Revascularization Of Internal Carotid Artery Research Articles

Assessment of cerebral autoregulatory function and inter-hemispheric blood flow in older adults with internal carotid artery stenosis using transcranial Doppler sonography-based measurement of transient hyperemic response after carotid artery compression

Unhealthy vascular aging promotes atherogenesis, which may lead to significant internal carotid artery stenosis (CAS) in 5 to 7.5% of older adults. The pathogenic factors that promote accelerated vascular aging and CAS also affect the downstream portion of the cerebral microcirculation in these patients. Primary treatments of significant CAS are eversion endarterectomy or endarterectomy with patch plasty. Factors that determine adequate hemodynamic compensation and thereby the clinical consequences of CAS as well as medical and surgical complications of carotid reconstruction surgery likely involve the anatomy of the circle of Willis (CoW), the magnitude of compensatory inter-hemispheric blood flow, and the effectiveness of cerebral microcirculatory blood flow autoregulation. This study aimed to test two hypotheses based on this theory. First, we hypothesized that patients with symptomatic and asymptomatic CAS would exhibit differences in autoregulatory function and inter-hemispheric blood flow. Second, we predicted that anatomically compromised CoW would associate with impaired inter-hemispheric blood flow compensation. We enrolled older adults with symptomatic or asymptomatic internal CAS (>70% NASCET criteria; n = 46) and assessed CoW integrity by CT angiography. We evaluated transient hyperemic responses in the middle cerebral arteries (MCA) after common carotid artery compression (CCC; 10 s) by transcranial Doppler sonography (TCD). We compared parameters reflecting autoregulatory function (e.g., transient hyperemic response ratio [THRR], return to baseline time [RTB], changes of vascular resistance) and inter-hemispheric blood flow (residual blood flow velocity). Our findings revealed that CAS was associated with impaired cerebral vascular reactivity. However, we did not observe significant differences in autoregulatory function or inter-hemispheric blood flow between patients with symptomatic and asymptomatic CAS. Moreover, anatomically compromised CoW did not significantly affect these parameters. Notably, we observed an inverse correlation between RTB and THRR, and 49% of CAS patients exhibited a delayed THRR, which associated with decreased inter-hemispheric blood flow. Future studies should investigate how TCD-based evaluation of autoregulatory function and inter-hemispheric blood flow can be used to optimize surgical techniques and patient selection for internal carotid artery revascularization.

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.

Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy.

Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.

180-degre carotid bifurcation with an internal carotid artery aneurysm.

Internal carotid artery (ICA) aneurysm is a rare pathology. In the clinical case we present, the patient had an ICA aneurysm as well as a rare anatomical variant of the carotid bifurcation. We present the case of a 45year old man, who had two episodes of TIA revealed by loss of mind. Computed tomography revealed the fusiform aneurysm of a left ICA in the first segment with maximal diameter of 16mm. There were no thrombotic mass in the dilated area. The carotid bifurcation angle was 180 degree. Although the aneurysm did not contain a thrombus mass, it was considered the source of the TIA because of turbulent blood flow. Distal and proximal ligation was performed. A 5-cm long graft from the great saphenous vein was used for ICA revascularization from common carotid artery. In our case, geometry of carotid bifurcation may have contributed to the ICA aneurysm, although there is no evidence for this correlation.

Isolated sublingual hematoma post internal carotid artery stenting for internal carotid artery stenosis in high-risk patients as uncommon and rare misadventure: A case report and review of literature.

Introduction and importanceIsolated sublingual hematoma is a rare complication seen in trauma, severe uncontrolled hypertension, dental operations, bleeding diathesis, and the use of dual antiplatelet and anticoagulant agents. In advanced and neglected cases, a sublingual hematoma may interfere with the patient's airway, causing suffocation and fatal airway obstruction. Our objective was to present a case of iatrogenic isolated sublingual hematoma in a 70-year-old business man, heavy smoker with a history of hypertension. Furthermore, to report the literature review, and to organize treatment strategies to reduce the rate of progression of the hematoma. In addition to recommend or advice a strategic plan to prevent this complication during carotid stenting.Case presentationThis case report has been reported in line with the SCARE Criteria. We represented a case report of an iatrogenic isolated mild/moderate sublingual hematoma in a 70-year-old business man. This hematoma developed as one of the rare complications of endovascular internal carotid artery revascularization because of injury to the sublingual branch of the lingual artery during wire manipulations or its advancement. This hematoma was treated by conservative treatment without any intervention.Clinical discussionImmediately after internal carotid artery stenting procedure, the patient developed a sudden onset of painful swelling in the floor of the mouth. The hematoma showing ecchymotic submucosal swelling underneath the tongue in the floor of the mouth. If it became enlarged, it may push the tongue against the palate and blocking the airway, causing serious airway obstruction. Fortunately, the swelling is isolated (has no extension to any side) and limited to the root and middle third of the tongue but, not extending to its tip. Its development most probably due to injured atherosclerotic sublingual branch of the lingual artery during the procedure.ConclusionsThe first step in management should be prompt airway management. Conservative treatment took place without any further intervention. To date, there is no consensus about the management regarding the hematoma itself. Mostly, clinicians start with observation for spontaneous resolution. When conservative treatment is not appropriate, surgical intervention must be performed. However, electively secure the airway is the main objective for treatment.

Микроциркуляция глазного дна после реваскуляризации внутренней сонной артерии в раннем послеоперационном периоде

Purpose. To study the effect of ICA revascularization on the parameters of the fundus microvasculature in patients with clinically significant ICA stenosis in the early postoperative period. Material and methods. Thirty-two patients with hemodynamically significant stenosis (≥ 75 %) of the right or left internal carotid artery (ICA) were studied using OCT angiography. Results. According to the results of OCT angiography before the revascularization procedure, there were no significant differences in hemodynamic parameters in the eyes on the side of the stenotic and non-stenotic ICA. In the early postoperative period (3–7 days), an increase in blood flow density and vascular density at the level of the superficial and deep plexuses in the macular region was observed in the ipsilateral eyes (p ≤ 0.05). In the contralateral eyes, after ICA revascularization, there was a partial improvement in microcirculation parameters according to OCT angiography (p ≤ 0.05). Peripapillary blood flow density and vascular density did not change significantly in both eyes. Conclusion. In patients with clinically significant ICA stenosis, ICA revascularization by stenting or CAEA contributed to an effective improvement of retinal microcirculation in both eyes. Keywords: optical coherence tomography-angiography, stenting of the internal carotid artery, revascularization, eye microcirculation.

Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video.

Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CTScore) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

Possibility of increasing the «therapeutic window» for revascularization of the carotid arteries in the acute period of ischemic stroke

Objective ‒ to assess the possibility of increasing the time of surgical restoration of blood flow in the acute period of ischemic stroke due to occlusive lesion of the internal carotid artery (ICA).Materials and methods. Among the patients who were admitted for treatmentat in the Regional Odessa Hospital with acute ischemic stroke in the carotid region a group of 6 patients was identified in whom the cause of stroke was occlusion of the ICA by an atherosclerotic plaque. Age of patients ‒ from 54 to 71 years. Patients were hospitalized later 6 hours from the onset of stroke. The survey was carried out according to the established protocol. Neurological deficits are mild to moderate. In order to eliminate the occlusion of the ICA, all patients underwent endarterectomy.Results. Carotidendarterectomy was performed from 2 to 11 days after onset of stroke. Retrograde blood flow through the ICA was obtained in three (50 %) patients in whom surgical interventions were performed up to 4 days after the disease. In the postoperativeperiod a typical therapy was carried out. In cases with the obtained retrograde blood flowon control carotid angiograms demonstrated revascularization of the ICA basin according to mTICI-3. On the control CT of the brain in postoperative period in one case the point subarachnoid hemorrhages was determined. In the other two cases there was no evidence hemorrhagic transformation. Operated patients showed positive dynamics: a decrease hemiparesis by 1 poin and regression of mental disorders. The patients were discharged withm RS 1‒2. During the follow-up examination 90 days the neurological condition of the patients improved to mRS 1‒0.Conclusions. Results obtained in increasing the “therapeutic window” for revascularization of the occluded ICA allow to continue research in the indicated direction and improve the quality of surgical care for patients with acute stroke.

To the issue of degree of removal of gliomas of supratentorial localization

Objective ‒ to assess the possibility of increasing the time of surgical restoration of blood flow in the acute period of ischemic stroke due to occlusive lesion of the internal carotid artery (ICA).Materials and methods. Among the patients who were admitted for treatmentat in the Regional Odessa Hospital with acute ischemic stroke in the carotid region a group of 6 patients was identified in whom the cause of stroke was occlusion of the ICA by an atherosclerotic plaque. Age of patients ‒ from 54 to 71 years. Patients were hospitalized later 6 hours from the onset of stroke. The survey was carried out according to the established protocol. Neurological deficits are mild to moderate. In order to eliminate the occlusion of the ICA, all patients underwent endarterectomy.Results. Carotidendarterectomy was performed from 2 to 11 days after onset of stroke. Retrograde blood flow through the ICA was obtained in three (50 %) patients in whom surgical interventions were performed up to 4 days after the disease. In the postoperativeperiod a typical therapy was carried out. In cases with the obtained retrograde blood flowon control carotid angiograms demonstrated revascularization of the ICA basin according to mTICI-3. On the control CT of the brain in postoperative period in one case the point subarachnoid hemorrhages was determined. In the other two cases there was no evidence hemorrhagic transformation. Operated patients showed positive dynamics: a decrease hemiparesis by 1 poin and regression of mental disorders. The patients were discharged withm RS 1‒2. During the follow-up examination 90 days the neurological condition of the patients improved to mRS 1‒0.Conclusions. Results obtained in increasing the “therapeutic window” for revascularization of the occluded ICA allow to continue research in the indicated direction and improve the quality of surgical care for patients with acute stroke.

The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke.

Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique. We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes. Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage. The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions.

In Reply to the Letter to the Editor Regarding “Hybrid Surgery for Internal Carotid Artery Revascularization”

In Reply to the Letter to the Editor Regarding “Hybrid Surgery for Internal Carotid Artery Revascularization”

Letter to the Editor Regarding “Hybrid Surgery for Internal Carotid Artery Revascularization”

Letter to the Editor Regarding “Hybrid Surgery for Internal Carotid Artery Revascularization”

Impacts of Internal Carotid Artery Revascularization on Flow in Anterior Communicating Artery Aneurysm: A Preliminary Multiscale Numerical Investigation

The optimal management strategy of patients with concomitant anterior communicating artery aneurysm (ACoAA) and internal carotid artery (ICA) stenosis is unclear. This study aims to evaluate the impacts of unilateral ICA revascularization on hemodynamics factors associated with rupture in an ACoAA. In the present study, a multiscale computational model of ACoAA was developed by coupling zero-dimensional (0D) models of the cerebral vascular system with a three-dimensional (3D) patient-specific ACoAA model. Distributions of flow patterns, wall shear stress (WSS), relative residence time (RRT) and oscillating shear index (OSI) in the ACoAA under left ICA revascularization procedure were quantitatively assessed by using transient computational fluid dynamics (CFD) simulations. Our results showed that the revascularization procedures significantly changed the hemodynamic environments in the ACoAA. The flow disturbance in the ACoAA was enhanced by the resumed flow from the affected side. In addition, higher OSI (0.057 vs. 0.02), prolonged RRT (1.14 vs. 0.39) and larger low WSS area (66 vs. 50 mm2) in ACoAA were found in the non-stenotic case. These acute changes in hemodynamics after revascularization may elevate the rupture risk of ACoAA. The preliminary results validated the feasibility of predicting aneurismal hemodynamics characteristics in revascularization procedures by using multiscale CFD simulations, which would benefit the management of this group of patients.

Hybrid Surgery for Internal Carotid Artery Revascularization

The management of chronic complete internal carotid artery (ICA) occlusion (COICA) has been challenging. Endovascular procedures have been performed with variable success and risks, depending on the type of occlusion and distal revascularization. We present a novel hybrid procedure to recanalize the ICA when previous endovascular interventions have failed or been deemed too risky. Two patients presented with symptomatic COICA after maximal medical management. They were deemed at high risk of endovascular intervention and/or previous endovascular attempts had failed. Thus, they had indications for a hybrid procedure. A hybrid technique was used to create a stump by surgical endarterectomy, followed by recanalization using an endovascular approach via femoral access. We have described the technique in detail. Postoperative computed tomography perfusion scanning showed normalization of the mean transient time, cerebral blood volume, and cerebral blood flow compared with the preoperative findings. Cerebral angiography showed successful recanalization of the ICA. Neither patient experienced any complications. A hybrid technique is feasible and should be considered for patients with COICA in whom maximal medical management has failed and who have a high-risk profile for endovascular intervention or in whom previous endovascular attempts have failed.

Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires

ObjectiveWe examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion.MethodsFiles of patients with acute ischemic...

Emergency revascularization of acute internal carotid artery occlusion: Follow the spike, it guides you

The present study sought to examine the incidence of the angiographic “spike sign” and to assess its predictive significance for achieving carotid revascularization in 54 patients with acute internal carotid artery (ICA) occlusions that required urgent endovascular revascularization. Clinical and imaging files of consecutive patients with ICA occlusion who were treated in a tertiary care academic medical center from 2011–2015 were retrospectively examined under Institutional Review Board approval with a waiver of the requirement for informed consent. All proximal ICA occlusions were treated by stent-assisted carotid angioplasty, and all distal embolic occlusions were managed with stent-assisted mechanical thrombectomy. The study included 24 patients with acute ICA occlusion (group 1) and 30 patients with tandem ICA-intracranial occlusions (group 2). The spike sign was seen in 16/24 patients in group 1 (67%), and successful ICA revascularization was achieved in 14/16 (88%). The sign was seen in 26/30 patients in group 2 (87%), and ICA revascularization was successful in all 26 (100%). The remaining 12 patients had no spike sign, and ICA revascularization was successful in only 7/12 (58%). The spike sign is a transient finding that represents the proximal patent remnant of the stenotic corridor in fresh clot. Acute ICA occlusion frequently leaves the spike sign as a marker of the recent thrombotic event. The spike vertex points to the “path of least resistance” for the guidewire to cross the occlusion and engage the true arterial lumen, a critical step during ICA endovascular revascularization.

Abstract 15645: Carotid Artery Stenting and Endarterectomy in Patients With Stage 5 Chronic Kidney Disease: Insights of the Healthcare Cost and Utilization Project’s National Inpatient Sample

Background: Carotid artery stenting (CAS) has evolved into a viable alternative for the treatment of symptomatic and asymptomatic high-grade carotid artery stenosis, particularly in patients considered to be at a high surgical risk for carotid endarterectomy (CEA). Hypothesis: There is limited data on the outcomes of patients with stage 5 chronic kidney disease (CKD) (GFR&lt;15 mL/min/1.73 m 2 or dialysis) undergoing CEA or CAS. Methods: The Healthcare Cost and Utilization Project’s National Inpatient Sample was screened for hospital admissions of patients undergoing CAS and CEA from 2003-2012. Baseline clinical characteristics and outcomes were identified in patients with stage 5 CKD. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of in-hospital death, acute myocardial infarction and acute cerebrovascular accident (CVA). Results: Our study population consisted of 1,723 patients that underwent CEA and 544 patients that underwent CAS. Patients undergoing CAS were younger and had significantly lower rates of coronary artery disease, hypertension and hyperlipidemia. CAS patients experienced significantly higher rates of MACCE compared with patients that underwent CEA, mainly driven by a higher rate of in-hospital strokes (Fig. 1). In a multivariable analysis, CAS (OR 1.53, 95% CI 1.19-1.98) was an independent predictor of MACCE. Conclusions: In patients with stage 5 CKD (GFR&lt;15 mL/min/1.73 m 2 or dialysis ) undergoing internal carotid artery revascularization, CAS was associated with higher rates of in-hospital MACCE, driven by higher mortality and stroke rates when compared with CEA.

E-141 comparison of carotid endarterectomy and carotid stent revascularization of internal carotid artery pseudo-occlusion

Introduction The benefit of revascularization of internal carotid artery (ICA) pseudo-occlusion is not defined well, and the method of revascularization is controversial. There has been no comparison between carotid endarterectomy (CEA) and carotid stent (CAS) placement for pseudo-occlusion. The purpose of this study was to evaluate the safety of CEA and CAS and compare long term imaging and clinical follow up. Methods A retrospective database review was performed from 1/2010 to 1/2014 to identify patients who underwent carotid endarterectomy and carotid stent placement at two tertiary centers. The medical records and imaging studies of patients with ICA pseudo-occlusion were selected for analysis. Results 24 patients met the criteria for ICA pseudo-oclcusion, and 17 patients underwent CEA while 7 patients underwent CAS. All patients had technically successful revascularization of the ICA. All patients underwent 1 month and 1 year follow up imaging. CAS patients had 14% re-stenosis and 86% vessel maturation (defined as resolution of ICA hypoplasia) rates while CEA patients had 18% with re-stenosis and 88% vessel maturation. Peri-procedure complication for CAS was 0% and CEA was 6%. There were no deaths or strokes at 1 year in any patients. Conclusion CAS shows similar outcomes in restenosis and vessel maturation rates when compared to CEA for ICA pseudo-occlusion. There was no significant difference between the two treatments in clinical outcomes or peri-procedural complications. CAS is a revascularization option if the patient is considered high risk for CEA. Disclosures J. Kim: None. C. Miller: None. D. Damania: None. A. Grande: None. B. Jagadeesan: None. B. Jahromi: None. R. Tummala: None.

The Dotter method revisited: early experience with a novel method of rapid internal carotid artery revascularization in the setting of acute ischemic stroke

BackgroundTandem occlusive disease in the setting of acute ischemic stroke involving cervical and cerebral arteries has been associated with poor neurological outcome and poses significant challenges to neurointerventionists. Previously described...

Intracranial blood flow changes after extracranial carotid artery stenting.

Carotid artery stenting is an endovascular treatment option for patients with extracranial carotid stenosis. However, intracranial blood flow changes following stenting have not been established. To determine the effects of stenting on intracranial blood flow. Records of patients who underwent stenting at our institution between 2004 and 2012 and had flow rates obtained pre- and poststenting by the use of quantitative magnetic resonance angiography were retrospectively reviewed. Percentage stenosis, stenosis length, and minimum vessel diameter were measured from cerebral angiography images. Eighteen patients were included. Mean age was 65 years with 67% presenting with symptomatic stenosis. Degree of stenosis ranged from 60% to 90%. Internal carotid artery (ICA) mean flow improved significantly poststenting from 174.9 ± 83.6 mL/min to 250.7 ± 91.2 mL/min (P = .011). Ipsilateral middle cerebral artery (MCA) flow, however, was not significantly altered poststenting (107.8 ± 41.6 mL/min vs 114.3 ± 36.3 mL/min; P = .28). Univariate analysis revealed that improved minimum vessel diameter after stenting, but not percentage stenosis (P = .18) or stenosis length (P = .45), is significantly associated with increased ICA flow (P = .02). However, improved percentage stenosis, stenosis length, minimum vessel diameter, and ICA flow poststenting were not significantly associated with increased MCA flow (P = .64, .38, .13, .37, respectively). ICA flow was compromised at baseline, improving 43% on average poststenting. Increased minimum vessel diameter was the factor most significantly associated with increased flow. Conversely, MCA flow was not significantly compromised at baseline nor altered after stenting, suggesting compensatory intracranial collateral supply prestenting that redistributes following ICA revascularization.