Internal Carotid Artery Group Research Articles

Enterprise stents for the treatment of symptomatic non-acute intracranial artery stenosis disease: safety and efficiency evaluation

ABSTRACT Background Enterprise stent was approved for the treatment of wide-necked intracranial aneurysms. However, it has been widely used in the endovascular treatment of intracranial artery stenosis, which is still controversial. The purpose of this study was to evaluate the safety and efficiency of the Enterprise stent in the endovascular treatment of intracranial artery stenosis disease. Methods We conducted a retrospective case series of 107 patients with intracranial artery stenosis who received Enterprise stent implantation at Nanjing Drum Tower Hospital from January 2020 to December 2022. The rates of recanalization, perioperative complications, in-stent restenosis at 3–12 months and stroke recurrence were assessed for endovascular treatment. Results A total of 107 individuals were included in this study, 88 were followed up, and 19 (17.8%) patients were lost to follow-up. The operation success rate was 100%, During the procedure,4（3.7%）patients had vasospasm, and 2(1.9%) patients showed symptomatic bleeding. The overall perioperative complication rate was 5.6%, including 2.8% distal artery embolism, 0.9% in-stent thrombosis, and 1.9% symptomatic bleeding. 88 (82.2%) patients were followed up from 3 to 12 months, of whom 12 (13.6%) had in-stent restenosis, 4 (4.7%) recurrent strokes and 2 died of pulmonary infection caused by COVID-19. Patients were divided into 3 groups according to the cerebral artery, including the middle cerebral artery group, internal carotid artery group, and vertebrobasilar artery group. Conclusions In this study, the placement of the Enterprise stent in patients with symptomatic non-acute intracranial stenosis was successful. However, the occurrence of periprocedural and long-term complications after stenting remains of high concern.

Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study.

Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption. A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0-2. There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18-1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79-4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98-4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018-1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29-3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41-2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581). Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.

Key Factors Related to Internal Carotid Artery Stenosis Associated with Pituitary Apoplexy

Internal carotid artery (ICA) stenosis rarely occurs in pituitary apoplexy. Little is known of the causes of this condition. The present study investigated the factors related to ICA stenosis associated with pituitary apoplexy. Forty-five patients with pituitary apoplexy were retrospectively examined and divided into the stenotic and normal ICA groups. The baseline characteristics of patient background, tumor properties, clinical findings, and treatment overview were compared between the groups. Eight patients were assigned to the stenotic ICA group and 37 to the normal ICA group. Patient age in the stenotic ICA group was significantly lower than that in the normal ICA group (P= 0.001). Maximum tumor diameter (P= 0.001), tumor volume (P= 0.044), and Knosp grade (P < 0.001) were significantly greater in the stenotic ICA group than in the normal ICA group. The stenotic ICA group had a significantly greater incidence of sphenoid sinus mucosal thickening than the normal-ICA group (P= 0.039). Multivariate logistic regression analysis demonstrated that age (odds ratio 0.915, 95% confidence interval 0.846-0.991, P= 0.029) was a significant and independent predictor of ICA stenosis associated with pituitary apoplexy. Receiver operating characteristic curve analysis showed that the optimal cut-off point for age was 35.0 years (specificity 0.946, sensitivity 0.750). Our study revealed that age, tumor size, and sphenoid sinus mucosal thickening were strongly related to the occurrence of ICA stenosis in pituitary apoplexy. Among these factors, age had the potential of being an independent predictor of the condition.

Type A Aortic Dissection With Cerebral Malperfusion: New Insights

Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature. Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed. Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P= .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P < .001), and only 3 (11%) had a neurologic death (P < .001). ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.

Abstract TP137: Characteristics of Perfusion Profiles in Patients With Chronic Internal Carotid Artery Occlusion

Introduction: Internal carotid artery (ICA) occlusion may cause an acute stroke or may remain asymptomatic for years. Differences in the perfusion characteristics between patients with acute symptomatic ICA occlusions and those with chronic ICA occlusions have not been defined. The aim of this study is to identify the characteristics of the relatively “benign” perfusion pattern associated with chronic asymptomatic ICA occlusions and to determine if this pattern can be differentiated from the pattern observed in acutely symptomatic cases. Methods: We included 31 chronic ICA patients who had no history of a cerebral ischemic event for at least 1 year at the time of imaging and 20 patients with acute ischemic stroke caused by ICA occlusions from DEFUSE 2. All patients underwent MRI with perfusion. Perfusion parameters, including Tmax lesion volumes, hypoperfusion index (Tmax10/Tmax6), and CBV index (rCBV in Tmax6) were calculated by RAPID software. The status of the CBV, CBF, and MTT in the ischemic hemisphere was also rated by visual inspection on a 3-point scale (unchanged, reduced or increased). Differences were assessed by Mann-Whitney and Fisher’s exact tests. Results: The average age was 65.0±9.9 years in chronic vs. 64.7±14.2 years in acute ICA occlusion group ( p =0.90). Most of the chronic ICA patients had no territory with Tmax&gt;10s (29/31) or Tmax&gt;8s (24/31) in the ischemic hemisphere. The average Tmax lesion volumes were lower in the chronic ICA group (Tmax&gt;6 of 14 ml and Tmax&gt;4 of 81 ml) than in the acute ICA occlusion group (Tmax&gt;6 of 131 ml and Tmax&gt;4 of 220 ml, p &lt;0.0001 for both, Figure). CBV was unchanged in all chronic occlusion cases. In the acute occlusion group, there were 12 out of 20 cases (60%) with decreased CBV ( p &lt;0.0001). CBF was decreased in 1 (3%) patient with a chronic occlusion and 17 cases (85%) with acute occlusions ( p &lt;0.0001). MTT prolonged in 7 cases (22%) with chronic occlusions vs. all cases (100%) with acute occlusions ( p &lt;0.0001). Conclusions: Several features on perfusion MRI distinguish chronic ICA occlusions from acute occlusions. Patients with chronic ICA occlusions tend to have none or a minimal volume of tissue with Tmax&gt;8s or &gt;10s delay, smaller volumes of tissue with Tmax&gt;4s and &gt;6s delay, and normal appearing CBV and CBF maps.

Clinical, imaging features and outcome in internal carotid artery versus middle cerebral artery disease.

BackgroundOnly a very few studies had compared the differences in topographic patterns of cerebral infarcts between middle cerebral artery (MCA) and internal carotid artery (ICA) disease. Besides, the comparison of clinical features and outcomes between MCA and ICA disease had rarely been reported.ObjectivesTo compare the clinical, imaging features and outcome of MCA versus ICA disease.MethodsWe prospectively enrolled 1172 patients with noncardiogenic ischemic stroke in ipsilateral ICA or MCA territory. Clinical, neuroradiologic and outcome of the two groups were compared in this observational cohort study.ResultsThe ICA group more frequently presented with decreased alertness, gaze palsy, aphasia, and neglect than the MCA group at admission, and more often had higher National Institute of Health stroke scale score at admission and discharge. Meanwhile, the ICA group more frequently had multiple acute infarcts, watershed infarcts, territorial infarct, small cortical infarct, and responsible artery stenosis ≥70%. Whereas penetrating artery infarct and parent artery occluding penetrating artery was more often associated with MCA disease. The ICA group more frequently had inhospital complications of pneumonia and deep vein thrombosis, more often had disability at discharge, and had more recurrent ischemic stroke or transient ischemic attack in 1 Year. Multivariable logistic regression identified male (OR, 1.99; 95% CI, 1.30 to 3.05; P = 0.002), history of coronary heart disease (OR, 1.85; 95% CI, 1.03 to 3.32; P = 0.041), multiple acute infarcts (OR, 4.18; 95% CI, 2.07 to 8.45; P<0.0001), and territorial infarct (OR, 2.23; 95% CI, 1.52 to 3.27; P<0.0001) was more often associated with ICA territory disease.ConclusionsThe clinical, radiologic characteristics and outcome are distinctively different between ICA and MCA disease. Compared to MCA disease, ICA disease has more serious clinical and radiologic manifestation, and poorer outcome.

Relationship between sphenoid sinus volume and protrusion of internal carotid artery and optic nerve: a 3D segmentation study on maxillofacial CT-scans

Anatomy of sphenoid sinuses has acquired a growing importance with the diffusion of transsphenoidal surgical procedures. A common risk in these practices is the damage of internal carotid artery (ICA) and optic nerve (ON), which may protrude into the sphenoid air cavities. This study aims at analysing the relationships between sphenoid sinuses volume and protrusion of ICA and ON. 260 head CT-scans were retrospectively analysed (equally divided among males and females, age range 20-92years). Volume was segmented through ITK-SNAP software. In addition, the subjects were classified into four groups: no protrusion of any structure (group 1), protrusion of ICA (group 2), protrusion of ON (group 3), protrusion of both ICA and ON (group 4). Possible statistically significant differences in prevalence of the four groups according to gender were assessed through Chi-squared test (p < 0.05). Differences in volume between the four groups were assessed through one-way ANOVA test (p < 0.05), separately for males and females. Group 1 was the most frequent (40.0%), followed by group 4 (27.7%) and group 2 (18.5%), without any difference according to gender. For what concerns volume, cases of ICA and concomitant ICA + ON protrusion had significantly larger sinuses, whereas isolated ON protrusion did not modify sinus volume. Results show that protrusion of ICA is positively related with the volume of sphenoid sinuses, whereas the same relation was not verified for ON: surgeons should accurately consider possible ON protrusion in each case, as it may occur independently from sphenoid sinuses volume.

Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature.

ObjectiveSubarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA.MethodsThe authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome.ResultsFifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability.ConclusionClinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.

Clinical Analysis of Traumatic Cerebral Pseudoaneurysms.

ObjectiveTraumatic pseudoaneurysms are rare but life-threatening lesions. We investigated the patients with these lesions to clarify their clinical characteristics and therapeutic strategies and we also reviewed the literatures on the treatment principles, possible options, and outcomes.MethodsThere were a total of 8 patients who were treated with traumatic intracranial pseudoaneurysms between April 1980 and January 2009. Medical charts and the imaging studies were reviewed for analysis. The outcome was measured with modified Rankin Scale (mRS) score at 6 months after treatment.ResultsAll 8 patients were male and the mean age was 25 years old. Six of those were located at the cavernous segment of the internal carotid artery (ICA) and the other 2 was located at the M2 segment of middle cerebral artery. The causes of trauma were car accidents in 6, penetrating injury through the orbit in 1, and slip down injury in 1 patient. Massive epistaxis or hematemesis occurred in all patients with a pseudoaneurysm at the cavernous and ophthalmic segment of the ICA. All 6 patients of the cavernous and ophthalmic ICA group showed favorable outcome of mRS 0 to 1. The outcome of patients with middle cerebral artery pseudoaneurysm was mRS 2 to 3.ConclusionUpon prompt diagnosis and proper treatment planning, it is possible to achieve favorable outcome in these patients. Lesions located at the cavernous segment of the ICA favored endovascular treatment while those at the middle cerebral artery favored surgical treatment.

Blunt traumatic occlusion of the internal carotid and vertebral arteries

The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

The impact of carotid artery disease on outcomes of patients undergoing coronary artery bypass grafting

Although the overall complication rate has been decreased significantly in recent years, stroke is a severe complication after coronary bypass operations. The purpose of this study is to evaluate the influence of carotid artery disease on the results of patients under CABG operation. In a retrospective cohort study, 1,978 patients under CABG operation were studied in Shariati Hospital between April 2002 and March 2006. The patients who had only valve replacement or non-CABG procedure were excluded from this study. As part of preoperative evaluation, carotid duplex ultrasonography scans were performed. In order to estimate the degree of carotid arteries stenosis, ultrasound imaging measurement and velocity criteria were considered. The patients were classified into three groups: those with no significant stenosis of the internal carotid artery (ICA) (moderate) group A, those with significant stenosis (sever) group B and those with the occluded ICA (critical) group C. Finally, all data were analyzed by SPSS software. Statistical analyses were performed using the following testes; chi-square, Fisher exact and Student's t tests. The distribution of the 1,978 patients undergoing CABG operation were as follows: group A = 1,938, group B = 30, and group C = 10. The results of the evaluations show that perioperative stroke rates were 1.2% (24 patients) in group A, 0.4% (eight patients) in group B and 0.3% (six patients) in group C (P<0.0001). Furthermore, perioperative mortality rates for groups A, B and C were 0.1% (two patients), 0.3% (five patients) and 0.4% (seven patients), respectively (P<0.0001). The stroke and mortality in patients undergoing CABG are increased when ICA occlusion is present.

Comparison of feasibility of transplanting neural stem cells through three ways to treat newborn piglets with hypoxic ischemic encephalopathy

Objective To compare three ways of transplanting neural stem cells(NSCs) to treat hypoxia-ischemic encephalopathy (HIE) ,such as through axillary vein,internal carotid artery and lumbar puncture. Methods Newborn piglets were divided into three groups randomly,and transplanted NSCs through axillary vein,through internal carotid artery or through lumbar puncture after hypoxic-ischemic damage operations. Each group had five piglets. Two hours after hypoxic ischemic damage,2 × 106 NSCs with green fluorescent protein were injected through axillary vein,internal carotid artery or lumbar puncture. Piglets were sacrificed 24 hours after operations. Slices were gotten at hippocarnpus, anterior horn of lateral ventricle and posterior horn of lateral ventricle. NSCs were counted at four visual fields of each four slices of each lays through fluorescence microscope with 400 amplification factor len. Results The positive cells of axillary vein group,internal carotid artery group and lumbar puncture group were 53. 80 ± 8. 78,69. 80 ± 11.90,265.00 ± 29.65respectively. The positive cells of lumbar puncture group were more than the other groups, and there was statistic significance(P < 0. 01). Conclusion The study proved NSCs injected through lumbar puncture could enter brain tissue. It is feasible to transplant NSCs through lumbar puncture to treat newborn with HIE. Key words: Cerebral hypoxia; Cerebral ischemia; Neural stem cells; Transplantation; Infant,newborn

Experimental Study on Targeted Methotrexate Delivery to the Rabbit Brain via Magnetic Resonance Imaging-Guided Focused Ultrasound

The purpose of this study was to investigate the effects of targeted and reversible disruption of the blood-brain barrier (BBB) by magnetic resonance imaging (MRI)-guided focused ultrasound (FUS) and delivery of methotrexate (MTX) to the rabbit brain. The brains of 20 rabbits were sonicated by MRI-guided FUS at different exposure times, and then Evans blue extravasation, contrast-enhanced MRI, and histologic examination were performed to determine the optimal exposure time for reversible BBB disruption with minimal damage. Five rabbits were sonicated at the optimal exposure time after MTX was injected intravenously (IV); the targeted locations were included in the sonicated group, and the nontargeted contralateral counterparts were included in the IV control group. Five other rabbits were not subjected to sonication and were administered internal carotid artery (ICA) injections of MTX; the specimens of the counterpart brain tissue were harvested as the ICA group. The MTX concentration in all of the specimens was determined by high-performance liquid chromatography. The MTX concentration in the sonicated group (mean +/- SD, 7.412 +/- 1.471 microg/g of tissue) was notably higher than that in both the IV control group (0.544 +/- 0.084 microg/g) and ICA group (1.984 +/- 0.65 microg/g; P <.01). Magnetic resonance imaging-guided FUS can disrupt the BBB reversibly and deliver IV administered MTX to targeted brain locations; it brings about a greater than 10-fold increase in the drug level and is much more effective (approximately 3.7-fold) than drug delivery through the ICA without sonication. This may facilitate the development of improved treatment methods for central nervous system disorders.

Recanalization and Outcome After Intra-Arterial Thrombolysis in Middle Cerebral Artery and Internal Carotid Artery Occlusion

Recent studies have reported sex differences in recanalization and outcome after intravenous thrombolysis (IVT) in acute ischemic stroke. We analyzed sex differences in outcome in consecutive patients with middle cerebral artery (MCA) M1 or M2 and internal carotid artery (ICA) occlusion treated with intra-arterial thrombolysis (IAT). Recanalization immediately after thrombolysis and outcome after 3 months were assessed. Two hundred five patients (111 men) with MCA and 43 (22 men) with ICA occlusion were identified. Baseline variables did not differ between the sexes except for a higher prevalence of smokers among men in the MCA group (31% vs 12%; P=0.001). Partial or complete recanalization (TIMI flow 2 or 3) of the MCA was observed in 71 (75%) women and 80 (72%) men (P=0.488). In the ICA group, 14 (67%) women and 11 men (50%) showed TIMI 2 or 3 recanalization (P=0.425). Favorable outcome (modified Rankin Scale score 0 to 2) was seen in 57 women (61%) and 63 men (57%) with MCA occlusion (P=0.512) and in 6 women (28%) and 4 men (18%) with ICA occlusion (P=0.656). After multiple-regression analyses, there was still no association between sex and outcome (P=0.763 for MCA and P=0.813 for ICA occlusion) or recanalization (P=0.488 for MCA and P=0.104 for ICA occlusion). There was no association between sex and recanalization or outcome after IAT. These findings are in contrast to previous studies reporting better recanalization and outcome after IVT in women and might have implications in the selection of patients for IAT or IVT.

The impact of an occluded internal carotid artery on the mortality and morbidity of patients undergoing coronary artery bypass grafting

Purpose: To evaluate whether the presence of stenosis or an occluded internal carotid artery (ICA) influences perioperative stroke and mortality rates in patients subjected to coronary artery bypass grafting (CABG). Material andmethods: Between January 1995 and July 1998, 3,344 patients (59% males; 41% females) had CABG performed at our institution. Preoperative carotid duplex scans performed by registered vascular technologists at an ICAVL accredited laboratory were available for review in all patients. Of these, 3,101 (92.7%) had <60% ICA stenosis (group A), 182 (5.4%) had 60% to 99% ICA stenosis (group B), and the remaining 61 (1.8%) had a occluded ICA (group C). In the latter group, 53 patients (87%) had <60% contralateral ICA stenosis, while 8 (13.1%) had significant (60% to 99%) contralateral stenoses. Concomitant carotid endarterectomies (CEAs) were performed in 70 patients in group B (40%) and in 2 patients in group C (3.2%). Age, indications for surgery, prevalence of diabetes, hypertension, and smoking were similar in all groups. The mean pump time for groups A, B and C were 132, 138, and 125 minutes, respectively. The aortic cross-clamp time for group A, B, C were 78, 75, and 75 minutes, respectively. Statistical analyses were performed using the chi-square, Fisher’s exact test, and unpaired t test. Results: Perioperative stroke rates (30 days) were 1.6%, 3.8%, and 6.5% for groups A, B, and C, respectively. Group A results varied significantly from groups B ( P <0.03) and C ( P <0.003). No statistically significant difference was noted between groups B and C ( P = 0.6). The presence of a contralateral ICA stenosis in group C patients was predictive of a perioperative stroke (25% versus 3.8%; P <0.0001). Concomitant CEAs for contralateral severe ICA stenosis in group C were associated with higher stroke rate (100%) when compared with those in group B patients (4.2%; P <0.02). Perioperative (30 days) mortality rates for groups A, B, and C were 3.6%, 6.6%, and 8.6%, respectively. The mortality rate for group A was lower than for groups B ( P <0.05) and C ( P <0.05). Conclusion: The presence of an ICA occlusion increases the morbidity and mortality in patients undergoing CABG. To the best of our knowledge, this is the first reported large series of patients that investigates the role of carotid occlusions.

Ultrasound Doppler spectral analysis in the diagnosis of occlusive lesions of the carotid arteries

To evaluate the accuracy of Ultrasound Doppler Spectral Analysis (USDA), 432 carotid arteries were examined [group I consisted of 145 cases of normal ICA (internal carotid artery), group II—187 cases of ICA stenosis and group III—100 cases of ICA occlusion. The maximal systolic peak (Smax), maximal diastolic peak (Dmax), the spectral broadening index (SB) and the pulsativity index (PI) were calculated and related to the degree of stenosis as determined by contrast arteriography. Our results indicate that the change of the value of Smax is the main diagnostic criterion: for carotid arteries' stenoses, it increases to over 3.2 kHz. A Smax over 6.0 kHz is a veritable index of ICA stenosis above 50%: in such cases as the stenosis increases by 10%, this corresponds to an approximately 1 kHz increase of Smax. In ICA occlusion, the main criterion was the absence of blood flow in the distal ICA segment. The UDSA sensitivity in hemodynamically insignificant stenosis is 73.9% which is far higher than in the periorbital Doppler examination; in hemodynamically significant stenosis and ICA occlusions, the sensitivity is 98.6 and 99%, respectively.