Common Carotid Artery Lesions Research Articles

Abstract 133: Safe Guiding Catheter Navigation in Carotid Artery Stenting for Low‐positioned Common Carotid Lesions: “No‐touching” Technique

Introduction In carotid artery stenting (CAS), a guiding catheter (GC) placement to the appropriate position is the first step of the successful procedure. In normal settings, GC is navigated along with stable support of guidewire and inner‐catheter which are sent distally to external carotid artery. In cases of low‐positioned common carotid artery (CCA) lesions, however, safe GC placement without touching lesions is often difficult. Herein, we report the technique of safe GC navigation of “no‐touching” to the low‐position CCA plaque using Newton‐shaped stiff inner‐catheter. Methods We reviewed CAS procedures with low‐positioned CCA lesions using “no‐touching” technique: a balloon guiding catheter (BGC) was coaxially advanced in combination with 4‐French Newton‐shaped stiff inner‐catheter (Newton‐T®, Medikit, Tokyo, Japan). With its advantage of shape and stiffness buffering the kickback force with support of lesser curvature of aortic arch, BGCs were navigated to the appropriate position without touching to the plaques. Results The technique were applied in 5 cases (age: 73‐85 years old, 4 males, 4 left‐sided lesions) among the 37 consequent CAS cases. GC fixation by GooseNeck snare was used concurrently in 2 cases. BGCs were successfully navigated without touching plaques in all cases. CAS procedures were subsequently undergone and no complication was observed. Conclusion GC navigation using “no‐touching” technique with Newton‐T catheter was safe and useful in CAS procedures for low‐positioned CCA lesions.

Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions.

Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90day mortality and combined neurological event and 90day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

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

Dissecting lesions of common carotid artery after carotid surgery: a case report

Dissecting lesions of common carotid artery after carotid surgery: a case report

Addition of common carotid intervention increases the risk of stroke and death after carotid artery stenting for asymptomatic patients

BackgroundA recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. MethodsVascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. ResultsThere were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P < .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42). ConclusionsThe addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting

BackgroundTandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study. MethodsVascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression. ResultsThere were 2016 carotid arteries stented in 1950 patients—1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006). ConclusionsThe addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.

Addition of Common Carotid Intervention Increases the Risk of Stroke and Death after Carotid Artery Stenting for Asymptomatic Patients

BACKGROUND A recent review of VSGNE data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery (CCA)+internal carotid artery (ICA)) is associated with a four-fold increase in perioperative neurological events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status. METHODS VQI data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models. RESULTS There were 18,886 carotid arteries stented (18,441 patients); 18,077 (96%) with isolated carotid artery lesions (ICAL), 809 (4%) with TCAL. Mean age was 70.0±9.7. Symptomatic lesions were present in 58.9% of cases (ICAL: 59.1% vs TCAL: 52.5%; p<0.001). More TCAL arteries had a prior CEA (38.3% vs. 23.8%; p<0.001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; p=0.026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; p=0.41). TCAL were independently associated with stroke/death in asymptomatic patients (OR 1.85; 95% CI: 1.03-3.33; p=0.039) but not symptomatic patients (OR 1.22; 95% CI: 0.76-1.97; p=0.42). CONCLUSION Addition of endovascular treatment of CCA lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Brachiocephalic atherosclerosis in patients with posterior circulation ischemic stroke

Aim. To study echographic and acoustic characteristics of atherosclerotic plaques (ASP) in brachiocephalic arteries (BCA) in patients with acute posterior circulation ischemic stroke (PCIS).Material and methods. In this study we included data of duplex ultrasound from 235 patients (men, 129; women, 106; age, 59±12 and 63±10 years, respectively) with PCIS. Pathogenesis of PCIS was established only in 23 cases: in 17 (74%) — atherothrombosis, in 3 (13%) — cardioembolism, in 3 (13%) — lacunar stroke. Atrial fibrillation was established in 18,5% of patients. A total of 903 asymptomatic individuals were included in the control group, comparable with studied patients by sex and age.Results. The prevalence of ASP in vertebral arteries (VA) was equal in both groups. Also, no significant differences in the degree of VA stenosis were observed. Atherosclerotic lesions of common (CCA) and internal carotid arteries (ICA) on both sides were more often observed in control group, but the degree of their stenosis was higher in PSIS group (р&lt;0,003). In ischemic stroke, stenosis of the right ICA was 47±17%, left ICA — 46±18%, while in asymptomatic individuals, right ICA stenosis was 40±14%, left ICA — 39±15%. In patients with PCIS, ASPs were significantly more often regarded as concentric (22,0% vs 10,4% in PCIS and asymptomatic individuals, respectively), prolonged (24,2% vs 7,5%), homogeneous (41,0% vs 21,1%), as well as were more likely to have an uneven contour (27,7% vs 2,8%).Conclusion. In patients with acute PCIS, the peculiarities of BCA atherosclerosis were recorded, distinguishing it from that in the asymptomatic population.

Transcarotid Artery Revascularization by Prosthetic Conduit for Patients With Unfavorable Common Carotid Anatomy

Transcarotid artery revascularization (TCAR) using the ENROUTE Transcarotid Neuroprotection and Stent System (Silk Road Medical, Sunnyvale, Calif) is a hybrid technique with excellent initial outcomes. The technical success of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet the anatomic criteria for TCAR and are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy by the adoption of a prosthetic arterial conduit. Patient 1, a 57-year-old man, presented with recurrent >90% internal carotid artery (ICA) stenosis after carotid endarterectomy for symptomatic disease. Arteriography demonstrated severe stenosis of the ICA and diffuse CCA atherosclerosis (Fig, A). The CCA was replaced with a 6-mm polytetrafluoroethylene interposition graft incorporating a side arm limb for stent deployment (Fig, B-D). Patient 2 was a 62-year-old man with prior neck irradiation and asymptomatic >90% stenosis of the distal CCA. Computed tomography angiography showed a <5-cm distance from clavicle to carotid lesion. We performed TCAR by a 6-mm Dacron conduit sewn to the CCA. Patient 3 was an 80-year-old woman with recurrent symptomatic >80% ICA stenosis. TCAR was performed in the same manner as in patient 2, secondary to short distance. Patient 4, a 65-year-old man with prior neck irradiation and ICA stent, presented with severe in-stent stenosis and distal CCA stenosis. TCAR was performed by a Dacron conduit sewn to the proximal CCA with stenting of both ICA and CCA lesions. Technical success was 100% (Table). The 30-day ipsilateral stroke rate was 0%; however, the 30-day patency was 75%. Patient 2 experienced anaphylaxis after protamine administration and a subsequent cardiac arrest. He recovered without consequence. Computed tomography angiography 1 month postoperatively demonstrated stent thrombosis. TCAR is an excellent option for many patients with carotid artery stenosis. Unfavorable CCA anatomy has limited the applicability of this hybrid technology. TCAR by a prosthetic conduit has the potential to expand the eligibility for this promising therapy.TableResultsProcedure time2 hoursFlow reversal time8.5 minutesTechnical success100%30-day patency75%30-day stroke0% Open table in a new tab

Simultaneous Treatment of Common Carotid Lesions Increases the Risk of Stroke and Death After Carotid Artery Stenting

Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. The addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy increases the risk of stroke and death. However, the stroke and death risk associated with totally endovascular treatment of tandem lesions is unknown and is the subject of this study. Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis <50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of any perioperative neurologic events (stroke and transient ischemic attack) and death. Predictors of stroke/death were determined with multivariable logistic regression. There were 2016 carotid arteries stented in 1950 patients, 1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. Mean age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001). Other covariates were similar between the groups. Symptomatic lesions were present in 42.3% of cases (isolated, 42.2%; tandem, 43.0%; P = .86). More tandem group arteries had a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). Neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), higher perioperative neurologic events (8.1% vs 2.0%; P < .001), and higher incidence of the composite primary outcome (8.9% vs 2.4%; P < .001). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.82; 95% confidence interval [CI], 1.96-7.43; P < .001), symptomatic lesions (OR, 2.55; 95% CI, 1.48-4.40; P = .001), use of multiple stents for the ICA lesions (OR, 2.29; 95% CI, 1.03-5.10; P = .043), history of coronary artery disease (OR, 1.91; 95% CI,1.11-3.29; P = .020), and increasing age (OR, 1.03 per year; 95% CI, 1.00-1.07; P = .041). The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a fourfold increase in perioperative neurologic events and death and should be avoided if possible.

Transradial Approach as the Primary Vascular Access with a 6-Fr Simmons Guiding Sheath for Anterior Circulation Interventions: A Single-Center Case Series of 130 Consecutive Patients

In coronary intervention, the transradial approach (TRA) is increasingly used as the primary vascular access because of its numerous advantages over the transfemoral approach. However, in neurointerventions, conventional TRA with a straight-shaped guiding system is used as an alternative vascular access because transradial carotid cannulation can be technically challenging for right common carotid artery (CCA) lesions with steep angulation to the right subclavian artery or left CCA lesions with a nonbovine origin. The purpose of the present study was to evaluate the feasibility and safety of TRA as the primary vascular access with a pre-shaped Simmons guiding sheath for anterior circulation interventions. Between June 2018 and September 2019, 130 consecutive patients (75 carotid artery stenting and 55 cerebral aneurysm coiling cases) who underwent TRA as the primary vascular access were included in this study. A 6-Fr Simmons guiding sheath was introduced into the target CCA by selecting a cannulation technique based on preprocedural image assessment. We retrospectively analyzed the carotid cannulation success, procedural success, and periprocedural or vascular access site complications. Carotid cannulation (69 right CCA, 6 left CCA with a bovine origin, and 55 left CCA with a nonbovine origin) and the subsequent procedure were successfully performed for all 130 patients without periprocedural or vascular access site complications. TRA with a 6-Fr Simmons guiding sheath for anterior circulation interventions is highly successful and safe for all target CCAs and aortic arch types. This method can be utilized as the primary vascular access for anterior circulation interventions.

Carotid artery stenting in high-risk patients: immediate and short-term results

Aim To review the immediate and short-term results of carotid artery stenting (CAS) in high-risk patients for surgery. Patients and methods This prospective study was carried out on 36 patients experiencing significant CAS. Patients were scheduled for CAS during the period between December 2015 and June 2018 and followed up for 1 year. All procedures were done in 6 October Insurance Hospital and Mahmoud Mosque Specialized Hospital. Most carotid lesions were internal carotid artery [33 (91.7%) patients], and only three (8.3%) patients had common carotid artery lesions. Overall, 31/36 patients had symptomatic carotid stenosis, whereas 5/36 patients were asymptomatic. The commonest presentation was stroke (58.3%) and transient ischemic attack (27.8%). Results Technical success was achieved in all patients. Embolic protection devices were used in all cases. Three (8.3%) patients developed stroke; two patients had intraoperative stroke after stent deployment and the other occurred during the 12-month follow-up. One (2.8%) patient developed cerebral hemorrhage. Six (16.7%) cases developed transient ischemic attack. Acute myocardial infarction occurred in three (8.3%) patients. Conclusion Management of CAS is challenging in high-risk patients. Stroke prevention is the main goal of successful treatment. Risk–benefit assessment should be based on patient status and procedural risk, rather than on the controversy between carotid endarterectomy and CAS.

Are Localized Lesions in the Common Carotid Artery a Risk Factor for Recurrence of Ischemic Stroke in Patients with Symptomatic Carotid Artery Stenosis?

Various studies have addressed risk factors for recurrence of ischemic stroke in patients with symptomatic carotid artery stenosis. However, no investigations have compared common localized carotid artery lesions and internal carotid artery lesions, including carotid bifurcation. This retrospective study investigated risk factors for ischemic stroke recurrence in patients with symptomatic carotid artery stenosis, including a comparison of lesion sites. Of 61 consecutive patients admitted to the authors' hospital due to a diagnosis of symptomatic carotid artery stenosis between April 2015 and March 2018, data from 59 were retrospectively reviewed(2 patients diagnosed with arterial dissection were excluded). The primary end point was recurrence of ischemic stroke caused by symptomatic carotid artery stenosis, the cause of the first event. Patients were censored at the time of surgical intervention;events occurring during and after surgical intervention were not included. In the ischemic stroke recurrence and non-recurrence groups, each item was analyzed using the Kaplan-Meier method, and a log-rank test was performed with a significance level set to 5%. Ischemic stroke recurrence before surgical intervention was observed in 5(8.5%)patients. In comparing the recurrence and non-recurrence groups, a significant difference was observed in age(p=0.027)and lesion site(p <0.001). A localized lesion in the carotid artery was a risk factor for recurrence of ischemic stroke in patients with symptomatic carotid artery stenosis. For individuals with symptomatic localized lesions in the common carotid artery, surgical intervention should be considered-in addition to medical treatment-regardless of the degree of stenosis.

Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting

ObjectiveTranscarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (tfCAS). We investigated the proportion of carotid arteries undergoing revascularization procedures that would be eligible for TCAR based on anatomic criteria and how many arteries at high anatomic risk for tfCAS would be amenable to TCAR. MethodsWe performed a retrospective review of consecutive patients who underwent carotid endarterectomy or carotid stenting between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck was not performed within 6 months of the procedure. We assessed TCAR eligibility on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif) and high anatomic risk for tfCAS on the basis of anatomic factors known to make carotid cannulation more difficult or hazardous. ResultsOf the 118 patients and 236 carotid arteries identified, 12 carotid arteries were excluded for presence of an occluded internal carotid artery (ICA). Of the remaining 224 carotid arteries, 72% were eligible for TCAR on the basis of the instructions for use criteria; 100% had 4- to 9-mm ICA diameters, 100% had ≥6-mm common carotid artery (CCA) diameter, 75% had ≥5-cm clavicle to carotid bifurcation distance, and 96% lacked significant CCA puncture site plaque. In addition, 7% of carotid arteries had bifurcation anatomy unfavorable for stenting; thus, of the entire cohort of arteries examined, 68% were eligible for TCAR. Hyperlipidemia (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.7-26; P < .01), chronic obstructive pulmonary disease (OR, 3.5; 95% CI, 1.5-8.3; P < .01), and older age (OR, 1.1; 95% CI, 1.0-1.1; P < .01) were independently associated with TCAR ineligibility, whereas white race (OR, 0.2; 95% CI, 0.0-1.0; P = .048) and beta-blocker use (OR, 0.3; 95% CI, 0.1-0.7; P < .01) were independently associated with TCAR eligibility. In addition, 24% of carotid arteries were considered to be at high risk for tfCAS for the presence of a type III aortic arch (7.6%), severe aortic calcification (3.3%), tandem CCA lesions (7.1%), moderate to severe stenosis at the carotid ostium (8.9%), and tortuous distal ICA precluding embolic filter placement (4.5%). Active smoking (OR, 4.4; 95% CI, 1.9-10; P < .01), hyperlipidemia (OR, 4.0; 95% CI, 1.2-14; P = .03), and older age (OR, 1.1; 95% CI, 1.0-1.1; P = .02) were independently associated with tfCAS ineligibility, whereas preoperative aspirin (OR, 0.1; 95% CI, 0.0-0.4; P < .001) or clopidogrel (OR, 0.3; 95% CI, 0.1-0.8; P = .01) use was associated with tfCAS eligibility. Of the arteries that were considered to be at high risk for tfCAS, 69% were eligible for TCAR. ConclusionsThe majority of carotid arteries in individuals selected for revascularization meet TCAR eligibility, making TCAR a viable treatment option for many patients.

NESVS25. Most Patients Are Eligible for Transcarotid Revascularization Despite Its Anatomic Restrictions

Transcarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (CAS). We evaluated how many patients with carotid stenosis would qualify for TCAR on the basis of anatomic criteria. We performed a retrospective review of consecutive patients who underwent carotid endarterectomy or CAS between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck within 6 months of the procedure was unavailable. We assessed eligibility of the patients on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Patients were deemed ineligible for TCAR if the target internal carotid artery diameter was not between 4 and 9 mm, the clavicle to carotid bifurcation distance was <5 cm, or the intended common carotid artery (CCA) puncture site had significant plaque. We also evaluated the proportion of CCAs that had access site depth ≥4 cm because of the increased complexity of the procedure. Of 478 patients examined, 118 had preoperative computed tomography angiography. All carotid arteries had internal carotid artery diameters between 4 and 9 mm, 74% had a clavicle to carotid bifurcation ≥5 cm, and 96% had minimal or no plaque at the CCA puncture site, resulting in 72% of patients being eligible for TCAR. Of carotid arteries eligible for TCAR, 13% were considered more challenging, given CCA depth ≥4 cm; but of these arteries, only 3.4% had depth ≥4.5 cm, and 39% had a longer clavicle to bifurcation distance of >6 cm. Patients who were ineligible for TCAR were older (72.5 ± 6.8 years vs 69.1 ± 9.2 years; P < .01) and more often had hyperlipidemia (95.5% vs 80.5%; P < .01) and chronic obstructive pulmonary disease (25.4% vs 8.9%; P = .001) but were less likely to have diabetes (25.4% vs 40.8%; P< .03) or to be taking beta blockers (50.7% vs 65.1%; P = .04). Twenty percent of patients were at high risk for transfemoral CAS based on presence of type III aortic arch (7.2%), severe aortic arch calcification (4.5%), tandem CCA lesions (6.4%), or moderate to severe stenosis at the carotid ostium (9.7%). Of the transfemoral CAS high-risk patients, 63% were eligible for TCAR. Of patients >80 years old, 64% were eligible for TCAR. The majority of carotid arteries in patients selected for revascularization meet TCAR eligibility.

"Modified No-touch technique using floating wire"- a novel technique of Unprotected Carotid Artery Stenting for aorto-ostial lesion.

Takayasu arteritis (TA) is chronic inflammatory large vessel vasculitis where aorta and its main branches bear the maximum burden. Here, we report a case of 23-yr-old hypertensive male that had an episode of transient ischemic attack (TIA) three months back. He was diagnosed with type I Takayasu’s arteritis (TA) showing long segment osteo-proximal lesion of right common carotid artery (RCC) with near total occlusion, along with lesion involving bifurcation and proximal part of internal carotid artery having similar degree of severity on computed tomographic angiography of aorta. It was successfully stented with two overlapping 6x19, and 6x18 mm Herculink stent (Abott Vascular, USA) distally at 12 atm pressure while aorto-ostial lesion was stented using 7x19, and 7x18 mm overlapping Herculink stents at 14 atm pressure achieving excellent results with no residual stenosis. Carotid artery stenting (CAS) was unprotected as no embolic protection device was used, and aorto-ostial lesion was stented keeping a floating wire in subclavian artery as a modification of no touch technique. At 4-year follow up, computed tomographic imaging revealed well apposed stents with excellent patency.

Subclavian-carotid replacement in chronic cerebrovascular insufficiency management

To present own experience of subclavian-carotid replacement for chronic cerebrovascular insufficiency management. For 12 years 7 subclavian-carotid reconstructions were performed that was 1.2% of all carotid repairs during this period. Great saphenous vein was always used as a graft. Carotid endarterectomy from proximal internal carotid artery was additionally performed if it was necessary. Patients had severe advanced lesion of supra-aortic vessels including bilateral carotid lesion and significant stenosis of ipsilateral proximal common carotid artery. The vast majority of them had cerebrovascular insufficiency grade 3-4. All patients underwent surgery without significant complications despite initially severe state due to advanced lesion of brachiocephalic arteries. Long-term postoperative patency of the grafts was satisfactory within the period from 12 years to 1.5 months. There were no neurological impairment and stroke. Subclavian-carotid grafting is an effective alternative for carotid endarterectomy in patients with advanced atherosclerotic lesion of common and internal carotid arteries.

BYPASS SURGERY IN PATIENTS WITH COMBINED ATHEROSCLEROTIC LESIONS OF COMMON AND INTERNAL CAROTID ARTERY

An analysis of data of carotid angiographies was made in 146 patients with chronic cerebrovascular disease. Combined lesions of the common and internal carotid artery with clinical signs were revealed in 2 (1,4%) patients. A crossed extraanatomic bypass from the left common carotid artery to the right internal carotid artery was performed in one patient. The orthotopic common-internal autovenous bypass on the right side was carried out for another patient. According to obtained results, the authors suggested that the orthotopic or extraanatomic common-internal carotid artery bypasses could be applied in case of impossibility of endovascular intervention, when patients had the combined atherosclerotic lesions of common carotid and internal carotid artery.

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.

Efficacy of early carotid endarterectomy for vulnerable plaque in the common carotid artery

Dear Editor Steno-occlusive disease in the common carotid artery (CCA) is relatively rare. Clinical and plaque features of CCA stenosis have thus seldom been investigated [6, 7]. We report here a case of refractory ischemia due to mild common carotid artery stenosis treated with carotid endarterectomy (CEA). A 59-year-old Japanese male developed mild right hemiparesis. Ischemic lesions in the left hemisphere due to mild left distal CCA stenosis with vulnerable plaque were revealed on diffusion-weighted imaging (DWI), time-of-flight imaging (TOF), and three-dimensional computed tomography angiography (3DCTA). Oral clopidgrel and rosuvastatin were initiated. Ten months later, symptoms recurred, and DWI revealed new ischemic lesions (Fig. 1a). Oral aspirin was added. TOF showed an increased plaque volume with retention of the lumen (Fig. 1b, c), indicating expansive remodeling. A fibrous cap (Fig. 1b) was disrupted, and the plaque was directly exposed to the lumen (Fig. 1c). The stenosis remained mild on 3DCTA (Fig. 1d, e upper). However, an intraluminal filling defect implied a mobile plaque (Fig. 1e lower). T1-weighted black-blood imaging showed protrusion of a high-intensity plaque into the lumen (Fig. 1f). Intravenous heparin was therefore started. Nevertheless, the third ischemic event occurred 4 days after the second onset. Six days after the third event, CEAwas performed without major perioperative complications. A large amount of fragile plaque with inner fibrous tissues was resected. A portion of the plaque was exposed directly to the lumen (Fig. 1g). No intraluminal thrombus was identified. Histopathological study showed fragile atheroma containing intraplaque hemorrhage. A portion of the inner fibrous tissues was disrupted (Fig. 1h). The patient has not developed further events after 12months of follow-up. Recently, plaque characteristics have been accurately evaluated using MRI [8, 10]. Intraplaque hemorrhage [1, 9], fibrous cap rupture [5, 9], expansive arterial remodeling [4], and a mobile plaque [2, 3] indicate plaque fragility and a higher risk of ischemic events. Steno-occlusive disease of the CCA is rare (1 %–5 % of stroke patients) because extracranial carotid atherosclerotic disease usually arises from the ICA [6, 7]. CCA lesions are supposed to frequently cause amaurosis fugax due to hemodynamic insufficiency [6]. In this case, the patient suffered repeated cerebral embolisms from mild CCA stenosis. A previous study reported that all CCA lesions showed less than 75 % stenosis [7]. However, from this case, we learned a lesson that an extent of stenosis in the CCA is not necessarily correlated with a risk of stroke as seen in the ICA. Although the vessel retains its lumen, the outer circumference might be increasing, which implies increasing plaque volume and vulnerability [4]. In this case, plaque imaging studies suggested plaque fragility and a higher * Yoshio Araki y.araki@med.nagoya-u.ac.jp