支架置入治疗颈动脉狭窄

颈动脉支架置入术 (carotidarterystenting ,CAS)是应用血管腔内外科技术治疗颈动脉狭窄的新方法。 1979年Mathias等首次应用颈动脉球囊扩张术(PTA)。为克服PTA的不足 ,1989年支架被第一次应用于颈动脉狭窄的球囊扩张术中 ,从而形成了真正意义上的CAS。1995年Bergeron等首次报道了应用CAS治疗颈动脉狭窄 13例。以后又有学者作了相继报道 ,综合各家报道 ,其临床效果满意。一、CAS操作技术1.操作技术 :患者平卧 ,局麻下采用Seldinger技术经皮穿刺插管于股动脉 ,放置一 9F动脉鞘 ,注射 5 0 0 0U肝素 ,全身肝素化可预防操作中血栓形成…     

颈动脉支架植入术并发症分析

目的 总结颈动脉球囊扩张及支架植入术(carotid artery stenting,CAS)治疗颈动脉狭窄术后并发症及处理措施.方法 回顾性分析2006年7月至2012年1月因颈动脉狭窄而接受颈动脉球囊扩张及支架植入术(carotid artery stenting)72例患者的临床资料.CAS操作采取标准治疗方法,患者术前5d均口服阿司匹林100 mg与氯吡格雷75 mg,所有患者均先放置远端保护装置,90％以上狭窄患者进行前扩张,残留狭窄＞30％则进行后扩张.结果 72例患者成功地植入颈动脉自膨式支架80枚,全部使用远端脑保护装置,5例患者行同期手术,其中冠状动脉搭桥手术( off-pumpcoronary artery bypass grafting,OPCABG)2例,左锁骨下动脉支架植入2例,1例肾动脉支架植入.住院期间并发症的发生率为37.5％(27例),其中严重并发症(死亡/卒中/心肌梗死)发生率为1.39％(1例同侧小卒中);其他神经系统并发症包括2例同侧TIA(2.78％),1例高灌注综合征(1.39％),血液动力学不稳定并发症的发生率为29.2％(21例),其中1例高血压(1.39％),5例心动过缓(8.33％),15例术后低血压(20.8％),其他2例出现穿刺点血肿(2.78％).结论 血液动力学改变(低血压、心动过缓)是CAS围手术期主要并发症,神经系统并发症发生率较低,严重并发症少见.     

无症状颈动脉狭窄患者颈动脉支架成形术后新发弥散加权成像病灶的危险因素分析

目的应用高分辨MRI分析无症状颈动脉狭窄患者接受CAS后新发弥散加权成像(diffusion weighted imaging,DWI)病灶的危险因素。方法回顾性分析2017年1月至2019年5月在复旦大学附属中山医院接受CAS的216例无症状患者临床资料,通过单因素和多因素Logistic回归分析CAS术后新发DWI病灶的危险因素。结果 CAS术后出现新发DWI病灶患者61例(28.24%)。Logistic回归分析结果显示,亚急性期斑块内出血(OR=20.167,95%CI=6.201～65.587,P0.001)和开环支架的应用(OR=3.201,95%CI=1.251～8.189,P=0.015)显著增加CAS术后新发DWI病灶的风险,斑块内钙化是CAS术后新发梗死的保护性因素(OR=0.256,95%CI=0.101～0.647,P=0.004)。结论亚急性期斑块内出血和开环支架是无症状颈动脉狭窄患者CAS术后新发DWI病灶的独立危险因素。术前对无症状颈动脉狭窄患者行斑块MRI检查将有助于减少CAS术后脑梗死的发生风险。     

抽吸取栓治疗颈动脉支架成形术后早期支架内血栓的效果分析

目的探讨颈动脉支架成形术(CAS)后早期颈动脉支架内血栓(EST)患者的临床特点与抽吸取栓治疗效果。方法本研究为回顾性病例系列研究。收集2021年1月至2023年9月于首都医科大学附属北京朝阳医院神经外科行颈动脉支架成形术, 术后出现EST的5例患者的临床资料。患者均为男性, 年龄(64.0±11.9)岁(范围:48～77岁);占同时期行颈动脉支架成形术患者的2.0%(5/244)。其中3例患者术前未接受标准双联抗血小板治疗, 1例二磷酸腺酐抑制率不达标;4例置入XACT颈动脉支架, 1例置入Wallstent颈动脉支架。5例CAS术后均存在较高残余狭窄表现, 残余狭窄率为43%～55%。患者均行急诊抽吸取栓治疗, 收集患者围手术期情况、血管再通情况和临床预后。结果患者CAS术后至EST发生的时间间隔为3 h至14 d, 主要临床症状为突发性意识障碍及对侧肢体肌力下降。患者术前均未进行静脉溶栓治疗, 术中均通过抽吸取栓再通血管。4例术中行球囊扩张, 2例应用第2枚支架套叠。术中2例患者出现术中栓子脱落至C2段, 1例栓子使用颅内取栓支架取出, 1例通过导引导管抽吸取出。术后患者脑梗死溶...     

近端血流阻塞式脑保护装置下颈动脉支架成形术的临床研究

目的 研究近端血流阻塞式脑保护装置MO.MA系统在颈动脉支架成形术中预防脑血管栓塞的疗效,并评价其安全性及可操作性.方法 2007年10月至2008年7月,23例符合外科治疗指征的颈动脉硬化狭窄患者入选本研究,其中19例(82.6%)患者有神经系统症状.全脑血管造影后在脑保护装置MO.MA系统下行颈动脉球囊扩张及支架成形术,计算术中脑缺血时间,观察术中及术后30 d神经系统事件的发生情况.结果 颈动脉造影示,6例(26.1%)颈动脉狭窄50%～70%,17例(73.9%)颈动脉狭窄>70%.所有病例在MO.MA系统保护下颈动脉球囊扩张及支架植入均顺利进行,颈动脉平均阻断时间(5.3±1.2)min.术中及围手术期无死亡及脑卒中发生;2例在颈总动脉球囊阻断时出现短暂意识丧失伴对侧肢体短暂抽搐;2例术后出现心动过缓和低血压,持续时间分别为6 h及1周.9例患者术中颈动脉抽血中可见细小斑块碎片.术后30 d随访有1例TIA发作,1例对侧新发脑卒中,术后30 d累积脑卒中发生率及病死率为4.3%.结论 应用近端血流阻断式脑保护装置MO.MA系统在颈动脉支架成形术中预防神经系统事件发生是安全有效的,尤其适合重度及不稳定性斑块的颈动脉硬化狭窄支架成形术治疗.     

颈动脉支架成形术前应用非增强多对比高分辨磁共振斑块成像评估价值研究

目的 分析非增强多对比高分辨磁共振成像技术在颈动脉支架成形术（CAS）术前评估中的应用价值。方法 回顾性分析2017年1 月至2018 年3月在复旦大学附属中山医院接受颈动脉狭窄接受治疗的181例病人资料,通过单因素和多因素Logistic回归分析明确颈动脉斑块性质与CAS术后脑梗死病灶的关系。结果 共纳入接受CAS手术病人181例,其中术后63例（34.8%）出现无症状性新发弥散加权成像（DWI）病灶,2例（1.1%）出现有症状性脑梗死。病人Logistic回归分析结果显示颈动脉斑块内出血是预测CAS术后的无症状DWI病灶的独立危险因素（IPH）（亚急性期IPH vs. 无IPH：OR=9.393;95%CI 4.431~19.911）。结论 术前应用非增强多对比高分辨磁共振成像对斑块成分进行评估可以发现斑块不稳定成分,对CAS手术病例的选择有重要的潜在价值。     

颈动脉支架内再狭窄的早期随访结果分析

目的分析颈动脉支架成形术(CAS)后发生再狭窄的早期随访结果,为临床治疗和预防术后支架内再狭窄(ISRS)提供依据。方法2003年1月至2005年9月在我院行CAS治疗的患者,分别于术后1、3、5、12和24个月行彩色多普勒超声随访,分析术前及术中诸多高危因素对术后ISRS发生的影响。结果共计37例患者接受了随访,其中,男性占91.9%(34/37),女性占8.1%(3/37);平均年龄(70.5±5.9)岁;平均随访(12.2±7.7)个月。术后发生ISRS16例(43.2%),再狭窄程度≥50%者仅占2.7%(1/37);其余均为30%~50%的轻度狭窄;3例女性患者均发生轻度狭窄。术后发生ISRS与患者性别、术中颈动脉球囊后扩以及是否合并其他外周血管动脉粥样硬化有关。结论CAS术后重度ISRS发生率较低;女性患者CAS术后可能更容易发生ISRS;术中球囊后扩对预防再狭窄可能有一定的作用;颈动脉狭窄的患者应同时加强对动脉粥样硬化的治疗。     

颈动脉再通术后重度再狭窄病变的诊治策略

目的评估颈动脉支架成形术(CAS)和颈动脉内膜切除术(CEA)治疗颅外颈动脉狭窄后重度再狭窄的诊断和治疗策略。方法回顾性分析2012年1月至2017年1月在复旦大学附属中山医院接受颈动脉再通手术治疗后发生严重再狭窄而二次手术治疗的15例患者资料,其中CEA术后再狭窄3例,CAS术后再狭窄12例,均通过血管多普勒超声检查和数字减影血管造影明确诊断。结果对于CEA术后再狭窄的患者,治疗包括脑保护下CAS手术(2例)、球囊扩张(1例);对于CAS术后再狭窄的患者,治疗包括再次行CEA及补片血管成形术(7例)、球囊扩张(3例)、再次行脑保护下CAS术(2例)。患者围术期无脑卒中或死亡发生。1例CAS术后再狭窄患者采用单纯球囊扩张治疗后,6个月随访再次发生颈动脉再狭窄且伴有短暂性脑缺血发作的症状,接受CEA及补片血管成形术,术后随访1年显示颈动脉血流通畅。其余患者在术后随访过程中未见脑卒中或再狭窄发生。结论血管多普勒超声检查和数字减影血管造影是诊断颅外颈动脉再通术后再狭窄的重要手段。对于重度再狭窄的患者,需注意个体化治疗方式,围术期疗效及中期再狭窄复发率较满意,但仍需密切随访,注意再狭窄复发的风险。     

颈动脉支架置入术在合并无症状颈动脉重度狭窄的冠状动脉旁路移植术中的应用北大核心CSCD

目的对比分析颈动脉支架置入术(carotid artery stenting,CAS)联合冠状动脉旁路移植术(coronary artery bypass grafting,CABG)和单纯CABG两种术式治疗冠心病合并无症状重度颈动脉狭窄患者的围手术期情况及随访资料,评估CAS-CABG联合手术的安全性和有效性。方法回顾性分析2018年1月至2022年12月在北京安贞医院、北京朝阳医院、北京天坛医院行CABG治疗的700例冠心病合并无症状颈动脉重度狭窄患者的病历资料。根据是否进行CAS处理,分为CAS-CABG组(116例)和单纯CABG组(584例)。CAS-CABG组平均(64.8±7.3)岁,均仅行单侧CAS手术;单纯CABG组平均(65.5±7.6)岁。比较两组患者术后30天及中位24个月随访的主要结果。应用logistic回归法行单因素和多因素分析。结果CAS-CABG组患者术后早期卒中发生率显著降低(2.6%对9.1%,P=0.02),CAS联合CABG手术并未增加随访期间病死率和不良事件发生率。亚组分析发现,两种术式治疗无症状单侧颈动脉重度狭窄的卒中发生率差异无统计学意义,高龄、房颤史和卒中史是无症状单侧颈动脉重度狭窄CABG术后早期卒中的独立危险因素。结论CAS联合CABG治疗冠心病合并无症状颈动脉狭窄安全有效,可降低患者术后早期卒中发生率。应合理筛选合并无症状颈动脉狭窄的CABG患者,进行预防性CAS以降低此类患者术后卒中风险。     

颅外颈动脉狭窄的支架成形术治疗

颈动脉狭窄是引起中风从而致残甚至死亡的主要原因。颈动脉内膜切除术(CEA)是公认的标准术式，但近年国内、外学者越来越多地将颈动脉支架成形术(carotid angioplasty and stenting，CAS)应用于颅外颈动脉狭窄的治疗。1980年，Kerber等首先报道应用腔内球囊扩张术治疗颈动脉狭窄。以后     

The relationship between nesfatin-1 and carotid artery stenosis

Abstract

Objectives. Nesfatin-1 is a novel anorectic neuropeptide with potent metabolic regulatory effects. Nesfatin-1 regulates blood pressure, heart rate, cardiomyocyte metabolism, and permeability. We aimed to evaluate the relationship between carotid artery stenosis (CAS) and nesfatin-1. Design. Three groups were established as patients with no atherosclerotic plaques (n?=?60), CAS <60% (n?=?60), and CAS ≥60% (n?=?60). Then, patients with CAS were divided into 2 subgroups as patients with calcific (n?=?67) and non-calcific (n?=?53) carotid artery stenosis according to plaque morphological features. Nesfatin-1 levels and baseline data were compared between groups. Results. Serum nesfatin-1 levels were higher in the control group than CAS <60% group (p?<?.001). Serum nesfatin-1 levels were also higher in CAS <60% group than CAS ≥60% group (p?<?.001). Multivariable logistic regression analyses demonstrated that serum nesfatin-1 levels were independently associated with CAS. In addition, nesfatin-1 levels were higher in calcific plaques. Conclusions. Nesfatin-1 levels are inversely associated with severtiy of CAS and plaque morphology.     

CTP与HR-MRI对颈动脉狭窄患者行颈动脉支架置入术疗效的评估及应用价值

背景与目的 颈动脉狭窄是导致脑卒中尤其是缺血性脑卒中的重要原因,早期发现及有效治疗是减少缺血性脑卒中发生的关键。颈动脉支架置入术（CAS）是治疗颈动脉狭窄的常用方法,但术中和术后可能发生各种并发症,以及发生再次狭窄或闭塞的风险,因此,通过有效的方法对其进行疗效评估具有重要的临床意义。本研究分析CT灌注成像（CTP）与高分辨磁共振成像（HR-MRI）对颈动脉狭窄患者CAS术后疗效的评估效能。方法 收集2017年2月—2020年2月期间44例颈动脉狭窄并接受CAS治疗的患者资料,所有入选患者于手术前、手术后2个月行CTP、HR-MRI以及DSA检查,比较患者手术前后CTP与HR-MRI参数的差异,以DSA检查结果作为金标准,比较两种方法诊断颈动脉残余狭窄的效能。结果 CTP结果显示,与术前比较,患者术后2个月大脑动脉相对脑血流量明显增多,相对通过时间、相对达峰时间明显减少（均P<0.05）,相对脑血容量无明显差异（P>0.05）;HR-MRI结果显示,与术前比较,患者术后2个月血管面积、管壁面积以及管腔面积无明显差异（均P>0.05）,斑块面积、斑块负荷明显减小（均P<0.05）。DSA检查出16支颈动脉存在狭窄,颈动脉狭窄改善率为80.00%,CTP检查出颈动脉存在狭窄12支,颈动脉狭窄改善率为85.00%,HR-MRI检查出颈动脉存在狭窄14支,颈动脉狭窄改善率为82.50%,两种检查方式对颈动脉残余狭窄的诊断效能相当（P>0.05）。结论 CTP、HR-MRI均可用于颈动脉狭窄患者CAS疗效评估,两种方法补充使用,具有一定的临床应用价值。     

血流彩色编码成像技术评估颈动脉植入支架前后血流动力学变化

目的探讨彩色血流编码DSA(CC-DSA)评估颈动脉支架植入术(CAS)前后血流动力学变化的可行性。方法回顾性分析接受CAS治疗的颈内动脉起始段重度狭窄患者16例。将CAS前后颈动脉造影图像经CC-DSA后处理得到相应的彩色血流编码图像,分别于颈总动脉、颈内动脉C1段、大脑中动脉M1段及横窦处设置感兴趣点(POI),分别检测达峰时间(TTP)及相对达峰时间(rTTP)。同时收集CAS前后颈动脉狭窄段及颈内动脉C1段远端(管腔正常处)收缩期峰值流速(PSV)及舒张末期流速(EDV)。结果 CAS治疗后颈内动脉C1段及大脑中动脉M1段TTP及rTTP均较术前降低(P均0.05),CAS治疗前后颈总动脉、横窦TTP及横窦rTTP差异均无统计学意义(P均0.05)。CAS治疗后颈动脉狭窄段PSV及EDV均较术前降低,颈内动脉C1段远端PSV较术前升高(P均0.05)。CAS治疗前后颈内动脉C1段TTP变化值与其远端(管腔正常处)超声参数PSV、EDV变化值均呈正相关(r_s=0.500、0.522,P=0.049、0.038)。结论 CC-DSA可量化评估颈内动脉狭窄患者CAS治疗后血流动力学变化。     

Continuity in the Treatment of Carotid Artery Disease: Results of a Carotid Stenting Program Initiated by Vascular Surgeons

The treatment of carotid artery stenosis currently constitutes a major component of vascular surgical practice. Carotid angioplasty and stenting (CAS), however, is mainly performed by nonvascular surgeon interventionalists with cerebral protection devices available only through investigational protocols. This study reports the initial results of a CAS program initiated and performed by vascular surgeons using commercially available cerebral protection devices. Fifty-seven patients were enrolled in the study over a 14-month period. All patients were at high risk for conventional endarterectomy (7 resentosis, 4 irradiation, and 46 medically high-risk ASA III). Mean age was 75.7 years (range, 45-93 years). High-grade stenosis of the carotid artery was present in all cases (mean stenosis, 85%; range, 80-99%). Twenty-four percent of patients were symptomatic. Cerebral protection was performed with an occlusion balloon-wire in 32 cases and with a filter-wire device in 24; no cerebral protection was used in 1 patient with restenosis after endarterectomy. Initially in the study, atropine was administered selectively for the development of bradycardia. Currently atropine is administered routinely prior to the initial balloon angioplasty of the carotid bulb. Clopidogrel (75 mg/day) was administered for 5 days prior to CAS and for 30 days after CAS. All 57 patients underwent successful dilatation of their carotid stenoses without occlusion or dissection. Ten of 32 patients in whom balloon occlusion was used for cerebral protection exhibited transient evidence of cerebral ischemia during protection balloon occlusion. These symptoms resolved completely without permanent neurological deficit in all cases. Development of bradycardia with a heart rate <50 bpm was significantly reduced by routine administration of atropine prior to the initial dilatation within the carotid bulb (p = 0.01). Mean hospital length of stay was 1.33 days (range, 1-5 days). There were two periprocedure myocardial infarctions, two postprocedure transient ischemic attacks, and one reversible ischemic neurologic deficit. There was no 30-day mortality. There have been no instances of hemodynamically significant restenosis during a mean follow-up period of 5.4 months. From these results we have concluded that CAS can be performed effectively and safely using commercially available cerebral protection devices. A program initiated and performed exclusively by vascular surgeons is effective and should be the standard model used in the endovascular treatment of carotid artery stenosis.Presented at the 13th Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 31-February 2, 2004.     

Evaluation and Management of Plaque Protrusion or Thrombus following Carotid Artery Stenting

Carotid artery stenting (CAS) has become a common treatment for carotid artery stenosis. However, complications, such as an ischemic event, can occur with CAS during intra- and post-operative periods. Among these ischemic complications, plaque protrusion into the stent and thrombus on the stent have occurred after CAS. We retrospectively evaluated the temporal profile and treatment options for these complications in 32 consecutive cases who underwent CAS at our hospital between April 2009 and December 2011. The cases were evaluated pre-operatively for risk factors, as well as the plaque morphology and characteristics using computed tomographic angiography (CTA), ultrasound (US), and magnetic resonance imaging (MRI). Post-operatively, lesions were examined by CTA and/or US within 1 week of CAS. As a result, among the 32 cases, 8 experienced plaque protrusions or thrombus, which were treated with medication (anti-platelet and/or anti-coagulation reinforcement). In 7 of these 8 cases, the plaque protrusion or thrombus was stabilized with medication alone. However, the remaining case showed growth and migration of the plaque protrusion or thrombus when treated with medication alone, and therefore, required further endovascular treatment. We identified that a history of symptomatic cerebral infarction and plaques with ulceration were risk factors for plaque protrusion or thrombus formation after CAS, and pre dilatation can decrease the risk of these complications. Medication was effective in most cases of plaque protrusion or thrombus; however, further endovascular treatment was required when medication alone was unsuccessful.     

Impact of plaque dilation before carotid artery stent deployment

ObjectivePlaque stability is of utmost importance for stroke prevention in the perioperative period (within 24 hours) following carotid artery stenting (CAS). Although carotid plaque is entrapped between stent struts after stent deployment, postdilation can cause a scissoring effect on the plaque, increasing the risk of postprocedural embolic events due to plaque prolapse. Maximum carotid plaque dilation before stent deployment may reduce this risk. This study analyzed the effect of maximum dilation of the carotid plaque before stent deployment (max-pre-SD) or after stent deployment (post-SD) on macroscopic plaque debris, hemodynamic depression (HD), and immediate major adverse events.MethodsThis prospective nonrandomized multicenter study analyzed patients treated for carotid artery stenosis with CAS from January 2014 to August 2016. Clinical and morphologic characteristics and operative details were analyzed with logistic regression analysis for macroscopic debris and HD. The number of microembolic signals (MESs) was assessed by transcranial Doppler and analyzed.ResultsA total of 309 patients were enrolled and treated with standard CAS performed using a proximal occlusion cerebral embolic protection device; 149 received max-pre-SD and 160 were treated with post-SD. Technical success was achieved in 100% of cases. Macroscopic debris and HD were significantly different between the two groups in favor of max-pre-SD (P < .001). A significant difference in intraprocedural MESs between the groups was detected. Compared with post-SD, max-pre-SD significantly reduced mean MES counts (8.1% vs 68.1%; P < .001). Patients treated with post-SD had a significantly increased risk of MESs in the immediate postoperative period compared with patients treated with max-pre-SD (41.9% vs 1.3%; P < .001).This result was mainly due to the small number of events encountered. Patients treated with post-SD had a 12-fold increased risk of macroscopic debris collection (odds ratio [OR], 12.36; 95% confidence interval [CI], 5.68-26.87; P < .001) and an 18 times increase in HD risk (OR, 17.80; 95% CI, 5.27-60.17; P < .001) compared with patients treated with max-pre-SD. The heterogeneous, mainly echolucent plaque type significantly highly increased the risk of macroscopic debris (OR, 78.45; 95% CI, 8.70-707.09; P < .001) while acting as a protective factor against HD (OR, 0.02; 95% CI, 0.006-0.11; P < .001) along with echogenic or echolucent complex plaques with irregular surface plaque types (OR, 0.10; 95% CI, 0.031-0.336; P < .001). No significant differences between groups (max-pre-SD group and post-SD) were detected in immediate major adverse events (minor stroke, 2.0% and 2.5% [P = .461]; major stroke, 0% and 0.6% [P = .334], respectively).ConclusionsMax-pre-SD seems to be a safe and feasible technical modification to the CAS procedure. Macroscopic debris, HD, and MESs are significantly reduced compared with CAS with post-SD. Further research with larger, randomized cohorts of patients is required to establish the superiority of this technical modification.     

Hemodynamic instability after extracranial carotid stenting

Summary Objective. Hemodynamic instability (hypertension, hypotension and bradycardia) is a well-known complication of carotid endarterectomy. Carotid angioplasty and stenting (CAS) is becoming a valuable alternative treatment for patients with severe carotid stenosis and increased surgical risk. CAS implies instrumentation of the carotid bulb, so baroceptor dysfunction may provoke hemodynamic instability. The aim of this work was to calculate the incidence of this complication and to detect factors to predict it. Methods. Medical records and angiograms of 51 consecutive patients submitted to CAS for severe atherosclerotic stenosis (40 cases) or postsurgical restenosis (11 cases) were retrospectively reviewed in order to detect the occurrence of intra- and post-procedural hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <60 beats/min). The relationship between clinical, procedural and angiographic factors and the occurrence of hemodynamic instability was assessed with univariate and multivariate analysis (logistic regression). Results. Transient mild systolic post-procedural hypertension occurred in five cases (10%); preprocedural hypertension, asymptomatic stenosis and ipsilateral post-surgical restenosis predicted this. Hypotension with bradycardia also occurred in five cases (10%), one with neurological sequelae. Transient periprocedural bradycardia occurred in 19 cases (37%). Severe bradycardia without hypotension arose in one case only. Factors predicting post-procedural hypotension included the presence of a fibrous plaque and the ratio between the pre- and post-stenting diameter of the internal carotid artery. Peri-procedural bradycardia predicted post-procedural bradycardia. None of these factors were confirmed by multivariate analysis as a significant prognostic predictor. Conclusion. Mild systolic hypertension may occur after CAS, but is resolved by medical treatment. Prolonged hypotension and bradycardia may also arise and this can be dangerous because it may cause neurological deterioration due to hypoperfusion. These complications cannot be predicted by clinical, procedural, and angiographic factors.     

Is haemodynamic depression during carotid stenting a predictor of peri-procedural complications?

OBJECTIVE: The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains unclear. The aim of this study was to analyze the frequency and predictors of HD during CAS in a single centre experience. METHODS: A prospective protocol for CAS was applied in a 15-month interval. Patients with restenosis, on betablockers, or with arrhythmias were excluded. A standardized dose of atropine (0.4mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. HD was defined as systolic pressure <90mmHg and/or heart rate <50 beats/min. Fifteen potential predictors of HD (age, gender, hypertension, smoking, diabetes, coronary artery disease, previous myocardial infarction, symptoms, degree of carotid stenosis contralateral CEA or CAS, calcified/hyperechoic plaque, plaque length, stent oversizing and type of stent) were tested in multivariate analysis. RESULTS: Two hundred and twenty three consecutive patients were enrolled. HD occurred in 98 cases (44%): in 68 cases HD required additional pharmacological support. At 30 days, any stroke rate was 3.1% (3 major and 4 minor), TIA rate 1.8%, myocardial infarction rate 0.4%. No deaths were recorded. No difference in complication rates were found in patients with or without HD. From regression analysis only the presence of calcified plaque (HR 9.5; 95% CI 5.0 to 18.2; p<0.0001) and the plaque length (HR 1.77; 95% CI 1.03 to 3.06; p=0.038) were associated significantly with HD. CONCLUSIONS: HD during CAS is a common, relatively benign event, without increased risk of peri-operative complications. Careful pharmacological treatment is necessary to decrease HD and the potential complications, especially in patients with more severe calcified lesions. These results require confirmation in a separate, larger cohort.     

Carotid plaque with expansive arterial remodeling is a risk factor for ischemic complication following carotid artery stenting

Background

Carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke than carotid endarterectomy. For better patient selection, more accurate risk factors should be identified. The aim of this study was to determine whether expansive arterial remodeling can predict ischemic complications in patients undergoing CAS.

Methods

This retrospective study included 82 patients with carotid stenosis treated by CAS. The plaque component was evaluated using MR plaque imaging before the procedure. Following the procedure, lesion assessment was performed using MRI diffusion-weighted imaging (DWI), and patients were classified as DWI positive or negative for comparison between groups.

Results

Fifteen patients were classified as DWI positive and 67 patients as DWI negative. The mean expansive remodeling rate was 1.76 ± 0.21 in the DWI-positive group and 1.35 ± 0.18 in the DWI-negative group (P < 0.001). Receiver-operating characteristic analysis revealed that the threshold for the expansive remodeling rate separating the two groups was 1.52 (area under the curve = 0.933). The positive predictive value of postoperative new DWI lesions in the high-intensity plaque associated with a high expansive remodeling rate was 64.3%, and the negative predictive value of the isointensity plaque associated with a low expansive remodeling rate was 97.8%. These values were higher than those of the plaque component alone (32.1% and 81.7%, respectively).

Conclusions

This study revealed that expansive arterial remodeling is a strong risk predictor of ischemic complication in CAS. Expansive remodeling rate measurements are very simple and provide useful information for determining treatment strategies for patients with carotid stenosis.

     

Open operative balloon angioplasty of the internal carotid artery: A technique in evolution

Open operative balloon angioplasty is a treatment alternative for certain nonatherosclerotic lesions of the internal carotid artery (ICA) including fibromuscular dysplasia (FMD). Standard operative exposure of the carotid bifurcation is performed with atraumatic passage of a guidewire and balloon through a carotid bulb arteriotomy. Under direct fluoroscopic guidance, precise dilatation of the involved area is possible with minimal risk of intimal tear/flap or distal embolization as compared with graduated intraluminal dilatation or percutaneous balloon angioplasty. Vascular control of the common and external carotid arteries lessens the risk of embolization resulting from the constant backflow of blood through the ICA before, during, and after balloon angioplasty, adding to the overall safety and efficacy of the procedure. We report a case of asymptomatic critical carotid artery stenosis associated with FMD successfully treated with open operative balloon angioplasty and review the current literature regarding treatment options for FMD of the ICA.Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, January 23, 1994.