Karotisstents – eine Standortbestimmung

Clinical/methodical issue

Therapy of carotid stenosis should be based on an accurate assessment of the stenosis and a differentiation between symptomatic and asymptomatic patients.

Standard radiological methods

According to current guidelines carotid artery stenting (CAS) can be considered as an established therapeutic alternative to carotid endarterectomy (CEA).

Methodical innovations

For the therapy of carotid stenosis CAS has become established as a minimally invasive alternative to CEA because the complication rate has been reduced due to growing experience, technical innovations and external quality assessment.

Performance

The CAS procedure should be performed in centers with documented complication rates of <?3?% for asymptomatic and <?6?% for symptomatic stenoses.

Achievements

Overall there are no significant differences between CAS and CEA in the treatment of carotid stenosis concerning the secondary prophylactic effect.

Practical recommendations

Ideally an interdisciplinary approach should be chosen for the therapy regime. Revascularization of asymptomatic stenoses should be considered critically as these patients might profit from optimized conservative medicinal therapy.     

Long-term outcome in patients with carotid artery stenting and contralateral carotid occlusion: a single neurovascular center prospective analysis

Introduction

The aim of this study was to analyze the clinical features and early and late outcome of patients treated with carotid artery stenting for carotid stenosis with occlusion of the contralateral vessel (CAS-CCO), and compare them to patients without occlusion (CAS-NO).

Methods

From 1999 through 2010, 426 patients with 479 procedures were prospectively recorded, 61 patients (14.3%) CAS-CCO, and 365 patients CAS-NO. Immediate CAS complications, complications within the first 30?days and long-term complications were documented through annual clinical and ultrasonological follow-up visits. Stenosis rate was recorded.

Results

Patients with mean age of 68.4?years, 80% men had: (1) periprocedural stroke in three cases (0.7%), (2) cumulative 30-day stroke, ischemic cardiopathy, and death in 4.2%, without differences between groups (CAS-CCO 3.3%, CAS-NO 4.4%). Mean follow-up period was 55?±?32.78?months, median 56?months. (3) Stroke during the follow-up in 8%, without differences between CAS-CCO and CAS-NO groups (3.7% and 8.8%). (4) Myocardial infarction in 11.2% and (5) global mortality in 24.3%, without statistical differences between groups. Of the 254 cases enrolled in the restenosis analysis, 44 patients (17.3%) had restenosis of any grade during a mean follow-up period of 52?months, without statistical differences between CAS-CCO and CAS-NO groups. Only 7.5% presented restenosis?≥?50%. Its occurrence was statistically associated with previous neck radiation.

Conclusions

Periprocedural risks and long-term outcomes of patients treated with CAS and presenting a contralateral carotid occlusion does not differ from regular patients treated with CAS. Based on the low stenosis rate of our study, our results do not give credit to extra surveillance measures in patients with contralateral carotid occlusion.     

Carotid artery stenting: findings based on 8 years’ experience

Purpose

Carotid artery stenting (CAS) may be an alternative to surgical endarterectomy not only in high-risk patients. Few data are available regarding the long-term clinical efficacy of CAS with the use of cerebral protection devices and the incidence of restenosis. Our experience demonstrates that if certain requirements are fulfilled, CAS can be considered a safe and effective treatment with high short-and long-term success rates.

Materials and methods

In the past 8 years, we treated 1,003 patients (1,096 arteries) affected by internal carotid artery stenosis, 93 with bilateral stenosis. Of these, 567 (51.74%) were symptomatic and 529 (48.26%) asymptomatic lesions. The preprocedural evaluation was performed with Doppler ultrasound (US), magnetic resonance (MR) angiography/computed tomography (CT) angiography and a neurological evaluation. Antiplatelet therapy was administered before and after the procedure.

Results

Technical success was achieved in 1,092 cases (99.6%), and a cerebral protection device was successfully used in 1,019 procedures (92.9%). The 30-day transient ischaemic attack (TIA)/stroke/death rate was 2.16%: death (0.18%) major stroke (0.45%) and minor stroke/TIA (1.53%). During a follow-up up to 8 years, restenoses occurred in 39 cases (3.57%), of which 28 were post-CAS (2.57%) and 11 post-CAS performed for restenosis after carotid endarterectomy (1%). Only five symptomatic restenoses >80% were treated with a repeated endovascular procedure.

Conclusions

A retrospective analysis of our experience suggests that CAS is a safe and effective procedure with better results than endarterectomy. In up to 8 years of follow-up, CAS seems to be effective in preventing stroke, with a low restenosis rate.     

Calcium at the carotid siphon as an indicator of internal carotid artery stenosis

Objectives

Carotid siphon calcification is often visible on unenhanced head CT (UCT), but the relation to proximal carotid artery stenosis (CAS) is unclear. We investigated the association of carotid siphon calcification with the presence of CAS.

Methods

This IRB-waived retrospective study included 160 consecutive patients suspected of stroke (age 64?±?14 years, 63 female) who underwent head UCT and CTA of the head and neck. CAS was rated on CTA as not present or present with non-significant (<50 %), moderate (50–69 %) or significant (≥70 %) stenosis. Presence, shape (on UCT) and volume (on CTA) of carotid siphon calcifications were related to CAS.

Results

Carotid siphon calcification was absent in 41 % of patients and bilateral in 94 % of those with calcifications. Presence, shape and volume of calcification resulted in odds ratios for having significant CAS of 10.1, 3.9 and 8.4, with 95 % CIs of 1.3–79.6, 1.1–14.1 and 2.6–26.8, respectively. Corresponding NPVs were 0.98, 0.98 and 0.96, while PPVs were 0.14, 0.07 and 0.29, respectively.

Conclusion

Absence of calcification in the carotid artery siphon on UCT has high negative predictive value for carotid artery stenosis in patients with suspected stroke. However, siphon calcification is not a reliable indicator of significant carotid artery stenosis.

Key Points

? Many stroke patients do not have calcification in the carotid artery siphon. ? Carotid stenosis ≥50?% is unlikely in stroke patients without siphon calcification. ? Carotid siphon calcium is a poor indicator of significant carotid artery stenosis.     

Initial experience of carotid artery stenting using the Carotid WALLSTENT and FilterWire EZ in Japan

Purpose

The Carotid WALLSTENT (CWS) and Filter-Wire EZ (FWEZ) embolic protection devices for use in carotid arterial stenting (CAS) were newly approved for national health insurance coverage in Japan in April 2010. This article describes our initial experience of CAS using the CWS and FWEZ.

Material and methods

A group of 14 patients (12 men, 2 women; mean age 70.1 years, range 59?C83 years) with 15 carotid artery stenoses at high risk for carotid endarterectomy were treated by CAS using the CWS and FWEZ. Of these stenoses, 5 were symptomatic with ??50% stenosis of the common or internal carotid artery (ICA), and 10 were asymptomatic with ??80% stenosis. The rates of technical success, ICA flow impairment during filter protection, periprocedural ischemic stroke, 30-day major adverse events (MAEs) (stroke, death, myocardial infarction), and development of new ischemic lesions on diffusion-weighted imaging (DWI) were assessed.

Results

CAS was successful in all cases. There was no ICA flow impairment, periprocedural ischemic stroke, or MAEs. DWI showed new ipsilateral ischemic lesions in only one patient (6.7%).

Conclusion

Our initial clinical experience using the CWS and FEWZ for CAS was generally excellent, and the incidence of postprocedural ischemic lesions was low.     

Uterine Artery Embolization versus Myomectomy: Impact on Quality of Life—Results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial

Purpose

This study was designed to compare quality of life (QoL) outcomes after uterine artery embolization (UAE) or myomectomy.

Methods

Women with symptomatic fibroids diagnosed by ultrasound who wished to preserve their uterus were randomized to myomectomy (n?=?81) or UAE (n?=?82). Endpoints at 1?year were QoL measured by a validated questionnaire, hospital stay, rates of complications, and need for reintervention.

Results

UAE patients had shorter hospitalization (2 vs. 6?days, p?significant and equal improvements in QoL scores had occurred in both groups (myomectomy n?=?59; UAE n?=?61). There had been two (2.9%) major complications among UAE versus 6 (8%) among myomectomy patients (not significant). By 2?years, among UAE patients (n?=?57) there were eight (14.0%) reinterventions for inadequate symptom control compared with one (2.7%) among myomectomy patients (n?=?37). Half of the women who required hysterectomy had concomitant adenomyosis missed by US.

Conclusions

UAE and myomectomy both result in significant and equal improvements in QoL. UAE allows a shorter hospital stay and fewer major complications but with a higher rate of reintervention.     

Effect of carotid artery stenting on cerebral blood flow: evaluation of hemodynamic changes using arterial spin labeling

Introduction

The purpose of this work was to quantitatively evaluate the hemodynamic changes after carotid artery stenting (CAS) by measuring cerebral blood flow (CBF) using arterial spin labeling (ASL).

Methods

Twenty sets of pre- and postprocedural CBF maps were acquired using ASL in patients who underwent CAS. Vascular territory- and anatomical structure-based regions of interest were applied to the CBF maps. Relative CBF (rCBF) was calculated by adjusting ipsilateral CBF with contralateral CBF. To assess the changes in rCBF after CAS (ΔrCBF), we calculated the following difference: $ \Delta\mathrm{rCBF}=\mathrm{rCB}{{\mathrm{F}}_{\mathrm{postprocedural}}}-\mathrm{rCB}{{\mathrm{F}}_{\mathrm{preprocedural}}} $ .

Results

Postprocedural CBFs were significantly higher than preprocedural CBFs for internal carotid artery and middle cerebral artery territories (P?<?0.05 in both). Postprocedural rCBFs were also significantly higher than preprocedural rCBFs for internal carotid artery and middle cerebral artery territories (P?<?0.05 in both). Significant correlations were observed between preprocedural rCBF and ΔrCBF for the internal carotid artery and middle cerebral artery territories (r?=??0.7211, P?=?0.0003 and r?=??0.6427, P?=?0.0022, respectively). Areas in which the ΔrCBF values were >5.00 ml?100 g^?1 min^?1 were the precentral, postcentral, middle frontal, middle temporal (caudal), superior parietal, and angular gyri.

Conclusions

ASL has potential as a noninvasive imaging tool for the quantitative evaluation of hemodynamic changes after CAS. CAS improves cerebral perfusion in patients with carotid artery stenosis, and patients with greater perfusion deficits prior to CAS have greater improvement in perfusion after CAS. In addition, eloquent areas show the greatest improvement in perfusion.     

Complication rate in unprotected carotid artery stenting with closed-cell stents

Introduction

The discussion on the use of protection devices (PDs) in carotid artery stenting (CAS) is gaining an increasing role in lowering the periprocedural complication rates. While many reviews and reports with retrospective data analysis do promote the use of PDs the most recent multi-centre trials are showing advantages for unprotected CAS combined with closed-cell stent designs.

Methods

We retrospectively analysed 358 unprotected CAS procedures performed from January 2003 to June 2009 in our clinic. Male/female ratio was 2.68/1. The average age was 69.3 years. Seventy-three percent (261/358) showed initial neurological symptoms. All patients were treated on a standardised interventional protocol. A closed and small-sized cell designed stent was implanted in most cases (85.2%). One hundred seventy-one (47.8%) were controlled by Doppler ultrasonography usually at first in a 3-month and later in 6-month intervals.

Results

The peri-interventional and 30-day mortality/stroke rate was 4.19% (15/358). These events included three deaths, five hyperperfusion syndromes (comprising one death by a secondary fatal intracranial haemorrhage), one subarachnoid haemorrhage and seven ischaemic strokes. Only 20% (3/15) of all complications occurred directly peri-interventional. The overall peri-interventional complication rate was 0.8% (3/358). Most complications occurred in initial symptomatic patients (5.36%). The in-stent restenosis rate for more than 70% was 7% (12/171) detected at an average of 9.8 month.

Conclusion

Our clinical outcome demonstrates that unprotected CAS with small cell designed stents results in a very low procedural complication rate, which makes the use of a protection device dispensable.     

Evaluation of distal turbulence intensity for the detection of both plaque ulceration and stenosis grade in the carotid bifurcation using clinical Doppler ultrasound

Objectives

To determine the interrelationship of stenosis grade and ulceration with distal turbulence intensity (TI) in the carotid bifurcation measured using conventional clinical Doppler ultrasound (DUS) in vitro, in order to establish the feasibility of TI as a diagnostic parameter for plaque ulceration.

Methods

DUS TI was evaluated in a matched set of ulcerated and smooth-walled carotid bifurcation phantoms with various stenosis severities (30, 50, 60 and 70 %), where the ulcerated models incorporated a type 3 ulceration.

Results

Post-stenotic TI was significantly elevated owing to ulceration in the mild and moderate stenoses (P?<?0.001). TI increased with stenosis severity in both the ulcerated and non-ulcerated series, with a statistically significant effect of increasing stenosis severity (P?<?0.001). Whereas TI in the mild and non-ulcerated moderate stenoses was less than 20.4?±?1.3 cm s^?1, TI in the ulcerated moderate and severe models was higher than 25.6 ±1.3 cm s^?1, indicating a potential diagnostic threshold.

Conclusion

We report a two-curve relationship of stenosis grade and ulceration to distal TI measured using clinical DUS in vitro. Clinical DUS measurement of distal TI may be a diagnostic approach to detecting ulceration in the mild and moderately stenosed carotid artery.

Key Points

? Patients with carotid artery plaque ulcerations are at higher risk of stroke. ? Clinical Doppler ultrasound is routinely used to detect carotid artery stenosis. ? Doppler ultrasound turbulence intensity can detect ulceration in realistic flow models. ? Turbulence intensity also increases with stenosis severity independent of ulceration. ? Doppler ultrasound should help in assessing both stenosis severity and ulceration.     

United Kingdom Carotid Artery Stent Registry: Short- and Long-Term Outcomes

Background

Carotid artery stenting (CAS) has evolved to treat carotid artery disease with the intention of prevent stroke. The British Society of Interventional Radiologists developed a voluntary registry to monitor the practice of this novel procedure. We present the data from the United Kingdom (UK) CAS registry for short and long-term outcomes for symptomatic and asymptomatic carotid disease.

Methods

The UK CAS registry collected data from 1998 to 2010 from 31 hospitals across the UK for 1,154 patients. All interventions were enrolled in the registry for both asymptomatic and symptomatic patients. Initial entry forms were completed for each patient entered with data including indications, demographic data, CAS data (including stents and protection device details) and 30-day outcomes. Complications were documented. Follow-up data were collected at yearly intervals.

Results

Nine hundred fifty-three (83 %) symptomatic and 201 (17 %) asymptomatic patients were enrolled into the registry. The 30-day all stroke and death rates for symptomatic patients were 5.5 and 2.2 % for those with asymptomatic disease. The 30-day mortality rate was 1.7 % for symptomatic and 0.6 % for asymptomatic patients. For symptomatic patients undergoing CAS, the 7-year all-cause mortality rate was 22.2 % and for asymptomatic patients 18.1 %. The 7-year all-cause mortality and disabling stroke rates were 25.3 and 19.4 %, respectively.

Conclusion

These data indicate that outside of the tight constraints of a randomised trial, CAS provides effective prophylaxis against stroke and death.     

Are flow-mediated vasodilatation and intima-media thickness of the brachial artery associated with restenosis after endovascular treatment of peripheral arterial occlusive disease?

Objective:

Restenosis after percutaneous angioplasty of peripheral arteries is still an unsolved matter. Previous studies reported an association between flow-mediated dilatation (FMD), a marker of endothelial dysfunction, and restenosis after coronary angioplasty. This study evaluates the influence of FMD and brachial intima-media thickness (B-IMT) on restenosis after angioplasty of peripheral arteries.

Methods:

One hundred and eighty-four patients (124 male) with claudication related to peripheral arterial disease participated in this trial. FMD and B-IMT were assessed before endovascular revascularisation. In a 12-month follow-up duplex ultrasound examinations were performed to detect restenosis. Finally 128 patients (91male, 37 female) were eligible for statistical analysis.

Results:

Restenosis was found in 54 patients (42.2%). Mean FMD was 3.53?±?3.56%, with no difference between the patients with restenosis (3.55?±?3.64%) and those without (3.52?±?3.48%; p?=?0.716). B-IMT had a mean value of 0.326?±?0.134 mm. B-IMT significantly differed between the patients with restenosis (0.326?±?0.134 mm) and those without (0.256?±?0.133 mm; p?=?0.007). We confirmed that a B-IMT over 0.21 mm was an independent risk factor for restenosis [OR 2.9 (1.3–6.3)].

Conclusion:

Endothelial dysfunction is not associated with restenosis. Conversely patients with enlarged B-IMT are at risk of restenosis after angioplasty of peripheral arteries.     

A classification of patterns of fetal middle cerebral artery velocity waveforms as seen on Doppler ultrasound

Purpose

To identify, classify, and study the clinical significance of different patterns of fetal middle cerebral artery peak systolic velocity waveforms that can be seen on Doppler ultrasound.

Materials and methods

The patterns of fetal middle cerebral artery (MCA) velocity waveforms encountered in our study (n?=?1128) conducted on a rural obstetric population were analyzed.

Results

Broadly, three different waveform-patterns (type I to type III) were identified from 1100 cases on which satisfactory studies were conducted. Types IA and IB were found in normal fetuses of the first (n?=?254, 23.1?%) and second (n?=?386, 35.1?%) trimesters, respectively. Type IC (n?=?418, 38?%) included normal fetuses in the second (n?=?25) and third (n?=?317) trimesters, and 76 of 118 IUGR fetuses. Type II consisted of IUGR category; 17 (1.5?%) cases in type IIA, 10 (0.9?%) in IIB, and 11 (1.0?%) in IIC. Type III (n?=?4, 0.4?%) was found in the critical cases with severe anemia secondary to feto-maternal hemorrhage.

Conclusion

Although different patterns of uterine and umbilical artery velocity waveforms have been described in the obstetric literature, there is no mention of patterns of fetal MCA velocity waveforms. This is the first study to demonstrate, classify, and state the clinical significance of different patterns of fetal middle cerebral artery peak systolic velocity waveforms.     

Fragmentation of calcified plaque after carotid artery stenting in heavily calcified circumferential stenosis

Introduction

We assessed the morphological change of calcified plaque after carotid artery stenting (CAS) in vessels with heavily calcified circumferential lesions and discuss the possible mechanisms of stent expansion in these lesions.

Methods

We performed 18 CAS procedures in 16 patients with severe carotid artery stenosis accompanied by plaque calcification involving more than 75% of the vessel circumference. All patients underwent multidetector-row computed tomography (MDCT) to evaluate lesion calcification before and within 3 months after intervention. The angiographic outcome immediately after CAS and follow-up angiographs obtained 6 months post-CAS were examined.

Results

The preoperative mean arc of the calcifications was 320.1?±?24.5° (range 278–360°). In all lesions, CAS procedures were successfully carried out; excellent dilation with residual stenosis ≤30% was achieved in all lesions. Post-CAS MDCT demonstrated multiple fragmentations of the calcifications in 17 of 18 lesions (94.4%), but only cracks in the calcified plaque without fragmentation in one (5.6%). Angiographic study performed approximately 6 months post-CAS detected severe restenosis in one lesion (5.6%) without fragmentation of calcified plaque.

Conclusions

Excellent stent expansion may be achieved and maintained in heavily calcified circumferential carotid lesions by disruption and fragmentation of the calcified plaques.     

Characterisation of carotid plaques with ultrasound elastography: feasibility and correlation with high-resolution magnetic resonance imaging

Objectives

To evaluate the ability of ultrasound non-invasive vascular elastography (NIVE) strain analysis to characterise carotid plaque composition and vulnerability as determined by high-resolution magnetic resonance imaging (MRI).

Methods

Thirty-one subjects with 50 % or greater carotid stenosis underwent NIVE and high-resolution MRI of internal carotid arteries. Time-varying strain images (elastograms) of segmented plaques were generated from ultrasonic raw radiofrequency sequences. On MRI, corresponding plaques and components were segmented and quantified. Associations between strain parameters, plaque composition and symptomatology were estimated with curve-fitting regressions and Mann–Whitney tests.

Results

Mean stenosis and age were 72.7 % and 69.3 years, respectively. Of 31 plaques, 9 were symptomatic, 17 contained lipid and 7 were vulnerable on MRI. Strains were significantly lower in plaques containing a lipid core compared with those without lipid, with 77–100 % sensitivity and 57–79 % specificity (P?<?0.032). A statistically significant quadratic fit was found between strain and lipid content (P?<?0.03). Strains did not discriminate symptomatic patients or vulnerable plaques.

Conclusions

Ultrasound NIVE is feasible in patients with significant carotid stenosis and can detect the presence of a lipid core with high sensitivity and moderate specificity. Studies of plaque progression with NIVE are required to identify vulnerable plaques.

Key points

? Non-invasive vascular elastography (NIVE) provides additional information in vascular ultrasound ? Ultrasound NIVE is feasible in patients with significant carotid stenosis ? Ultrasound NIVE detects a lipid core with high sensitivity and moderate specificity ? Studies on plaque progression with NIVE are required to identify vulnerable plaques     

Carotid artery stenting in difficult aortic arch anatomy with or without a new dedicated guiding catheter: preliminary experience

Objectives

To evaluate carotid artery stenting (CAS) procedures with or without a new dedicated guiding catheter in anatomically challenging aortic arches in our experience.

Methods

We retrospectively reviewed 172 procedures of CAS performed from December 2006 to October 2011 in 159 consecutive patients (100 men, mean age 78 years): 15 patients had type III aortic arch, 13 had a bovine aortic arch, 6 had an acute angle at the origin of the left common carotid artery from the aortic arch, 2 had type III aortic arch with bovine aortic arch, and 1 had a bicarotid trunk with an aberrant right subclavian artery. In this group of difficult anatomy (37 cases), CAS was performed with (13 cases) or without (24 cases) a new dedicated guiding catheter.

Results

Mean time of fluoroscopy (16 min vs. 18 min, P?<?0.01), mean total procedural time (68 min vs. 83 min, P?<?0.001), technical failure (0/13 vs. 3/24 cases, P?=?0.01), clinical failure (0/13 vs. 4/21 cases, P?=?0.02) and local complications (0/13 vs. 2/24 cases, P?<?0.0001) were significantly lesser in the dedicated guiding catheter group.

Conclusions

The new dedicated guiding catheter may be more effective and less risky for CAS in anatomically challenging aortic arches.

Key Points

? Complex anatomy of the aortic arch is not rare ? Endovascular carotid artery stenting (CAS) is more difficult when the anatomy is complex ? A new dedicated guiding catheter may help CAS when the arch anatomy is complex ? The new dedicated guiding catheter may be less risky in complex arches     

Influence of carotid artery stenting on cognitive function

Introduction

There have only been a few studies on cognitive changes in patients with carotid occlusive disease, and the results of these show major discrepancies in the extent to which treatment affects neuropsychological function. We sought to clarify these discrepancies by evaluating the effects of carotid artery stenting (CAS) on the cognitive function.

Methods

Forty-one asymptomatic CAS patients were administered a test battery of neuropsychological tests measuring cognitive speed and memory function before and 3 months after the procedure. A control group was also evaluated. To test for thromboembolic lesions, diffusion-weighted imaging was used.

Results

CAS led to a significant increase in cognitive speed (p?<?0.001) but did not afford any change in memory function. This was regardless of the degree or side of stenosis or patient age or gender.

Conclusion

CAS significantly improved functions that involve cognitive speed. Earlier studies did not differentiate between speed and memory tests and thus might have missed these changes. Further studies correlating changes in brain perfusion with increase in cognitive speed are needed.     

Wall shear stress distribution at the carotid bifurcation: influence of eversion carotid endarterectomy

Objectives

To test the feasibility of four-dimensional (4D) flow MRI to quantify the systolic wall shear stress (WSS_systole) and oscillatory shear index (OSI) in high-grade internal carotid artery (ICA) stenosis before and after endarterectomy (CEA).

Methods

Twenty patients with ≥60 % ICA stenosis were prospectively and consequently included. Four-dimensional flow MRI was used to measure individual time-resolved 3D blood flow velocities. Segmental WSS_systole and OSI were derived at eight wall segments in analysis planes positioned along the ICA, common (CCA) and external carotid artery (ECA).

Results

Regional WSS_systole of all patients decreased after CEA (P?<?0.05). Changes were most prominent at the ICA bulb but remained unchanged in the CCA and ECA. OSI was significantly lower after CEA in the lateral vessel walls (P?<?0.05). For analysis planes at the stenosis in- and outlet, a reduction of mean WSS_systole by 32 % and 52 % (P?<?0.001) and OSI distal to the stenosis (40 %, P?=?0.01) was found after CEA.

Conclusions

Our findings show the potential of in vivo 4D flow MRI to quantify haemodynamic changes in wall shear stress even in patients with complex flow conditions.

Key Points

? The 4D flow MRI allows in vivo measurement of individual 3D blood flow. ? Regional wall shear stress can be derived from such 3D flow data. ? Even complex flow in high-grade internal carotid artery stenosis can be analysed. ? This technique could be valuable for future studies of carotid atherosclerosis.     

Effect of Pitavastatin on Preventing Ischemic Complications with Carotid Artery Stenting: A Multicenter Prospective Study—EPOCH-CAS Study

Purpose

Periprocedural ischemic stroke is one problem associated with carotid artery stenting (CAS). This study was designed to assess whether preoperative statin therapy reduces the risk of periprocedural ischemic complications with CAS.

Methods

In this prospective study at 11 centers, patients with carotid artery stenosis (symptomatic ≥50 %, asymptomatic ≥80 %) and a high risk of carotid endarterectomy but without previous statin treatments were divided into two groups by low-density lipoprotein cholesterol (LDL-C) levels. With LDL-C ≥120 mg/dl, the pitavastatin-treated (PS) group received pitavastatin at 4 mg/day. With LDL-C <120 mg/dl, the non-PS group received no statin therapy. After 4 weeks, both groups underwent CAS. Frequencies of new ipsilateral ischemic lesions on diffusion-weighted imaging within 72 h after CAS and cerebrovascular events (transient ischemic attack, stroke, or death) within 30 days were assessed.

Results

Among the 80 patients enrolled, 61 patients (PS group, n = 31; non-PS group, n = 30) fulfilled the inclusion criteria. New ipsilateral ischemic lesions were identified in 8 of 31 patients (25.8 %) in the PS group and 16 of 30 patients (53.3 %) in the non-PS group (P = 0.028). Cerebrovascular events occurred in 0 patients in the PS group and in 3 of 30 patients (10.0 %) in the non-PS group (P = 0.071). Multivariate analyses demonstrated the pitavastatin treatment (β = 0.74, 95 % confidence interval 0.070–1.48, P = 0.042) to be an independent factor for decreasing post-CAS ischemic lesions.

Conclusion

Pretreatment with pitavastatin significantly reduced the frequency of periprocedural ischemic complications with CAS.     

Ultrasound-guided core-needle biopsy of extra-ocular orbital lesions

Objective

To evaluate the diagnostic yield of ultrasound-guided core-needle biopsy of extra-ocular orbital lesions.

Methods

Fifty-five patients with monolateral exophthalmos prospectively underwent computed tomography (CT) to investigate the presence of an extra-ocular mass (n?=?25). Excluding benign lesions (n?=?7) and patients in whom CT revealed an unknown primitive malignancy (n?=?5), 13 patients (7 male, 6 female; mean age 62?±?16 years) underwent ultrasound. Lesion appearance (echotexture, power Doppler vascularisation), size, position with respect to the cone and to the globe were recorded. Ultrasound-guided biopsies were performed (automatic, n?=?9; semi-automatic 18-G needle, n?=?4). Sample adequacy and complication rate were recorded.

Results

Ultrasound demonstrated hypoechoic lesions with mild power Doppler vascularity, that were completely (n?=?7) or partially extra-conal (n?=?6), located laterally (n?=?8) or posteriorly (n?=?5) to the globe. Mean size was 3.25 cm. All biopsies yielded adequate material for histological and immunohistochemical analysis (nine non-Hodgkin’s lymphomas, two adenocarcinomas, one lymphoid hyperplasia, one inflammatory pseudotumour). Complications included cutaneous eyelid haematoma (n?=?3) and retro-bulbar haematoma (n?=?1), treated conservatively and resolved at 10-day follow-up. No immediate or delayed vision reduction was reported.

Conclusions

Ultrasound-guided core-needle biopsy of extra-ocular orbital lesions is feasible and accurate, being free from long-term complications. This procedure provided 100 % adequate samples to achieve final diagnosis.

Key Points

? Ultrasound-guided core-needle biopsy of extra-ocular orbital lesions seems feasible and accurate. ? In this series it provided a final diagnosis in 13/13 cases. ? It appears free from long-term complications. ? It provides immunohistochemical analysis of the specimen. ? It should represent a valuable alternative to surgical biopsy.     

Frequency and predictors of endoleaks and long-term patency after covered stent placement for the treatment of intracranial aneurysms: a prospective, non-randomised multicentre experience

Objective

We investigated immediate/late endoleaks and long-term patency following stent-graft placement for treatment of intracranial aneurysms located within the distal internal carotid artery (ICA) or vertebral artery (VA).

Methods

Forty-five aneurysms in 41 patients receiving covered stents in three centres were followed. Outcome measures included aneurysm occlusion rate, endoleaks, late in-stent stenosis rate, clinical improvement, neurological deficiencies and death.

Results

Total aneurysm exclusion was achieved in 69.2% (n?=?27), with 30.8% (n?=?12) experiencing immediate residual endoleaks. Angiographic follow-up (mean 43.5?±?14.3 months) revealed that 87.2% (n?=?34) were completely occluded with only 12.8% (n?=?5) showing residual endoleaks. Predictors of immediate endoleaks in our patient group were stent number (P?=?0.023) and stent diameter (P?=?0.022), while predictors of late endoleaks in our patient group were stent diameter (P?=?0.035) and stent angulation (P?=?0.021). Late in-stent stenosis rates were 18.0?±?13.3 and 29.0?±?18.5% compared with the period immediately following implantation at 2- and 6-year follow-ups respectively. Smoking (P?=?0.017) and stent angulation (P?=?0.020) were predictors of late in-stent stenosis.

Conclusion

Treating intracranial aneurysms with Willis stent-grafts has an acceptable immediate and late occlusion rate and long-term stented artery patency rate.

Key Points

? Covered stents can be a treatment option for intracranial aneurysms. ? Technical success for treating distal ICA and VA aneurysms can reach 97.6%. ? However immediate and late endoleaks occur in 30.8 and 12.8% respectively. ? The number, diameter and angulation of stents are possible predictors of endoleaks. ? Smoking and stent angulation seem to predict late in-stent stenosis.