Intracranial angioplasty: experience and complications.

PURPOSETo review our experience with intracranial angioplasty, including the complications we encountered.METHODSDuring a 3-year period, from 1993 to 1996, 10 patients had intracranial percutaneous transluminal angioplasty (PTA). The stenosed vessels included three internal carotid arteries, one middle cerebral artery, one basilar artery, and five vertebral arteries. Stenosis in all patients was 75%, or greater. PTA was technically successful in eight patients; in two patients it could not be performed owing to inability to traverse the stenosed area.RESULTSTwo patients had successful and uneventful PTA. Five patients had vasospasm, which resolved with local vasodilators in two and with repeat PTA in one. Vasospasm led to stroke in two patients. Compromise of perforating vessels and arterial dissection were associated with stroke in two patients.CONCLUSIONIntracranial PTA is technically feasible but associated with risks related to vasospasm, arterial trauma, and compromise of perforating vessels.     

Direct puncture of the proximally occluded internal carotid artery for treatment of carotid cavernous fistulas

Three patients with symptomatic carotid cavernous fistulas (CCFs) characterized by complete occlusion of the proximal internal carotid artery were treated by percutaneous puncture and embolization. Two patients had CCFs associated with traumatic dissections of the internal carotid artery and were treated initially with trapping procedures. Both patients had persistent symptoms related to the CCF and underwent additional surgical procedures (ophthalmic artery ligation and intraoperative embolization) without improvement. The third patient had traumatic occlusion of the internal carotid artery. After direct percutaneous puncture of the carotid artery above the occlusion, a catheter was advanced into the petrous internal carotid artery. Balloons (one case) or coil emboli (two cases) were placed into the cavernous sinus to produce CCF closure. There were no complications from this procedure. Direct puncture of the carotid artery is an alternative treatment for patients lacking safe access for CCF embolization.     

Balloon test occlusion of the internal carotid artery with hypotensive challenge.

PURPOSETo evaluate the usefulness of provocative testing with hypotensive challenge during balloon test occlusion of the internal carotid artery before carotid sacrifice and to correlate tolerance of balloon test occlusion with clinical outcome after carotid artery sacrifice.METHODSForty-seven consecutive cases of balloon test occlusions performed at our institution during the past 4 years were retrospectively reviewed. Occlusion was performed under normotensive conditions with distal perfusion of heparinized saline for 20 minutes, or until a deficit was perceived. If 20 minutes of normotension was tolerated, hypotension was induced to two thirds of mean arterial pressure for 20 minutes, or until a deficit was perceived.RESULTSOf 47 patients, 4 (9%) had deficits at normotension. Of the remaining 43 patients, 9 (21%) had deficits at hypotension. One patient with a positive hypotensive test occlusion underwent carotid artery sacrifice after extracranial-intracranial bypass without sequelae. In one of the 19 patients who clinically tolerated test occlusion with hypotension and had carotid sacrifice (surgical ligation of the intracranial carotid artery), a mild embolic stroke developed, probably from the giant carotid wall aneurysm. This patient fully recovered; MR imaging showed mild changes consistent with emboli distal to the aneurysm. Symptomatic complications were noted in 2 (4%) patients, and asymptomatic arterial dissections were noted in 3 (6%) patients.CONCLUSIONBalloon test occlusion with hypotensive challenge is safe, economical, and greatly increases the sensitivity of balloon test occlusion. The predictive value of a negative test is high. However, to determine the test''s specificity compared with quantitative imaging, controlled trials will be necessary.     

Endovascular therapy of intractable epistaxis complicated by carotid artery occlusive disease.

Three cases of intractable spontaneous posterior epistaxis refractory to nasal packing and complicated by ipsilateral carotid artery occlusive disease were successfully treated with internal maxillary artery occlusion with microcoils. There were no complications and no recurrent episodes of epistaxis at a mean follow-up of 12 months. The presence of ipsilateral carotid artery disease requires modification of standard distal internal maxillary artery embolization because of the recruitment of external carotid to internal carotid and external carotid to ophthalmic artery collateral pathways, with subsequent risk of particle embolization of these arterial distributions. Proximal internal maxillary artery microcoil embolization eliminates this risk and is equivalent to surgical internal maxillary artery ligation. This procedure also provides additional information about the internal carotid artery collateral circulation.     

Helical CT for the follow-up of cervical internal carotid artery dissections.

PURPOSEThe aim of this study was to assess the changes over time of internal carotid artery (ICA) dissections by using helical CT.METHODSTwenty-seven patients with 30 angiographically proved ICA dissections were followed up with helical CT at 7 to 62 months (median, 24 months) after conventional angiography. CT scans, analyzed independently by two radiologists in a blinded fashion, were evaluated for the presence of mural thickening, aneurysmal formation, and arterial occlusion. In cases without persisting occlusion or aneurysm, we measured the external diameter of the ICA at its upper segment.RESULTSThe interobserver agreement was good. Mild mural thickening was observed in four cases of 30 previously dissected ICAs. All stenotic and nearly occlusive dissections without an aneurysm (n = 12) reverted to a normal or nearly normal diameter. Half the aneurysms resolved spontaneously (four of eight). Of the 10 occluded ICAs, nine were recanalized, but their external diameter was significantly smaller than that of normal carotid arteries, and a hypoplastic appearance was seen throughout the cervical segment of the ICA in three cases.CONCLUSIONMost arterial lesions tend to improve or disappear spontaneously, but persisting ICA narrowing may be observed in the late course of occlusive-type dissections.     

Vertebrocarotid collateral in extracranial carotid artery occlusions: digital subtraction angiography findings

The internal and external carotid arteries are usually considered occluded distal to a common carotid artery occlusion but some collateral vessels may provide blood keeping the internal and external carotid arteries patent distal to the occlusion. Most common communication in such a case is diversion of blood from muscular branches of the vertebral artery to occipital branch of the external carotid artery which in turn could maintain blood flow into the internal carotid artery, a condition called carotid steal. We encountered vertebrocarotid anastomoses maintaining the patency of carotid circulation in six patients. Patients were four females and two males, ages ranging from 40 to 67 (mean age: 56) years. Five of the patients had ischemic cerebral symptoms. The origin of the external carotid artery was occluded in two and the whole common carotid artery in the remaining four patients. Two patients had double steal, carotid and subclavian at the same time. There was also severe stenosis or occlusion of at least one other major extracranial cerebral artery in all the cases. This concomitant involvement of the second extracranial cerebral artery was thought to be the main reason for the development of vertebrocarotid collateral. In contrast to most of the previously published reports claiming the inadequacy of angiography when compared with colour Doppler ultrasonography, angiography finely depicted the distal patency of the carotid circulation and all the collaterals in detail in every case. Selective injection of the vertebral artery ipsilateral to the occlusion, is the key to demonstrate distal patency of the carotid circulation in cases of proximal carotid occlusion. Demonstration of patency of the distal circulation is very important because some of the patients might get benefit from a reconstructive surgery.     

Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment.

PURPOSETo define the role of angiography and embolization in the treatment of patients who have arterial injuries during transsphenoidal surgery.METHODSWe retrospectively studied the arterial hemorrhagic complications, their management, and the clinical outcomes that occurred in 21 of the more than 1800 patients who had transsphenoidal surgery for pituitary adenomas.RESULTSOf the 21 patients who had complications, 17 had internal carotid injuries and four had injuries of the sphenopalatine artery. Angiography was performed in 18 patients. Bleeding occurred and was controlled during surgery in 16 cases. Delayed epistaxis occurred in 10 patients, including five whose surgery was uneventful. After internal carotid injury, the most frequent angiographic findings were carotid occlusion (eight patients), stenosis (five patients), and false aneurysms (three patients). Internal carotid balloon occlusion was performed in five patients. No rebleeding occurred in patients who had complete carotid occlusion either from surgical packing or balloon embolization. Two of the patients who had carotid stenosis after surgical packing had delayed epistaxis necessitating balloon occlusion. Injuries to the sphenopalatine artery were successfully treated by surgery (one patient) or by endovascular treatment (three patients) without complication. Three deaths and five permanent deficits were directly related to the arterial injury or its treatment.CONCLUSIONProfuse bleeding during and after transsphenoidal surgery should be investigated by angiography. Lesions of the sphenopalatine arteries are effectively treated by embolization. Internal carotid injuries are best treated by carotid infusion to prevent life-threatening epistaxis.     

血管内支架在治疗颈内动脉高度狭窄疾病中的应用

目的 探讨血管内支架在颈内动脉高度狭窄病例中的应用。方法 １９９８～１９９９年,对８例颈内动脉高度狭窄病例进行了经皮血管内成形术（ＰＴＡ）与支架治疗,采用了３种支架。在充分准备后,根据病变的不同,采取不同的支架与操作,使手术完全成功。结果所有病例术后影像学复查表明是成功的,临床症状消失或好转。８例一过性缺血（ＴＩＡ）及头痛、头晕完全消失;８例肢体无力者６例恢复,２例好转;４例一过性黑朦症状消失;     

Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease

BACKGROUND AND PURPOSE: The safe performance of percutaneous transluminal cerebral angioplasty for intracranial atherosclerotic lesions requires that the risk of complications, such as acute occlusion or symptomatic dissection, and restenosis be reduced. Our purpose was to assess the effectiveness, safety, and short-term arteriographic and clinical outcome of cerebral angioplasty and stenting (CAS) for intracranial vertebrobasilar and distal internal carotid atherosclerotic occlusive lesions. METHODS: Between March 1998 and November 1998, 10 patients with 12 intracranial atherosclerotic lesions of the vertebrobasilar artery and the distal internal carotid artery underwent treatment with flexible balloon-expandable coronary stents. RESULTS: Although in two of the 10 patients CAS was not successful because of the inability to access the site of arterial stenosis, 10 lesions in eight patients were successfully dilated with stents. No complications occurred during or after the procedure and no neurologic ischemic events or restenoses occurred during the follow-up period. CONCLUSION: CAS appears to be a safe and effective means for treating intracranial atherosclerotic occlusive disease, yielding a favorable arteriographic and clinical outcome.     

Unilateral absence of the external carotid artery

We report a patient with absence of the external carotid artery. The major external branches originate from the internal carotid artery which is really a common arterial trunk. The embryology and clinical significance of this rare vascular anomaly are discussed.     

Dynamic Computed Tomography Angiography in Suspected Brain Death: A Noninvasive Biomarker

Purpose

Neurologic determination of death or brain death is primarily a clinical diagnosis. This must respect all guarantees required by law and should be determined early to avoid unnecessary treatment and allow organ harvesting for transplantation. Ancillary testing is used in situations in which clinical assessment is impossible or confounded by other factors. Our purpose is to determine the utility of dynamic computed tomographic angiography (dCTA) as an ancillary test for diagnosis of brain death.

Materials and Methods

We retrospectively reviewed 13 consecutive patients with suspected brain death in the intensive care unit who had dCTA. Contrast appearance timings recorded from the dCTA data were compared to findings from 15 controls selected from patients who presented with symptoms of acute stroke but showed no stroke in follow-up imaging.

Results

The dCTA allows us to reliably assess cerebral blood flow and to record time of individual cerebral vessels opacification. It also helps us to assess the intracranial flow qualitatively against the flow in extracranial vessels as a reference. We compared the time difference between enhancement of the external and internal carotid arteries and branches. In all patients who were brain dead, internal carotid artery enhancement was delayed, which occurred after external carotid artery branches were opacified.

Conclusion

In patients with suspected brain death, dCTA reliably demonstrated the lack of cerebral blood flow, with extracranial circulation as an internal reference. Our initial results suggest that inversion of time of contrast appearance between internal carotid artery and external carotid artery branches at the skull base could predict a lack of distal intracranial flow.     

Antiphospholipid antibodies: findings at arteriography.

PURPOSEThe purpose of this study was to determine the frequency and types of abnormalities at arteriography in patients with antiphospholipid antibodies (APA) and ischemic cerebrovascular events.METHODSTwenty-three patients with APA and ischemic cerebrovascular events who underwent arteriography were identified. Patients over the age of 65 years were excluded. No patients met diagnostic criteria for systemic lupus erythematosus. All angiograms were reviewed by two neuroradiologists.RESULTSSeventeen patients (74%) between the ages of 28 and 64 years (average age, 40 years) had abnormal angiograms. Sixteen patients had arterial abnormalities and one had dural sinus thrombosis. Ten had solely intracranial abnormalities (nine arterial and one venous), six had solely extracranial arterial abnormalities, and one had both intracranial and extracranial arterial abnormalities. Intracranial arterial abnormalities included stem or branch occlusions of the cerebral or basilar arteries, which were generally solitary (six patients), and findings suggestive of vasculitis (four patients). Four patients had stenoses of the origins of two or more great vessels. Two patients had extracranial internal carotid artery stenoses or occlusions that were not typical of atheromatous disease, considered to be embolic in one patient. In another patient, a stenosis of the origin of the internal carotid artery was present that appeared typical of atheromatous disease. Infarctions were seen on CT or MR studies in 13 of 17 patients with abnormal angiograms.CONCLUSIONIn our group of patients, typical atheromatous lesions at the common carotid artery bifurcation were rare. Some lesions that are infrequent in the general stroke population (eg, vasculitis-like findings and stenoses at the origin of great vessels) were common. Patients with APA and cerebrovascular events appear to differ from the general stroke population with regard to types of arterial abnormalities seen at arteriography.     

Percutaneous transluminal angioplasty of the carotid artery

Summary The successful dilation of postsurgical concentric stenosis of an internal carotid artery using percutaneous transluminal angioplasty (PTA) is reported here. Only one such case has been previously documented. Review of the literature disclosed 16 patients who received transluminal angioplasty for stenosis of carotid arteries by percutaneous or open arteriotomy techniques. The authors feel that PTA may be the treatment of choice for postoperative concentric stenosis of a short segment of the carotid artery as opposed to surgical repair.     

Gortex graft-external carotid artery anastomotic stricture treated by percutaneous transluminal angioplasty

We describe successful percutaneous transluminal angioplasty (PTA) of a gortex-right external carotid artery anastomotic stricture in a 49-year-old man with amaurosis fugax and occlusion of the right internal carotid artery. No neurological complications occurred during the procedure. The patient had had three previous carotid operations, and PTA enabled successful transcranial arterial bypass surgery to be carried out, with complete relief of symptoms.     

Common carotid artery occlusion: evaluation with duplex sonography.

PURPOSETo demonstrate the efficacy of carotid duplex ultrasound to diagnose common carotid artery occlusion (CCAO) and to define the clinical features of CCAO.METHODSWe reviewed 5400 carotid duplex ultrasonograms obtained over a 7-year period for suspected carotid artery disease. In cases of CCAO, medical records were reviewed.RESULTSThirteen cases (0.24%) of CCAO were diagnosed by carotid duplex ultrasonography, including five cases of isolated CCAO. Seven cases were proved by cerebral angiography. Cerebral angiography failed to demonstrate patent internal carotid arteries in two cases of isolated CCAO. Mean age of onset was 67 +/- 9 years. The main clinical presentation was stroke in nine cases (69%). The most common vascular risk factors were hypertension (62%) and heart diseases (54%). Three patients had a history of radiation therapy to the neck. Two of five patients with isolated CCAO had major stroke, with good recovery in one, whereas five of eight patients with CCAO had major stroke; among them, only one had good recovery.CONCLUSIONPatients with isolated CCAO may have a better outcome than patients with CCAO. Duplex sonography, particularly with color-coded flow imaging, provides an accurate examination to define the patency of the arteries distal to the carotid bifurcation. The clinical features of CCAO are similar to those of internal carotid artery occlusion except for the low prevalence of CCAO.     

Takayasu arteritis: angiographic findings and results of angioplasty

Takayasu arteritis is a systemic disease characterized by occlusion of the aorta and its branches. We performed coronary angiography and thoracic and abdominal aortography on 47 patients with Takayasu arteritis. Angiographic findings included arterial stenosis, occlusion, or aneurysm. The left subclavian artery was involved in 26 cases (55%), the abdominal aorta in 25 cases (53%), the right renal artery in 21 cases (45%), the right subclavian and left renal arteries in 18 cases (38%), the descending thoracic aorta in 15 cases (32%), and the left common carotid artery in 14 cases (30%). The coronary arteriograms in the 47 patients showed coronary involvement in seven (15%). Proximal or osteal lesions were present in six cases. Percutaneous transluminal angioplasty was performed successfully in eight patients for treatment of three aortic lesions, nine renal artery lesions, one subclavian artery lesion, and one coronary artery lesion. In the three cases with recurrence after 4-7 months, repeated angioplasty was successful. For appropriate management of Takayasu arteritis, we suggest thorough angiographic evaluation and proper intervention, including percutaneous transluminal angioplasty in selected cases for revascularization.     

Angioplasty of the occluded internal carotid artery.

PURPOSETo review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful.METHODSWe reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed.RESULTSAll four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent.CONCLUSIONIn acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Percutaneous embolization of arteriovenous fistulas of the external carotid artery

Nineteen arteriovenous fistulas of the external carotid branches in 17 patients were treated by a variety of percutaneous transvascular techniques. There were nine females and eight males; 11 fistulas were traumatic in origin, five were "spontaneous," and three were thought to be congenital. The most frequent presenting symptoms were a bruit and thrill, followed by pulsatile tinnitus, pulsatile mass, headaches, and ocular problems. The symptoms were related to fistula site and venous drainage. The middle meningeal artery was involved most often, followed by the superficial temporal, occipital, internal maxillary, and ascending pharyngeal arteries. All patients except one were successfully cured, including one recurrence. There were no complications, and the hospital stay averaged 3 days.     

动脉栓塞治疗男性先天性盆腔动静脉畸形一例

报道1例长期原因不明肉眼血尿多囊肾患者。影像检查显示两侧盆区动静脉畸形(CPAVM)。经超选择栓塞髂内动脉8支分支血尿治愈,随访6个月,血尿无复发。文献复习表明CPAVM发病甚少,形态多样。介入治疗是有效的微创方法。     

Endovascular Treatment of Lower Limb Penetrating Arterial Traumas

Purpose: The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma. Materials and Methods: Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients. Results: On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient. Conclusions: We conclude that embolization—particularly n-butyl cyanoacrylate embolization—is technically feasible in patients with penetrating peripheral arterial trauma.