The impact of increasing age on anatomic factors affecting carotid angioplasty and stenting

PURPOSE: Current evaluations of carotid artery angioplasty and stenting (CAS) have suggested equivalency compared with carotid endarterectomy (CEA). However, the incidence of stroke and death with CAS may be higher in elderly patients. We assessed the anatomic characteristics of patients undergoing CAS and compared them based on age older or younger than 80 years. The impact of age on the incidence of postoperative complications was also determined. METHODS: From February 2003 to August 2005, 135 CAS procedures were performed in 133 patients. Digital subtraction angiograms for each patient were evaluated by two independent observers blinded to patient identifiers. Anatomic characteristics that impact the performance of CAS were assessed as either favorable or unfavorable. These included aortic arch elongation, arch calcification, arch vessel origin stenosis, common and internal carotid artery tortuosity, and treated lesion stenosis, calcification, and length. Postoperative events were defined as myocardial infarction, stroke, and death. Fisher's exact test and chi(2) tests were used to determine statistical significance (P < .05). RESULTS: Of the 133 patients treated, 87 (65%) were men and 46 (35%) were women; and 37 (28%) were >or=80 years of age. The cohort >or=80 years old had an increased incidence of unfavorable arch elongation (P = .008), arch calcification (P = .003), common carotid or innominate artery origin stenosis (P = .006), common carotid artery tortuosity (P = .0009), internal carotid artery tortuosity (P = .019), and treated lesion stenosis (P = .007). No significant difference was found for treated lesion calcification or length. Perioperative cerebral vascular accidents occurred in four patients (3.0%, 3 with no residual deficit, 1 with residual deficit), myocardial infarction in three (2.2%), and one patient (0.8%) died secondary to a hemorrhagic stroke. The combined stroke, myocardial infarction, and death rate for the entire population was 3.7%. The rate was significantly increased in patients aged >or=80 years old (10.8%) compared with those aged <80 years old (1%, P = .012). CONCLUSIONS: Elderly patients, defined as those aged >80 years, have a higher incidence of anatomy that increases the technical difficulty of performing CAS. This increase in unfavorable anatomy may be associated with complications during CAS. Although the small number of perioperative events does not allow for determination of a direct relationship with specific anatomic characteristics, the presence of unfavorable anatomy does warrant serious consideration during evaluation for CAS in elderly patients.     

Measurement and impact of proximal and distal tortuosity in carotid stenting procedures

BACKGROUND: Proximal and distal carotid tortuosity is considered of paramount importance in carotid artery stenting (CAS) procedures. Specifically, distal internal carotid coiling or kinking is thought to interfere with proper distal protection devices, thus contraindicating CAS. The type of the aortic arch is also considered a key factor in CAS success; however, no standardized method of evaluation of these indicators is available in the literature. We have evaluated the impact of arch angulation and proximal and distal tortuosity in a series of CAS procedures. METHODS: In patients undergoing CAS, arch angulation and tortuosity of both common and distal internal carotid arteries were evaluated prospectively by calculating the sum of all angles diverging from the ideal straight axis, considering a 90 degrees ideal angle for the origin from the arch (tortuosity index, TI). All procedures were through a transfemoral approach and with distal protection. Results were correlated with technical procedural success (residual stenosis <30%) and neurologic complication by Student t test. Multivariate logistic regression analysis was conducted to identify independent predictors of results. RESULTS: In a group of 298 CAS procedures, the mean proximal TI was 111.9 degrees +/- 96.77 degrees and the mean distal TI was 123.4 degrees +/- 117.47 degrees . Technical success was obtained in 272 patients (91.2%). Causes for the 26 technical failures were incapacity to obtain stable proximal access in 25 (96.1%), and uncrossable stenosis in one (3.9%). Neurologic protection was achieved with distal filters in all cases. Neurologic complications occurred in 23 patients (7.7%), consisting of 16 transient ischemic attacks and seven minor strokes. The proximal TI was significantly greater in the 26 cases of technical failure (158.4 degrees +/- 102.2 degrees vs 107.6 degrees +/- 95.3 degrees , P = .01). The distal TI was not different in the two groups (89 degrees +/- 99.1 degrees vs 126.5 degrees +/- 118.6 degrees , P = .11). Similarly, the proximal TI was significantly greater in neurologic complications (162.8 degrees +/- 111.8 degrees vs 107.6 degrees +/- 18.2 degrees , P = .03); the distal TI was not different in the two groups (112.6 degrees +/- 110.1 degrees vs 124.3 degrees +/- 96.1 degrees , P = .5) By logistic regression analysis, a proximal TI >150 was an independent predictor of both neurologic complications and technical failure. Age was also independently associated with technical failure. Appropriate distal filter placement was possible in all cases with a crossable stenosis, irrespective of the internal carotid TI. CONCLUSIONS: The proximal TI is significantly associated with both technical success and neurologic complications after CAS, whereas the distal TI did not influence either outcome. The presence of distal kinking or coiling should not be considered a contraindication to CAS.     

Technical challenges in a program of carotid artery stenting

OBJECTIVES: Successful carotid artery stenting (CAS) involves gaining access to the common carotid artery, characterizing and crossing the lesion, deploying an anti-embolic device and stent, and retrieving the anti-embolic device. These steps are critical determinants of the complexity of the procedure. The frequency with which technical challenges are encountered during CAS is ill-defined. The purpose of this investigation was to review the incidence and types of technical challenges encountered during CAS and determine their effect on outcome. METHODS: Data were prospectively collected for 194 consecutive CAS procedures (177 patients) and separated into group 1, standard CAS technique, and group 2, procedures with technical challenges requiring modifications to the technique. Technical challenges were defined as difficult femoral arterial access (aortoiliac occlusive disease), complex aortic arch anatomy (elongated or bovine arch, deep takeoff of the innominate artery, tandem stenoses (CCA, innominate artery), difficult internal carotid artery anatomy (tortuosity, high-grade stenosis), and circumferential internal carotid artery calcification. The incidence of technical challenges, types of technical modifications required, and effect on outcomes were determined. RESULTS: Fifty technically challenging situations (26%) were encountered in 194 CAS procedures (group 2), which required advanced technical skills. Standard methods were used in the other 144 procedures (group 1, 74%). No significant differences in 30-day stroke and death rates were noted between the groups (group 1, 3.1%; group 2, 2.0%; P = .564). CONCLUSIONS: Twenty-six percent of the procedures required a modification in the standard technique for successful CAS. Circumferential calcification and severe tortuosity continue to be relative contraindications to CAS. Recognition of these technical challenges and increasing facility with the methods to manage them will enable expanded use of CAS without increased morbidity and mortality.     

Accuracy and utility of three-dimensional contrast-enhanced magnetic resonance angiography in planning carotid stenting

BACKGROUND: Contrast-enhanced magnetic resonance angiography (CE-MRA) is a proven diagnostic tool for the evaluation of carotid stenosis; however, its utility in planning carotid artery stenting (CAS) has not been addressed. This study assessed the accuracy of three-dimensional CE-MRA as a noninvasive screening tool, compared with digital subtraction angiography (DSA), for evaluating carotid and arch morphology before CAS. METHODS: In a series of 96 CAS procedures during a 2-year period, CE-MRAs and DSAs with complete visualization from the aortic arch to the intracranial circulation were obtained before CAS in 60 patients. Four additional patients, initially considered potential candidates for CAS, were also evaluated with CE-MRA and DSA. The two-by-two table method, receiver operating characteristic curve, and Bland-Altman analyses were used to characterize the ability of CE-MRA to discriminate carotid and arch anatomy, suitability for CAS, and degree of carotid stenosis. RESULTS: The sensitivity and specificity of CE-MRA were, respectively, 100% and 100% to determine CAS suitability, 87% and 100% to define aortic arch type, 93% and 100% to determine severe carotid tortuosity, and 75% and 98% to detect ulcerated plaques. CE-MRA had 87% sensitivity and 100% specificity for the detection of carotid stenosis >/=80%. The accuracy of CE MRA to determine optimal imaging angles and stent and embolic protection device sizes was >90%. The operative technique for CAS was altered because of the findings of preoperative CE-MRA in 22 procedures (38%). The most frequent change in the operative plan was the use of the telescoping technique in 11 cases (18%). CAS was aborted in four patients (5%) due to unfavorable anatomy identified on CE-MRA, including prohibitive internal carotid artery tortuosity (n = 1), long string sign of the internal carotid artery (n = 2), and concomitant intracranial disease (n = 1). Among patients considered suitable for CAS by CE-MRA, technical success was 100%, and the 30-day stroke/death rate was 1.6%. CONCLUSIONS: Contrast-enhanced magnetic resonance angiography of the arch and carotid arteries is accurate in determining suitability for CAS and may alter the operative technique. Certain anatomic contraindications for CAS may be detected without DSA. Although CE-MRA is less accurate to estimate the degree of stenosis, it can accurately predict imaging angles, and stent and embolic protection device size, which may facilitate safe and expeditious CAS.     

Analysis of Anatomic Factors and Age in Patients Undergoing Carotid Angioplasty and Stenting

Recent data suggest that patient age >80 years may be associated with increased risk of periprocedural complications from carotid angioplasty and stenting (CAS). In this study, we analyzed anatomic risk factors in patients undergoing CAS based on age >80 or <80 years. Our hypothesis was that patients >80 would have more challenging anatomy. Between February 2003 and August 2004, 82 patients underwent CAS. Images for 57 lesions were available for review. Eighteen patients were ≥80 years old and 39 were <80. Cerebral protection devices, including EPI Filterwire, Percusurge, Accunet, and Angioguard, were used in all but two cases; and self-expanding stents (Wallstent, NexStent, Acculink, Precise) were placed in all. Arterial anatomic characteristics were assigned a score based on complexity and associated procedural risk. Characteristics evaluated using angiographic images were aortic arch elongation classification, arch calcification, common carotid/innominate stenosis, common carotid tortuosity, internal carotid tortuosity, index lesion length, index lesion calcification, and index lesion stenosis. Statistical analysis was performed using Fisher’s exact test. CAS was successfully completed in 98% of cases. The two patients in whom we could not perform CAS were 79 and 83 years old. The anatomic characteristics that were statistically significantly more complex/severe in patients ≥80 were arch calcification (p = 0.045), common carotid/innominate stenosis (p = 0.023), common carotid tortuosity (p = 0.049), and internal carotid tortuosity (p = 0.032). There was no statistically significant difference in arch elongation classification, lesion length, lesion calcification, or stenosis severity (p = nonsignificant). Overall, patients ≥80 years had an increased incidence of complex anatomic risk factors compared to younger patients (p < 0.001). Cerebrovascular accident without residual deficits occurred in two patients; both were >80 years old. Complex arterial anatomy is more often present in patients >80 years and may explain the increased complication rates associated with CAS. Pre- or intraoperative consideration of these characteristics may help provide better risk assessment in candidates for CAS. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

Are there predictive risk factors for complications after carotid artery stenting?

AIM: The aim of this study was to identify predictive risk factors for complications during and after carotid artery stenting (CAS). METHODS: A multivariate analysis was performed on the databases of 4 European high-volume centers regarding risk factor distribution between patients presenting with or without neurological complications 30 days after CAS. The cumulative 30-day neurological complication rate (death, major stroke, minor stroke and transient ischemic attack) was 2.8% in the total examined cohort of 3 179 consecutive CAS procedures. The following risk factors were taken into consideration for statistical analysis: age, symptomatic, male gender, nicotine abuse, hypertension, hypercholesterolemia, polyvascular disease, diabetes, restenosis after carotid endarterectomy (CEA)/CAS, calcified internal carotid artery. RESULTS: Symptomatic (P=0.02) or hypercholesterolemic (P=0.02) patients are at significantly increased risk for neurological events 30 days after CAS. Asymptomatic women and men without hypercholesterolemia have the lowest risk on any 30-day neurological complications after CAS. CONCLUSIONS: CAS is a safe technique in experienced hands. Preprocedural neurological complaints and hypercholesterolemia can be defined as predisposing factors for 30-day neurological complications after CAS.     

Outcome of carotid artery stenting for primary versus restenotic lesions

Carotid artery stenting (CAS) for restenosis (RS) after carotid endarterectomy (CEA) is presumed to have fewer complications than CAS for primary atherosclerotic (PA) lesions. It has been proposed that interventionalists may limit themselves to CAS for RS initially, while they gain additional experience during their learning curve. However, there are few studies objectively comparing the outcomes of the two groups of patients to substantiate this assumption. We analyzed prospectively collected data on CAS performed at our institution from 1996 to April 2006. Complication rates were compared between CAS performed for RS versus PA lesions. Specific end points studied included in-hospital and 30-day stroke and death rates. The incidence of transient ischemic attack (TIA) was also recorded. Patient demographic features (gender, age, hypertension, diabetes mellitus, coronary artery disease, smoking, hypercholesterolemia, and presence of preoperative neurological symptoms) were recorded. A neurologist examined all patients before and after CAS. Patients with previous CAS with in-stent RS and tandem common carotid artery-internal carotid artery or arch ostial stenoses were excluded from this analysis. CAS procedures (n = 217) performed on 210 patients fulfilled inclusion criteria for this study. Indications for CAS included RS (n = 118, 54%) and PA (n = 99, 46%). The two groups were well matched for all demographic features except hypercholesterolemia, which was more common in the PA group. Thirty-day stroke and stroke + death rates for the entire series were 2.8% and 4.1%, respectively. Within this cohort, 30-day stroke and stroke + death rates were not significantly different between the RS (2.5% and 5.1%) and PA (3.0% and 3.0%) groups. Within the RS group, these outcomes were also similar when patients treated for late recurrence (>24 months after CEA, n = 49) were compared to those treated for early recurrence (< or = 24 months after CEA, n = 67). Only when stroke and TIA were combined was a difference observed between the late recurrence (10.0%) and the early recurrence (1.5%) groups (p = 0.049). Contrary to general opinion, 30-day stroke and stroke + mortality rates from CAS for RS versus PA were not significantly different. Lower neurological event rates were only seen in CAS for early RS compared with late RS after endarterectomy when TIAs were included as an end point in the analysis. CAS for RS must therefore not be considered a low-risk procedure. Technical proficiency for CAS must be equivalent regardless of the etiology of the stenosis. These observations also underscore the need for appropriate patient selection and close follow-up of all patients undergoing CAS.     

Timing of Complications during Carotid Artery Stenting. How Can they Be Predicted ?

Carotid artery stenting (CAS) is becoming increasingly common for the treatment of carotid stenosis. Accumulating data, but not randomised data, suggest that CAS has promising efficacy in preventing stroke with an acceptable rate of procedure-related complications when compared to carotid endarterectomy (CEA). However, CAS procedures can carry a risk of non-negligible complications such as cerebral embolization, cerebral hemorrhage, severe hypotension and bradycardia. These may occur after the first 24 hours. Lessons may be learned from the timing of occurrence of CAS adverse events. The most severe neurological complications are generally due to embolism and occur intraprocedurally especially during catheter, wire or sheath manipulation in the aortic arch and common carotid. These strokes, obviously, cannot be prevented by using cerebral protection devices and enhance the importance of an appropriate learning curve that includes proper material choice, patient selection, good technique and the skill of “know when to quit”.     

Timing of complications during carotid artery stenting. How can they be predicted?

Carotid artery stenting (CAS) is becoming increasingly common for the treatment of carotid stenosis. Accumulating data, but not randomised data, suggest that CAS has promising efficacy in preventing stroke with an acceptable rate of procedure-related complications when compared to carotid endarterectomy (CEA). However, CAS procedures can carry a risk of non-negligible complications such as cerebral embolization, cerebral hemorrhage, severe hypotension and bradycardia. These may occur after the first 24 hours. Lessons may be learned from the timing of occurrence of CAS adverse events. The most severe neurological complications are generally due to embolism and occur intraprocedurally especially during catheter, wire or sheath manipulation in the aortic arch and common carotid. These strokes, obviously, cannot be prevented by using cerebral protection devices and enhance the importance of an appropriate learning curve that includes proper material choice, patient selection, good technique and the skill of "know when to quit".     

Risk factors and angiographic technical considerations to guide carotid intervention

Carotid angioplasty and stenting (CAS) with embolic protection is currently accepted as treatment for patients considered to be at high risk for carotid endarterectomy (CEA). The purpose of this study was (1) to determine what proportion of patients treated with CEA would be categorized as "high" risk by currently accepted criteria, (2) to characterize preoperative angiographic findings in patients with carotid stenosis, and (3) to determine the potential technical challenges of CAS in these patients. Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, perioperative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied, and preoperative angiograms were examined for technical limitations to CAS. Two hundred and seventy-nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%), or stroke (8%) during the study period. Of these, 35.5% (n = 99) would have met one or more high-risk criteria. Overall risks of perioperative stroke, myocardial infarction, and death were 1.1%, 2.2%, and 0.4% (n = 279), respectively, with a combined major complication rate of 3.3%. No difference in major complication rates was observed between standard-risk and high-risk patients. Preoperative angiograms were available for review in 83.5% of CEAs (n = 233). The distribution of aortic arch configurations included types I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (n = 35) of angiograms. There were 77.7% (n = 181) with one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had relative angiographic contraindications to CAS. A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as high risk and considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which limit the ability to perform CAS, are common and should be anticipated when planning CAS.     

One-stage total repair of aortic arch anomaly using regional perfusion.

OBJECTIVE: Primary repair of aortic arch obstructions and associated cardiac anomalies is a surgical challenge in neonates and infants. Deep hypothermic circulatory arrest prolongs myocardial ischemia and might induce cerebral and myocardial dysfunction. METHODS: From March 2000 to December 2005, 69 neonates or infants with aortic arch anomaly underwent one-stage biventricular repair with continuous cerebral perfusion in the presence of a nonworking beating heart using the dual perfusion technique on the innominate artery and aortic root. Preoperative diagnoses of arch anomaly comprised aortic coarctation (n=54) or an interrupted aortic arch (n=15). Combined anomalies were ventricular septal defect (n=52), anomalous origin of the right pulmonary artery from ascending aorta (n=3), hypoplastic left heart syndrome (n=2), truncus arteriosus (n=2), atrioventricular septal defect (n=2), double outlet right ventricle (n=1), total anomalous pulmonary venous return (n=1), partial anomalous pulmonary venous return (n=1), and aortic stenosis (n=1). RESULTS: The mean regional perfusion time was 27.8+/-9.8 min. There was no operative mortality. Postoperative low cardiac output was present in four patients (5.8%). A neurologic complication was noted in one patient (1.5%) who developed transient chorea, but recovered completely. During 32.8+/-17.5 months of follow-up, one late death (1.5%) occurred. There was neither reoperation associated with arch anomaly nor recoarctation except in one patient. One patient developed left main bronchial compression necessitating aortopexy. CONCLUSIONS: One-stage total arch repair using our regional perfusion technique is an excellent method that may minimize neurologic and myocardial complications without mortality. Our surgical strategy for arch anomaly has a low rate of residual and recurrent coarctation when performed in neonates and infants.     

Carotid artery stenting: Influence of experience and cerebrovascular risk factors on outcome

AimTo evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery.Patients and methodsOne hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions.ResultsTechnical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators.ConclusionsCAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.     

Aortic arch reconstruction using regional perfusion without circulatory arrest.

OBJECTIVES: Deep hypothermic circulatory arrest during repair of aortic arch anomalies may induce neurological complications or myocardial injury. Regional cerebral and myocardial perfusion may eliminate those potential side effects. METHODS: From March 2000 to March 2002, 48 neonates or infants with complex arch anomaly were operated on using the regional perfusion technique. Thirty-three patients were male and the median age was 24 days (range 5-301 days). Preoperative diagnosis consisted of coarctation or interruption of the aorta associated with ventricular septal defect (group I, n = 26) and arch anomaly with complex intracardiac defects such as hypoplastic left heart syndrome or its variants (group II, n = 22). Arterial cannula was inserted through the innominate artery and the flow rate was regulated to about 50-100 ml/kg per min during regional perfusion. Simultaneous myocardial perfusion was maintained using a Y-connected infusion line. Cardioplegia was applied during intracardiac repair. RESULTS: Cardiopulmonary bypass and aortic cross-clamp times were 154 +/- 49 and 39 +/- 34 min, respectively. Temporary circulatory arrest for intracardiac procedures was performed in eight patients. However, the mean arrest time was minimized (range 1-18 min). The descending aorta clamping time was 33 +/- 16 min. Operative mortality rates in each group were 0 and 18.2% (0/26 and 4/22). Late mortality rates were 0 and 11.1% (0/26 and 2/18) during 9.1 months of follow-up. Complications consisted of low cardiac output in eight cases, transient neurological problems in two cases, and transient renal insufficiency in two cases, respectively. CONCLUSIONS: Regional perfusion is feasible and can be used with acceptable results. It may reduce potential complications following aortic arch reconstruction using circulatory arrest. However, repair of aortic arch in the patients with complex intracardiac defects still imposes a significant rate of mortality and morbidity.     

The frequency and clinical significance of congenital defects of the posterior and anterior arch of the atlas

OBJECT: In this study the authors investigated the anatomical, clinical, and imaging features as well as incidence of congenital defects of the C-1 arch. METHODS: The records of 1104 patients who presented with various medical problems during the time between January 2006 and December 2006 were reviewed retrospectively. The craniocervical computed tomography (CT) scans obtained in these patients were evaluated to define the incidence of congenital defects of the posterior arch of C-1. In addition, 166 dried C-1 specimens and 84 fresh human cadaveric cervical spine segments were evaluated for anomalies of the C-1 arch. RESULTS: Altogether, 40 anomalies (2.95%) were found in 1354 evaluated cases. Of the 1104 patients in whom CT scans were acquired, 37 (3.35%) had congenital defects of the posterior arch of the atlas. The incidence of each anomaly was as follows: Type A, 29 (2.6%); Type B, six (0.54%); and Type E, two (0.18%). There were no Type C or D defects. One patient (0.09%) had an anterior arch cleft. None of the reviewed patients had neurological deficits or required surgical intervention for their anomalies. Three cases of Type A posterior arch anomalies were present in the cadaveric specimens. CONCLUSIONS: Most congenital anomalies of the atlantal arch are found incidentally in asymptomatic patients. Congenital defects of the posterior arch are more common than defects of the anterior arch.     

腔内治疗颅外颈动脉闭塞性疾病的近期疗效

目的回顾性分析颈动脉成形加支架植入术（CAS）治疗颅外颈动脉闭塞性疾病（ECOD）的近期疗效。方法48条颈动脉接受了CAS。手术进路经股动脉穿刺完成。术后随访分2阶段：≤30d和〉30d。分析病死率和主要的并发症发生率。结果本组男性占91.7％;女性占8．3％,平均年龄（70．6±5.9）岁。术前无脑缺血症状占37．5％,有症状占62．5％。颈动脉内径平均狭窄程度（71．2±14．8）％。术前仅合并1种高危因素的为43．8％;2种或2种以上的47．9％。33．3％的患者对侧颈内动脉内径狭窄≥50％或完全闭塞。CAS的成功率为100％。术后无死亡及明显脑卒中发生。4．2％的患者发生了一过性脑缺血,18．8％的患者发生了颈动脉窦压迫综合征。30d后的随访中,有4．2％的患者出现了〉50％支架内再狭窄;无支架变形发生。结论CAS可用于治疗ECOD,特别对于那些合并有颈动脉内膜切除术高危因素的患者,具有安全、术后致残率和病死率低的优点。     

Safety of arch aortography for assessment of carotid arteries.

PURPOSE: To retrospectively review the safety of arch aortography and compare complication rates with published figures for selective catheter angiography. METHODS: The medical records of patients undergoing arch aortography over the last 3 years (n=311; 180 male, 131 female; mean+/-SD age 71.0+/-9.2 years, range 42-90 years) were retrospectively reviewed. Any peri-procedural (0-48 h) complications were recorded. A certified neurologist (MSR/GSV) classified all questionable neurological events. RESULTS: There were no focal neurological events or deaths (n=0; 0%; CI: 0-0.96%). Non-focal neurological events included mild disorientation (n=2; 0.6%; CI: 0.176-2.31) and unequal pupils (n=1; 0.3%; CI: 0.056-1.79%). Cardiovascular events included symptomatic hypotension (n=4; 1.3%; CI: 0.50-3.25%), angina (n=1; 0.3%; CI: 0.056-1.79%) and arrhythmia (n=4; 1.3%; CI: 0.50-3.25). There were 27 minor access site complications (8.7%; CI: 6.0-12.3). None of these complications extended hospital stay. None of the arch angiograms had to be followed by selective carotid angiography. CONCLUSION: Arch aortography appears to have a lower neurological complication rate than selective carotid angiography.     

Does carotid artery stenting work on the long run: 5-year results in high-volume centers (ELOCAS Registry)

AIM: Although the first long-term results of Carotid Artery Stenting (CAS) became available only recently, CAS has become an accepted treatment for carotid artery disease. We report CAS data up to 5 years, both late stroke rate and patency rates as observed in 4 high-volume European centers. METHODS: Between February 1, 1993 and December 31, 2004, 2 172 patients were selected over the 4 participating centres, with intention to treat endovascularly. Conscientious follow-up was done according to the in-hospital stipulations of each centre and was entered into a database both retrospectively and prospectively. Long-term restenosis and stroke-death rates were investigated and statistically analysed and stratified using the Kaplan-Meier method. RESULTS: Of the 2 172 patients with intention to treat 2 165 (99.7%) were technically successful. Of these 306 (14.1%) were performed without and 1 859 (85.9%) with embolic protection device (EPD); 96 patients (4.4%) received balloon dilation only and stenting was performed in 2 069 (95.6%) cases. Kaplan-Meier analysis of major stroke/all death and of significant restenosis (>50%) for the total population showed stroke/death rates of 4.1% (nar=1 356), 10.1% (nar=476) and 15.5% (nar=138); and restenosis rates of 1% (nar=1 363), 2% (nar=480) and 3.4% (nar=139), after 1, 3 and 5 years respectively. CONCLUSIONS: The patency and stroke/death rates resulting from our database analysis are pleasing and indicate that CAS also on longer term is a valuable treatment method for carotid artery disease. Due to the fact that our dataset contains prospective as well as retrospective data, it may have its limitations. Until this moment, data indicating that certain patient subgroups are at increased risk for neurological complications and in-stent restenosis during and after CAS are sparse. Further multivariant analysis on this unique dataset is mandatory in order to identify any potential links in between plaque morphology, preprocedural neurological complications, risk factor distribution, procedural steps and clinical outcome.     

Lateral congenital anomalies of the pharyngeal apparatus: part II. anatomy of the abnormal for the surgeon

"Anatomy of the abnormal"-a branch of surgical anatomy-deals with relations of an anomaly to surrounding entities. Here, lateral congenital anomalies of the pharyngeal apparatus are examined; their relations to entities of the neck can be explained embryologically. Location of embryonic pharyngeal arches, clefts, and pouches in the adult is presented and terminology of these anomalies (fistulas, sinuses, cysts) is defined. First "cleft and pouch" anomalies relate with the parotid and facial nerve. Second cleft and pouch anomalies course deeply to second arch structures and superficially to third arch structures. Consequently, they relate with hypoglossal and glossopharyngeal nerves and internal and external carotid arteries. Third cleft and pouch anomalies pass deep to third arch entities and superficial to those of the fourth arch and relate with glossopharyngeal, hypoglossal, superior and recurrent laryngeal nerves, and the internal carotid artery. The complicated course of fourth cleft and pouch anomalies brings them into relationship with glossopharyngeal, hypoglossal, superior and recurrent nerves, internal carotid, aorta, and subclavian arteries. Found superficially are veins (external and anterior jugular, common facial, communicating), nerves (transverse cervical, great auricular, mandibular, cervical branches of facial), and relevant spinal nerves (e.g., accessory). Knowledge of these anatomical relations helps prevent anatomical complications.     

Cardiac troponin I assessment and late cardiac complications after carotid stenting or endarterectomy

PURPOSE: When compared with carotid endarterectomy (CEA), percutaneous carotid angioplasty with stent replacement (CAS) is a less invasive technique in the treatment of carotid stenosis. However, periprocedural hemodynamic instability still remains a challenge. This instability might lead to myocardial damage, which is now measured accurately by using cardiac troponin I (CTnI). METHODS: This study was designed to compare the periprocedural variation of CTnI in 150 consecutive patients scheduled to undergo CEA (n = 75) or CAS (n = 75). The levels of CTnI were measured until the third postoperative day in all patients. Short-term (1 month) and long-term (up to 5 years) postoperative cardiac outcome were assessed by means of chart review, regular follow-ups, and telephone calls. RESULTS: There was not any statistically significant difference between the 2 groups regarding the demographic characteristics and preprocedural medical status. The incidence of increase of CTnI (>0.5 ng/mL) was significantly higher in the CEA group (13%) compared with that in the CAS group (1%; P = .001). During the acute postprocedural period, the CAS group was significantly more prone to hypotension, requiring vasopressor therapy, whereas the CEA group had more hypertension, necessitating hypotensive medications (P < .001). At 5 years, the overall incidence of major cardiac complications (nonfatal myocardial infarction and death related to cardiac origin) was significantly more frequent in the CEA group (20% vs 5%, P < .01). CONCLUSION: The results of our study suggest that CAS yielded less myocardial damage in the short and long term when compared with CEA. Larger randomized multicenter trials with long-term outcomes are necessary to confirm our findings.