Radiation-induced Carotid Stenosis Research Articles

Impact of head and neck radiation on long-term outcomes after carotid revascularization

ObjectiveRadiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. ResultsA total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. ConclusionsPrior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.

Carotid Artery Replacement With Reversed Superficial Femoral Artery in a Patient With Recurrent Radiation-Induced Carotid Stenosis

Carotid Artery Replacement With Reversed Superficial Femoral Artery in a Patient With Recurrent Radiation-Induced Carotid Stenosis

Progression rate of radiation-induced carotid stenosis in head and neck cancer survivors after statin treatment: a retrospective cohort study.

Whether statin treatment is effective in retarding the progression of radiation-induced carotid stenosis (RICS) in head and neck cancer (HNC) survivors has not been well studied. The purpose of this study was to assess the association of statin treatment with RICS progression rate in HNC survivors after radiotherapy. We conducted a retrospective cohort study at Sun Yat-sen Memorial Hospital, Sun Yat-sen University in Guangzhou, China. Between January 2010 and December 2021, we screened HNC survivors whose carotid ultrasound scans had shown stenosis of the common and/or internal carotid arteries. The primary outcome was the RICS progression rate. We compared eligible patients treated with statins with those who did not in multivariable Cox regression models. A total of 200 patients were included in this study, of whom 108 received statin treatment and 92 did not. Over a mean follow-up time of 1.5 years, 56 (28.0%) patients showed RICS progression, 24 (42.9%) and 32 (57.1%) in the statin and control groups, respectively. The statin group showed less RICS progression than the control group (adjusted-HR 0.49, 95% CI 0.30-0.80, P = 0.005). In the subgroup analysis, there was no significant interaction in the effect of statins on lowering RICS progression rate in the subgroups stratified by baseline low-density lipoprotein cholesterol (LDL-C) levels (P for interaction = 0.53) or baseline degrees of stenosis (P for interaction = 0.50). Statin treatment was associated with a lower risk of RICS progression in patients with HNC after radiotherapy, regardless of baseline LDL-C level and baseline stenosis degrees.

Amaurosis Fugax Due to Radiation-induced Carotid Stenosis Treated by Carotid Artery Stenting

59-year-old male had four episodes of transient, painless vision loss in right eye in the last 20 days which had resolved spontaneously. Three years ago, patient had been diagnosed with oropharyngeal squamous cell carcinoma, which had been treated with six cycles of chemotherapy and radiotherapy. MRI brain angiogram showed diffuse long segment wall thickening of Right Internal Carotid Artery with luminal narrowing with no acute infarct or haemorrhage; which was later confirmed by four vessel DSA. He was treated with Right Carotid Artery angioplasty with a cutting balloon while using a distal protection device, followed up by stenting. The patient recovered well on follow-up and there were no further episodes. Thus, amaurosis fugax may be a presentation of carotid artery stenosis, especially after radiotherapy and such patients can be treated by carotid angioplasty and stenting.

Radiation-induced carotid stenosis

Background and Aims : With the expanded use of radiation in the treatment of neck and mediastinal malignancies, reports of radiation-induced extracranial carotid stenosis became more prevalent. Radiation is commonly used to treat many vascular pathologies, including arteriovenous malformations, arteriovenous fistulas, cavernous malformations, and vascular tumors. In some cases, however, radiation to the normal artery can induce pathology. Histologic studies have demonstrated that radiation has variable effects, depending on the arterial size and radiation dose.

Successful Bilateral Re-Stenting of Re-Stenosis after Carotid Artery Stenting in a Patient with Radiation-Induced Carotid Stenosis

Successful Bilateral Re-Stenting of Re-Stenosis after Carotid Artery Stenting in a Patient with Radiation-Induced Carotid Stenosis

Optical Coherence Tomography Evaluation of Carotid Artery Stenosis and Stenting in Patients With Previous Cervical Radiotherapy.

ObjectivesCervical radiotherapy can lead to accelerated carotid artery stenosis, increased incidence of stroke, and a higher rate of in-stent restenosis in irradiated patients. Our objective was to reveal the morphological characteristics of radiation-induced carotid stenosis (RICS) and the stent–vessel interactions in patients with previous cervical radiotherapy by optical coherence tomography (OCT).Materials and MethodsBetween November 2017 and March 2019, five patients with a history of cervical radiotherapy were diagnosed with severe carotid artery stenosis and underwent carotid artery stenting (CAS). OCT was conducted before and immediately after the carotid stent implantation. Two patients received OCT evaluation of carotid stenting at 6- or 13-month follow-up.ResultsThe tumor types indicating cervical radiotherapy were nasopharyngeal carcinoma (n = 3), cervical esophageal carcinoma (n = 1), and cervical lymphoma (n = 1). The median interval from the radiotherapy to the diagnosis of RICS was 8 years (range 4–36 years). Lesion characteristics of RICS were detected with heterogeneous signal-rich tissue, dissection, and advanced atherosclerosis upon OCT evaluation. Post-interventional OCT revealed 18.2–57.1% tissue protrusion and 3.3–13.8% stent strut malapposition. Follow-up OCT detected homogeneous signal-rich neointima and signal-poor regions around stent struts. In the patient with high rates of tissue protrusion and stent strut malapposition, the 6-month neointima burden reached 48.9% and microvessels were detected.ConclusionThe morphological features of RICS were heterogeneous, including heterogeneous signal-rich tissue, dissection, and advanced atherosclerosis. Stenting was successful in all 5 patients with severe RICS. One patient, with high rates of tissue protrusion and stent strut malapposition immediately after stenting, received in-stent neointimal hyperplasia at a 6-month follow-up.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions: Presented at the Thirty-fourth Annual Meeting of the Eastern Vascular Society (Virtual), Weekly Program Series, October 7-November 18, 2020.

Objective Limited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes.

Treatment results of carotid endarterectomy and carotid artery stenting for patients with radiation-induced carotid stenosis.

PurposeExposure to ionizing radiation over the head and neck accelerates atherosclerotic changes in the carotid arteries. Owing to the characteristics of radiation-induced carotid stenosis (RICS), the results regarding the optimal revascularization method for RICS vary. This study compared treatment outcomes between carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RICS.MethodsThis was a single-center retrospective review of consecutive patients who underwent CEA or CAS for carotid stenosis. RICS was defined as carotid stenosis (>50%) with the prior neck irradiation for cancer treatment on either side. For the analyses, demographics, comorbid conditions, carotid lesion characteristics based on imaging studies, surgical complications, neurologic outcomes, and mortality during the follow-up period were reviewed. To compare CEA and CAS results in RICS, a 1:1 propensity score matching was applied.ResultsBetween November 1994 and June 2021, 43 patients with RICS and 2,407 patients with non-RICS underwent carotid revascularization with CEA or CAS. RICS had fewer atherosclerotic risk factors and more frequent severe carotid stenosis and contralateral carotid occlusions than non-RICS. CAS was more commonly performed than CEA (22.9% vs. 77.1%) for RICS due to more frequent unfavorable carotid anatomy (0 vs. 16.2%). Procedure-related complications were more common in the CEA than in the CAS. However, there was no significant difference in neurologic outcomes and restenosis rates between CEA and CAS in RICS.ConclusionConsidering its lesion characteristics and cumulative incidence, RICS requires more attention than non-RICS. Although CAS has broader indications for RICS, CEA has shown acceptable results if selectively performed.

Carotid Endarterectomy with Intraoperative Ultrasonography for Radiation-induced Carotid Stenosis: A Case Report

放射線治療後の頚部頚動脈狭窄の治療はいまだ議論がある．プラークが不安定かつ多量のため血栓内膜剝離術（CEA）により治療した症例を経験したので報告する．

Amaurosis fugax due to radiation induced carotid stenosis treated by carotid artery stenting

Amaurosis fugax can be a presentation of a patient presenting with radiation induced carotid artery stenosis and such patients can be safely managed by carotid angioplasty and stenting.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions

ObjectiveLimited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. ResultsA total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). ConclusionsRICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.

Revascularization approaches in patients with radiation-induced carotid stenosis: an updated systematic review and meta-analysis.

Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen owing to medical advancements in the field. As a consequence, the incidence of carotid artery stenosis in these high-risk patients has increased. In this study we sought to compare the outcomes of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) for radiation-induced carotid artery stenosis. This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 2020. A random-effects model meta-analysis was conducted, and odds ratios (ORs) were calculated. The I-square statistic was used to assess for heterogeneity. Seven studies and 201 patients were included. Periprocedural stroke, myocardial infarction (MI), and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR, 7.40; 95% CI, 1.58-34.59; I2 = 0%). Analysis revealed no significant difference in terms of long-term mortality (OR, 0.41; 95% CI, 0.14-1.16; I2 = 0%) and restenosis rates (OR, 0.69; 95% CI, 0.29-1.66; I2 = 0%) between CEA and CAS after a mean follow-up of 40.5 months. CAS and CEA appear to have a similar safety and efficacy profile in patients with radiation-induced carotid artery stenosis. Patients treated with CEA have a higher risk for periprocedural CN injuries. Future prospective studies are warranted to validate these results.

Clinical outcomes of radiation-induced carotid stenosis: A systematic review and meta-analysis

ObjectivesClinical outcomes of radiation-induced carotid stenosis are still unclear. Therefore, a systematic review and meta-analysis is needed to evaluate the short- and long-term outcomes after interventions to treat radiation-induced carotid stenosis. MethodsPubMed, EMBASE, the Cochrane Library and Web of Science were searched from 1 January 2000 for relevant RCTs and observational studies which reported outcomes after carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) for carotid stenosis induced by radiation. Risk of bias were assessed through different scales according to study design. I2 statistic were used to evaluate the heterogeneity, and meta-regression were performed to investigate the source of heterogeneity. Visual inspection of funnel plots was used to judge publication bias. ResultsA total of 26 studies with 1002 patients were included. CEA was performed in 364 patients and CAS in 638 patients. The overall estimated rate of short-term stroke was 0.19% (95% CI: 0–0.90%), and the rate of long-term stroke was 2.68 % (95% CI: 1.19–4.57%). The rate of cranial nerve injury in CEA group was significantly higher than that in CAS group [risk ratio (RR): 6.03, 95% CI: 1.63–22.22, P = .007]. The univariate regression analysis showed that the risk of stroke in CAS group were significantly higher than CEA group in both short- and long-term [incidence rate ratio (IRR): 3.62, 95% CI: 1.21–10.85, P = 0.22; IRR: 2.95, 95% CI: 1.02–8.59, P = .046, respectively]. ConclusionsThis systematic review provided the worldwide profile of outcome of treatment for radiation-induced carotid stenosis, and also found that CEA can yield better results for these patients than CAS. Nonetheless, as large-scale studies have not yet been conducted, and there is a definite need for further studies in the future.

Surgical repair of radiation-induced carotid stenosis

ObjectiveCarotid endarterectomy and carotid artery stenting are both valid therapeutic options for the treatment of radiation-induced carotid stenosis (RICS). The second has the advantage of being less invasive, although it seems to result in more restenosis than the first. Meanwhile, progress in radiation therapy and head and neck surgery has significantly increased the survival of these patients. As a result, treatment of RICS should be considered from a long-term perspective. This works presents perioperative and follow-up outcomes of surgical treatment of RICS. MethodsThis single-center retrospective study included all patients who underwent carotid endarterectomy for RICS from January 1998 to June 2017. Clinical and duplex ultrasound examination-based follow-up was performed postoperatively, at 1 month, 6 months, 12 months, and yearly thereafter. Kaplan-Meier curves were used for survival plots based on a log-rank test. Any abnormal finding led to angio-computed tomography scan and specialized neurovascular examination. ResultsBetween 1998 and 2017, 128 patients (162 lesions) were treated. The median interval between radiation therapy and surgery was 16 years. Forty-five patients (35%) were symptomatic. The eversion technique was performed in 79 cases (49%), and the patch was favored in 24 cases (15%), prosthetic bypass graft in 51 cases (31%), and a venous bypass graft in 8 cases (5%). Two postoperative deaths (1.5%) (one secondary to massive stroke) were noted. The primary end point of early postoperative cerebrovascular event was 2.5%. Two cervical hematomas (1.2%) required surgical revision and seven cases of permanent cranial nerve injury were recorded. The median follow-up was 29 months (range, 2-199 months). There were no additional strokes. The 3-year primary patency rate was 96% and the 3-year freedom from neurologic event was 98%. ConclusionsOpen surgical treatment of RICS lesions is a safe and durable option. Our results suggest that the outcomes of such treatment are good and in particular that rates of cerebrovascular event and restenosis are low and that cranial nerve injury should not be a concern. As a result, we consider that open surgery for RICS lesions should be offered as a first-line treatment. However, comparative data are mandated to address this issue.

Two cases of symptomatic, radiation-induced carotid stenosis diagnosed and followed-up using contrast-enhanced ultrasonography and volume isotropic turbo spin-echo acquisition

Two cases of symptomatic, radiation-induced carotid stenosis diagnosed and followed-up using contrast-enhanced ultrasonography and volume isotropic turbo spin-echo acquisition

Abstract TP196: Utility of CHADVASC2 Score in Predicting Clinical Outcomes of Patients Undergoing Carotid Angioplasty &amp; Stent Placement

Background: CHA2DS2-VASc score is used for stroke risk stratification in atrial fibrillation patients. We considered the possible use of the CHA2DS2Vasc score to predict perioperative stroke and subsequent stroke risk in patients undergoing CAS for symptomatic or asymptomatic atherosclerotic carotid disease. Methods: CAS Patients were identified from a prospectively collected neuroendovascular database maintained at our institution. We then collected the demographic information and the elements necessary to calculate the CHA2DS2vasc score. Primary outcomes were stroke within 30 days of the procedure and during follow-up. Mortality due to stroke and all-cause mortality were secondary outcomes. Patients were stratified into three groups based on their CHADVASC score. 0-3 (low risk), 4-6 (moderate risk) and 7-9 (high risk). We then compared the clinical outcomes amongst the three groups and high risk group was used as a reference during multivariate analysis. Results: From January 2010 to June 2018, 210 patients underwent CAS at our institution but after excluding patients with tandem lesions and radiation induced carotid stenosis,161 patients were included in the analysis [mean age 67 ± 25 years, 52 (32 %) were women]. Among the patients, 26 (16%) patients had CHA2DS2Vasc-score 0-3, 100 (62 %) in 4-6 group and 35 (22 %) in 7-9 group. A total of 10 (6.2%) had perioperative stroke and 4 (2.5 %) patients had perioperative death. Mean follow-up time was 17 months (range 0-96). Higher number perioperative strokes were observed in the patients with CHADVASC score 7-9 compared to moderate and low risk groups [(14% versus 3% versus 11.5 %) respectively; p-value 0.016]. Similarly recurrent stroke rate was significantly higher in high risk group compared to the other two [31.4% vs 4% vs 3.8% respectively); p-value &lt;0.001]. After adjusting for age and gender, low risk patients (OR 0.011; p-value 0.03)] and moderate risk patients (OR 0.08, p-value 0.001)] had significantly less recurrent strokes when compared to high risk patients. Conclusion: In this analysis of CAS patients, higher CHA2DS2Vasc-Score predicted the increased perioperative and recurrent stroke risk. This should be validated further in large registries and trials of CAS patients.

A comparative dosimetric study comparing dose to the carotid artery using 3D conformal radiotherapy and intensity-modulated radiotherapy for T1-T2 glottic cancer at Gharbia Cancer Society, Egypt

AbstractPurposeThis is a dosimetric study to compare the feasibility of carotid artery sparing as a primary objective, as well as planning target volume coverage and dose to spinal cord as a secondary objective, by using 3D conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) for patients with early glottis cancer.Patients and methodsSix patients who had been treated for early stage glottic carcinoma (stage T1-2 N0M0) were included in this study. All patients were immobilised in the supine position with a thermoplastic mask and treatment planning computed tomography scans were obtained from the top of the skull to the top of aortic arch with a 3-mm slice thickness. Two plans were created for every patient, one using 3DCRT and the second using IMRT. Comparison between the two plans was undertaken and analysis was made regarding the dose to the carotids arteries, target coverage and doses to the organs at risk.ResultsFor target coverage, theV95%for both plans was the same with no significant difference, hot spots were the highest in 3DCRT withp=0·002, the homogeneity index for IMRT plan was better than 3DCRT (p=0·0001). Regarding the dose to the carotids, it was significantly lower in the IMRT plan compared with the 3DCRT plan (p=0·01). The spinal cord dose was significantly higher in the IMRT plan.ConclusionIMRT significantly reduces the radiation dose to the carotid arteries compared with 3DCRT while maintaining clinical target volume coverage. Such a results assists in decreasing the incidence of radiation-induced carotid stenosis, thus improving the quality of life for patients.

放射線治療後の頚動脈狭窄症に対するCEA

放射線治療後の頚動脈狭窄症に対するCEA

Relationship between histologic features and outcomes of carotid revascularization for radiation-induced stenosis

This study aimed to elucidate the relationships between preoperative carotid imaging results, histologic characteristics, and surgical treatment outcomes of radiation-induced carotid stenosis (RICS), using control subjects without RICS for comparison. We retrospectively reviewed records of 17 patients who underwent carotid revascularization for 22 instances of RICS, including 10 cases of carotid artery stenting (CAS), 11 cases of carotid endarterectomy (CEA), and 1 case of CEA with retrograde CAS, between July 2004 and April 2013. The controls were 475 patients with no history of radiation therapy who underwent carotid revascularization in a similar period. Preoperative magnetic resonance imaging (MRI), ultrasonography (US), and computed tomography angiography results were correlated with outcomes of histologic analysis of CEA specimens. End points included ipsilateral and contralateral stroke, myocardial infarction, restenosis, in-stent thrombosis, and target lesion revascularization. Vulnerable plaques on carotid MRI (86% vs 64.2%; P = .010) and mobile (27% vs 8.0%; P = .008) and ulcerative (50% vs 15.8%; P < .001) plaques on US were more frequent in the RICS group. All revascularization procedures were successful, and no occlusion occurred. Adverse events in the CAS group, including one minor stroke and one transient ischemic attack within 30 days as well as five ipsilateral neurologic events after 30 days, including three minor strokes and two transient ischemic attacks, were significantly more frequent than in the CEA group. All three cases of late ipsilateral stroke displayed vulnerable plaque on preoperative MRI and late in-stent thrombosis or restenosis on US. Our radiologic and histologic analyses revealed that advanced RICS is often accompanied by formation of vulnerable plaque. CEA can prevent undesirable late outcomes in such cases.