External Carotid Artery Stenting to Treat Patients With Symptomatic Ipsilateral Internal Carotid Artery Occlusion: A Multicenter Case Series

Abstract

Conclusion: Stenting of the external carotid artery (ECA) in the face of symptomatic ipsilateral internal carotid artery (ICA) occlusion can be effective in some patients to relieve ischemic symptoms. Summary: The ECA is a significant extracranial-to-intracranial collateral source for the brain when the ICA is occluded. It may contribute, under those circumstances, 10% to 15% of middle cerebral artery blood flow (Fearn SJ, et al, J Vasc Surg 2000;31:989-93). Chronic neurologic symptoms ipsilateral to the combination of a ICA occlusion and ECA stenosis may be due to emboli originating from the ECA, emboli from a stump of the ICA, or direct reduction of collateral perfusion (Street DL, et al, J Vasc Surg 1987;6:280-2; and Nano G, et al, Cardiovasc Internvent Radiol 2006;29:140-2). Surgical treatment of ECA stenosis is infrequently performed but is a well-known and recognized procedure. However, endovascular management of ECA stenosis with angioplasty and stenting is a rare procedure. For this report, the authors gathered data from five academic medical centers to identify patients who underwent ECA stenting after 1998 and correlated clinical data, procedural details, and follow-up results for analysis. Half the patients came from a single medical center, with no more than three patients from each of the other four contributing institutions. There were 12 patients with a median age of 66 years (range, 45-79 years). Of these, 11 had ECA stenosis ≥70%, and all had ipsilateral ICA occlusion. Symptoms included amaurosis fugax, stroke, and transient ischemic attack. After endovascular treatment, there was resolution of symptoms in five patients at a median follow-up of 26 months (range, 1-87; mean, 29 months). One patient's procedure was complicated by aphasia and contralateral hemiplegia. This patient also subsequently developed a contralateral stroke and died 4 months after the procedure. An additional patient developed ipsilateral TIAs 3 weeks after stenting and subsequently underwent an extracranial-to-intracranial bypass, with no further symptoms. There was no apparent symptomatic in-stent restenosis, although >50% in-stent restenosis was noted in two patients on follow-up. Comment: Stenting of the ECA is an unusual procedure. (The article actually has more authors, 14, than patients, 12!) The results are certainly not a mandate for ECA stenting for apparently symptomatic ECA stenosis. However, there are also no compelling data for open revascularization of the ECA. Revascularization of the ECA, whether by endovascular or open surgical treatment, is supported by nothing more than individual case series and is never likely to be supported by anything other than case series.