Internal Carotid Artery Lesions Research Articles

Management of internal carotid artery pathology with a covered stent: illustrative cases.

Endovascular treatment of internal carotid artery (ICA) pathology includes reconstructive or deconstructive options. One reconstructive option is covered stent placement, although this is limited by a lack of devices designed specifically for neurointervention. The PK Papyrus is a balloon-mounted covered coronary stent that has a lower profile and is more flexible than other stent grafts, which makes it more suitable for treating ICA lesions. The PK Papyrus was used to treat patients with iatrogenic cavernous ICA injury and symptomatic cervical ICA pseudoaneurysms. In both cases, the stent could be easily delivered without the use of an intermediate catheter or stiff microwire. Stent deployment resulted in immediate angiographic resolution of the pathology, and there were no peri- or postoperative complications. The PK Papyrus covered coronary stent is a good option for treating cervical and cavernous carotid pathology. Its single-layer design makes it more flexible and deliverable than other stent grafts, but additional case series are needed. https://thejns.org/doi/10.3171/CASE24517.

Correlations between intravascular pressure gradients and cerebral blood flow in patients with symptomatic, medically refractory, anterior circulation artery stenosis: an exploratory study

BackgroundFractional flow reserve is widely used in coronary disease management, with a threshold of 0.80. However, similar thresholds are unclear in functional assessment of intracranial atherosclerotic stenosis (ICAS).ObjectiveTo investigate the...

ORTHOSTATIC RESPONSE OF PERIPHERAL AND CENTRAL BLOOD PRESSURE IN PATIENTS WITH HYPERTENSION AND ATHEROSCLEROTIC CAROTID STENOSIS

Objective: To determine the frequency and severity of orthostatic responses of central and peripheral blood pressure (BP) during the Active Stand Test (AST) in patients with arterial hypertension (HTN) and hemodynamically significant stenosis of the internal carotid artery (ICA). Design and method: The intervention group included patients aged 18 years and older with HTN and ICA stenosis >50% (NASCET) of atherosclerotic origin. Patients with HTN without ICA lesions were considered as controls. In all patients AST was performed with the measurement of peripheral BP in the sitting and standing positions after 3 minutes. Orthostatic hypotension (OH) was diagnosed as per current Guidelines: fall of systolic (S)BP equal or more than 20 mmHg or diastolic BP equal or more than 10 mmHg during AST. In the intervention group, central BP assessment during AST and pulse wave contour analysis were also performed. Results: There were 77 patients in the intervention group (69±8 years, 44 men) and 77 patients in the control group (68±6 years, 43 men). According to the dynamics of peripheral BP, OH was diagnosed in 21 patients (27%) in the intervention group and in 17 patients (22%) in the control group (p=0,46), but systolic OH was more frequently observed in the former (21 vs. 9 patients; p=0.015). The reduction in central systolic (S)BP was more pronounced than delta peripheral SBP (p =0.001). Changes in peripheral SBP during AST were associated with the presence of a significant ICA lesion (beta in ICA =0.201, p=0.03) and baseline SBP (beta= -0.348, p=0.001). The same variables (the fact of ICA lesion and baseline SBP) mostly explained the development of systolic OH (OR 2.95 (95% CI [1.1-7.7], p=0.03 and beta= 0.437, p<0.001, respectively). Conclusions: Asymptomatic OH occurred in 27% of patients with HTN and ICA stenosis, more frequently in the form of isolated systolic OH. The amplitude of central SBP reduction significantly exceeded the dynamics of peripheral SBP The presence of carotid stenosis and higher initial values of peripheral SBP associated with the dynamics of SBP in standing and the occurrence of OH.

Abstract 2029: Augmenting Mitochondrial Respiration In Immature Smooth Muscle Cells Is A Therapeutic Target For Moyamoya-like Cerebrovascular Disease

Introduction: Moyamoya disease (MMD), characterized by occlusive lesions in the distal internal carotid arteries, is a malignant cause of pediatric stroke. Surgical revascularization is the mainstay treatment, but peri- and postoperative ischemic complications are common. Multiple identified genes account for only a small percentage of cases. Identifying a common pathway of disease pathogenesis would enhance care for MMD patients. Goal and Approach: We used cellular and animal models for a rare cause of MMD-like cerebrovascular disease, heterozygous ACTA2 p.R179 pathogenic variants, to define molecular mechanisms and assess therapeutic strategies. Our prior work showed that smooth muscle cells (SMCs) with ACTA2 p.R179 variants are incompletely differentiated. We hypothesized that these immature phenotypes could be rescued by manipulation of cellular metabolism. We validated our results with cellular models of other pediatric MMD-associated variants: loss-of-function variants in Pcnt (explanted from a mouse model) and a pathogenic variant in RNF213 (generated via Crispr/Cas9 in human iPSCs). Results: Acta2 SMC-R179C/+ SMCs have increased glycolysis and reduced oxidative respiration on Seahorse analyses. Molecular characterization showed that Acta2 SMC-R179C/+ SMCs have reduced mitochondrial mass and decreased complex I activity, which is rescued by nicotinamide riboside (NR) treatment. NR surprisingly also increases SMC differentiation and decreases migration. Acta2 SMC-R179C/+ mice and littermate controls were subjected to carotid artery ligation, and 33% of Acta2 SMC-R179C/+ mice died due to strokes while all control mice survived (Kaplan-Meier p<0.01). Surviving Acta2 SMC-R179C/+ mice have significant cerebrovascular remodeling and persistent occlusive carotid artery lesions. Treatment with NR reduces death (Kaplan-Meier p=0.08) and resolves persistent lesions (p<0.05) in Acta2 SMC-R179C/+ mice after carotid ligation. Pcnt and RNF213 mutant SMCs have a similar phenotype of incomplete differentiation and decreased mitochondrial respiration as ACTA2 p.R179 and are responsive to NR treatment. Conclusions: These data provide evidence for a common and therapeutically targetable pathway in pediatric MMD patients.

How to Penetrate the Wall of an Unintentionally Deployed Wallstent in the External Carotid Artery for Stenting of an Internal Carotid Artery Lesion

AbstractCarotid artery stenting is increasingly performed among patients with proper indications for carotid artery revascularization. It has a low complication rate with a short recovery time. In this case, we report a new complication due to unintended stent deployment in the external carotid artery covering the ostium of the internal carotid artery requiring penetration and stenting of the deployed Wallstent wall to advance the second stent in the proper position in the internal carotid artery.

Flow-mediated protection for the treatment of tandem lesions via a transcarotid approach

In patients presenting with both internal carotid and proximal common carotid stenosis, there are many options for repair including open, endovascular, and hybrid approaches. For internal carotid artery lesions, transcarotid artery revascularization (TCAR) has shown an excellent safety profile and allows for a minimally invasive approach. A previous multicenter study assessing the safety of using the same ENROUTE neuroprotection device to treat concurrent proximal lesions of the common carotid artery showed 100% success and 0% stroke or TIA rate within 30 days in the initial sixteen patients. Here we describe the peri‑operative and intra-operative technique to replicate this procedure.

Evolution of surgical approaches to carotid bifurcation

Carotid endarterectomy is preferable for prevention of acute cerebrovascular accident associated with atherosclerotic lesions of internal carotid artery. Modern interest in minimizing local complications and small excisions is also actual in carotid surgery. The authors review the modern literature data on evolution of carotid arteries exposure. Cutaneous mini-incision, transverse skin incision and retrojugular approach are discussed. The authors consider the advantages and possible complications of each technique.

Off-pump coronary artery bypass surgery in patients with multifocal atherosclerosis and inoperable internal carotid artery lesion

Off-pump coronary artery bypass surgery in patients with multifocal atherosclerosis and inoperable internal carotid artery lesion

Abstract 059: The Tenzing‐Dotter Technique for Endovascular Management of Atherosclerotic Cervical ICA Tandem Large Vessel Occlusions

Introduction The endovascular treatment of acute ischemic stroke due to atherosclerotic occlusion/near‐occlusion of the cervical internal carotid artery (ICA) and a concurrent intracranial large vessel occlusion (LVO) remains challenging, and the optimal approach remains unclear. Options include initial angioplasty and/or stenting of the cervical lesion followed by intracranial thrombectomy versus Dotter navigation of catheters through the cervical lesion to first target the intracranial LVO. We describe a novel Tenzing‐Dotter technique which utilizes a Tenzing device for the Dotter delivery of large bore (0.070”) and super‐large bore (0.088”) catheters through cervical atherosclerotic lesions to gain access to the intracranial circulation in tandem LVO patients. Methods We performed a retrospective review our single center experience of atherosclerotic tandem occlusion patients in which the Route 92 Medical Tenzing ® 7 (T7®) and Tenzing ® 8 (T8®) delivery catheters were used to Dotter‐deliver large bore or super‐large bore catheters, respectively, through the cervical ICA lesion to gain access to the intracranial circulation. We reviewed clinical, radiographic and procedural data to describe the safety and efficacy of this approach. Results Twenty patients were identified that that atherosclerotic occlusion/near‐occlusion of the cervical ICA and a single symptomatic intracranial LVO. The mean age was 65 (44 – 89), and 40% were female. The mean NIHSS was 14 (7‐25) and 40% were treated initially with intravenous thrombolytics. The ipsilateral cervical ICA was occluded in 11 of 20 patients (55%) and nearly‐occluded (degree of stenosis 90‐99%) in 9 of 20 patients (45%). The intracranial occlusions were carotid terminus (5), M1 middle cerebral artery (14) and M2 middle cerebral artery (1). Seven patients were treated with Tenzing 7 paired with a large bore catheter (6 with Medtronic React 71 and 1 with Route 92 Medical Hipoint 70), while 13 were treated with Tenzing 8 paired with a super‐large bore catheter (11 with Route 92 Medical Hipoint 88 catheter and 2 with Route 92 Medical Freeclimb 88 catheter). In all cases, successful navigation of the paired catheter through the cervical lesion was achieved in 100% of patient using the Tenzing‐Dotter delivery technique. The mean time from groin puncture to successful Tenzing‐Dotter delivery was 11 minutes, and the mean time from groin puncture to device delivery to the intracranial occlusion was 15 minutes. TICI 2B or greater reperfusion (self‐adjudicated) as achieved in 100% of patients, with a mean time to best TICI of 21 minutes. The degree of cervical ICA stenosis following thrombectomy improved from 96.5% to 67.4%. No symptomatic intracranial hemorrhage or cervical arterial dissections were noted. Conclusion The Tenzing‐Dotter technique, in which a Route 92 Medical Tenzing ® delivery catheter is utilized to Dotter navigate a large or super‐large bore catheter through an occluded or nearly‐occluded cervical atherosclertotic lesion, may be a promising technique for safe and fast access to the intracranial circulation in patients presenting with tandem large vessel occlusion acute ischemic strokes.

Experience in surgical treatment of extra-intracranial tandem ICA stenosis at the National Medical Research Center for High Medical Technologies named after A. A. Vishnevsky of the Ministry of Defense of the Russian Federation

To date, the effectiveness and safety of reconstructive surgery for steno-occlusive lesions of the internal carotid artery (ICA) have been proven by multicenter cooperative studies Despite this, the indications and tactics of surgical treatment of patients with extra-intracranial tandem stenotic lesions of the ICA remain controversial. In the period 2010-2020, 32 patients with symptomatic (15 cases) and asymptomatic tandem ICA lesions were hospitalized for surgical treatment. The distribution of tandem lesions was as follows: 10 patients had bicarotid hemodynamically significant stenotic and occlusive lesions of the ICA ostium in combination with stenosis of more than 50% of the petrous (4 cases), cavernous (8 cases), and clinoid segments (5 cases), of these, four had bilateral intracranial stenosis; 22 patients with hemodynamically significant lesions of the ICA and vertebral artery (VA) in combination with stenosis of more than 50% of the petrous (10 cases), foramen lacerum (2 cases), cavernous (16 cases), clinoid (14 cases), and ophthalmic segments (1 cases), of these, six had bilateral intracranial stenosis of the ICA. All patients underwent staged surgical interventions on the arteries of the carotid and vertebrobasilar systems. In the postoperative period, there was one case of repeated ischemic stroke in the territory of the reconstructed artery after the application of extra-intracranial microanastomosis (EICMA). There were no relapses of restenosis or acute cerebrovascular accident (CVA) in the follow-up. Staged reconstructive and revascularization treatment is safe and effective for tandem extra-intracranial lesions of the ICA. It is necessaryto continue further study of this issue in order to develop unified tactics and methods of surgical treatment.

Perfusion Computed Tomography in the Choice of Treatment Tactics for Chronic Critical Tandem Lesion of the Internal Carotid and Middle Cerebral Artery (Case Report)

A clinical case of surgical treatment in patient with tandem ipsilateral lesion of the right internal carotid artery: (95–99 % stenosis at the ostium) and the middle cerebral artery (occlusion) described in the article. Further treatment tactics could be determined with the help of PKT performed on the patient during hospitalization. Changes in the blood supply to the cerebral hemisphere revealed by PKT were of decisive importance in determining the further treatment tactics for this patient. The patient was operated in the range of right side carotid endarterectomy. Control brain tomography perfusion, performed 6 months after surgery, demonstrated the absence of areas with impaired blood flow in the cerebral hemispheres.

Unilateral approach for bilateral clipping of posterior communicating artery aneurysms in a hybrid operating room: A technical note.

Bilateral posterior communicating (pComm) artery aneurysms represent only 2% of mirror intracranial aneurysms. Usually, these are surgically approached through bilateral craniotomies for clipping. We present the case of a 50-year-old female presenting with headache and horizontal diplopia. Neurological examination revealed a left oculomotor palsy, with no other neurological deficits. Imaging studies revealed bilateral aneurysmatic lesions in both internal carotid arteries (ICA). A conventional left pterional approach was planned in order to treat the symptomatic aneurysm, and, if deemed feasible, a contralateral clipping through the same approach. The procedure was performed in a hybrid operating room (HOR), performing an intraoperative digital subtraction angiography (DSA) and roadmapping assistance during dissection and clipping. Transoperatively, a post-fixed optic chiasm was identified, with a wide interoptic space, which allowed us to perform the contralateral clipping through a unilateral approach. This technique for clipping bilateral pComm aneurysms can be performed when the proper anatomical features are met.

How team work makes the dream work: Successful management of internal carotid artery lesion during routine Functional Endoscopic Sinus Surgery (FESS)

We present the case of a 60-year-old male patient with a history of chronic rhinosinusitis with nasal polyps grade III who suffered an injury to the Internal Carotid Artery (ICA) during a scheduled Functional Endoscopic Sinus Surgery (FESS). After careful analysis of the case

Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) ( P <0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) ( P =0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P =0.673). Conclusions In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.

Bailout technique for entangled stent retriever and carotid stent during tandem large vessel occlusion endovascular therapy.

Endovascular thrombectomy for patients with tandem occlusions could be challenging. Exposure to potential technical complications and bailout rescue techniques are of utmost importance. A 73-year-old woman with tandem internal carotid artery and middle cerebral artery lesions underwent an unsuccessful retrograde revascularization approach in the setting of tortuous anatomy. Antegrade approach revascularization was then pursued. Following cervical internal carotid artery revascularization, a triaxial system of aspiration catheter, microcatheter and micro guidewire was navigated through the stented curved cervical ICA and intracranial stent retriever pass was performed. Upon retrieving the clot-incorporated stent retriever with the intention to retrieve the entire stent retriever into the locally placed aspiration catheter, the triaxial system collapsed into the distal common carotid artery. Large thrombus was recovered from the aspiration catheter aspirate however the proximal end of stent retriever and distal internal carotid artery stent got tangled. After unsuccessful maneuvering to disentangle stent retriever from the internal carotid artery stent, we decided to attempt safe separation of the stent retriever from its pusher wire and leave behind the patent internal carotid artery stent/stent retriever metal construct in place. Gradual pulling pressure was applied to the stent retriever wire while maintaining distal exchange-length microwire access and fully inflated extracranial balloon over the entangled portion to ensure continuous vascular access. The stent retriever wire was then safely separated from the stent retriever and fully retracted outside the body. Delayed angiographic runs continued to demonstrate full patency of the internal carotid artery lumen. No residual dissection, spasm, or thrombus was noted. This case illustrates a novel bailout endovascular salvage technique that could be considered in such cases. These techniques minimize intraoperative complication, focus on patient safety, and promote efficiency for endovascular thrombectomy in unfavorable anatomy.

Evaluation of vessel-wall contrast-enhancement on high-resolution MRI in European patients with Moyamoya disease

ObjectivesData regarding MR vessel-wall imaging (VWI) in patients with Moyamoya disease (MMD) is sparse, particularly in non-asian cohorts. We contribute data regarding the frequency of vessel wall contrast-enhancement (VW-CE) and its potential clinical significance in a European patient group. Materials and methodsPatients with a diagnosis of MMD who were examined by VWI were included in the study. VW-CE of stenoocclusive lesions of the terminal internal carotid artery and/or its proximal branches was rated qualitatively. Changes of VW-CE on available follow-up were recorded. VW-CE was correlated with diffusion-restricted lesions and magnetic resonance angiography (MRA) findings. ResultsEleven patients (eight female, three male) were included. Twenty-eight stenoocclusive lesions were analyzed, of which 16 showed VW-CE (57.1%). VW-CE was mostly concentric (n=15), rather than eccentric (n=1). In all three patients in whom follow-up VWI was available, changes of VW-CE were documented. Diffusion-restricted lesions were more frequently related to stenoocclusive lesions with VW-CE (n=9) than without VW-CE (n=2), bordering statistical significance. The affected arteries were assessed as stenotic and as occluded in 14 cases each and VW-CE was seen significantly more often in stenotic (n=12) than in occluded arteries (n=4). No correlation was found between the presence of VW-CE and moyamoya stages determined by MRA. ConclusionsOur data suggest that concentric VW-CE is a relatively frequent finding in European MMD patients. VW-CE may change over time and occur in certain stages, possibly representing “active stenosing”. Larger studies are needed to validate these findings and determine the clinical relevance of VW-CE in MMD.

Transcarotid artery revascularization of a symptomatic carotid artery with a tortuous intrathoracic component

We present the case of a tortuous intrathoracic common carotid artery (CCA) with a symptomatic right internal carotid artery lesion. This patient had a complex medical history, including a previous intraoperative cardiac arrest during attempted carotid endarterectomy (CEA) initially attributed to heparin anaphylaxis. She received maximum medical management but presented 6 months later to our institution with a secondary transient ischemic attack. Surgical options for the case were discussed amongst a multidisciplinary team. Transfemoral and transradial stenting were deemed non-viable due to the tortuous nature of the CCA. Repeat CEA under general anesthesia was deemed risk-prohibitive from a cardiac risk perspective. For these reasons, the patient was offered transcarotid artery revascularization (TCAR) under regional anesthesia. Intraoperatively, the “sheath stopper” was removed from the TCAR device, allowing the sheath to be advanced to 6 cm, effectively removing the tortuous component of the CCA. Flow reversal was established, and the operation proceeded in the standard fashion without neurologic change. The patient has remained on dual antiplatelet therapy and completed 2-year follow-up without evidence of restenosis, access site complication, or repeat neurologic event. This case demonstrates the potential applicability of TCAR to benefit a subset of patients who previously lacked a surgical option due to anatomical constraints.

Percutaneous Superficial Temporal Artery Access Facilitating Carotid Artery Stenting Performed From Distal Radial Artery.

The purpose of the study is to describe carotid artery stenting (CAS) via distal transradial access (dTRA) facilitated by additional superficial temporal artery (STA) access, in a patient with complex aortic arch vessel anatomy. A 72-year-old woman with a prior history of complex cervical surgery and radiotherapy due to laryngeal malignancy, presented with a symptomatic 90% stenosis of the left internal carotid artery (ICA). Due to high cervical lesion, the patient was rejected from carotid endarterectomy. Angiography demonstrated 90% stenosis of the left ICA and a type III aortic arch. After failure of left common carotid artery (CCA) cannulation with appropriate catheter support via dTRA and transfemoral approaches, CAS was attempted a second time. After percutaneous ultrasound guided access to right dTRA and left STA, a 0.035 inch guidewire introduced to the left CCA from the contralateral dTRA was snared and externalized via left STA to improve wire support for guiding advancement. Thereafter, the left ICA lesion was successfully stented with a 7×30 mm self-expanding stent via right dTRA. All vessels involved were patent at 6-month follow-up. The STA may be a promising adjunctive access site to increase transradial catheter support for CAS or neurointerventional procedures in the anterior circulation. Transradial cerebrovascular interventions have been gaining popularity, however, unstable catheter access to distal cerebrovascular structures limits its widespread use. Guidewire externalization technique via additional STA access may improve transradial catheter stabilty and increase procedural success with possibly low access stie complication rate.

Abstract Number ‐ 148: Emergent Carotid Artery Stenting On Acute Stroke Patients With Carotid Occlusion: Benefit Or Harm?

Introduction Almost one out of four patients with acute middle cerebral artery occlusion also have ipsilateral internal carotid artery occlusion (ICAO). The interventions for acute stroke due to extracranial ICAO with or without intracranial occlusions are still a challenge. Case series reported early revascularization reduced stroke recurrence and improved outcomes. The benefits of this intervention on hyperacute ischemic strokes (within 6 hours) were much less known. We reported here two hyperacute stroke patients who emergent CAS on ICAO. Methods Electronic medical charts were reviewed, assessing intracranial hemorrhage (ICH) in two hyperacute stroke patients resulting from emergent carotid artery stenting (CAS) on the occluded internal carotid artery (ICA). Results Case description:The first patient was a 60‐year‐old male who had acute right hemiparesis, aphasia, and left gaze deviation with NIHSS12. The last known normal was five hours ago. Head and neck CT angiography (CTA) showed left anterior M2 branch artery occlusion and left ICAO. Head CT perfusion (CTP) showed a small core infarct with a large perfusion mismatch. Emergent CAS was performed without distal embolic protection (DEP) and followed by distal mechanical thrombectomy (MT). TICI 2B recanalization was achieved. After CAS, aspirin and clopidogrel were administrated. He had a large left MCA and PCA stroke from fetal PCA. A few days later, the patient developed large intraparenchymal hemorrhage (IPH) and intraventricular hemorrhage (IVH). He expired shortly. The second was a 52‐year‐old male had acute right facial droop, aphasia, dysarthria, and decreased consciousness (NIHSS 8). CTA showed left ICAO but patent intracranial arteries. CT perfusion showed a large mismatch without core infarction. He received intravenous tPA and had emergent CAS with a DEP. Aspirin 600 mg was administrated afterward. A few hours later, he had worsened weakness. Head CT showed left IPH, IVH, and subarachnoid hemorrhages with cerebral edema, and midline shift. He was medically managed for a prolonged stay and was discharged to a rehabilitation facility. Conclusions We presented two consecutive cases of emergent revascularization of ICAO in hyperacute stroke carried a high risk of ICH with poor outcome. Our online database search found that only a few case series of emergent CAS on ICAO were reported. Overall, emergent CAS carried about 20% risk of ICH and high mortality. Other series reported angioplasty on stenotic or occluded cervical ICA lesions with MT on distal occlusions had less hemorrhagic risk because there was no need fordual antiplatelet treatment. Most emergent CAS cases were performed on tandem occlusions for faster direct access and better efficacy of distal recanalization. A futurestudy comparing hemorrhagic risk betweenemergent CAS versus angioplasty of ICAO in patients with tandem occlusions can help to establish a standard MT protocol. For isolated ICAO with patent intracranial arteries from good collaterals, CTP may not be a good guidance tool for decision‐making of emergent CAS as it can falsely show mismatch from existing collaterals due to occlusion. A randomized clinical trial of comparison of medical management versus emergent CAS on those patients is warranted.

Endovascular treatment of multilevel brachiocephalic artery lesions in asymptomatic patients: a case series

Objective: To evaluate the outcomes of complete endovascular carotid revascularization in asymptomatic patients with tandem lesions of common carotid arteries (CCA) and internal carotid arteries (ICA) and to demonstrate the endovascular technique.Methods: Endovascular treatment of two-level brachiocephalic artery lesions was performed in 23 patients at the Almazov National Medical Research Centre from 2017 to 2022. The mean age of the patients was 71.3 years. The lesions were localized in the left CCA and ICA in 11 patients, in the right CCA and ICA in 7 patients, and in the brachiocephalic trunk and right ICA in 5 patients. All patients were asymptomatic on the affected side. Results: Completed with successful stent implantation, all the procedures were effective, with no complications at the access site (hematoma, dissection, bleeding) and no perioperative mortality or residual stenoses. Postoperative neurological disorders developed in two patients including ipsilateral neurological symptoms (NIHSS score 4, Rankin score 1) in one of them and moderate aphasia and dysarthria NIHSS score 2, Rankin score 1) in the other. Brain MSCT showed signs of ischemic stroke that did not require any additional surgical treatment in the second patient. Following the rehabilitation, the neurological symptoms regressed. The mean hospital stay was 4 days. Two years after the intervention two patients required reintervention, i.e. repeat angioplasty of the ICA stent, due to in-stent restenosis.Conclusion: The outcomes in a series of patients with tandem brachiocephalic artery lesions indicate the efficacy of complete endovascular intervention with good short-term results. Received 23 June 2022. Revised 31 July 2022. Accepted 23 August 2022 Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interests: Authors declare no conflict of interest. Contribution of the authorsLiterature review: A.V. Soboleva, V.A. SolovievDrafting the article: A.G. Vanyurkin, Yu.K. BelovaCritical revision of the article: M.A. ChernyavskiySurgical treatment: M.A. Chernyavskiy, A.G. Vanyurkin, N.V. SusaninFinal approval of the version to be published: A.G. Vanyurkin, A.V. Soboleva, N.V. Susanin, Yu.K. Belova, V.A. Soloviev, M.A. Chernyavskiy