Protected carotid artery stenting in patients with severe stenosis

Intraplaque hemorrhage (IPH) and ulcers are the major findings of unstable plaques. In addition, initial symptoms are associated with postprocedural complications after carotid artery stenting (CAS). The aim of this study was to determine the safety of CAS using an embolic protection device in symptomatic patients with severe carotid artery stenosis and unstable plaques such as IPH and ulcers.This retrospective study included 140 consecutive patients with severe carotid stenosis. These patients underwent preprocedural carotid vessel wall imaging to evaluate the plaque status. We analyzed the incidence of initial clinical symptoms, such as headache, nausea, and vomiting, after CAS. The primary outcomes analyzed were the incidence of stroke, myocardial infarction, and death within 30 days of CAS.Sixty-seven patients (47.9%) had IPH, and 53 (38.9%) had ulcers on carotid wall imaging/angiography. Sixty-three patients (45.0%) had acute neurological symptoms with positive diffusion-weighted image findings. Intraluminal thrombi on initial angiography and flow arrest during CAS were significantly higher in patients with IPH and symptomatic patients. Symptoms were significantly higher in patients with IPH than in those without (63.5% vs 35.1%, P < .001). There were no significant differences in clinical symptoms after stenting or in primary outcomes, regardless of IPH, ulcer, or initial symptoms.IPH and plaque ulceration are risk factors in symptomatic carotid stenosis. However, IPH and plaque ulceration were not a significant risk factors for cerebral embolism during protected carotid artery stent placement in patients with carotid stenosis. Protected CAS might be feasible and safe despite the presence of unstable plaques.     

Utilization of Intravascular Ultrasound during Carotid Artery Stenting

For patients at high risk for surgery, carotid artery stenting (CAS) is a viable alternative to help reduce risk of stroke for patients with high-grade carotid artery stenosis; however, a higher incidence of perioperative stroke has been observed in patients undergoing stenting compared to those undergoing open surgery. Intravascular ultrasound (IVUS) is commonly used during coronary artery procedures to help evaluate lesions and to guide stent placement. Multiple groups have sought to determine whether IVUS could also be used during CAS. While IVUS has been shown to be both feasible and safe during CAS, there is limited evidence that demonstrates direct improvement in procedural outcomes. Further studies focusing on clinical outcomes should be conducted in order to justify routine use of this technology during CAS.     

Transulnar carotid artery stent placement

Carotid artery stenting (CAS) has increased in popularity as an alternative to carotid artery endarterectomy for the treatment of significant carotid artery stenosis. The access site is predominantly the femoral artery, with radial or brachial access used less often. Here, we describe a case of CAS after failure of brachial access. Transulnar CAS was performed successfully without complications. Transulnar access represents an additional option in a patient undergoing CAS when conventional femoral, brachial, and radial arteries are not applicable. © 2012 Wiley Periodicals, Inc.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

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。     

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.     

经皮血管内支架成形术治疗高龄颈动脉狭窄患者的临床研究

目的　对平均80岁以上的高龄颈动脉狭窄患者进行经皮血管内支架成形术治疗的可行性,安全性和效果进行探讨。方法　对18例(年龄76～92岁)单侧颈动脉狭窄和其中1例合并椎动脉狭窄患者经磁共振和数字减影血管造影(DSA)确诊,后行经皮颈动脉支架和椎动脉支架血管内成形手术。结果　19例次支架置放均获成功。DSA显示狭窄段的颈动脉直径明显扩大,同侧颅内脑血管循环时间和染色趋于正常。仅1例出现部分运动性失语。随访3～18个月,无1例再发生脑缺血事件;B超复查未见明显支架内再狭窄。结论　对高龄颈动脉狭窄行经皮血管内成形治疗的安全性高,效果可靠。但需重视预防和及时处理围手术期出现的并发症。     

颈动脉粥样硬化性狭窄患者支架置人术围手术期并发症的防治探讨

目的探讨颈动脉支架置入术(CAS)治疗颈动脉粥样硬化性狭窄患者围手术期并发症防治的初步经验。方法回顾性分析413例动脉粥样硬化性颈动脉狭窄患者经全脑血管数字减影血管造影术诊断后,均采用自膨式支架经股动脉入路行CAS治疗,术中及术后严密监控血压、心率、意识等生命体征,并采取综合措施防止并发症的发生。结果 413例患者中,CAS成功412例(99.8%)。CAS前狭窄率70%～95%,CAS后残余狭窄率为0～20%,患者脑缺血症状及体征均有明显改善。脑出血5例,治愈2例,死亡3例;CAS后3 d发生支架内血栓形成1例,经溶栓治疗后血管再通;支架内再狭窄2例,均行二次CAS治疗;消化道出血1例,对症治疗痊愈;股动脉穿刺处假性动脉瘤5例,经超声波引导定点压迫痊愈2例,瘤腔内注射凝血酶治愈3例;临时起搏器电极造成心室壁穿孔引起心包填塞1例,经紧急开胸手术修补治愈;低血压导致心内膜下心肌梗死2例,经适当升压症状缓解。结论 CAS微创安全有效,围手术期应采取综合措施预防CAS后并发症的发生,以确保疗效。     

Intravascular ultrasound identification of intraluminal embolic plaque material during carotid angioplasty with stenting.

INTRODUCTION: Carotid angioplasty with stenting (CAS) has evolved as a viable method for treating patients at high risk for carotid endarterectomy. Strokes complicating CAS are most commonly caused by the liberation and distal embolization of embolic material from plaque during the procedure. METHODS: CAS with distal embolic protection (DEP) was performed using the assistance of intravascular ultrasound (IVUS) in a 68-year-old man with asymptomatic carotid artery stenosis. Evaluation of the plaque pretreatment was performed using virtual histology software. IVUS evaluation was also performed after prestent angioplasty, stenting, and poststent angioplasty. RESULTS: Initial degree of angiographic stenosis was 78.9%. Final degree of stenosis was 15.7%. By IVUS, stenosis by minimum lumen diameter and minimum lumen area were 75.6% and 93.4% pretreatment, respectively, and 42.2% and 47.1% posttreatment, respectively. An intraluminal lesion was noted in the distal aspect of the stent after poststent angioplasty but before DEP device removal. Ultrasonographic characteristics of the intraluminal defect were consistent with ruptured plaque material. Angiographic runs failed to demonstrate the lesion. A repeat IVUS run performed approximately 10 min later failed to depict the lesion, suggesting that distal embolization had occurred. Embolic material was noticed in the DEP device after removal. The patient did not experience any ischemic neurological symptoms. CONCLUSIONS: IVUS can identify intraluminal plaque material, which may be a precursor for embolism and delayed ischemic events after CAS. IVUS may allow for treatment before distal embolization of plaque material. Virtual histology IVUS software may help to identify carotid lesions at higher risk for significant embolization during CAS.     

复合手术在颈动脉狭窄病变治疗中的初步应用

目的探讨颈动脉内膜切除术（CEA）联合其他术式（一站式复合手术）在治疗复杂性颈动脉狭窄病变中的临床意义。方法回顾性分析2010年3月-2013年10月因复杂缺血性颈动脉病变（包括颈动脉颅外段多处重度狭窄、单支颈动脉颅外段串联狭窄、支架内再狭窄、颈总动脉或颈内动脉完全闭塞）在首都医科大学宣武医院和山东省聊城市人民医院行一站式复合手术的10例患者的临床资料。复合手术方式分为3类,①病变侧CEA＋支架置入术;②颈动脉直视下支架置入术;③CEA＋透视下球囊导管取栓术。结果①2例接受CEA＋支架置入术的患者,术后影像学检查示闭塞或重度狭窄的血管管腔狭窄消失、血运恢复,头晕、肢体麻木、乏力、黑蒙等症状明显改善;②2例接受颈动脉直视下支架置入术的患者,术后影像学检查示狭窄的血管重新成形,血运良好,患者头痛、头晕等症状得以改善或未再加重;③6例接受CEA＋透视下球囊导管取栓术的患者,术后影像学检查示闭塞或重度狭窄的颈动脉开通、血运恢复,患者一侧肢体乏力、头晕、发作性头痛等症状得以缓解或未再加重。④随访患者6～24个月,影像学复查显示无再狭窄发生,再通血管血流通畅,颅内血供较术前明显改善。结论一站式复合手术可有效解除颈动脉分又过高或斑块远端过高、颈动脉串联样狭窄、颈内动脉合并颈总动脉狭窄、支架术后再狭窄等单一传统手术无法完成的复杂的狭窄性颈动脉病变。     

Carotid Artery Stenting–Historical Context,Trends, and Innovations

Surgical carotid endarterectomy (CEA) has been proven effective in both primary and secondary stroke prevention and, until recently, has been considered the standard treatment approach for patients with severe carotid artery disease. Because of its technical limitations and less favorable outcomes, carotid artery stenting (CAS) has been offered preferably to patients considered to be too comorbid to undergo surgical treatment. However, CAS has evolved over time into a reliable method and is currently considered an alternative to CEA. The aim of this review was to discuss the historical aspects, trends, and innovations in CAS.     

Carotid Endarterectomy: Current Concepts and Practice Patterns

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.     

糖尿病对颈内动脉狭窄介入治疗患者脑血管储备功能的影响

目的 探讨糖尿病对颈内动脉狭窄患者颈动脉支架置入术(CAS)前后脑血管储备功能的影响.方法 颈动脉狭窄≥70％的无症状性或狭窄≥50％的症状性颈动脉狭窄患者55例,分为糖尿病组(16例)和无糖尿病组(39例). 患者吸入5％CO2和95％O2混合气体诱发高碳酸血症,通过经颅多普勒超声检查,计算大脑中动脉(MCA...     

Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital.

OBJECTIVES: The goal of this study was to determine whether carotid angioplasty and stenting (CAS) is equivalent to carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis >70% by a randomized, controlled trial in a community hospital. BACKGROUND: Carotid angioplasty and stenting has been suggested to be as effective as CEA for treatment of symptomatic carotid artery stenosis. METHODS: A total of 104 patients presenting with cerebrovascular ischemia ipsilateral to carotid stenosis were selected randomly for CEA or carotid stenting and followed for two years. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique as determined by sequential ultrasound. One death occurred in the CEA group (1/51); one transient ischemic attack occurred in the CAS group (1/53); no individual sustained a stroke. The perception of procedurally related pain/discomfort was similar. Hospital stay was similar, although the CAS group tended to be discharged earlier (mean = 1.8 days vs. 2.7 days). Complications associated with CAS prolonged hospitalization when compared with those sustaining a CEA-related complication (mean = 5.6 days vs. 3.8 days). Return to full activity was achieved within one week by 80% of the CAS group and 67% of the patients receiving CEA. Hospital charges were slightly higher for CAS. CONCLUSIONS: Carotid stenting is equivalent to CEA in reducing carotid stenosis without increased risk for major complications of death/stroke. Because of shortened hospitalization and convalescence, CAS challenges CEA as the preferred treatment of symptomatic carotid stenosis if a reduction in costs can be achieved.     

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。     

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。     

颈动脉狭窄患者的脑功能储备评价

颈动脉支架置入术（CAS）和颈动脉内膜切除术（QEA）是目前颈动脉狭窄患者最主要的非药物治疗方法。评价颈动脉狭窄患者的脑功能储备,不仅能筛选出近期可能面临卒中的高危患者,而且还能对无症状颈动脉狭窄患者行CEA和CAS的纳入标准进行修正,从而为患者提供最佳的治疗方案。文章对颈动脉狭窄患者的脑功能储备评价和MRI在其中的应用做了综述。     

颈动脉支架置入术对脑血管反应性的影响

目的探讨颈动脉支架置入术(CAS)对脑血管反应性(CVR)的影响。方法选择行CAS治疗的59例患者作为手术组,并根据是否伴有临床症状分为无症状组1 4例和症状组45例;将症状组再分为中度狭窄组12例和重度狭窄组33例;同期选择未行CAS的缺血性脑卒中住院患者32例作为对照组。利用经颅多普勒结合CO_2吸入试验检测手术前后CVR的变化。结果与对照组比较,手术组患者手术前手术侧和手术对侧CVR明显降低,差异有统计学意义(P0.01)。手术组患者手术前手术侧CVR明显低于手术对侧(P0.01);术后手术侧和手术对侧CVR均显著高于手术前(P0.01)。症状组和无症状组患者手术后手术侧CVR均显著高于手术前(P0.01)。重度狭窄组患者手术前手术侧和手术对侧CVR均明显低于中度狭窄组(P0.01),手术后手术对侧CVR明显低于中度狭窄组(P0.05)。结论 CAS能有效改善颈动脉狭窄患者的CVR;经颅多普勒结合CO_2吸入试验可作为检测CVR的方法之一。     

Guidelines for patient selection and performance of carotid artery stenting

The endovascular treatment of carotid atherosclerosis with carotid artery stenting (CAS) is controversial. The inter-collegiate Carotid Stenting Guidelines Committee (CSGC) recommends that CAS should not be performed in the majority of patients requiring carotid revascularization. CAS may be considered for specific high risk patients with symptomatic severe carotid stenosis who have contraindications for carotid endarterectomy, or in those under 70years of age where carotid re-vascularization is considered appropriate. Advances in endovascular technologies and the long-term results of randomized controlled trials will guide future revisions of these guidelines.     

What's happening in carotid stent? A case report of prominent plaque protrusion after carotid artery stenting observed on angioscopy

Thromboembolic complications after carotid artery stenting (CAS) remain an unsolved problem, and several intravascular imaging tools have been proposed to clarify the mechanism of these complications. We report a case of intraprocedural plaque protrusion revealed by angioscopy. A 64-year-old woman underwent CAS for left carotid artery stenosis. After stent placement, optical frequency domain imaging demonstrated some plaque protrusion, and angioscopy showed prominent mobile plaque fragments protruding into the vessel between stent struts and confirmed the coverage of the protruded plaque after the overlapping stent was placed. Compared with other tools, angioscopy more clearly revealed plaque protrusion in the vessel after CAS.