Protection of anastomotic pathways to the vertebral artery during stenting of external carotid artery stenosis

A 61-year-old man presented with a severe external carotid artery (ECA) stenosis with concomitant ipsilateral internal carotid artery (ICA) occlusion manifesting as amaurosis fugax. The left ophthalmic artery was supplied from the left ECA. The left intracranial ICA was supplied by the collateral flow from the contralateral ICA and ipsilateral ECA through the ophthalmic artery. The left vertebral artery also participated in the latter collateral pathway through the left occipital artery and ascending pharyngeal artery. Percutaneous revascularization of the ECA was performed using a nitinol self-expanding stent. To prevent embolic complications through the ophthalmic or vertebral arteries, distal protection was performed using a balloon. During a 22-month follow-up period, the patient was completely free from any ocular or neurological symptoms. The present case of severe ECA stenosis with ipsilateral ICA occlusion showed that percutaneous balloon angioplasty with stenting is feasible and effective. This intervention requires cautious evaluation of the anastomotic pathways connecting the ECA to the cerebral circulation to avoid embolic complications.     

Complications of carotid artery stenting

AIM: The aim of this study was to deal with complications that can be managed by vascular surgery. METHODS: From March 2000 through May 2004, 171 patients (112 male, 59 female, mean age 66.2 years) underwent carotid artery stenting (CAS). Of these 171 interventions, 154 were CAS with percutaneous trasluminal angioplasty (PTA), 5 CAS without PTA, and 12 patients had only a PTA. RESULTS: In 171 patients who received CAS, 5 suffered a stroke within 7 days and 3 a transient ischemic attack. Twenty-one percent of the patients developed an in-stent restenosis >50% within 6 months following the intervention. Twenty-two patients with a recurrent in-stent restenosis were treated by re-PTA. Eight patients of this group of 22 re-PTAs developed a recurrent in-stent restenosis. They were converted with patch angioplasty or PTFE interposition. These 8 conversions were performed without morbidity or mortality. CONCLUSIONS: The preferable operative technique in patients with recurrent in-stent restenosis is open conventional operation with stent removal and patch angioplasty or graft interposition. The procedure can be performed at a low risk. In our series, we had no morbidity and mortality, and no cranial nerve lesion.     

颈动脉内膜剥脱术和颈动脉支架的客观评述

自1954年Eastcott完成首例颈动脉内膜剥脱手术(CEA)以来,已有50多年的历史,但初期并没有得到人们的认同和接受.直至20世纪90年代初,欧美国家进行了一系列关于颈动脉狭窄治疗的前瞻性临床研究,包括对于有症状和无症状颈动脉狭窄以及中度和重度颈动脉狭窄的前瞻性临床研究,证实颈动脉内膜剥脱术是一种安全有效的方法,治疗效果优于药物治疗,可以使有症状或无症状的中、重度颈动脉狭窄患者获益,多年来一直被认为是治疗颈动脉狭窄、预防卒中的"金标准".     

Current status of carotid artery stenting

This Clinical Update summarizes the results of larger case series, industry-sponsored registries, and randomized trials of carotid artery stenting (CAS). In >20 case series that studied >24,000 patients undergoing CAS, 51% of patients were symptomatic, most procedures (97%) resulted in successful stent deployment, and 30-day stroke rates varied from 1% to 8%, with a trend toward lower rates as experience and embolic protection device (EPD) use increased. In 12 industry-sponsored registries (none were published in peer-reviewed journals), 30-day stroke rates varied from 2% to 7%, and 30-day combined adverse events, including stroke, death, and myocardial infarction, were 3% to 9%. More than 12 randomized trials comparing CAS and carotid endarterectomy (CEA) have been initiated since 1998. Results have varied over time, depending on the population studied and the technology used. However, the largest and most recent results of the completed SAPPHIRE trial in high-risk patients undergoing CAS with the use of EPDs demonstrated that CAS is at least not inferior to CEA, with a 1-year combined adverse event rate of 12% for CAS and 20% for CEA (P = .05). Other ongoing trials will address not only whether CAS could be superior to CEA in high-risk patients but also, more importantly, whether CAS is beneficial in other subgroups, such as low-risk and asymptomatic patients.     

颈动脉内膜剥脱术抑或颈动脉支架术: 颈动脉狭窄手术治疗的金标准之争

脑卒中是当今第三大致死病因,是成年人致残的首要原因。颈动脉狭窄是导致缺血性卒中事件发生的最常见原因。20世纪80～90年代已有多个随机对照试验证实颈动脉内膜剥脱术相比于内科药物治疗对于预防卒中具有明显优势。近年来,随着介入技术和器材的不断进步,血管腔内介入治疗愈发成熟,其安全性及有效性正在为一些大规模的临床随机对照试验所证实,腔内介入治疗颈动脉狭窄正在挑战着外科内膜剥脱术的＂金标准＂地位。     

Reconstruction of the external carotid artery

Reconstruction of a stenotic external carotid artery associated with occlusion of the ipsilateral internal carotid artery is described in four cases. In two of them there was also a significant stump of internal carotid artery following the occlusion, and the stump was oversewn at the reconstructive operation. All four patients improved after the operation. Two still required medication which, however, had been ineffective preoperatively but now was beneficial. Reconstruction of the external carotid artery is indicated in patients with ipsilateral occlusion of the internal carotid artery and symptoms of artery-to-artery embolization.     

Revascularization of the external carotid artery

Numerous reports describe the relative effectiveness of external carotid artery (ECA) revascularization in patients with ipsilateral internal carotid artery occlusion. Most, however, suffer from small numbers of patients or lack of detailed follow-up data. In addition, controversy persists regarding the safety with which this procedure can be performed. Twenty-two patients underwent a total of 27 ECA revascularizations. There were no perioperative strokes or deaths. During a mean follow-up period of 46 months, no strokes occurred and only two patients suffered transient ischemic attacks. Revascularization of the ECA is an effective means of treating the patient with ipsilateral internal carotid artery occlusion and may be performed with minimal morbidity and mortality.     

颈动脉内膜切除术和支架植入术的合理选择

颈动脉内膜切除术（CEA）及颈动脉支架植入术（CAS）是目前广泛应用的治疗颅外段颈动脉狭窄的有效手段,由于操作方式、适应人群及围手术期并发症的不同,一直存在关于如何选择治疗方式的争论,笔者就其发展历史和相关临床对照研究结果进行总结。

     

颈动脉支架植入术并发症分析

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

Economic evaluation of carotid artery stenting versus carotid endarterectomy for the treatment of carotid artery stenosis

BACKGROUND: The clinical effectiveness of carotid endarterectomy (CEA) is well established. But the economic impact of CEA and carotid artery stenting (CAS) is still uncertain. The objective of this study was to compare hospital costs and reimbursement for CAS and CEA. STUDY DESIGN: We performed a retrospective database analysis on pair-matched patients who underwent CEA (n = 31) and CAS (n = 31) at the Richard M Ross Heart Hospital in Columbus, OH. The hospital's clinical and financial databases were used to obtain patient-specific information and procedural charges. Cost data were generated by applying the hospital's ratio of cost to charges for all DRG charges. The Wilcoxon signed-rank test was used to examine the differences between costs of these procedures. RESULTS: Data are reported as mean +/- SD. The mean age of patients in CAS group was 70.14 years (+/- 1.60 years) versus 68.64 years (+/- 1.75 years) for CEA patients (p < 0.05). The total direct cost associated with CEA ($3,765.12+/-$2,170.82) was significantly lower than the CAS cost ($8,219.71+/-$2,958.55, p < 0.001). The mean procedural cost for CAS ($7,543.61+/-$2,886.54) was significantly higher than that for CEA ($2,720.00+/-$926.38, p < 0.001). The hospital experienced cost savings of $9,690.87 for CEA versus $4,804.79 for CAS from private insurance. Similarly, savings obtained by Medicare-enrolled CEA patients were higher than those for CAS patients ($1,497.79). CONCLUSIONS: CAS is significantly more expensive than CEA, with a major portion of cost attributed to the total procedural cost. The hospital experienced significant savings from CEA procedures compared with CAS under all DRG classifications and insurers. Hospitals must develop new financial strategies and improve the efficiency of infrastructure to make CAS financially viable.     

Acute carotid artery stenting in symptomatic high-grade cervical carotid artery stenosis

The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset). We evaluated modified Rankin scale (mRS) scores 90 days after CAS. For patients treated during the hyperacute phase without intravenous tissue-type plasminogen activator (IV-tPA), two had mRS scores of 2 and one had a score of 3. Two patients treated in the hyperacute phase with IV-tPA had scores of 5: one with symptomatic intracerebral hemorrhage and the other with acute brain swelling. For patients treated in the advanced phase, mRS scores were 1, 3, and 5; the patient with 5 had contralateral cerebral infarction. All patients treated in the acute phase had scores of 2 or lower. Patients treated with IV-tPA in advanced or acute phases had no severe post-CAS complications. CAS was effective and safe for treating ischemic stroke within 2 weeks of onset. However, IV-tPA treatment may be a risk factor for CAS treatment during the hyperacute phase.     

How to optimize carotid artery stenting

Carotid angioplasty and stenting is now an alternative to surgical endarterectomy to treat carotid occlusive disease and is becoming mainstream in medical practice. However, the information available, the procedure techniques and the technologies are still evolving and several issues are still being discussed. Mandatory training, familiarity with the indications and contraindications, knowledge of the technology and devices are paramount for the success, however, the devices for carotid stenting are still under development. The impact of stent design seems to be greater than previously appreciated. Carotid plaque morphology may be important for the indication of the procedure. The pre, trans, and postprocedure patient management of the patient is essential for reducing morbidity and mortality. Due to the devastating potential complications, compared with other endovascular and minimally invasive procedures, carotid stenting requires a much more strict scrutiny of the operators training and outcomes, since the improvement in the learning curve is accompanied by a comparative reduction in the complication rates. This article presents a review of the information available on how to optimize carotid stenting.