Value of diffusion-weighted MRI during carotid angioplasty and stenting.

INTRODUCTION: The incidence of neurological injury following carotid angioplasty and stenting is of great interest to those advocating it as an alternative to endarterectomy in the management of critical carotid stenosis. A significant inter-observer variation exists in determining the presence or absence of a neurological deficit following the procedure objective imaging would be advantageous. In this study, we sought to assess diffusion weighted MRI as a diagnostic tool in evaluating the incidence of neurological injury following carotid angioplasty and stenting (CAS). PATIENTS AND METHODS: The first 110 cases of CAS in our unit were included in this series. The procedure was abandoned in three patients. Patients underwent intracranial and extracranial MR angiography, together with diffusion-weighted MRI (DWI) prior to and following CAS and had a formal neurological assessment in the intensive care unit after the procedure. RESULTS: One hundred and ten Procedures were attempted in 98 patients. Twenty-eight percent were asymptomatic. Following CAS, 7.2% of patients had a positive neurological exam (two major strokes with one fatality) and 21% had positive DWI scans, equating to a sensitivity of 86% and a specificity of 85% for DWI in detecting cerebral infarction following CAS. The positive predictive value of the test was 0.3 and negative predictive value 0.99. The major stroke and death rate was 1.8%. While the use of a cerebral protection device appeared to significantly reduce the incidence of cerebral infarction (5% vs. 25%, p = 0.031) this may be a reflection of the learning curve encountered during the study. CONCLUSION: The incidence of subclinical DWI detected neurological injury was significantly higher than clinical neurological deficit following CAS. Conventional methods of neurological assessment of patients undergoing CAS may be too crude to detect subtle changes and more sensitive tests of cerebral function are required to establish whether these subclinical lesions are relevant.     

Subclinical embolization after carotid artery stenting: new lesions on diffusion-weighted magnetic resonance imaging occur postprocedure

OBJECTIVES: The reported rate of subclinical brain injury after carotid artery stenting (CAS) seen on diffusion-weighted magnetic resonance imaging (DWI) varies from 10% to >40%. Data from transcranial Doppler after CAS indicate that embolization may continue for several days, suggesting that that at least some lesions seen on DWI occur postprocedure. Because DWI lesions appear or=60 microm. RESULTS: There were two periprocedural strokes and one transient ischemic attack (TIA), but no strokes or TIAs occurred during follow-up. In the 23 patients imaged 1 hour postprocedure, new lesions were found in two (9%), and 18 (78%) had new lesions at 48 hours (P < .001). For the entire study group, the incidence of new lesions at 48 hours was 67% (36/54). The median number of DWI lesions was four (range, 1 to 17). Every protection device examined had atherosclerotic debris, with a mean of 135 +/- 73 fragments (range, 18 to 310) sized >60 microm and a mean of eight fragments (range, 2 to 21) sized >500 microm. Findings on postprocedure DWI did not correlate with the degree of stenosis, size of angioplasty balloon, or number of inflations, nor with the number or size of fragments retrieved from the protection device. CONCLUSIONS: CAS can be performed with a very low incidence of clinically evident neurologic events; however, it is associated with embolization during and after the procedure. Protection devices effectively prevent clinical and subclinical events during the procedure. Significant embolization continues for at least 48 hours postprocedure, causing lesions on DWI when there is no mechanism for cerebral protection. These data correlate with transcranial Doppler reports of continued embolization after CAS and indicate that DWI should be done as late as possible to accurately assess the rate of subclinical brain injury with CAS procedures.     

Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of percutaneous angioplasty and stenting (PAS) in comparison with traditional open surgical (OS) revascularization for the treatment of chronic mesenteric ischemia. METHODS: Over a 3.5-year period, 28 patients (32 vessels) underwent PAS (balloon angioplasty alone, 5 [18%] of 28; angioplasty and stenting, 23 [82%] of 28) for symptoms of chronic mesenteric ischemia. These patients were compared with a previously published series of 85 patients (130 vessels) treated with OS (bypass grafting, 60 [71%] of 85; transaortic endarterectomy, 19 [22%] of 85; or patch angioplasty, 6 [7%] of 85). RESULTS: The PAS and OS groups were similar with respect to baseline comorbidities, duration of symptoms (median: 6.7 vs 10.5 months, P =.52), and the number of vessels involved, but the patients differed in their age at presentation (median: 72 vs 65 years, P =.005). Fewer vessels were revascularized per patient in the PAS group (1.1 +/- 0.4) compared with the OS group (1.5 +/- 0.6, P =.001). Overall, 85.7% (24/28) had one vessel and 14.3% (4/28) had two vessels revascularized in the PAS group versus 48.2% (41/85) with one-vessel and 47.1% (40/85) with two-vessel revascularization in the OS group. No difference was noted in the early in-hospital complications (median: 17.9% [PAS] vs 32.9% [OS], P =.12) or mortality rate (10.7% [PAS] vs 8.2% [OS], P =.71). A reduced length of hospital stay in the PAS patients did not attain statistical significance (median: 5 days [PAS] vs 13 days [OS], P =.08). Although the 3-year cumulative recurrent stenosis (P =.62) and mortality rate (P =.99) did not differ, the PAS treatment group had a higher incidence of recurrent symptoms (P =.001). CONCLUSION: Although the results of PAS and OS were similar with respect to morbidity, death, and recurrent stenosis, PAS was associated with a significantly higher incidence of recurrent symptoms. These findings suggest that OS should be preferentially offered to patients deemed fit for open revascularization.     

A comparative analysis of long-term mortality after carotid endarterectomy and carotid stenting

Background

The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of “real-world” outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort.

Carotid artery stenting after carotid endarterectomy

Atherosclerotic carotid artery disease remains an important cause of cerebrovascular ischemic disease. We present a patient with residual stenosis of the distal internal carotid artery following carotid endarterectomy that was treated with stenting. The case highlights the potential complimentary benefits of carotid endarterectomy and carotid stenting.     

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.     

Subarachnoid hemorrhage after carotid artery stenting

We describe subarachnoid hemorrhage (SAH) in a 66-year-old man, who underwent technically successful carotid stenting for a string-stenosis of the right internal carotid artery (ICA) in a presence of contralateral ICA occlusion with recurrent right hemisphere transient ischemic attacks. At 2 hours, the patient developed headache and vomiting, but no focal neurological deficits. Performed transcranial color-coded Doppler (TCCD) showed over 2.8-fold increase of the peak systolic velocity in the right middle cerebral artery. The emergent CT of the brain showed SAH with the right hemisphere edema. Patient was treated with Nimodipine in continuous infusion, diuretics i.v. and additional hypotensive therapy depending on blood pressure values. Clopidogrel was stopped for 5 days. Over next 4 weeks, a gradual cerebral velocities decrease was observed on TCCD, which was related to clinical and CT resolution.     

Altered flow territories after carotid stenting and carotid endarterectomy

BACKGROUND: The hemodynamic effects of carotid angioplasty with stent placement (CAS) on the collateral blood supply and on the regional cerebral blood flow (rCBF) have not been established. Recently, arterial spin-labeling (ASL) magnetic resonance imaging (MRI) has been introduced as the first method to quantify the actual territorial contribution of individual collateral arteries as well as to noninvasively measure rCBF. This study investigated alterations in flow territories and rCBF in patients with symptomatic internal carotid artery (ICA) stenosis and compared them with healthy control subjects. In addition, we investigated whether possible differences in flow territories and rCBF were present between patients undergoing CAS and patients undergoing carotid endarterectomy (CEA). METHODS: The study included 24 consecutive patients (15 men and 9 women; age 67+/-9 years) with symptomatic ICA stenosis. CAS was performed in 12 patients, and 12 patients underwent CEA. Flow territory mapping and rCBF measurements were performed with ASL MRI before intervention and 1 month after. The control group consisted of 40 subjects (25 men and 15 women; age 67+/-8 years). RESULTS: The flow territory of the ipsilateral ICA in patients with ICA stenosis was smaller, and the territories of the contralateral ICA and vertebrobasilar arteries were larger compared with control subjects (P<.05). After CAS, rCBF in the ipsilateral hemisphere increased from 60.2+/-16.9 mL/(min.100 g) to 68.9+/-9.2 mL/(min.100 g) (P<.05). Differences in flow territories and rCBF between patients and control subjects disappeared after CAS. Changes in flow territories and rCBF were similar in patients who underwent CAS or CEA. CONCLUSIONS: CAS results in a normalization of the territorial distribution and rCBF, as assessed by ASL MRI. The degree of improvement is similar to that seen after CEA.     

Arterial infection and staphylococcus aureus bacteremia after transfemoral cannulation for percutaneous carotid angioplasty and stenting

In this report, we present a patient who developed an infected femoral artery after repuncture cannulation for carotid angioplasty and intraluminal stenting. The case was complicated by persistent bacteremia and a delay in diagnosis before it was managed successfully with an autogenous replacement graft and appropriate antibiotics. Overt stent infection is exceedingly rare, but according to the literature describing transfemoral coronary artery intervention, the spectrum of clinical syndromes related to infection of the arterial puncture site includes local invasion, pseudoaneurysm formation, septic embolization to the distal limb, and bacteremia. The diagnosis requires a high degree of clinical suspicion and is often delayed. Although the incidence of infectious complications reported for percutaneous intra-arterial interventions historically has been low, the absolute number of these complications almost certainly will increase in the future because of the expanding array of interventional procedures that is becoming available.     

Horner's syndrome after carotid artery stenting: case report

BACKGROUND

Angioplasty and stenting of various lesions of the carotid artery is gaining in popularity. Our knowledge of the efficacy and limitations of this promising technology is incomplete. Although Horner’s syndrome and its variants have been described after traumatic, spontaneous, or surgical carotid dissection, it has not been reported after carotid artery stenting.

CASE DESCRIPTION

A 36-year-old woman presented with left neck and ear pain and a 3-year history of rushing noises in her left ear. Angiography demonstrated evidence of dissection of the left internal carotid artery at the skull base with a pseudoaneurysm.

The pseudoaneurysm was treated with a 6-mm diameter self-expanding stent in a 4-mm diameter left internal carotid artery. A few hours later, she developed partial Horner’s syndrome with a subtle ipsilateral ptosis and miosis without anhidrosis. Angiography performed on the next day did not demonstrate further dissection or aneurysm growth but did show distention of the artery wall because of the stent. She did not develop any further sequelae.

CONCLUSION

This case suggests that stretching of the artery wall may result in stretching of surrounding structures. The sympathetic fibers surrounding the internal carotid artery are clearly sensitive to this degree of stretch. Possible complications associated with stretch injury must be considered when choosing the stent diameter.     

Restenosis after carotid angioplasty and stenting: a follow-up study with duplex ultrasonography.

OBJECTIVES: To prospectively document the incidence, location, risk factors for and clinical consequences of restenosis after carotid artery angioplasty and stenting (CAS). METHODS: Serial duplex and neurological examinations were performed in 217 patients one day (n = 216), 3 (n = 189), 12 (n = 129) and 24 (n = 48) months, after CAS. The relationship between patient, lesion and procedure variables and restenosis was determined at 12 months. RESULTS: The prevalence of restenosis > or = 50% was 14, 16, 18, and 21%, respectively, and was only significantly related with loss of proximal stent apposition (odds ratio 3.4, 95% confidence interval: 1.0-11.7, p < 0.05). Four restenoses were symptomatic. CONCLUSIONS: Restenosis after CAS is common, unpredictable but infrequently symptomatic.     

An uncommon cause for carotid artery stenosis after carotid stenting

Carotid artery stenting (CAS) has evolved as a minimally invasive alternative to carotid endarterectomy, particularly among patients with prior neck surgery or external beam radiation for malignancy. Restenosis after CAS remains low yet is typically due to neointimal hyperplasia and manifests within the first 2 years after stent placement. We present an unusual case of carotid artery stenosis 18 months after angioplasty and stenting as a result of recurrent malignancy, which was treated with repeat stent placement.     

Ischemic cerebral lesions after carotid surgery and carotid stenting.

OBJECTIVES: To evaluate the risk of new ischemic cerebral lesions after carotid endarterectomy and carotid stenting and their clinical significance. METHODS: Prospective and non-randomized single-center study including 121 patients with symptomatic and asymptomatic significant carotid stenosis. 60 patients were treated by surgery and 61 treated by carotid stenting. Stenting was restricted to patients at high risk for surgery. Neurological examination and Diffusion-Weighted Cerebral Magnetic Resonance (DW-MRI) were performed before and after each procedure. The presence, location and volume of new cerebral lesions were determined. RESULTS: In the surgical group, 2 minor strokes were registered. DW-MRI showed new lesions in 7 patients (11.6%). All except one were located in the ipsilateral anterior circulation. In the stenting group, 1 minor stroke and 1 occurrence of quadranopsia were registered. DW-MRI showed new lesions in 26 patients (42.6%). 10 of these patients (38.4%) had lesions in the contralateral hemisphere and 7 patients (26.9%) in the posterior circulation. Deficits are found in patients with higher lesion volumes. CONCLUSIONS: Cerebral ischemic lesions are significantly (p<0.0001) more frequent after carotid stenting than after endarterectomy. The majority of these lesions have no immediate clinical implication, but more specific tests are needed to evaluate their exact significance.     

颈动脉支架术后视网膜动脉栓塞1例

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