.
Participants are encouraged to bring in as many of their own patients in order to perform live surgeries themselves under the direct supervision of MQ and, thereby, implement the procedures directly into their dental practices. Closed-circuit TV coverage of live procedures are relayed into the main lecture room for all participants to observe the surgical sessions.
Please download and fill the attachments for the details of this extraordinary 7-session, (3-day/ session), a highly intensive '1' Year Multi-System, the '23rd' Comprehensive Course on Implant & Reconstructive Surgery at the MQI.
Please feel free to call for any inquiries at the numbers given below.
Ms. Humaila (Kay)
Mob: 0333 4213120, 0300 7340020Pakistan Academy of Implant Dentistry
1051-B, LMQ Road, Multan-60700, Ph: (92)(61) 6520123,For Appointments: 0342 9541923, 0300 7340020, Fax: (92)(61)6224123,www.qureshidental.com Facebook Page: Pakistan Academy of Implant Dentistry


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CodePlexProject Hosting for Open Source Software
Hi, very helpful work !
In my case, I've got a little problem: I'm not sure but the WcfServiceLibrary you write do not seem to work if one service is defined by myservice1.contracts.dll & myservice1.service.dll (about reflection and linking config to service...)
Am I right?
How can I solve this, my services being already used and written with this assemblies architecture?
P.S. sorry for my english, I'm french, that explains...
Are you sure you want to delete this post? You will not be able to recover it later.
Are you sure you want to delete this thread? You will not be able to recover it later.


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Training Package for MARSS00008 Shipboard Safety Skill Set - Release 2
This Skill Set reflects the work required by people who need an Australian Maritime Safety Authority (AMSA) Elements of Shipboard Safety Certificate
Shipboard Safety Skill Set Course Flyer
Training and Assessment are conducted in accordance with the MAR (Maritime) Training Package. See www.training.gov.au for more information.
Fire Fighting:
MARF002 - Follow procedures to minimise and fight fires on board a vessel.
Please contact an accredited Fire Fighting Training Organisation to obtain a Fire Warden Certificate.
Survive at Sea:
MARF001 - Apply basic survival skills in the event of vessel abandonment
MARF004 - Meet work health and safety requirements
MARF005 - Survive at sea using survival craft
Training for Survive at Sea is provided by SMIT.
First day of course:
SMIT Training Centre
Second day of course:
East Point Reserve - Flare Demonstration
Parap Pool - Survival using life raft
Certificates are available after completion of the Survive at Sea course and the original certificate of completion from your Fire Warden training is sighted.
Survive at Sea $550. Payment and your completed enrolment form is required before the start of the course.
Our Shipboard Safety Skill Set training dates:
29 - 30 January, 2018


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Product or Service
Sell composite manhole cover and frame
Profile:Other|Ref:PSL16500YH | Country: China | Export: No
Manhole covers, gully grating, tree grate are made of composite material (SMC, BMC, HMC). These items are competitive in both of price and quality than the castings. The samples and drawings from buyer are available.
Sales Conditions & certifications:
ISO9001 and EN124
Contact the company


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Secure Coding Fundamentals
Learn to look at software like hackers do. In this immersive, one-day workshop, taught in Dutch or English, you'll gain the ability to detect vulnerabilities and security leaks by hacking into your own applications. Develop the skills and knowledge you need to write and deliver safer and better software.
Audience Profile Secure Coding Training
You will benefit from Secure Coding training if:
- you work as a developer
Achievements upon completion
- achieve the ability to write secure code
- deliver safer, better software, faster
You will learn:
- how to write secure code
- how to prevent your code from working against you
- how to identify and protect against the most common web application attacks (including the OWASP top-10)
- how to identify various injections, cross-site scripting (XSS) and cross-site request forgery (CSRF)
You will gain hands-on experience in:
- manage sessions/ tokens
- validate input
- log and respond to mistakes
- apply hacking and security tools
- review code
- social engineering
You will develop the skills to:
- identify and prevent potential security leaks
- develop less vulnerable web applications
- write and deliver safer, better software
Additional Information
Prerequisites & Notes
You'll need your own laptop for this training with the following requirements:
- Windows/ Linux/ OSX
- modern web browser installed (preferably Firefox)
- required software will be provided


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A few days ago, we came across this fantastic library from the Dropbox team, to encode and decode JSON using C++11. Syntax is very clean and attractive which makes the library very easy to use.
Also, this library is an ideal example to show how to upload to biicode your library like I did.
Why would you want to upload to biicode your library ?
Once it's uploaded to biicode, everyone (including yourself) can reuse it easily and without any complex configuration.
This is key: If you make a good job configuring and uploading the library to biicode, nobody will EVER do this job again. The library will work for anyone just by typing #include "lasote/json11/json11.hpp".


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New to the Table
What is IF:Table?
A place to gather women and share a simple meal and dive deep with people over real stories and Christ centered conversations. A time for a whole lot of laughter – and maybe a few tears – but time spent that leaves us with glad hearts. Full hearts. Grateful hearts.
We're inviting you to join us by hosting a dinner with us. Once a month in your local communities
The vision is
6 women
4 questions
2 hours
(Acts 2:46)
Invite your people, prepare a simple meal, and we will provide the conversation cards 2 weeks before each IF:Table.
When is IF:Table?
We encourage you to eat with us on the Second Sunday of every month. However, if that time does not work for you and your guests, then do it another time that day or week!
Where is IF:Table?
At YOUR Table! Wherever that may be… However messy… Pinterest uninspired… Regardless, Tweet/Instagram/Facebook pictures of your women and your table using the hashtag #IFTable
Who do I invite to my IF:Table?
You feel free to invite whoever you like to this first IF:Table dinner! In the future, we will provide ideas or challenges for women to gather around the table.
Do I ask different women each month or the same group of 6 month to month?
We want you to dream and pray about who you gather around your IF:Table. This month, invite whoever you feel called to invite. In future months, we will provide ideas and maybe even a challenge to you for who to invite and to connect with around the table
Do I have to have my IF:Table group on the second Sunday?
If the second Sunday doesn't work for you, plan your IF:Table on another day. But do join us online as we celebrate monthly together.
I want to host an IF:Table but I don't know who to invite – is there a way I can meet people that might want to do this in my area?
Yes! We encourage you to check out IF:Local on Facebook to see if there are women in your area. If you can't find them there, consider getting outside your comfort zone. Pray. Ask God who you should invite. Then go for it! We'll be here to encourage you.
Will there be a live video or any other technical elements to the IF:Table?
Nope! We do not want to distract from the deep connections that are possible around the table. All you need are the conversation cards, and we want to hear from you after your table gathering. Tweet/post/email ([email protected]) photos and stories from your table. Don't forget the hashtag #IFTable.


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Psychics have been a common fixture in the annals of cartoonish anime hyperviolence, and for damn good reason. As we all know, it's a small step from bending spoons and guessing cards to smearing people all over the hot pavement like jam on inedible toast. Shinsekai Yori is well aware of how psychics in fiction apparently don't like internal organs to remain firmly in place, and so makes pavement jam out of innocent bystanders in just a few minutes. It's practically nauseating, though that may be the result of the persistent shaky-cam blur making me wonder if my glasses malfunctioned for a few minutes. But they didn't, and the lush visuals and even lusher setting came in clear as a bell.
At this point, describing a show as gorgeous often comes across as disingenuous praise, but it's not just the animation that's been lavished with loving attention, groomed for the world to gawk at. The setting itself, though not the first to feature a small town after civilization's Big Crunch, manages to give an eerie vibe without compromising the normalcy that it has for the characters. To coin a pretentious, seemingly contradictory term, Shinsekai Yori's setting is a Benign Dystopia that appears strange from our perspective, but exists for the safety of the villagers.
The psychic powers themselves are also portrayed surprisingly well, divided into separate categories beyond simple telekinesis. There's something delightfully unsettling about mental killing potential being treated as the norm, even more so that the village discourages exploring both those abilities and the world beyond the village's boundaries; despite being barely in their teens, these children are expected to have the restraint of adults, or they'll be considered problems in need of eradication.
While the transition from psychics smearing pavement with people jam to the world reverting to a more localized lifestyle isn't elaborated on, it doesn't feel as abrupt as it could have. The reversal doesn't have the blatant social criticism of Jinrui either, lending itself to horror that builds in a slow boil. The closest comparison in terms of setting would be Shiki, whose start was also a bit underwhelming. It requires patience and somewhat of a keen eye, but there's a lot simmering under the relatively benign surface beyond the feline-esque Black Shuck stalking the underperforming psychic children. It's a world full of people that encourage paranoia, with dangers lurking beyond the boundaries of the village and subtle problems plaguing the townsfolk.
This is what I love in horror, and what gives it a special place in my heart; however, I'll acknowledge that it might not be to everyone's taste, and I don't mean that in a backhanded "you just don't get it because you're not smart enough" way. It's a damn slow start with little to no payoff and a few directorial quirks that show signs of some potholes; many will be put off by this, but I sure enjoyed it. However, my positive response doesn't change the fact that only time will tell if this becomes just as good and atmospheric as Shiki, or a meandering, pretentious slog like Kamisama Dolls, though I'm banking on the former based on how there seems to actually be some semblance of originality here.


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GraphicRiver Love Neighbour Logo 8520078
Category: Logo Template | Comment: ( 0 )
GraphicRiver Love Neighbour Logo 8520078
Logo Template \ Symbols
Neighbor \ Member \ Meeting \ Neighbour \ Relationship \ Team \ Social \ Love \ House
Logo Template - Love Neighbour Logo 8520078 by APIYOT_P @ GraphicRiver
Logo Template \ Symbols
Graphics Files Included: Vector EPS, AI Illustrator; Layered: No; Minimum Adobe CS Version: CS; Resolution: Resizable.
Love Neighbour Logo design for creative studio company.
- AI CS4 Document
- EPS 10 Document
- PDF Document
- CMYK 100 % Vector (Re-sizable)
This Logo use free font more detail in help file.
Star Flora Logo; Play Audio Logo; ButterFly 2 Logo; Medical Sound Logo; Music Mixer Logo; Coffee Focus Logo; Focus Chat Logo.
Keywords: board, chat, community, family, friend, group, home, house, love, meeting, member, neighbor, neighbour, relationship, social, team.


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What are you made of…?
Borrowing Strength Builds Weakness – A Lesson From My 104 Year Old Great Grandmother.
The strongest people in life are the ones who have endured the most.
Whether by choice or through life circumstance, strength comes as a result of confronting and overcoming difficulties and challenges.
How does a person strengthen their body? By challenging it through exercise.
How does a person strengthen their mind? By challenging it through expansive thinking.
How does a person strengthen their spirit? By challenging it through inward reflection.
These aren't the only methods, of course.
Life is full of challenging opportunities through which you can become a stronger person… But I'm sure you already knew that (we have all faced our fair share of challenges).
The difference then, between those who are strong and those who are not is how they choose to respond to challenge. Continue reading
Which Are You? Carrots, Eggs, or Coffee Beans? A Powerful Short Story About Handling Problems in Life.
A young woman went to her grandmother and told her about her life and how things were so hard for her. She did not know how she was going to make it and wanted to give up. She was tired of fighting and struggling. It seemed as one problem was solved a new one arose.
Her grandmother took her to the kitchen. She filled three pots with water. In the first, she placed carrots, in the second she placed eggs and the last she placed ground coffee beans. She let them sit and boil without saying a word.
In about twenty minutes she turned off the burners. She fished the carrots out and placed them in a bowl. She pulled the eggs out and placed them in a bowl. Then she ladled the coffee out and placed it in a bowl. Turning to her granddaughter, she asked, "Tell me what do you see?"


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Mazzio's, Hungry Howie's deploy management software suite
Mazzio's Italian Eatery and Hungry Howie's Pizza have begun using ShiftNote's web-based management software suite to improve shift management at the store level.
These two join a growing list of national restaurant and hospitality clients, which include Landry's Inc., California Pizza Kitchen, Tommy Bahama, The DoubleTree by Hilton, Holiday Inn Express, Famous Dave's, Panera Bread and Smokey Bones.
Tulsa, Okla.-based Mazzio's Italian Eatery, established in 1961, includes 155 corporate and franchised locations in 10 states.
"We chose ShiftNote because it is a great program at an affordable price," said Erica McMains, operations services specialist for Mazzio's Italian Eatery. "This is allowing us to move away from the paper-based mess that clutters all our managers' offices and now the entire management team is involved in active communications. It's really improved our efficiency."
Taylor, Mich.-based Hungry Howie's was established in 1973 and currently operates more than 545 locations in 21 states.
"We were looking for an electronic solution to replace our Manager Log Books," said Al Newman, director of Training for Hungry Howie's Pizza. "ShiftNote had all the features we needed and now our communication between unit level management and multi-unit supervisors is more streamlined than ever before."
The ShiftNote Suite is a subscription-based solution that includes two components:
- ShiftNote Manager's Logbook allows users to log notes from each shift into a secure web-based system – eliminating the need for paper binders. The manager can then share documents, assign tasks, create events and send messages for single or multiple locations at once.
- ShiftNote Scheduler lets managers create and edit schedules online from any Internet-enabled computer. Schedules can be published for the entire staff to see via a secure online interface, giving them the ability to release and pick-up shifts from their own computers.
Read more about systems and technology.
Topics: Operations Management, Staffing & Training, Systems / Technology
Sponsored Links:


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I was pulling images for a 2012 year-in-review post I'll be putting up next week and I realized I posted almost nothing from New York, despite shooting out there about five times! I love shooting in New York and its a bit of a second home for me as so many of my clients live out there. New York destination engagement sessions have a totally different spirit than all the ones here. In Chicago, I find that there are certain locations that are "go-tos" that couples tend to lean toward, but in NYC, the shoots tend to be more a reflection of the couple, their interests and their own neighborhood, which I just love. Every shoot I did there last year felt totally unique and very personal to the couple and who they are. Lillian and Josh in particular really wanted a shoot that reflected them, and I had a great time going to one of their favorite delis for egg creams and even capturing them just buying their coffee at Zabar's. We also went to Lincoln Center as Lillian loves dance, and I loved her vintage inspired dress that really lent such a classic and fun look to the shoot. These two are so stinking cute together and just the most fun – I am so so excited for their wedding in just a few months!
January 3, 2013


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I talked to a rep tonight in the store and we all know that they are 100% reliable in the store! He said rumor has it in May 2013 Verizon switch all out of contract unlimited data users to 2GB plans.
I am looking to get the Samsung Note II for $199, I still have a new every two discount on another account. I was going to get the Note II on this other account and then switch it to my unlimited data account.
1. Verizon says that they will only add a 30 data option to the 1st account which will not effect the old America's Choice plan that its on now. I thought everything under renewal went to a Share Everything plan?
2. If they are going to cancel my unlimited data in May, is it really worth getting the phone now or wait until line 2 is upgrade eligible?
3. If I don't have to switch to a share everything plan, what will they put me on?


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Have you ever made a mistake that caused you to start breaking bad habits?
We all have bad habits we'd love to break, but seldom do we get around to it until something makes us change.
When things are going well, it's easy to stick to your habits without questioning what you are doing. When you screw up and have to fix it, you have to learn new ways of doing things, which is a great opportunity to fix your bad habit.
Making mistakes helps in two ways. First, you look at the problem in new way. You move away from acting out of habit and you question your assumptions about what exactly you were accomplishing with your old approach.
Secondly, you reexamine your resources. Look to the things you have to solve the problem.
The Tale of the Bad Bags
We use a lot of disposable products in our house. Heck, last year when we did our no spend month, Jon put paper plates second on the list of things he missed having around the house.
Paper plates, paper towels, plastic forks, plastic bags...I know they are all expensive substitutes for permanent and ecologically-friendly products. Still, we use them because they are easy and functional.
Even when Little Bit went to her outdoor super-ecologically focused preschool, she was the only kid bringing lunch and snacks in plastic bags. They kept her food fresh and they were easy to pack in her lunchbox.
Plastic bags cost money, though, so a couple of months ago when I needed a new box, I bought 150 foldover sandwich bags instead of the 40 sealing ones for the same price.
Big mistake. Yeah, the sealing bags seal. The foldover kind? Not so much. All of a sudden, Little Bit came home with loose pretzels and cereal in her backpack and strawberries staining her lunchbox. She also began complaining that her snacks had gone stale. It didn't take long to realize that those foldover bags didn't work very well for us.
We needed a better solution.
I could buy new bags and toss the old ones, but that offended my (limited and contradictory) frugal sensibilities. I tried using rubber bands and chip clips to seal the bags better, but the clips and bands inevitably fell off and my picky eater still complained about stale food that hadn't been stale 4 hours earlier.
So I sorted through my stash of plastic tubs and found a few takeout Chinese soup and sauce containers that would easily fit in Little Bit's lunchbox. Instead of plastic bags, i used the takeout containers for cheese and crackers, fruit, pretzels and everything else.
There were a few hangups at first. For instance, Little Bit asked why I'd sent her onion cream cheese for lunch one afternoon. I laughed and showed her the sliced plum that lay in the container. Since then I've either used a clear container or made a point to tell her what was in her lunchbox.
Last week, I finally used the last of the crappy sandwich bags, and bought some of the better ones. I'm not using them nearly as often, though. For the most part, the little washable containers work better. The food doesn't get mashed or crumbled bumping around in Little Bit's backpack as much, and I like not generating quite as much trash.
I would never have switched my habits, though, if I hadn't made a mistake and bought the wrong bags.
So What Does a $2.00 Mistake Teach?
You're probably wondering why I'm talking about a purchase so small and insignificant. After all, I spent at most $2.00 on generic plastic sandwich bags each month. Does it really matter than I'm using fewer of them?
But I knew using the disposable stuff as often as I was using it was a bad habit i wanted to break. Using disposable bags hurts the environment by generating more trash. It wastes money.
I'm not proud of our plastic bag habit, sot I am grateful to find a different approach to food storage and transportation that seems to be working just as well. It just took a shake up to get me breaking this bad habit.
It's not the first time I've found myself forced into breaking bad habits. In my 20's, having my credit cards cancelled led to much better spending and saving habits. Losing my job last year eventually led to spend tracking and budgeting. Avoiding Jon's
nagging reminders means I no longer swear like a sailor
But big changes don't have to come from outside. You can also shake things up yourself. Going on our spending freeze last year taught me a lot about why i spend, and how I could more effectively live within our budget.
Now it's just time to change a few more things.
So what bad habits remain?
I often leave things until later, only to find that I don't get them done or scramble at the end. What's not working? What I'm doing. My current practices lead to lack of exercise, too much convenience food, and less productivity than I might like.
What resource haven't I used to tackle it? A task-oriented focus.. I can be really productive when focused, but I've lacked focus. I just kind of drift from task to task.
New Approach: The to do list. Okay, it's hardly novel. Lots of people use them. Also, since I do well with routine, I need to shake mine up a bit. I'm using the times I'm most able to accomplish things (mornings) to accomplish tasks that don't need a lot of focus. I need to prioritize exercise earlier in the day and move my blog scanning to either early morning (while I'm drinking coffee) or later afternoon.
Too Much Mindless Internet
Two days ago, I decided I'd try to avoid web surfing, facebooking and phone games after 6 pm. I'm finding those activities are sucking time and preventing me from interacting as well with my family as much as I should.
I don't mind mindful internet and productive uses. Working on this blog or reading and commenting on other blogs is useful, checking out the latest celebrity gossip is not. Playing video games with Little Bit on a game system also qualifies as legit and interactive.
I just don't need to be hunched over my phone screen for an hour or so playing Word Hero.
I failed in my mindless internet ban two days ago, in part because I kept the phone beside me. Yesterday, I grabbed my knitting and things seemed to go better. The best thing I can probably do though, is go plug my phone in during the evening so it's no where near me. Today, that's the plan.
Breaking Two Bad Habits
I'm not saying those are my only two bad habits. i have several more, but these two seem to be the root of a lot of related issues. I'm not accomplishing what I want to accomplish, and need to do a better job of prioritizing and not wasting time on things that don't add a lot of value to my life.
Breaking bad habits isn't easy, so whenever opportunities come to get rid of them, you should take them.
Have you every made a mistake that led you to shed some behaviors or practices you didn't like? What's your best method for breaking bad habits?
*Part of Financially Savvy Saturdays on brokeGIRLrich and, Disease Called Debt*


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LENNOX PHILLIPS passed the 100-goal mark for the past two seasons on Sunday - and his goals could not have been more important.
His brace helped Gunnersbury-based Park Place Sports Club U13s land the League Cup with a 3-1 win over Ballers FC at Osterley Sports Club. Phillips, who has had trials with Watford, scored 50 goals last season and made it 52 for this campaign with his cup final double.
But it was Ballers who took an early lead which they held until half-time, although Park hit the post and bar. Their persistence paid off after the break when just a few minutes in, Abdel Ghallani, who has trialled with Charlton, played Phillips in for the equaliser.
Reese Jones, who scored 38 goals last season and has hit 36 this term from the right wing, crossed for Phillips, whose shot was parried by the Ballers keeper onto the head of one of his own defenders and in.
Phillips made the game safe with his second with 10 minutes left, thanks to some quick-thinking from Jay Grewal. The youngster dummied a throw-in to Jones, taking two defenders out of the game, and instead launched it 30 yards for Phillips to run on to and score.
Manager Jay Grewal said: "The lads were fantastic, and Ballers were very sporting too - giving us three cheers at the end and applauding us when we got the cup.
"I even did my Achilles tendon in running onto the pitch celebrating!"


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PSNH requesting rate reduction in filing
Public Service of New Hampshire is requesting the rate reduction in a filing with the Public Utilities Commission this week.
The company said customers buying energy from Public Service would see an average rate cut of about 4.3 percent. Customers who buy power from another supplier would see rates drop about 2.7 percent.
The company wants to cut its energy service rate to 8.98 cents per kilowatt hour from 9.54 cents and make adjustments in other rates.
The energy rate reduction is due to changes in renewable energy rules. Other savings are due to the expiration of expensive contracts with independent power producers and efficient operation of generators.
If you'd like to leave a comment (or a tip or a question) about this story with the editors, please email us. We also welcome letters to the editor for publication; you can do that by filling out our letters form and submitting it to the newsroom.


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Illumina Beats Life Tech DNA Patent Infringement Claims
U.S. District Judge Cathy Ann Bencivengo found that Illumina and its Solexa Inc. unit had not infringed three patents covering a method and product for amplification of nucleic acids. The patents are owned by the Institute for Protein Research of the Russian Academy of Sciences and three individuals who are co-plaintiffs in the suit, but Applied Biosystems...
To view the full article, register now.
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US fast food chain Denny's wants Tolkien fans to prepare their intestines for an unexpected journey with its Hobbit-inspired menu, probably the weirdest movie tie-in served up.
While Peter Jackson is dabbling in the latest technology to bring Tolkien's much beloved children's book to the screen, Denny's is going old school to bring you closer to Middle-earth.
On the menu are such fattening dishes as The Shire Sausage Skillet, Radagast's Red Velvet Pancake Puppies, Bilbo's Berry Smoothie, Gandalf's Gobble Melt and The Ring Burger (but not raw fish for all those Gollums out there).
After throwing that lot down your throat like a fat greedy Hobbit, you'll probably need your own Master Samwise to carry you home or to a local wizard for some indigestion cure.
Second breakfast, anyone?
Originally published as Hobbit menu takes tie-ins to weird level