Contralateral Internal Carotid Artery Occlusion Research Articles

Society for Vascular Surgery duplex ultrasound surveillance guidelines are safe and cost effective for transcarotid artery revascularization

BackgroundCarotid duplex ultrasound (CDUS) examination is used in the long-term surveillance after transcarotid artery revascularization (TCAR). The objective of this study was to evaluate the usefulness and cost effectiveness of post-TCAR CDUS surveillance regimens in monitoring for in-stent restenosis (ISR) and associated stroke risk at a single-center community institution. MethodsCDUS data were collected retrospectively from patients who had undergone TCAR between January 2017 and January 2023. ISR >50% was defined as a peak systolic velocity (PSV) of >220 cm/s and an internal carotid artery (ICA) to common carotid velocity ratio of >2.7. ISR >80% was defined as a PSV of >340 cm/s and an ICA/common carotid artery ratio of >4.15. Study outcomes included incidences of ISR, reintervention, transient ischemic attacks (TIAs), strokes, and mortality. A Kaplan-Meier survival analysis was done to calculate the rates of freedom from ISR. ResultsDuring the study period, 108 TCAR stents were deployed in 104 patients. Eight patients were excluded in analysis or lost to follow-up. Preoperatively, 62% of patients had >80% stenosis, and 39% were symptomatic. No intraprocedural complications were noted. One patient suffered an immediate postoperative dissection. Eight stents (8%) experienced ISR progression from <50% to >50%. Three of the eight had further ISR progression to >80%. One patient had high-grade ISR and a contralateral ICA occlusion that warranted reintervention. There were no occurrences of postoperative TIAs, strokes, or TCAR-related deaths. Rates of freedom from ISR progression from <50% to >50% were 97.4%, 95.9%, 90.9%, 88.2%, and 88.2% at 6, 12, 24, 36, and 42 months, respectively. Rates of freedom from ISR >80% were 100%, 100%, 98.5%, 95.5%, and 95.5% at the same time points. Patients with >50% ISR tended to be females with hyperlipidemia. In addition, they had higher average lesion lengths and lower rates of postdilation balloon angioplasty. The 5-year estimated surveillance cost in this cohort using the Society for Vascular Surgery 2022, and 2018 guidelines, as well as our current protocol would be $113,853, $221,382, and $193,207, respectively. ConclusionsThis study revealed a low incidence of ISR progression, as well as no TIA, stroke, or TCAR-related deaths, highlighting the safety and efficacy of TCAR. Post-TCAR CDUS examination using the updated Society for Vascular Surgery guidelines are safe and cost effective. Patients with contralateral occlusion or stenosis, or who have significant risk factors, should have more frequent surveillance regimens.

Change in Peak Systolic Velocity Estimation in Internal Carotid Artery Following Contralateral Near Occlusive Carotid Endarterectomy

Carotid artery stenosis (CAS) is one of the main causes of stroke, as the internal carotid artery (ICA) is a major source of cerebral blood supply. A common surgical intervention for CAS is carotid endarterectomy (CEA), which carries a high risk of stroke and mortality. CEA is indicated for 50% to 99% stenosis in symptomatic patients and 60% to 99% stenosis in asymptomatic patients. Carotid duplex ultrasound is frequently used to estimate peak systolic velocity (PSV), end diastolic velocity (EDV), and ICA/common carotid artery (CCA) ratio to determine the extent of stenosis. This does not account for other factors that can artificially change PSV and EDV, such as a contralateral carotid artery near occlusion with >90% stenosis. Although >70% contralateral stenosis has been previously studied, limited research exists on the impact of ICA near occlusions. We hypothesize that the degree of stenosis in an ipsilateral patent vessel can be more accurately estimated by examining the change in PSV pre- vs post-CEA of the contralateral ICA near occlusion. A retrospective study was conducted on 239 patients, at least 18 years of age, who underwent standard, routine carotid duplex ultrasound at a single institution. Patients who qualified for the study had bilateral carotid stenosis with ICA near occlusive disease on at least one side and underwent CEA. Near occlusion was determined by either a carotid duplex ultrasound >70% with one of the following criteria: PSV >400, EDV >140, or ratio of ICA/CCA >6, or a carotid computed tomography angiography showing near occlusion interpreted by a physician. Preoperative duplex velocities contralateral to the CEA were recorded and compared postoperatively. Interestingly, in the presence of contralateral >50% ICA stenosis, the PSV, EDV, and ICA/CCA ratio in the unoperated artery increased significantly following contralateral CEA (P < .001). In greater than 70% contralateral ICA occlusion, PSV, EDV, and ICA/CCA ratio increased to a greater extent compared with >50% contralateral ICA stenosis (P < .001). In detecting ≥70% stenosis of the patent vessel pre-CEA, PSV ≥250 cm/s had 87.2% sensitivity. In predicting ≥70% stenosis of the patent vessel pre-CEA, PSV >300 cm/s had 96.0% sensitivity. The present study deviates from the current theoretical model and shows that ultrasound PSV, EDV, ICA/CCA ratios can be significantly elevated in the patent vessel pre-CEA and post-CEA of the contralateral ICA near occlusion. This study provides novel insight into customized duplex ultrasound criteria for estimation of stenosis and to avoid unnecessary high-risk surgery.

Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients.

Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion (P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.

Role of Doppler Ultrasound Analysis of Blood Flow Through the Ophthalmic and Intracranial Arteries in Predicting Neurologic Symptoms During Carotid Endarterectomy.

Carotid endarterectomy (CEA) is frequently performed under locoregional anesthesia. The intraoperative clamping of the internal carotid artery (ICA) leads to cerebral hypoperfusion, which may in some patients result in the development of neurologic symptoms (NS). The objective of our study was to investigate whether there is an association between the preoperative ultrasound (US) Doppler flow in the ophthalmic artery (OA) and intracranial artery and the occurrence of these intraoperative NS. We compared 50 patients with NS and 150 patients without NS during CEA. We analyzed their preoperative blood flow characteristics by Doppler US and their clinical and demographic characteristics. The contralateral ICA occlusion increased the likelihood of intraoperative NS (odds ratio [OR], 8.4; P < .001). Abnormal contralateral OA flow also increased the likelihood of NS (OR, 1.84; P < .001), whereas ipsilateral abnormal OA flow reduced it (OR, 0.73; P=.06). Increased flow in the ipsilateral anterior cerebral artery (ACA) increased the likelihood of NS (OR, 3.3), whereas reversed flow decreased it (OR, 0.1; P=.03). Inverse flow in the contralateral ACA increased the risk (OR, 5.4), whereas increased flow reduced it (OR, 0.2; P=.02). Male patients had a higher risk of NS (P=.09) as well as older patients (P=.05). Eight percent of the patients with NS developed a transient ischemic attack or stroke. Doppler US analysis of the OA and ACA in combination with analysis of ICA stenosis may be a promising predictor of NS during ICA clamping. This, in turn, may warn the patient and the surgeon of an increased risk during surgery.

Follow-up after carotid endarterectomy and stenting: What to look for and why

Duplex ultrasound testing after open or endovascular extracranial carotid artery interventions is a clinical practice guideline with a strong recommendation from the Society for Vascular Surgery. Neurologic outcomes are improved by the recognition of repair site stenosis or atherosclerotic disease progression in the unoperated carotid artery. The benefit of surveillance outweighs its risk because duplex testing is free of complications and accurate in the detection of internal carotid artery (ICA) stenosis or occlusion. Surveillance for >70% ICA stenosis is recommended within 30 days of the procedure, then every 6 months for 2 years, and annually thereafter. Repair site and contralateral ICA stenosis classification should be based on angle-corrected pulsed Doppler measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), and the ratio of PSV at the stenosis to a proximal, nondiseased common carotid artery (CCA) segment (ICA/CCA ratio). Interpretation criteria of PSV >300 cm/s, EDV >125 cm/s, and ICA/CCA ratio >4 predicts >70% repair site stenosis. Endovascular intervention is recommended for a carotid repair site stenosis based on the occurrence of an ipsilateral neurologic event and appropriate anatomy for angioplasty. For asymptomatic restenosis, intervention is based on stenosis progression to elevated PSV and EDV >70% stenosis threshold values and the patient is deemed high risk for stroke due to contralateral ICA occlusion or incomplete functional patency of the circle of Willis.

Carotid endarterectomy with concomitant distal endovascular intervention is associated with increased rates of stroke and death

ObjectiveCarotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA. MethodsThe Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ2 test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke. ResultsFrom 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation. ConclusionsAlthough markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures.

Carotid Endarterectomy With Shunt for Preoperative or Intraoperative Indication Is Associated With Increased Rate of Stroke

Carotid endarterectomy (CEA) is performed frequently both with and without the use of shunting, and previous studies have shown similar 1% to 2% rates of stroke with both techniques in asymptomatic patients. The rate of stroke when shunting is performed for a preoperative or intraoperative indication remains understudied. We aimed to evaluate the rate of stroke by shunt indication and to compare this cohort with routine shunt and no shunt cohorts in a large national registry. The Vascular Quality Initiative CEA registry was used to identify patients undergoing CEA for asymptomatic carotid stenosis from 2013 to 2019. Exclusion criteria included symptomatic patients (defined as ipsilateral transient ischemic attack or stroke within 6 months of operation), concomitant coronary intervention, proximal or distal endovascular intervention, and urgent or emergent procedures. Categorical variables were analyzed using χ2 test, and continuous variables were analyzed using analysis of variance. Multivariable logistic regression was used to evaluate demographic and perioperative predictors of stroke. There were 69,903 CEAs identified, which consisted of 33,459 without shunt, 31,711 routine shunts, 1369 shunts for preoperative indication, and 3364 shunts for intraoperative indication patients. The cohort with shunt for preoperative indication was more likely to be male, to be transferred from an outside hospital, and to have contralateral internal carotid artery (ICA) occlusion. In addition, the cohorts with shunt for indication had slightly increased procedure length, rates of re-exploration at time of initial operation, and protamine use (Table I). The rate of stroke was increased in shunt for preoperative and intraoperative indication cohorts (no shunt, 0.8%; routine shunt, 0.9%; preoperative indication, 1.8%; intraoperative indication, 1.3%; P < .01). On multivariable analysis, both shunt for preoperative indication and shunt for intraoperative indication are associated with stroke. Other perioperative and demographic variables associated with stroke include hypertension, any prior neurologic event, contralateral ICA occlusion, completion angiography, postoperative hemodynamic instability requiring intravenous medications, and re-exploration at the time of initial operation (Table II). The proportion of shunt for preoperative indication varies by region (East, 1.4%; North, 2.2%; South, 1.5%; West, 4.3%; P < .01). Regional variation is present in preoperative indication for shunt as the proportion of patients with contralateral ICA occlusion or >60% contralateral ICA stenosis varied widely (East, 55.3%; North, 62.9%; South, 52.2%; West, 47.6%; P < .01). CEA with shunt for preoperative or intraoperative indication is associated with increased rates of stroke, even in asymptomatic patients, suggesting a high-risk cohort that is poorly defined by registry data. Identifying this cohort may alter the risk-benefit ratio of the operation and inform clinical decision-making.Table IDemographic characteristics, preoperative workup, and intraoperative variablesDemographic characteristicsNo shunt (n = 33459)Routine shunt (n = 31711)Shunt: Preop indication (n = 1369)Shunt: Intraop indication (n = 3364)PAge, years (SD)70.7 (8.7)71.0 (8.8)70.4 (9.1)71.1 (8.9)<.01Sex (male)20263 (60.6)18715 (59.0)876 (64.0)1918 (57.0)<.01Comorbidities HTN29950 (89.5)28615 (90.2)1236 (90.3)3079 (91.5)<.01 CAD9092 (27.2)9061 (28.6)404 (29.5)926 (27.6)<.01 CHF3659 (10.9)3637 (11.5)157 (11.5)391 (11.6).15 Diabetes11988 (35.8)11881 (37.5)508 (37.1)1280 (38.0)<.01 Current Smoker7976 (23.8)8043 (25.4)330 (24.1)885 (26.3)<.01 ESRD352 (1.1)366 (1.2)16 (1.2)49 (1.5).16 ASA Class ≥45539 (16.6)6026 (19.0)274 (20.0)605 (18.0)<.01 Lived at Home33178 (99.2)31343 (99.1)1346 (98.4)3313 (98.5)<.01 Transfer OSH383 (1.1)341 (1.1)35 (2.6)46 (1.4)<.01Neurologic History Ipsi Neuro Event >6 months1891 (5.7)1803 (5.7)147 (10.8)214 (6.4)<.01 Ipsi Stroke >6 months1110 (3.3)1075 (3.4)103 (7.5)138 (4.1)<.01 Contra CEA5213 (15.6)5169 (16.3)156 (11.4)528 (15.7)<.01 Contra ICA Occlusion937 (2.8)1620 (5.2)370 (27.4)336 (10.3)<.01 Ipsi Stenosis ≥70%30362 (92.1)28306 (91.3)1232 (91.4)2932 (90.2)<.01 Contra Stenosis ≥70%6116 (18.6)5888 (19.0)314 (23.3)624 (19.2)<.01 Anatomic High Risk1433 (4.3)1232 (3.9)53 (3.9)147 (4.4).06Operative Factors Procedure Length (SD)114 (44)112 (42)122 (44)121 (43)<.01 Protamine23494 (70.2)21643 (68.3)985 (72.0)2581 (76.8)<.01 Patch27831 (83.3)30607 (96.5)1289 (94.2)3165 (94.1)<.01 Re-explore at Initial Operation459 (1.4)390 (1.2)19 (1.4)72 (2.1)<.01ASA, American Society of Anesthesiologists; CAD, coronary artery disease; CHF, congestive heart failure; Contra, contralateral; ESRD, end stage renal disease requiring dialysis; HTN, hypertension; ICA, internal carotid artery; Ipsi, ipsilateral; Neuro, neurologic event >6 months from procedure; OSH, outside hospital; SD, standard deviation. Open table in a new tab Table IIMultivariable logistic regression: strokeStrokeOdds ratio (OR)95% Confidence intervalPP2Y12 Inhibitor0.640.53-0.77<.01Male Gender0.810.69-0.96.02Shunt for Intraop Indication1.431.02-2.01.04Shunt for Preop Indication1.611.05-2.53.03Completion Angiogram1.691.22-2.35<.01Hypertension1.701.20-2.40<.01Contralateral ICA Occlusion1.781.34-2.38<.01Any Prior Neurologic Event1.931.63-2.29<.01Postop IV Medication for Hemodynamic Instability3.432.91-4.05<.01Re-explore at Initial Operation9.5411.31-17.08<.01 Open table in a new tab

Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative

ObjectiveCarotid endarterectomy (CEA) is among the most commonly performed vascular procedures. Some have suggested worse outcomes with contralateral internal carotid artery (ICA) occlusion. We compared patients with and patients without contralateral ICA occlusion using the Society for Vascular Surgery Vascular Quality Initiative database. MethodsDeidentified data were obtained from the Vascular Quality Initiative. Patients with prior ipsilateral or contralateral CEA, carotid stenting, combined CEA and coronary artery bypass graft, or <1-year follow-up were excluded, yielding 1737 patients with and 45,179 patients without contralateral ICA occlusion. Groups were compared with univariate tests, and differences identified in univariate testing were entered into multivariate models to identify independent predictors of outcomes and in particular whether contralateral ICA occlusion is an independent predictor of outcomes. ResultsPatients with contralateral ICA occlusion were younger and more likely to be smokers; they were more likely to have chronic obstructive pulmonary disease, preoperative neurologic symptoms (56% vs 47%), nonelective CEA (16% vs 13%), and shunt placement (75% vs 53%; all P < .001). The 30-day ipsilateral stroke risk was 1.3% with vs 0.7% without contralateral ICA occlusion (P = .004). The 30-day and 1-year survival estimates were 99.0% ± 0.5% and 94.1% ± 1.1% with vs 99.6% ± 0.1% and 96.0% ± 0.2% without contralateral ICA occlusion (log-rank, P < .001). Logistic regression analysis identified prior neurologic event (P = .046), nonelective surgery (P = .047), absence of coronary artery disease (P = .035), and preoperative angiotensin-converting enzyme inhibitor use (P = .029) to be associated with 30-day ipsilateral stroke risk, but contralateral ICA occlusion remained an independent predictor in that model (odds ratio, 2.29; P = .026). However, after adjustment for other factors (Cox proportional hazards), risk of ipsilateral stroke (including perioperative) during follow-up was not significantly greater with contralateral ICA occlusion (hazard ratio, 1.21; P = .32). Results comparing propensity score-matched cohorts mirrored those from the larger data set. ConclusionsThis study demonstrates likely clinically insignificant differences in early stroke or death in comparing CEA patients with and those without contralateral ICA occlusion. After adjustment for other factors, contralateral ICA occlusion was not associated with a greater risk of ipsilateral stroke (including perioperative) in longer follow-up. Mortality was greater with contralateral ICA occlusion, and this difference was more pronounced at 1 year despite younger age of the contralateral ICA occlusion group. CEA risk remains low even in the presence of contralateral ICA occlusion and appears to be explained at least in part by other factors. CEA should still be considered appropriate in the face of contralateral ICA occlusion.

Outcome of Near-Infrared Spectroscopy–Guided Selective Shunting During Carotid Endarterectomy in General Anesthesia

To analyze the outcome of near-infrared spectroscopy (NIRS)-guided selective shunting during carotid endarterectomy and the procedural outcome. In this retrospective single-center study, patients undergoing carotid endarterectomy in general anesthesia and receiving bihemispheric NIRS as single neuromonitoring tool between January 2009 and January 2014 were included. Shunting was applied if the reduction in the NIRS values after cross-clamping on the ipsilateral side exceeded 15%. Patients with contralateral occlusion of the internal carotid artery (ICA) were excluded, as were patients operated on by surgeons performing routine shunting. All patients underwent intraoperative angiography after vessel recanalization. NIRS trend was available in 441 patients. Twenty-eight were excluded from this study (14 due to preference for general shunting, 13 due to contralateral ICA occlusion, and 1 due to intraoperative ICA occlusion), resulting in a final sample of 413 patients. We observed a >15% drop in NIRS values on the ipsilateral side in 29 (7%) patients. Accordingly, an intraluminal shunt was placed into the ICA. Shunting was not performed in 384 patients (<15% drop in NIRS values). Interestingly, the NIRS values on the contralateral side were significantly elevated after cross-clamping compared with baseline in the group without shunt (P<0.0001). On the contrary, patients requiring an ICA shunt revealed a statistically significant reduction in the rSO2 on the contralateral side compared with the baseline (after ipsilateral clamping) (P=0.047). Three patients overall suffered a stroke, all of whom were in the no-shunt group (combined stroke rate of 0.8% [3/384] with no significant intergroup difference). There was no difference in morbidity factors between the two groups. However, surgical revision after intraoperative angiography was significantly more frequent in the shunt group (17.2%, 5/29) versus the no-shunt group (6%, 23/384), (P<0.037). An NIRS-guided selective shunting strategy was associated with excellent clinical outcomes and has the potential to identify patients at risk for hypoperfusion during the clamping period. However, a potentially shunt-associated higher rate of requiring local revisions (due to flaps, twisting, stenosis, and kinking) in ICA was observed. Additional studies are needed to further refine cut-off values for NIRS, indicating the need for shunting.

"Interlocking" Clipping of an Irregular Middle Cerebral Artery Bifurcation Aneurysm: 2-Dimensional Operative Video.

Middle cerebral artery (MCA) aneurysms often have an irregular morphology that might require creative clipping techniques even in the case of small aneurysms. In this video, we illustrate the case of a patient with an incidental but very irregular MCA aneurysm. The presence of 2 separate, asymmetric lobes was dealt with by utilizing the "interlocking" clip technique in which a regular clip is used to obliterate 1 portion of the aneurysm and a fenestrated clip, with the ring of the fenestration circling the body of the first clip, is used to obtain obliteration of the other lobe. This patient also had a contralateral internal carotid artery occlusion, and we discuss the pitfalls of temporary clipping in such a situation.

Вибір методу профілактики гострого порушення мозкового кровообігу при атеросклеротичному ураженні сонних артерій

Introduction. Atherosclerotic lesions of the internal carotid artery (ICA) cause the development of acute cerebrovascular disease (ACVD) in almost 75% of patients.The aim of the study. Evaluation the criteria for selecting patients for carotid endarterectomy (CEA) and carotid artery stenting, and to analyze the results of treatment.Materials and methods. The results of treatment of 120 patients with ICA stenosis over the period from 2012 to 2017 were analyzed. There were 75 (62.5%) patients with symptomatic ICA stenosis and 45 patients with asymptomatic ICA stenosis. All the patients were divided into 2 groups according to the treatment method: Group I included 82 (68.3%) patients who underwent carotid endarterectomy; Group II comprised 38 (31.7%) patients who underwent carotid artery stenting. When selecting the method of treatment, carotid endarterectomy was the preferred one. In 49 (57%) patients, eversion CEA was performed; 25 (30.5%) patients underwent traditional CEA with surgical plasty of the ICA; in 8 (9.8%) patients, intraoperative shunting was used. Endovascular stenting was performed in 19 symptomatic patients at high surgical risk, 7 patients with contralateral ICA occlusion and 12 patients with a combination of significant lesions of several supraaortic vessels.Results and discussion. In Group I, 2 (2.4%) patients developed acute cerebrovascular disease; 1 (1.2%) patient died. In 3 (3.7%) patients, postoperative bleeding was observed. In Group II, 1 (2.6%) patient developed ACVD in the early postoperative period. The comparison of the postoperative results of carotid endarterectomy and ICA stenting in our study did not reveal any statistically significant difference.Conclusions. Surgical and endovascular prevention of ACVD in patients with ICA stenosis allows achieving good postoperative results. The selection of the treatment method (carotid endarterectomy – stenting) should be based on the consensus achieved by vascular surgeon, interventional radiologist and neurologist.

Results of Carotid Endarterectomy in Patients With Contralateral Internal Carotid Artery Occlusion From the Society for Vascular Surgery Vascular Quality Initiative

Results of Carotid Endarterectomy in Patients With Contralateral Internal Carotid Artery Occlusion From the Society for Vascular Surgery Vascular Quality Initiative

IP095. Severe Tandem Carotid Lesions in an Irradiated Field with Tracheostomy and Contralateral Carotid Occlusion and Contraindication to Carotid Artery Stenting

This is a case report and literature review of a patient with severe tandem carotid lesions in an irradiated field after radical neck dissection with tracheostomy, contralateral carotid occlusion, and contraindication to carotid artery stenting. We conducted a systematic review of the English language literature with information on severe tandem carotid lesions in a hostile field (previous surgical intervention, irradiation) and contralateral carotid occlusion. We present the case of a 71-year-old woman with asymptomatic, severe carotid artery stenosis and a past medical history significant for laryngeal cancer status post laryngectomy with stoma, radical neck dissection, and neck irradiation. Aortic arch and carotid angiography demonstrated a left internal carotid artery (ICA) occlusion, right common carotid artery (CCA) stenosis of 80%, right ICA stenosis of 50% to 60% with severe tortuosity, and occluded right external carotid artery. Given the severe ICA tortuosity with tandem lesions, carotid artery stenting was not feasible, and we proceeded with carotid endarterectomy, ICA resection, and primary anastomosis. Intraoperatively, the ICA was mobilized and the proximal ICA was resected, thus addressing the tortuosity and the distal tandem lesion. For the proximal tandem lesion located in the CCA, we performed a standard endarterectomy of the proximal portion of the CCA lesion and an eversion endarterectomy of the distal transected CCA. Next, we performed an end-to-end anastomosis of the ICA to the CCA. This was completed with a Sundt shunt in place, given the contralateral ICA occlusion. Postoperatively, the patient has done well and continues to be free of any complication, with duplex ultrasound demonstrating patency. After a thorough literature review, it is clear that this in an unusual case with a novel solution. The patient’s prior radical neck dissection with tracheostomy and irradiation would generally have made her an ideal candidate for carotid artery stenting. However, the patient was at high risk for carotid artery stenting, given the tortuosity and tandem lesions. The literature provides ample data on the benefits of carotid artery stenting for carotid stenosis in hostile necks. However, there is very little information clarifying how to approach lesions in a hostile neck when they are not amenable to stenting. Our case represents a novel open carotid endarterectomy approach to tandem lesions with associated tortuosity in a hostile operative field.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Cerebral Neuromonitoring during Carotid Endarterectomy and Impact of Contralateral Internal Carotid Occlusion

The aim of this study was to identify the reliability of carotid artery stump pressure (SP) in predicting the neurologic changes and correlation with contralateral internal carotid artery (ICA) occlusion in patients undergoing eversion carotid endarterectomy (CEA). The optimal method for monitoring cerebral perfusion during CEA, performed under either local or general anesthesia, is still controversial. We prospectively analyzed 118 consecutive patients undergoing eversion CEA under local anesthesia. We had 78 symptomatic (66%) and 40 asymptomatic patients (33.9%). Selective shunting was performed in patients who developed neurologic changes after carotid clamping regardless of SP. Correlation of preoperative symptom status, a degree of stenosis, status of contralateral ICA, arterial blood pressure, SP value, and the intraoperative need for shunting due to neurologic changes was evaluated for both groups: shunted and nonshunted. Selective shunting was performed in 12 patients (10%). There was no significant difference among the groups regarding the demographic characteristics. Mean carotid clamping time was 14.57 minutes. We had no perioperative mortality, stroke, or myocardial infarction. None of the patients required conversion to general anesthesia. We found a mean SP of 31 mm Hg as a reliable threshold for shunting (P < .001; sensitivity 92.3%; specificity 91.3%). Contralateral carotid occlusion was correlated with the significantly lower SP (27 ± 13 mm Hg; P = .001) and the higher need for shunt (50%). SP measurement is a reliable and simple method for monitoring the collateral cerebral perfusion and can predict the need for shunting during CEA. Patients with the contralateral ICA occlusion showed significantly lower SP, although it did not have impact on the outcome.

Ultrasonographical Features Associated with Progression of Atherosclerosis in Patients with Moderate Internal Carotid Artery Stenosis.

Carotid artery stenosis (CAS) is a leading cause of ischemic stroke. Plaque stabilization is a major management approach. Information about the ultrasonographical and clinical features associated with the progression of moderate internal carotid artery (ICA) stenosis (50-69%) could assist with prognostication and risk factor modifications. We evaluated 287 patients with moderate ICA stenosis (50-69%) and subsequently evaluated them at follow-up points at 12, 24, and 36months. Patients were divided into three groups according to the degree of ICA stenosis: progression (70-99%, n = 48), stable (50-69%, n = 210), and regression (< 50%, n = 29). Responsible plaque thickness (RPT) across groups during follow-up was compared using a repeated measure ANOVA test. An ordinal regression was subsequently applied to identify risk factors for atherosclerosis progression. Male (P = 0.04), hypoechoic plaque (P < 0.01), smoking (P = 0.02), plaque ulceration (P = 0.05), and contralateral severe CAS or occlusions (P = 0.04) on ultrasound was more frequent in the progression group vs. other two groups. The ordinal regression revealed that only hypoechoic plaque (OR, 7.03; 95% CI, 3.34-14.81; P < 0.01) and contralateral ICA severe stenosis or occlusion (OR, 2.86; 95% CI, 1.41-5.80; P < 0.01) were independently associated with stenosis progression, while statin use was inversely associated with stenosis progression (OR, 0.26; 95% CI, 0.13-0.54; P < 0.01). Of note, symptomatic vs. asymptomatic moderate CAS at baseline was not associated with progression. For patients with moderate CAS, hypoechoic plaque, contralateral severe stenosis or occlusion on ultrasonography, and statin use are independently related to stenosis progression. Statin use may delay the progression of carotid stenosis.

Very Early CEA Without Shunting for Stroke—The Preferred Therapy

There has been an evolution toward early carotid endarterectomy (CEA) after stroke, but there remains a reluctance to perform CEA earlier than 2 weeks. There has also historically been a bias toward shunting for previous stroke. This study analyzed the results of early CEA (<2 weeks) for stroke patients without shunting over a 12-year period to determine whether CEA earlier than 2 weeks after stroke was safe and whether a strategy of no shunting absent neuromonitoring changes was justified. A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. All patients with stroke were included except modified Rankin scale 6. The decision to shunt was based only on defined changes in continuous electroencephalography/somatosensory evoked potentials dynamics reflecting ischemia intraoperatively. Patient demographics, including age, degree of internal carotid artery (ICA) stenosis, preoperative neurologic symptoms, and medications were reviewed. Thirty-day outcomes were tabulated, including stroke, transient ischemic attack, death, and other major complications. A total of 432 patients (100 men [62.5%]) with a mean age of 69.4 years (range, 44-91 years) underwent 451 CEAs. There were 220 CEAs (49%) for symptomatic disease; of these, 183 had a documented stroke. CEA was performed within 72 hours in 162 stroke patients (88%) and within 5 days in the remaining 21 patients. Of the stroke cohort, mean pre-CEA modified Rankin scale was 3.8. One patient of this cohort had a new stroke (contralateral). The 72-hour perioperative stroke rate for the whole CEA group was 0.66% (3 of 451). The 30-day stroke, transient ischemic attack, and death rates were 5 (1.1%), 0 (0%), and 5 (1.1%), respectively. There was one intraoperative stroke, and the remainder of the four strokes occurred within 30 days. Early CEA for stroke (ie, <72 hours) can be performed safely without the need for shunting and does not increase postoperative stroke, morbidity, or mortality. Electroencephalography and somatosensory evoked potentials monitoring dramatically reduces the need to place a shunt during CEA. Recent stroke, contralateral ICA occlusion, or contralateral high-grade ICA stenosis are not an indication for intraoperative shunting. CEA for stroke is best done early, with no additional increase in perioperative stroke, thus shielding the patient from the early risk of recurrent stroke.

Outcome of carotid artery stenting in the hands of vascular surgeons.

To analyze the procedural and clinical outcomes of carotid artery stenting (CAS) in the hands of endovascular trained vascular surgeons. Between April 2008 to May 2013, 1197 patients were treated for extracranial internal carotid artery (ICA) stenosis. The proportion of endovascular treated patients was 5.0% (CAS n=60 vs. carotid endarterectomy (CEA) n=1137). All patients in the CAS group (44 males, median age 70years) were treated by two senior vascular surgeons experienced in endovascular methods. Restenosis was the indication for CAS in 32 out of 60 patients (53.3%). Further indications were contralateral ICA occlusion (n=14, 23.3%), radiogenic ICA stenosis (n=5, 8.3%), high-risk candidates for CEA (n=4, 6.6%), and the presence of contralateral recurrent paresis (n=2, 3.3%). High-risk patients for CEA were defined as patients with history of severe cardiac disease and patients with impaired general condition. 84.4% (n=27) of the restenosis were asymptomatic with a mean degree of stenosis of 83.7%, and 12.9% (n=4) were symptomatic (degree of stenosis of 90%). Mean procedural and fluoroscopy time were 61 and 14min. Study endpoints were periprocedural stroke-related mortality and morbidity, restenosis rate, and overall survival. Follow-up was performed by duplex ultrasound with a median follow-up period of 12 months (range 1-55). The periprocedural stroke rate of CAS within 30 days was 3.3% (one ischemic stroke, one intracranial hemorrhage); two additional patients suffered TIA (3.3%). None of the patients had a myocardial infarction perioperatively. The mortality rate was 0. CAS procedures were completed in 90.0% (n=54) of cases. Dropout rate was 8.3% (n=5) for morphological reasons (e.g., carotid kinking). Intraoperative complication rate was 1.7% (n=1) including one patient who suffered intraoperative rupture of access vessels. The conversion rate with subsequent CEA procedure was 6.6% (n=4 of 5). The restenosis rate during follow-up was 3.3% after CAS. The reintervention rate during the median follow-up period of 12 months (1-55 months) was 5.5% (n=3/54). Two patients received a reintervention with successful balloon angioplasty; in one case, a diagnostic angiography was performed excluding the presence of a relevant restenosis. No additional stent was implanted. The survival rate was 100% at 1 year, 90.4% at 2 years, and 77.7% at 3 years. CAS, in the hands of vascular surgeons, is feasible with a moderate perioperative risk in a highly selected patient cohort. A procedure termination rate of approximately 10% shows that the complementary therapy using CAS procedure is not overused by surgeons.

Abstract TP138: Carotid Endarterectomy for Complicated Carotid Artery Disease∼ Application of Extracorporeal Circulation Technique

Intorduction: In performing carotid endarterectomy (CEA), indwelling shunt tube placement is necessary in some cases with poor collateral flow. Particularly, in patients with critical hemodynamic insufficiency like contralateral internal carotid artery (ICA) occlusion, shorter cross-clamping duration is preferable. Furthermore, in patients who have common carotid artery (CCA) ulceration, shunt placement can be dangerous because of the risk of embolic complication through the indwelling shunt tube. For such cases, we introduced extracorporeal circulation technique for cerebral perfusion during CEA. Methods: In 309 consecutive CEA cases, 16 cases (5.2%) were performed CEA under extracorporeal circulation. Using roller pump, arterial blood was supplied from brachial or femoral artery to the distal portion of the cervical ICA. In cases with contralateral ICA occlusion, distal ICA cannulation was performed without any cross clamping by using Seldinger technique. Other cases with CCA ulceration, distal ICA cannulation was performed with conventional indwelling shunt tube insertion technique. Results: In 6 cases with contralateral ICA occlusion and 9 cases with ipsilateral CCA ulceration concomitant with ICA stenosis, and in one case had both contralateral ICA occlusion and ipsilateral CCA ulceration, we successfully performed CEA under extracorporeal circulation. No ischemic event was observed in all the cases. Conclusions: This extracorporeal circulation procedure is very useful in patients with carotid artery disease who have extremely poor collateral flow or have severe CCA lesions.

対側閉塞を伴う高度石灰化内頸動脈狭窄症に対して段階的血行再建術が有効だった1 例

対側閉塞を伴う高度石灰化内頸動脈狭窄症に対して段階的血行再建術が有効だった1 例

Lesion-Related Carotid Angioplasty and Stenting with Closed-Cell Design without Embolic Protection Devices in High-Risk Elderly Patients—Can This Concept Work Out? A Single Center Experience Focusing on Stent Design

To compare the performance differences of three carotid artery stents in high-risk elderly patients without embolic protection devices (EPDs) on the basis of stent design, procedure-related complications, conveniences in handling, in-stent restenosis, 30-day outcome, and long-term follow-up. A total of 101 symptomatic internal carotid stenoses of 94 patients were prospectively treated with stent-protected angioplasty to 94 patients. Three closed-cell stents, one of those being hybrid cell design, were chosen depending on vascular anatomy: curved vessel, lesion length > 1 cm: 64 Carotid Wallstent (Boston Scientific, Natick, MA); curved vessel, lesion length < 1 cm: 21 Cristallo Ideale (Invatec, Roncadelle, Italy); straight vessel, lesion length > 1 cm: 16 Xact (Vascular Abbott, Santa Clara, CA). Comparisons of demographics, procedures, and outcomes were performed. The mean age of patients was 73.1 years (standard deviation [SD], ± 7.9; range, 58-87 years), 71% of the patients were older than 70 years and 20% were octogenarians. Male/female ratio was 3.1:1. About 13.9% (14/101) had contralateral internal carotid artery occlusion. Overall peri-interventional complication rate was 2.9% and 30-day mortality rate was 1%. During the long-term follow-up (34 months, range 1-59) no ipsilateral stroke was documented. Ten deaths (three after MI) were recognized. Two in-stent restenosis were detected (> 70% North American Symptomatic Carotid Endarterectomy Trial) during follow-up, one patient was detected with previous carotid endarterectomy. Especially, if individual anatomical variance is considered, lesion-related stent-protected carotid angioplasty with lesion-adapted closed-cell design is an effective, reliable, safe, and comprehensible treatment option in symptomatic patients. Even without EPDs, the rate of complications is low, when compared with symptomatic carotid artery stenosis described in the literature. In-stent restenosis seems to play no significant role in follow-up.