Angioplasty and stenting for the occluded internal carotid artery

To investigate the feasibility and efficacy of angioplasty and stenting for symptomatic occlusion of carotid artery. From December 2004 to June 2009, 17 patients with progressive or reoccurred ischemic stroke or repeated transient ischemic attack resulted from the total occluded carotid artery underwent angioplasty and stenting were reviewed. All patients with successful procedure were followed up. Clinic and angiography data were documented prospectively. The median time from symptoms onset to procedure was 23 days (range 3–94 days). Twelve of the 17 patients (70%) were obtained technique success. Eight patients were observed the collapse of internal carotid artery between occluded location to origin of ophthalmic artery after the occlusion was patent. Two patients had clots which were solved with urokinase. The collapsed internal carotid artery was improved markedly in the compute tomography angiograph 7 days after the procedure. No any complications related procedures occurred. One patient died from myocardial infarct and one suffered from ischemic minor stroke in brainstem for a median follow-up of 346.5 days. One of 9 patients (11.1%) was observed in-stent stenosis in the follow-up angiography. Angioplasty and stenting was a potential alternative therapy for symptomatic occlusion of carotid artery. Further study is required to determine the safety of this treatment.     

Bilateral carotid angioplasty and stenting.

Bilateral carotid stenosis is generally treated by staged stenting procedure and rarely simultaneously due to concerns about hemodynamic impairment from stimulation of the carotid sinus baroreflex (severe bradycardia, hypotension) and the risk of cerebral hyperperfusion syndrome. Most of the accounts of bilateral carotid stenting are of small series. The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral carotid angioplasty and stenting (CAS) in comparison with staged procedure. We retrospectively analyzed the procedural outcome and complications of bilateral CAS done between February 1995 and June 2004 in a consecutive series of 57 high-risk patients. Mean age was 64 +/- 9 years (male, 43; female 14). One hundred fifteen arteries were treated (one patient had bilateral internal carotid artery stenosis associated to an ostial common carotid artery stenosis). Thirty-nine patients were symptomatic (70%). Thirty-six patients had severe coronary artery disease. Seventeen patients underwent a simultaneous bilateral CAS (group 1), 40 in a staged manner (group 2). Among these 40 patients 10 were treated with a time interval of 24 hr, while the 30 other ones were treated with a time interval of 2 days to 2 months. A neuroprotection device was used in the last 42 patients. There was technical success in all patients and transient bradycardia and/or hypotension in 25 patients (44%). There was no prolonged bradycardia or hypotension. At 30 days, we observed in group 1 (simultaneous bilateral CAS) no transient ischemic attack (TIA), no minor stroke, one (5.8%) major stroke (hyperperfusion syndrome with brain hemorrhage leading to death in a patient under IIb/IIIa inhibitors), one myocardial infarction leading to death, and two (11.7%) death/stroke/myocardial infarction; in group 2 (staged procedure), two (5%) TIAs, no minor stroke, no major stroke, and one (2.5%) hyperperfusion syndrome with rapid recovery. Among the 10 patients treated with a time interval of 24 hr, we observed one TIA. Among carefully selected patients, bilateral CAS is feasible simultaneously or the day after, with a safety and complication rate comparable to that of large published series of CAS or endarterectomies in high-risk patients. Nevertheless, careful monitoring of the patient, blood pressure, and heart rate is mandatory to avoid complications related to hyperperfusion syndrome. Routine use of neuroprotection device and meticulous technique should improve the outcomes of bilateral CAS.     

Magnetic resonance imaging in internal carotid artery agenesis with computed tomography and angiographic correlation--case reports.

The authors present two cases of agenesis of the internal carotid artery (ICA) discovered incidentally on magnetic resonance imaging and confirmed on computed tomography, magnetic resonance angiography, and conventional angiography. They also propose a clinical algorithm for the workup of patients with suspected absence of the ICA.     

Successful stenting seven days after atherothrombotic occlusion of the intracranial internal carotid artery.

PURPOSE: To report a case of successful stenting after a subacute stroke. CASE REPORT: A 75-year-old man presented with sudden onset of right-sided weakness and difficulty speaking. Imaging revealed an occlusion of the left petrous to lacerum internal carotid artery (ICA) segment and slightly decreased cerebral blood flow in the left hemisphere; there were stenoses of the ostial and cavernous ICA segments on the right. On the seventh day after the stroke, he underwent protected carotid angioplasty of the left intracranial ICA occlusion to reduce the high risk of ischemic stroke owing to bilateral disease. An external arteriovenous shunt was established with an occluding balloon in the proximal ICA and a filter in the femoral vein. After protected balloon dilation of the ICA occlusion, a 3.5 x 18-mm balloon-expandable coronary stent was deployed across the residual stenotic segment. An intraluminal filling defect of the petrous ICA segment suggested an arterial dissection or intraluminal thrombus, so another 2 coronary stents were deployed. Macroscopically visible materials were captured in the filter. The patient had a good clinical course and was discharged without neurological deficits on the twelfth day after the stroke. Angiography at 3 months confirmed no restenosis of the stented vessel. CONCLUSION: This experience suggests that short atherothrombotic intracranial ICA occlusions can be opened in the subacute stroke stage without distal migration of thrombi under proximal protection and flow reversal.     

Percutaneous internal carotid artery angioplasty with stenting: early and long-term results

BACKGROUND. Cerebro-vascular accidents are the third most common cause of death. The most frequent localisation of lesions responsible for stroke are bifurcation of the common carotid artery or the proximal internal carotid artery (ICA). Surgical carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the non-pharmacological methods used to treat carotid artery stenosis. AIM. To assess the efficacy and safety of CAS of ICA. METHODS. CAS was performed in 75 patients (49 males, 26 females) with a mean age of 65.2+/-9.1 years. Twenty (26.7%) patients underwent CAS with the use of the central nervous system (CNS) protective devices. The immediate, mid-term, and long-term results were analysed. RESULTS. In total, 84 stents were implanted to 80 ICA in 73 patients. In two patients stent implantation was not possible. In 7 (9%) patients with a stenosis of both ICA, a bilateral procedure was performed. In two patients concomitant dilatations of the vertebral artery, and in the other two - of subclavian artery, were performed. In 38 patients coronary angiography was performed directly before CAS; one patient underwent coronary angioplasty. In 20 patients protective CNS devices were used. During the procedure four patients developed ischaemic stroke on the side of CAS. In one patient neurological symptoms completely disappeared within 48 hours. The type of technique used during CAS did not influence the frequency of ischaemic complications. Four patients developed hyperperfusion syndrome which disappeared after a few days. There were fire deaths during follow-up: three due to myocardial infarction (MI), one - after urgent CABG, and one due to pulmonary embolism. There were no deaths due to stroke. No new ischaemic changes in CNS nor significant changes in the neurological status, using the UNSS or Barthel scales, were observed. Asymptomatic restenosis was documented in six patients whereas one patient developed symptomatic restenosis due to stent deformation. CONCLUSIONS. Percutaneous angioplasty of an internal carotid artery carries a risk not exceeding that of surgical endarterectomy. In our study, a one-year follow-up revealed a minor risk of ischaemic stroke. Percutaneous angioplasty with the use of protective devices should be tested in larger groups of patients in order to establish the real clinical usefulness and improved safety of this technique.     

Intra-aortic counterpulsation during carotid stenting.

Postprocedural hypotension following endovascular stent placement of carotid artery disease (CAS) predicts increased in-hospital complications and long-term risk of death. Intra-aortic balloon counterpulsation (IABP) both increases mean arterial pressure and cerebral blood flow and therefore possibly reduces complications due to hemodynamic instability during and after CAS. In this study, we describe the use of IABP in a patient with severe depression of left ventricular function due to diffuse coronary artery disease undergoing CAS. Controlled studies are necessary to demonstrate a potentially protective role of IABP in high-risk CAS patients.     

The role of carotid stenting.

Despite a number of randomized trials, debate continues about the role of carotid angioplasty and stenting (CAS) for both symptomatic and asymptomatic disease. None of the trials has shown superiority of one treatment modality over the other, but protagonists of stenting have encouraged a shift away from conventional surgery. The minimally invasive nature of CAS is appealing, but concerns have been raised about the periprocedural stroke rate in the randomized trials. To counter this evidence, there are increasing numbers of registries and series, many partly or wholly sponsored by the endovascular industry, some of which demonstrate reasonable results. These need to be studied with caution, as patients deemed high risk of carotid endarterectomy may actually be at very low risk of stroke. Furthermore, strict inclusion and exclusion criteria mean that results may not be a true reflection of everyday clinical practice.The aim of this review is to document the evidence to date, predominantly from the randomized trials, for both symptomatic and asymptomatic carotid disease and establish the current role of carotid stenting.     

颈动脉支架成形术对颈内动脉重度狭窄患者认知功能的影响

目的观察颈动脉支架成形术(CAS)对颈内动脉重度狭窄患者认知功能与生活质量的影响。方法选择32例未发生大面积脑梗死的重度颈动脉狭窄(狭窄程度≥70%)患者行CAS,手术前及术后3个月采用简易智能状态检查量表(MMSE)及视觉保持测验(VRT)观察认知功能的变化,用WHO生存质量量表简表(WHOQOL-BREF)观察患者生活质量变化。结果所有患者均成功行CAS,成功率100%。与术前颈动脉狭窄率比较,术后3个月狭窄率明显降低[(83.4±7.6)%vs(4.3±1.3)%,P<0.01];与术前比较,术后3个月MMSE评分、VRT正确计分、WHOQOL-BREF评分明显升高,差异有统计学意义(P<0.05);VRT错误计分明显降低,差异有统计学意义(P<0.05)。随访期无症状性脑卒中复发。结论严重颈动脉狭窄可能是导致患者认知功能障碍的原因之一,CAS可以改善患者的认知功能和生活质量。     

Concerns on carotid stenting in octogenarians.

Zahn et al.¹ should be complimented for creating an inter-hospitalcarotid artery stenting (CAS) registry and for presenting their10 year experience, including many procedures performed on octogenarian.Although their analysis is retrospective in nature and unbalanced(321 patients > 80 years vs. 2557 patients < 80 years),it shows that     

Unilateral agenesis of internal carotid artery with subarachnoid hemorrhage: Report of two cases

Internal carotid artery (ICA) is a rare anomaly of embryologic development. Digital subtraction angiography examination showed no visualization of the ICA on the right side in a 30-year-old male patient and on the left side in a 47-year-old female patient. Computed tomography (CT) revealed the absence of the corresponding bony carotid canal. Doppler examinations of the common carotid and external carotid arteries on the affected sides demonstrated high-resistance flow characteristics. Two cases of ICA agenesis with subarachnoid hemorrhage were presented and the literature is reviewed.     

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient‘s refusal for surgery, direct carotid access was his only option.     

Carotid artery stenting: a therapeutic alternative in subtotal internal carotid artery occlusions

Carotid artery stenting (CAS) is emerging as a less invasive modality for treating atherosclerotic occlusive disease of the internal carotid artery (ICA). Randomized trials like the SAPPHIRE trial have demonstrated that CAS is not inferior to carotid endarterectomy (CEA) in the treatment of carotid artery stenosis, and maybe even superior in high-risk symptomatic patients. However, patients with subtotal ICA occlusions with thrombus are excluded from randomized CAS trials and CAS registries. To our knowledge, carotid angioplasty with stenting has not been attempted in these cases. We present three cases of symptomatic subtotal ICA occlusions successfully treated with CAS without any periprocedural complications. With careful patient selection and technical expertise, endovascular management could be considered as a treatment option in subtotal carotid occlusions.     

颈动脉支架成形术对单侧症状性颈内动脉重度狭窄患者脑血流和脑血管反应性的影响

目的探讨颈动脉支架成形术(CAS)对局部脑血流量(rCBF)和局部脑血管反应性(rCVR)的影响。方法选择2014年8月~2015年12月空军总医院神经内科进行CAS治疗的单侧症状性颈内动脉重度狭窄患者17例,术前1周及术后3个月通过单光子发射计算机断层扫描联合CO2负荷试验评估rCBF和rCVR,选择狭窄同侧大脑中动脉供血区感兴趣区分析。结果 17例患者共有68个感兴趣区,术前所有感兴趣区rCVR均受损,而仅16个(23.5%)感兴趣区rCBF受损。术前rCBF和rCVR均受损的感兴趣区术后平均rCBF较术前显著升高[(86.7±10.0)%和(79.1±7.5)%,P=0.001],术前rCBF正常且rCVR受损的感兴趣区术后平均rCVR较术前显著升高[(4.9±8.6)%vs(1.1±6.7)%,P=0.014]。术前rCBF和rCVR均受损的感兴趣区术后rCBF改善率显著高于术前rCBF正常且rCVR受损的感兴趣区(81.3%vs 50.0%,P=0.027);术前rCBF正常且rCVR受损的感兴趣区术后rCVR改善率显著高于术前rCBF和rCVR均受损的感兴趣区(59.6%vs 31.3%,P=0.047)。结论对于颈动脉狭窄患者,CAS能够改善术前存在脑血流动力障碍感兴趣区的rCBF和rCVR,其改善的模式与术前脑血流动力障碍严重程度有关。     

颈动脉狭窄血管内支架治疗并发症的临床分析

目的 探讨颈内动脉狭窄血管内支架治疗的并发症。方法 对478例颈内动脉狭窄患者行全脑血管造影及颈部超声检查。对195例患者使用脑保护装置，在未使用保护装置的283例患者中，对202例患者采用预扩张，占71．4％；66例采取后扩张，占23．3％；12例采用球囊扩张式支架，占4．2％；3例未扩张，占1．1％。结果 478例患者技术成功率为100%，患者症状消失或好转率为78．7％。心率＜50次／min者占26．4％；术中栓子脱落5例，其中2例治疗后恢复，2例遗留一侧肢体运动障碍，1例死亡；术后颅内出血死亡1例，术后30d内卒中或死亡6例，占1．26％。随访率为77．8％。再狭窄17例，占4．6％。结论颈内动脉狭窄的血管内支架治疗是安全的，若操作规范，可以减少并发症。     

Dual cerebral protection technique during carotid stenting.

PURPOSE: To present a technique for internal carotid artery stenting (CAS) with dual cerebral protection in patients with high-grade stenosis caused by large, soft atherosclerotic plaques. TECHNIQUE: The MO.MA proximal cerebral protection device is first placed in the external and common carotid arteries. Complete blockade of blood flow is achieved by inflating the occlusion balloons. A Spider filter is delivered to the distal internal carotid artery. All procedural steps of CAS are performed during continuous and simultaneous proximal occlusion and distal filter protection. After postdilation of the stent, the occlusion balloons are deflated, and antegrade flow is re-established with the distal filter basket still open. CONCLUSION: In selected patients with large atherosclerotic plaques, a dual cerebral protection technique during CAS may be a more efficacious form of cerebral protection than a single protection device.     

Simultaneous bilateral carotid stenting for postendarterectomy restenosis.

We report the successful treatment of bilateral postendarterectomy restenosis using simultaneously placed, bilateral carotid SMART stents and balloon angioplasty. Technical aspects and the results of 29-month follow-up are presented. The benefits derived from single-setting bilateral carotid stenting versus staged bilateral stenting are discussed.