Mid‐term outcomes of carotid artery stenting in patients with angiographic string sign

Objectives : To report on early and mid‐term outcomes of carotid artery stenting (CAS) in patients with angiographic string sign (SS). Background : Little is known about the prognosis of patients with carotid SS treated by CAS. Methods : We retrospectively evaluated early and mid‐term outcomes, together with ultrasound findings, in patients with SS treated by CAS at our institution. Results : Of 308 CAS procedures, SS was diagnosed in 6.2% (19 patients, 58% symptomatic). Carotid stent implantation was successful in 18 patients (success rate 95%). There were no peri‐procedural adverse events. One patient suffered from a transient ischemic attack during hospitalization and died of pneumonia. All remaining patients completed a 30‐day follow‐up, and no complications were reported (asymptomatic restenosis was diagnosed in 1 patient and successfully redilated). Six patients died of causes unrelated to CAS (pneumonia, decompensated heart failure, and contralateral stroke) before completing a 6‐month follow‐up. However, these patients presented with more pronounced, unfavorable clinical and angiographic characteristics compared to the rest of the patients. Conclusions : We suggest that CAS might be performed with acceptable procedural risk in patients presenting with SS, which is unsuitable for surgery. However, patients' clinical and angiographic characteristics must be carefully evaluated when considering interventional therapy, regardless of the favorable procedural outcomes. © 2011 Wiley Periodicals, Inc.     

Effects of carotid artery stenting on cognitive impairment in patients with severe symptomatic carotid artery stenosis

The effect of carotid artery stenting and medication on improvement of cognitive function in patients with severe symptomatic carotid artery stenosis is unknown. To investigate the effect of stenting compared with medication alone for severe carotid atherosclerotic stenosis on cognitive impairment. Patients with carotid stenosis and cognitive impairment were prospectively randomly divided into 2 groups of stenting or medication alone. Cognitive function was evaluated with the Montreal cognitive assessment (MoCA), Mini-Mental State Examination, and Barthel Index of Activities of Daily Living (BI). Continuous data in normal distribution were tested with the t-test but with the Mann-Whitney U test if not in normal distribution. Categorical data were presented as frequency and percentages and tested with the Fisher exact test. A P value < .05 was regarded as statistical significant. Carotid artery stenting was successfully performed in all patients (100%) in the stenting group. Compared with before treatment, the Mini-Mental State Examination, MoCA and BI scores at 6 months in the medication alone group and at 1, 3, and 6 months in the stenting group were significantly (P < .005) improved. The stenting group had significantly (P < .05) better scores than the medication alone group at the same time. At 6-month follow-up, the visuospatial/executive functions (3.69 ± 1.42 vs 2.42 ± 1.23), attention (5.24 ± 1.52 vs 3.63 ± 1.47), and language (2.64 ± 0.71 vs 1.96 ± 0.69) were significantly (P < .05) improved in the stenting group compared with the medication alone group. Carotid artery stenting may significantly improve cognitive impairment and neurological function compared with medication alone in patients with severe carotid atherosclerotic stenosis concurrent with cognitive impairment.     

Multidisciplinary approach to carotid stenting

Background: Stroke neurologists, vascular surgeons, interventional neuroradiologists and interventional cardiologists have embraced carotid angioplasty and stenting (CAS) because of potential advantages over carotid endarterectomy (CEA). At Austin Health, a multidisciplinary neuro‐interventional group was formed to standardise indications and facilitate training. The aims of this study were to describe our organisational model and to determine whether 30‐day complications and early outcomes were similar to those of major trials. Methods: A clinical protocol was developed to ensure optimal management. CAS was performed on patients with high medical risk for CEA, with technically difficult anatomy for CEA, or who were randomised to CAS in a trial. Results: From October 2003 to May 2008, 47 patients (34 male, mean age 71.5) underwent CAS of 50 carotid arteries. Forty‐three cases had ipsilateral carotid territory symptoms within the previous 12 months. The main indications for CAS were high risk for CEA (n= 17) and randomised to CAS (n= 21). Interventionists were proctored in 27 cases. The procedural success rate was 94% with two cases abandoned because of anatomical problems and one because of on‐table angina. Hypotension requiring vasopressor therapy occurred in 12 cases (24%). The duration of follow up was one to 44 months (mean 6.8 months). The 30‐day rate of peri‐procedural stroke or death was 6% and the one‐year rate of peri‐procedural stroke or death or subsequent ipsilateral stroke was 10.6%. Restenosis occurred in 13% (all asymptomatic). Conclusion: A multidisciplinary approach is a useful strategy for initiating and sustaining a CAS programme.     

Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting.

Although sporadic successful cases using the transradial approach (TRA) for carotid stenting have been reported, the safety and feasibility of carotid stenting using either TRA or a transbrachial approach (TBA) have not been fully investigated. Recently, we have developed a safe and feasible method of TRA for cerebrovascular angiographic studies. This study investigated whether a TBA approach using a 7-French (F) Kimny guiding catheter for carotid stenting is safe and feasible for patients with severe carotid stenosis. Thirteen patients were enrolled into this study (age range, 63-78 years). Seven of these 13 patients had severe peripheral vascular disease. A retrograde-engagement technique, involving looping 6-F Kimny guiding catheter, was utilized for carotid angiographic study. For carotid stenting, the 6-F Kimny guiding catheter was replaced with a 7-F Kimny guiding catheter, and the procedure was performed as the follows. First, an extra-support wire was inserted into the middle portion of external carotid artery (ECA). Second, a 0.035-inch Teflon wire was advanced into the common carotid artery. Then, the 6-F guiding catheter was exchanged for a 7-F Kimny guiding catheter. Third, if the first and second steps did not provide adequate support for exchanging the guiding catheter, a PercuSurge GuardWire was inserted into the ECA, followed by distal balloon inflation for an anchoring support. FilterWire EX was used in 9 patients and PercuSurge GuardWire in 4 patients to protect from distal embolization during the procedure. The procedure was successful in all patients. No neurological or vascular bleeding complications were observed and all patients were discharged uneventfully. The TBA for carotid stenting was safe and effective, providing a last resort for patients unsuited to femoral arterial access and surgical intervention.     

Feasibility of simultaneous bilateral carotid artery stenting.

Due to the progressive aging of the population, severe bilateral carotid stenosis has become a more frequent condition. On occasion, simultaneous revascularization may be appropriate. There is increased evidence that for these high-risk patients, a percutaneous revascularization may be the best approach. However, there are concerns that simultaneous bilateral carotid stenting may be associated with cerebral hyperperfusion, excessive bradycardia, and hypotension. We report a series of 10 consecutive patients who underwent simultaneous bilateral carotid stenting. All of these patients were not deemed to be surgical candidates due to high-risk comorbidities. All but one of the lesions were successfully stented. There were no procedural deaths, myocardial infarctions, or strokes. Thus, among carefully selected patients, simultaneous bilateral carotid artery stenting is a promising, technically feasible option.     

Starting a carotid artery stenting program is safe

Background : Little is known on the performance of newly initiated carotid artery stenting (CAS) programs. The safety of the procedure is being questioned following the publication of the EVA‐3S trial, a study criticized for the limited interventional experience required to enroll patients. Methods : Within a newly started academic CAS program, patient data and outcomes were collected prospectively. The outcomes of the first 100 consecutive patients treated are reported. A CAS‐fellowship‐trained interventionalist was involved in all procedures. All patients underwent clinical assessment by a neurologist before and after the procedure, and serial ECG and cardiac enzymes were routinely obtained. Primary outcome measures included 30‐day major adverse events (MAE), defined as death, stroke, or myocardial infarction, while on follow‐up deaths and ipsilateral strokes were added. Results : Between July 2003 and November 2006, 92 patients had a single internal carotid artery treated, while 7 underwent staged bilateral CAS. In one patient, the procedure was aborted prior to lesion treatment. The 30‐day MAE rate per procedure was 1.9% (one major and one minor stroke). By a mean follow‐up of 16 months (range 2–42 months), one patient had died of refractory heart failure, while one patient had a minor ipsilateral stroke and three had minor contralateral strokes, corresponding to total MAE per patient of 4%. The rate of any stroke or death was 7%. The rate of restenosis ≥50% per lesion by ultrasound was 3.8%. Conclusion : This single center experience suggests that it is safe to start a CAS program following dedicated fellowship. © 2008 Wiley‐Liss, Inc.     

Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性研究

目的回顾性分析颈动脉支架术(CAS)和冠状动脉旁路移植术(CABG)同期或分期Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性。方法入选2008年7月至2014年9月期间中国医学科学院阜外医院成人心脏外科收治的同期或分期实施CAS和CABG的冠心病合并严重颈动脉狭窄患者274例,依据两种手术是否同期实施分为两组:同期手术组(间隔≤7 d,n=35)和分期手术组(间隔7 d,n=239)。对两组患者的临床资料及预后进行比较分析。结果与同期手术组相比,分期手术组患者的搭桥数量、颈动脉支架植入个数以及肾动脉支架植入个数显著增加,而呼吸机辅助时间显著减少,差异均具有统计学意义(P0.05)。中位随访时间为45.6(28.1~65.4)个月,随访期间仅1例患者发生脑卒中而死亡。两组患者围手术期不良事件发生率间差异无统计学意义(P0.05)。截至随访终期,Cox模型分析结果显示,是否同期手术与患者复合终点事件发生率无明显相关性(OR=0.679,95%CI:0.12~3.72;P=0.66)。结论 CAS联合CABG是治疗冠心病合并严重颈动脉狭窄的一种安全、有效的微创策略。     

严重冠心病患者合并颈动脉重度狭窄应用AngioguardTM 远端保护装置行颈动脉支架术--附7例报告

目的评价远端保护装置(DPD)AngioguardTM血栓捕获导丝在严重冠心病多支病变患者颈动脉支架置入术(CAS)中应用的安全性和疗效.方法2002年8月至2003年7月,7例冠心病多支病变患者在冠状动脉造影同时行颈动脉造影提示存在严重颈动脉狭窄(＞75%),在于预冠状动脉病变前后行CAS治疗,术中均应用AngioguardTM DPD.7例患者均为男性,平均年龄(60.9±10.1)岁(46～72岁).4例有陈旧脑梗死史,1例有短暂性脑缺血发作史.结果2例患者于CAS前1周行经皮冠状动脉介入治疗(PCI),其余5例于CAS术后1～2周体外循环下行心脏冠状动脉旁路移植术(CABG)治疗.AngioguardTMDPD均顺利通过所有病变并回收,均成功置入支架,技术成功率100%.干预单侧颈动脉4例,其余3例同时干预双侧病变.3例双侧病变者于球囊扩张或支架释放过程中出现短暂窦缓、窦停,伴血压下降,经对症处理后恢复.围术期无新发脑血管意外及其他严重并发症.2例PCI和5例CABG治疗患者术后恢复良好,无神经系统并发症.结论在严重冠心病多支病变患者CAS中应用AngioguardTMDPD行远端保护是安全有效的.     

颈动脉内膜剥脱术和支架成形术治疗颈动脉狭窄的临床研究

目的探讨颈动脉内膜剥脱术(CEA)和颈动脉支架成形术(CAS)治疗颈动脉狭窄的临床价值。方法选择颈动脉狭窄患者43例,分为CEA组20例和CAS组23例,分析比较CEA和CAS 2种治疗方法的疗效。结果 CEA组成功率为95%,术后随访2年,再狭窄率为10%;CAS组成功率为100%,术后随访2年,发生再狭窄率为13%,2组的手术成功率和术后再狭窄率比较,差异无统计学意义(P>0.05)。结论 CEA和CAS是治疗颈动脉狭窄的有效方法,两者在安全性和有效性方面相同。     

颈动脉狭窄支架置入术后眼部并发症的临床分析

目的分析动脉内支架置入治疗过程中的眼部并发症,为减少严重的视力丧失提供指导方法收集412例住院行颈动脉内支架置入治疗的颈动脉狭窄患者的临床资料,分析其眼部并发症。结果 412例患者中有3例患者发生眼部并发症,其中发生眼缺血综合征1例,缺血性视神经病变1例,视网膜分支动脉栓塞1例,发生率为0.7%。结论颈动脉内支架置入治疗时需要注意颈动脉狭窄相关眼部并发症,详细的病史采集和眼部检查以及在治疗前和治疗过程中,明确眼动脉的起源或代偿供血血管非常重要。     

瑞舒伐他汀防治颈动脉支架术后再狭窄的临床疗效评价

目的观察瑞舒伐他汀防治颈动脉支架植入(CAS)后再狭窄的疗效。方法分析2014年3月至2015年8月我院收住的69例CAS后患者,随机分为对照组(34例)和治疗组(35例),对照组口服拜阿司匹林100 mg/d,治疗组口服拜阿司匹林100 mg/d、瑞舒伐他汀10 mg/d,连续治疗12个月,对两组的疗效进行评价分析。根据数据类型分别采用t检验、方差分析或X~2检验进行组间比较。结果颈动脉支架置入后12个月时复查颈动脉CT血管成像发现,治疗组支架光滑度、支架内径、支架近端和远端血管情况均优于对照组(P0.01),支架内管腔密度值、支架内再狭窄率均低于对照组(P0.01);治疗组血浆总胆固醇(TC)和低密度脂蛋白胆固醇(LDL-C)较治疗前显著降低(P0.01)、血浆脂联素(APN)较治疗前显著升高(P0.01),对照组TC、LDL-C、APN较治疗前差异无统计学意义(P0.05)。结论颈动脉支架置入后口服瑞舒伐他汀对于预防支架后再狭窄闭塞效果显著,可降低再狭窄率。     

Peri-procedural outcome of series of 104 carotid artery stenting procedures

BackgroundManagement of carotid artery stenosis is considered an important strategy for stroke prevention. Carotid artery stenting (CAS) has been introduced as an acceptable alternative to surgical carotid endarterectomy (CEA) in the treatment of internal carotid artery (ICA) stenosis.ObjectiveAssessment of peri-procedural outcome of CAS in 104 consecutive procedures.MethodsThe study included 104 consecutive CAS procedures. Included patients had ⩾50% ICA stenosis in the symptomatic group and ⩾70% stenosis in the asymptomatic group. Procedures were performed in cath. labs of Catania and Ragusa hospitals-Italy.ResultsIncluded procedures were done in 100 consecutive eligible patients with ICA stenosis. Four patients had undergone CAS procedures in both sides in 2 separate sessions. Patients were 71 males and 29 females, mean age was 71.9 ± 7.85 years, and 21 patients were ⩾80 years old (octogenarians). The majority of patients had asymptomatic ICA stenosis (76%) and was diagnosed accidentally during medical checkup. Twenty-four patients had symptomatic ICA stenosis (ipsilateral TIA or stroke). Technical success was obtained in 103 procedures (99%). Embolic protection devices were used in all succeeded cases. Combined cerebrovascular events had occurred in 5 patients with estimated rate = 4.8%. No cases of amaurosis fugax, MI or death had occurred. Adverse events was 4.1% in the symptomatic group and 1.3% in the asymptomatic group with no significant statistical difference (P = 0.064).ConclusionCAS with EPDs seems a feasible and safe procedure and could be performed with an acceptable rate of periprocedural adverse events.     

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: A single‐center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high‐risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3‐year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76 ± 10 years, mean follow‐up 18 ± 9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction ≤ 20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr. Cathet. Cardiovasc. Intervent. 50:1–8, 2000. © 2000 Wiley‐Liss, Inc.