Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes

PURPOSE: To describe the predictors of persistent hypotension after carotid artery stent (CAS) placement and define the clinical outcome of patients with this hemodynamic disturbance. MATERIALS AND METHODS: One hundred forty CAS procedures were performed in 133 consecutive patients. Post-CAS hypotension-defined as a greater than 40 mm Hg decrease in arterial pressure without evidence of hypovolemia, with a systolic pressure lower than 90 mm Hg at the end of CAS and lasting at least 1 hour-was observed in 25 patients (group 1); 108 patients did not have hypotension (group 2). RESULTS: Post-CAS hypotension developed in 33.9% of cases after balloon-expandable stent placement versus in 13.6% of cases after self-expanding stent placement (P =.04). In-hospital minor ipsilateral strokes occurred in 16% of cases in group 1 versus in 3% of cases in group 2 (P =.03). There was one (0.9%) major stroke (transient) and three (2.6%) transient ischemic attacks, all of which occurred in group 2 (not significant vs group 1 for both conditions). At 10 months +/- 4 (SD) of follow-up, there was greater total mortality in group 1 than in group 2 (20% vs 4%, P =.02), whereas neurologic events did not differ significantly between the groups. CONCLUSION: Hypotension due to carotid sinus stimulation is frequent after CAS with balloon-expandable stents. This phenomenon correlates with increased in-hospital complications and long-term risk of death.     

A rare complication of carotid artery stenting: displacement of marker ring causing locking of stent and incomplete stent expansion

We present a rare case of a complication of placement of a carotid artery stent represented by partial opening of a carotid Wallstent caused by displacement of its metal ring marker, which thus hindered complete expansion of the stent. An intraluminally locked carotid stent necessitated referral of the patient for urgent carotid endarterectomy. A possible reason of this unusual complication can be a manufacturing defect, which, to our knowledge, was not documented previously in open public data bases or on the Internet.     

The significance of incomplete stent apposition in patients undergoing stenting of internal carotid artery stenosis

BACKGROUND AND PURPOSE: Incomplete stent apposition after carotid angioplasty and stent placement (CAS) is often seen but little is known about how the incomplete attachment goes after stent placement. For example, some may change into restenosis around the stent edge and some may remain unchanged. The purpose of this study is to clarify the morphologic prognosis of an incomplete stent apposition at the stent edge. METHODS: CAS was attempted on 135 consecutive stenotic lesions (124 patients). Angiograms were then evaluated immediately after the procedure. An incomplete stent apposition at stent edge was found in 15 patients, and all of them were followed up by angiography and MR imaging with antiplatelet therapy. RESULTS: No ischemic event caused by the lesions occurred during the mean follow-up period of 11 months (from 4 to 32 months). The angiography findings of 15 lesions at a mean of 8.8 months (from 2 to 28 months) after CAS showed that all remained unchanged. No patients required any additional intervention. No new ischemic lesions were detected in any of the 15 patients who underwent follow-up MR imaging at a mean of 10 months (from 2 to 32 months) after CAS. CONCLUSION: In this study, the existence of a segment of incomplete stent apposition had no adverse morphologic or clinical effect.     

颈内动脉中重度狭窄支架置入血管成形术后局部脑灌注的变化及意义

目的 探讨颈内动脉支架置入血管成形术后脑血流动力学的变化情况.方法 对38例颈内动脉中重度狭窄患者行支架置入血管成形术,在手术前后对患者行脑CT灌注成像检查,观察患侧和对侧局部脑血流量(CBF)、脑血容量(CBV)及造影剂平均通过时间(MTT)的变化.结果 在支架置入血管成形术前,与对侧比较,患者患侧CBF、CBV降低...     

Post-traumatic dissecting aneurysm of extracranial internal carotid artery: endovascular treatment with stenting

Traumatic internal carotid dissection occurs frequently in motor vehicle accidents, typically extracranially, close to the skull base. Dissection may lead to stenosis or occlusion of the vessel, possibly with a pseudoaneurysm, symptoms ranging from neck pain to neurological deficits. In symptomatic patients and in cases of pseudoaneurysm, when conservative medical treatment fails, surgery or endovascular treatment are indicated. We report a post-traumatic dissecting aneurysm of the extracranial internal carotid artery successfully treated with stenting via a transfemoral approach. Received: 5 November 1998 Accepted: 5 December 1998     

Carotid angioplasty with stenting for chronic internal carotid artery occlusion: technical note

Introduction Carotid angioplasty with stenting (CAS) is becoming accepted as an effective and reliable treatment option for severe carotid artery stenosis. However, it is rarely applied for carotid occlusion, especially in its chronic stage. We report our experience of CAS for chronic internal carotid artery occlusion representing compromised cerebral blood flow using various protection methods.Methods A 77-year-old woman, who was already diagnosed with severe left internal carotid artery stenosis, suddenly had right hemiparesis and aphasia. At that time, she was treated conservatively because her neurological status was quite good, in spite of left carotid artery occlusion. Her symptoms improved in the short term, except slight aphasia, but deteriorated again 18 days from the onset, and magnetic resonance imaging (MRI) showed new ischemic lesions. CAS was then performed for the occluded carotid artery on the 23rd day from the first onset.Results Using the proximal protection technique, the occluded lesion was crossed carefully with a microguidewire. Stents were also placed successfully with the distal protection technique. The occluded carotid artery was completely recanalized without any unfavorable events or neurological deterioration.Conclusion In this patient, CAS was successfully to treat chronic carotid artery occlusion. These procedures and techniques are reviewed and discussed.     

Lateralized petrous internal carotid artery: imaging features and distinction from the aberrant internal carotid artery

Introduction

This study aimed to describe the lateralized petrous internal carotid artery (ICA), a rare variant of the intratemporal course of the ICA, and distinguish it from aberrant ICA.

Methods

A retrospective multi-institutional review of all patients diagnosed over a 10-year period with lateralized ICA was completed. Medical records were reviewed for demographic data as well as clinical information in all patients. Computerized tomography (CT) studies were reviewed in all patients. Magnetic resonance studies in this patient group were reviewed when available. In order to obtain normative data for the ICA, the intratemporal course of the ICA was evaluated on 50 consecutive high-resolution sinus CT scans.

Results

Sixteen cases of lateralized ICA were identified on CT scans in 12 patients. In each of these, the ICA entered the skull base in a position more lateral to the cochlea than normal and protruded into the anterior mesotympanum with dehiscent or thinned overlying bone. Magnetic resonance angiography was available in 5 of 12 patients and catheter angiography in 1 of 12.

Conclusion

Lateralized petrous ICA can be identified on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum. It can be distinguished from the aberrant ICA which enters the posterior hypotympanum through an enlarged inferior tympanic canaliculus, then courses across the inferior cochlear promontory to connect with the normal horizontal petrous ICA. Lateralized ICA is best considered an incidental petrous ICA variant. Awareness of this entity is important in the presurgical evaluation of the temporal bone to avoid vascular injury and confusion with the congenital diagnosis of aberrant ICA.     

Endovascular stenting for carotid artery stenosis: preliminary experience using the shape-memory- alloy-recoverable-technology (SMART) stent

We describe our initial clinical experience using the newly available self-expanding, Nitinol, shape-memory-, alloy-recoverable-technology (SMART) stent in treating carotid artery occlusive disease. Five stents were used in four carotid arteries in four consecutive patients with carotid stenosis of at least 70%. Technical success (<20% residual stenosis) was achieved in all cases. No procedural complications specifically related to use of the SMART stent were encountered. All patients remained symptom-free, with no evidence of transient ischemic attacks or new strokes during an average follow-up period of 6 months. Excellent performance of the SMART stent for the endovascular treatment of carotid artery stenosis has been shown based on our early experience. Validation with greater numbers and longer-term follow-up is required. The specific technical characteristics, potential advantages, and disadvantages of this stent are discussed and compared with other currently used carotid artery stents.     

颈内动脉起始段狭窄介入治疗时心率改变及治疗措施

颈内动脉起始段狭窄是造成缺血性脑卒中的重要原因之一。血管内治疗技术已经成为颈内动脉起始段狭窄的主要治疗方法,但是由于在进行球囊预扩张和支架置入过程中会引起患者心率骤然下降,如果不及时采取措施处理有可能出现严重后果[1,2]。为了能够深入分析颈动脉起始段狭窄介入治疗时心率变化规律及处理方法,回顾分析我院214例进行介入治疗的此类患者,现报道如下。1材料与方法1.1一般资料214例经血管超声检查和全脑血管造影证实颈内动脉起始段狭窄率大于70%的患者,进行介入治疗。其中男128例,女96例,年龄44~72岁。1.2所用介入材料保护过滤伞主…     

颅内外缺血性多血管病变的介入治疗选择

目的：通过选择性介入治疗颅内外缺血性多血管狭窄性病变,评价多血管病变介入治疗的安全性。方法：对150例颅内外缺血性多血管病变介入治疗的相关资料进行系统性回顾。结果：1150例多血管病变者,双侧颈内动脉同时狭窄〉70%者47例;单侧颈内动脉狭窄并单（或双）椎动脉狭窄〉70%者61例;双侧椎动脉狭窄〉70%者23例;单侧血管颅内外串联病变均需处理者19例。2共成功植入支架218枚,围手术期并发症5例（3.33%）,126例患者术后6-12个月随访无短暂性脑缺血发作及新发脑梗死。结论：通过对颅内外缺血性多血管狭窄性病变的介入治疗选择,可减少围手术期及远期并发症。     

颈动脉支架内再狭窄1例

患者 男性,69岁.2003年11月27日因左侧肢体无力6天入院.查体左侧肢体肌力Ⅳ级.CT:右侧基底节区及双侧半卵圆中心腔隙性梗塞.DSA检查左侧颈内动脉窦部动脉粥样硬化伴狭窄60%,行左侧颈内动脉血管内支架植入术.     

Changes in cerebral oxygenation during hemodialysis before and after carotid artery stenting

A 68-year-old man received hemodialysis (HD) for the treatment of end-stage renal failure for 6 years. Five years prior to carotid artery stenting (CAS), a neck ultrasound performed to screen for carotid atherosclerosis revealed an asymptomatic right internal carotid artery stenosis. One month prior, the stenotic lesion progressed to 74% by cerebral angiography; therefore, CAS was performed. To evaluate the influence of right internal carotid artery stenosis on the intradialytic cerebral circulation and oxygenation, cerebral regional oxygen saturation (rSO₂) at bilateral forehead was measured using the INVOS 5100c oxygen saturation monitor (Covidien Japan, Japan) during HD before and after CAS. Before CAS, right cerebral rSO₂ was maintained during HD, whereas left cerebral rSO₂ gradually increased from the initiation to end of HD. However, the differences of intradialytic cerebral rSO₂ changes between bilateral sides disappeared after CAS. In the present case, before CAS, the intradialytic increase in left cerebral rSO₂ might reflect the increase in the left cerebral blood flow to compensate for the ultrafiltration-associated decreases in the right cerebral blood flow and perfusion pressure. Furthermore, the preserved right cerebral rSO₂ before CAS might reflect the mechanism maintaining the right cerebral blood flow from the collateralized circle of Willis during HD. Throughout our experience, cerebral oxygenation monitoring during HD might disclose intradialytic changes in cerebral blood flow distribution between the ipsilateral and contralateral side in HD patients with carotid artery stenosis.     

Embolic protection in carotid artery stenting: new options

Carotid artery stenting (CAS) has emerged as an attractive alternative to carotid endarterectomy (CEA) in patients with carotid disease who are at high risk for CEA. With increasing experience and improved technique, results in CAS patients have improved consistently over time in several clinical trials. Carotid stenting is clearly not inferior to CEA in appropriately selected high-CEA-risk patients treated by experienced operators. With improving results, CAS now has the potential to be considered "front-line therapy" even in standard-risk CEA patients, as demonstrated in CREST and as being studied in ongoing trials, such as the ACT I trial. Successful, low-risk CAS can only be performed if distal embolization is minimized during this procedure. This can be accomplished only with appropriate patient and case selection, adequate operator training and experience, and meticulous attention to procedural detail. Embolic protection devices (EPDs) are an important cornerstone of low-risk CAS. There are well-established, study-validated embolic protection systems available for CAS. Four new EPD options have been introduced in the United States over the past 3 years. Results with these newer devices appear to be extremely promising, with low event rates seen in high-risk clinical patients. This article will offer a practical review of techniques to decrease distal embolization during CAS. We will review patient selection and provide a "cookbook" approach to procedural technique, emphasizing techniques unique to each of the various EPD systems currently available. We will also introduce the newer options in EPDs, provide practical tips on their use, and contrast their use and results with that of the existing EPD systems. We will provide practical procedural techniques that incorporate the use of various EPDs into strategies that will reduce distal embolization during CAS and also provide pertinent data referencing results of these devices seen in clinical trials.     

Reversal of flow during carotid artery stenting: use of the Parodi antiembolism system

Introduction To evaluate the flow reversal efficacy of the Parodi antiembolism system (PAES) in the prevention of distal emboli during carotid stenting. Methods A total of 90 patients were treated for internal carotid artery (ICA) stenosis with a stent device. A PAES device was used in 31 symptomatic and 5 asymptomatic patients (total 36 patients) with ICA stenosis, and 54 patients were stented without any protection device. Diffusion-weighted (DW) imaging was performed before and after stenting. Results In the group without PAES protection, 23 out of 54 patients showed new lesions on DW images after stenting. Of the lesions seen, 147 (2.72 lesions/patient) were in the vessel-dependent area. In the group with protection, 19 out of 36 patients had new lesions, and only 34 (0.94 lesions/patient) were noted in the vessel-dependent area. The number of new lesions in the nondependent vessel area did not differ if a protection system was used (P = 0.671). The use of PAES led to a significant reduction (P = 0.024) in the incidence of the most frequently seen lesions (size <2 mm). The stroke death rate was 3.3% overall, 3.7% in the group without protection device, and 2.7% in the PAES group. There were no permanent neurological deficits after 3 months. Conclusion The PAES is a safe and effective tool to reduce the incidence of embolic complications during carotid stenting. Older patients and patients with higher grade stenosis seem to profit more.     

Hyperperfusion syndrome after external carotid artery stent placement in a case of bilateral internal carotid occlusion and external carotid stenosis

The authors describe a patient with bilateral internal carotid artery occlusion, bilateral external carotid artery (ECA) stenosis, and suboptimal collateral circulation from the right ECA to the right cerebral hemisphere. The patient manifested clinical and radiographic signs of hyperperfusion syndrome following stent placement in the right ECA. This represents a rare case of a stent placed in the ECA of a patient in addition to the development of hyperperfusion syndrome after the procedure.     

颈内动脉前壁动脉瘤支架结合弹簧圈栓塞术后再出血：病例报道

目的 报道1例应用支架结合弹簧圈栓塞治疗颈内动脉前壁宽颈动脉瘤后发生早期再出血的病例.方法 将球囊膨胀型血管内支架跨动脉瘤颈部位置并准确释放后,微导管超选进入动脉瘤内填塞弹簧圈.结果 支架成功置人,完全覆盖瘤颈,动脉瘤得到人部栓塞(90%以上),载瘤动脉及毗邻的侧支血管保持通畅,患者术后恢复良好,但是术后16 d因动脉瘤再次破裂出血导致死亡.结论 血管内支架结合弹簧圈栓塞治疗颈内动脉前肇宽颈动脉瘤是可行的,但应充分认识动脉瘤早期再次破裂出血的风险,短期随访及再治疗非常必要.