High rate of restenosis after carotid artery stenting in patients with high-grade internal carotid artery stenosis

OBJECTIVE: Carotid endarterectomy (CEA) is the gold-standard procedure for the majority of patients with high-grade symptomatic internal carotid artery stenosis and also for specified high-grade asymptomatic stenoses; however, a proportion of patients are treated with carotid endovascular therapy. We aimed to document medium-term clinical and neurosonographical outcome after carotid artery stenting (CAS). METHODS: 53 patients (mean age: 65 +/- 8 years) with high-grade (> or = 70 % by means of duplex sonography) carotid artery stenosis were enrolled into the study. Nineteen patients had asymptomatic, 34 patients had symptomatic stenoses. All patients had a pre-interventional CT, Doppler and duplex sonography, and digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) prior to the procedural DSA. All patients were offered CEA as the gold-standard procedure and as an alternative to CAS. Both clinical and Duplex sonographical follow-up was obtained at day 1 and 7, month 1, month 3, month 6, month 12, and every subsequent 6 months after the procedure. Mean follow-up time was 22 +/- 1.6 months (+/- SEM). RESULTS: 2/53 patients suffered from stroke. A further 2 patients suffered from carotid artery occlusion shortly after CAS. The cumulative rate of restenosis during follow-up was 24.5 % (13/53). Four of these (7.5 %) were of high-grade and led to further interventional or surgical therapy. CONCLUSIONS: A high rate of restenosis was found during follow-up after CAS. Our analysis of non-selected patients emphasizes that CEA remains the gold-standard procedure for the treatment of symptomatic internal carotid artery stenosis. The frequently performed endovascular treatment of carotid stenosis outside the setting of a randomized controlled trial is not supported by our data.     

颈动脉支架成形术治疗症状性颈动脉狭窄患者的疗效观察

目的探讨应用颈动脉支架成形术(CAS)治疗症状性颈动脉狭窄患者的可行性及安全性。方法对60例症状性颈动脉狭窄患者(其中颈动脉起始段狭窄52例,颅外段狭窄8例;狭窄程度50%～70%14例,70%～90%28例,≥90%18例)予以CAS治疗,共释放64枚支架,15例应用保护伞。结果狭窄程度由术前(73.4±9.5)%降至术后(12.5±8.2)%,53例斑块消失;5例保护伞中有碎屑。所有患者临床症状在1周内消失,神经功能损害症状改善。术中及术后发生心率减慢53例,血压下降48例,血管痉挛5例,发生脑栓塞、高灌注综合征、低灌注综合征、晕厥各1例;随访3个月～2年,无1例发生短暂性脑缺血发作及脑梗死;20例复查DSA,仅1例出现轻度再狭窄。结论CAS是治疗症状性颈动脉狭窄安全、有效的方法;严格掌握适应证和熟练操作可降低手术风险。     

颈动脉支架术后过度灌注综合征的处理

目的探讨颈动脉支架植入术后过度灌注综合征的特点及正确处理方法。方法回顾分析62例颈内动脉支架植入后6例出现过度灌注综合征的临床资料,主要治疗方法包括适度控制血压、减轻脑水肿、预防性应用抗癫痫药物、监护脑血流、镇静机械通气、停用抗凝及抗血小板药物以及伴发脑出血时开颅手术等综合措施。结果 6例患者中,4例完全恢复,1例部分恢复,遗留偏瘫失语出院,1例死亡。结论过度灌注综合征的治疗重点是控制血压、保证适度的脑血流。     

颈动脉支架成形术后高灌注综合征临床分析

目的 探讨颈动脉支架成形术后高灌注综合征(HS)的临床特点及发生机制.方法 回顾性分析150例颈动脉支架成形术(12AS)后13例(8.7%)发生HS患者的临床资料.结果 本组患者术前颈动脉狭窄率平均为91%;术后15min～1周(平均2.5 h)均出现头痛(100%),其中伴高血压8例(61.5%)、癫癎部分性发作5例(38.5%)和局部神经功能缺损4例(30.8%).经颅多普勒(TCD)证实为支架侧大脑中动脉的峰血流增加≥100%.CT示有颅内出血4例,脑组织水肿7例,无明显异常2例.经控制血压、神经保护等治疗,7例完全恢复,4例部分恢复,2例死亡.结论 CAS术后HS主要表现为头痛、癫癎发作和局部神经功能缺损等脑出血及脑组织水肿表现,重度动脉狭窄可能是CAS术后HS的发病机制;术后TCD监测脑血流有助于及时诊断和治疗.     

血管成形术治疗症状性重度颈动脉狭窄的临床研究

目的 探讨颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉支架成形术(carotid artery stenting,CAS)治疗症状性重度颈动脉狭窄的近期和中期临床效果.方法 回顾性地分析了2016年1月至2018年12月在我院接受CEA或CAS治疗的203例症状性重度颈动脉狭窄患者的...     

Carotid artery stenting in patients with near occlusion: A single-center experience and comparison with recent studies

Objective

The optimal management strategy for carotid artery near occlusion is still controversial. Nevertheless, prior studies about carotid artery stenting in patients with near occlusion reported both technically and clinically inspiring results. To define the effectiveness, safety, and clinical outcomes of carotid artery stenting in patients with near occlusion, we analyzed our experiences and compared with recent studies.

Methods

We performed 24 carotid artery stenting procedures in 24 patients with near occlusion between January 2010 and July 2012. The patient group comprised 20 men (83.3%) and four women (16.7%) with a mean age of 69.5 years (range, 53–85 years). Eighteen patients had prior stroke or transient ischemic attack (75%), and six patients were asymptomatic (25%).

Results

Successful stent insertion was achieved in 23 of 24 patients (95.8%). Cerebral hyperperfusion syndrome and post-procedural vascular events occurred in four patients, and all of these developed within 24 h after the procedure (17.4%; two: hyperperfusion syndrome, two: acute myocardial infarction). The mean follow-up period after carotid artery stenting was 16.7 ± 9.2 months (range, 6–32 months). No stroke related to carotid artery stenting or significant restenosis of the inserted stent developed during the follow-up period.

Conclusions

Carotid artery stenting in patients with near occlusion seems to be a technically feasible and effective method to prevent stroke recurrence. But hyperperfusion syndrome and post-procedural vascular event rates may be high, as shown in this study.     

An audit of carotid endarterectomy for internal carotid artery disease at Dunedin Hospital

Carotid endarterectomy, mostly for symptomatic internal carotid artery stenosis, has been successfully performed in both the vascular and neurological surgery units at Dunedin Hospital. This study was performed to compare our results with those of the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. The 30-day perioperative morbidity and mortality rate was 4.3% (1.2% < 95% Cl > 7.4%) which compares favourably with an estimated upper limit of 5.5% based on recent trial reports. The present study highlights the difficulty in modelling local clinical practice on results of major trials when standards of patient evaluation and surgical skill may differ from those of the large studies. To justify generalization of indications for intervention based on the multicentre trials, there must be continual monitoring of local surgical results, and standardized use of diagnostic investigations.     

颈内动脉狭窄程度和血流速度与颈内动脉支架置入术后高灌注损伤的相关性研究

目的 探讨颈内动脉狭窄程度和血流速度与颈内动脉支架置入术后高灌注损伤的相关性。方法 选取2014年1月-2019年2月本院收治的298例颈内动脉狭窄患者为研究对象,全部患者采取颈内动脉支架置入术治疗,根据术后是否发生高灌注脑出血将其分为高灌注脑出血组(观察组,n=8)与未发生高灌注脑出血组(对照组,n=290); 采用改良RANKIN量表(mRS评分)评估2组受试者手术前、手术30 d后残疾程度,分别于手术前、手术后3 d采用彩色多普勒超声测定2组受试者患侧颈内动脉狭窄程度及血流速度,应用经颅多普勒TCD测定2组受试者患侧大脑中动脉血流速度; 采用NIHSS评分评估2组受试者手术前、手术30 d后神经功能缺损程度,采用LOGSTIC多元回归分析颈内动脉支架置入术后高灌注脑出血的影响因素。结果 观察组手术30 d后mRS评分高于对照组(P<0.05); 观察组手术前患侧颈内动脉狭窄程度高于对照组(P<0.05); 观察组手术前患侧大脑中动脉动脉血流速度(Vm)低于对照组(P<0.05); 观察组手术30 d后NIHSS评分高于对照组(P<0.05); Logistic多因素回归分析显示,颈内动脉支架置入术后高灌注脑出血与术前颈内动脉狭窄程度、血流速度、术后3 d患侧大脑中动脉血流速度(Vm)呈正相关(P<0.05),与术前患侧大脑中动脉血流速度(Vm)呈负相关(P<0.05)。结论 颈内动脉狭窄程度和血流速度是颈内动脉支架置入术后发生高灌注脑出血的独立影响因素。     

A Retrospective 10-Year,Single-Institution Study of Carotid Endarterectomy with a Focus on Elderly Patients

MethodsBetween January 2001 and December 2010, 649 carotid endarterectomies (CEAs) were performed in 596 patients for internal carotid artery occlusive disease at our institution; 596 patients received unilateral CEAs and 53 patients received bilateral CEAs. Data regarding patient characteristics, comorbidities, stroke, mortality, restenosis, and other surgical complications were obtained from a review of medical records. Since elderly and high-risk patients comprise a significant proportion of the patient group undergoing CEAs, differences in comorbidity and mortality were evaluated according to age when the patients were divided into three age groups: <70 years, 70-79 years, and ≥80 years.ResultsThe mean age of the included patients was 67.5 years, and 88% were men. Symptomatic carotid stenosis was observed in 65.7% of patients. The rate of perioperative stroke and death (within 30 days of the procedure) was 1.84%. The overall mortality rate was higher among patients in the 70-79 years and >80 years age groups than among those in the <70 years age group, but there was no significant difference in stroke-related mortality among these three groups.ConclusionsCEA over a 10-year period has yielded acceptable outcomes in terms of stroke and mortality. Therefore, since CEA is a safe and effective strategy, it can be performed in elderly patients with acceptable life expectancy.     

颈动脉狭窄患者血管成形和支架植入术后血流动力学的改变

目的探讨颈动脉狭窄患者血管成形和支架植入术(CAS)后血流动力学的改变。方法给31例颈动脉狭窄患者行CAS。在术前、术后第1 d、3个月及1年时进行颈动脉彩色多普勒血流显像(CDFI)检查。比较手术前后颈动脉狭窄段的血管内径、峰值流速(PSV)和舒张末期流速(EDV)。结果与术前比较,患者术后各时间点颈动脉的血管内径明显增大,PSV和EDV明显降低(均P0.01)。与术后第1 d比较,术后3个月的颈动脉CDFI各项指标的差异无统计学意义;与术后第1 d比较,术后1年的颈动脉血管内径缩小(P0.05),PSV和EDV的差异无统计学意义。结论 CAS术后颈动脉狭窄得到缓解,血流动力学指标显著改善。术后1年时部分患者出现支架处血管再狭窄,但血流动力学无明显改变。     

经桡动脉路径行椎动脉支架成形术的临床研究

目的 探讨经桡动脉路径行椎动脉支架成形术的可行性与安全性。方法 对18例术前评估股动脉入路困难或不愿意术后卧床的患者经桡动脉路径行椎动脉支架成形术(桡动脉组),与同期30例经股动脉行椎动脉支架成形术(股动脉组)的穿刺成功率、X线曝光时间、手术操作时间、手术成功率、术中出血量、术后血管并发症、术后卧床时间进行比较。结果 2组穿刺成功率及手术成功率均为100%,桡动脉组X线曝光时间、手术操作时间、术中出血量与股动脉组比较均无明显差异(P>0.05); 桡动脉组卧床时间、术后血管并发症发生率明显低于股动脉组(P<0.05)。结论 经桡动脉入路行椎动脉支架成形术安全、可行,经桡动脉入路可作为经股动脉入路重要的补充术式     

The Clinical Outcomes of 75 Consecutive Patients with Cervical Carotid Artery Stenosis Treated by Carotid Artery Stenting

Objective

The purpose of this study was to analyze the clinical outcome of 75 consecutive patients with cervical carotid artery stenosis and who were treated by carotid artery stenting (CAS) only.

Methods

From February 2003 to June 2008, there were 78 stents placed in 75 symptomatic patients (mean age : 67.3 years); 69 patients had carotid stenosis ≥70%, and 6 patients had asymptomatic stenosis ≥80%. No carotid endarterectomy (CEA) was performed during the same period. The patients were clinically followed-up for a mean of 20.1 months.

Results

The procedures were technically successful in all cases. Three (3.8%) patients had procedure-related complications. During the 30-day postprocedural period, there were no restenosis or major stroke. Minor stroke was noticed in 3 (3.8%) patients and 1 (1.3%) of the 75 patients suddenly expired 2 days after discharge. There were no new neurological symptoms that developed during the clinical follow-up period. The results of our series were not inferior to those the previously published in CAS studies, and in fact they were better.

Conclusion

Our results suggest that CAS may be safe and useful for the treatment of cervical carotid artery stenosis when it is used as the first line treatment in those institutions that lack enough experience with CEA.     

Risk factors for periprocedural complications in carotid artery stenting without filter protection

Introduction In highgrade stenosis, carotid artery stenting (CAS) may be chosen as an alternative to carotid surgery. Ischemic periprocedural complications may be documented best with diffusion–weighted MRI (DWMRI). In this prospective study serial DW–MRI and color–coded duplex sonography (CCDS) were used to identify carotid stenosis, which is associated with an increased risk of ischemic events due to CAS. Methods High resolution DW–MRI were performed in 74 out of 77 patients before and after CAS. All MRI scans were analyzed in a blinded manner. With CCDS each carotid stenosis was evaluated according to the grade, length, echo properties and plaque surface. Results In 42 out of 74 patients (56.8 %) a total of 188 new procedure– related DWI–lesions could be detected, while in 32 patients MRI–controls remained normal. Of the lesions 79.25 % had a size < 1 cm. In one major and two minor strokes due to CAS (total complication rate 3.9 %) corresponding territorial infarcts could be demonstrated. A highly significant correlation was found between the length of the stenosis and the incidence of new DWI–lesions (p = 0.0141). In contrast, neither the grade of ICA stenosis nor the sonographic plaque morphology or plaque surface correlated with the number of DWI–lesion in postinterventional scans. Conclusions The length—and not the degree—of an ICA stenosis seems to be the most decisive sonographic factor for estimating the periprocedural risk of embolism. DWI–lesions are much more frequent than clinical complications and may represent an important surrogate marker for improving the techniques of carotid artery stenting, especially comparing the benefit of different mechanical protection devices.     

支架置入术治疗颅内外动脉狭窄引起跌倒发作的疗效观察(附2例报告)

目的 观察应用血管内支架成形术治疗颅内外动脉狭窄引起的跌倒发作的疗效.方法 对2例颅内外动脉狭窄引起的跌倒发作患者(例1为基底动脉的中部、起始部,左椎动脉起始部及左锁骨下动脉重度狭窄;例2为双侧颈内动脉起始部重度狭窄)予以血管内支架成形术治疗,共释放6枚支架,例2应用保护伞.术后随访9个月～2年.结果 术后2例患者临床症状消失.例1随访9个月,术后6个月起因不规律服药,3个月后死于脑干梗死;例2术后1年复查DSA,无发生再狭窄,随访2年无临床症状复发.结论 血管内支架成形术是治疗颅内外动脉狭窄引起的跌倒发作安全、有效的方法.