Carotid Artery Stent Placement Research Articles

Usefulness of Hybrid Surgery Combining CEA and CAS for Carotid Artery Stenosis with a Large Amount of Vulnerable Plaque.

For carotid artery stenosis with a large amount of vulnerable plaque in a wide range, we performed a hybrid surgery combining carotid endarterectomy (CEA) and carotid artery stenting (CAS), and report the results of treatment. Surgical treatment for carotid artery stenosis in 216 patients was performed between January 2016 and June 2018. Of these, 15 patients were treated in a hybrid operating room because both CEA and CAS were judged to be risky. We treated these patients with preparation of stenting for remote lesions far from the CEA arterial incision. The perioperative treatment results were retrospectively examined. Of the 15 patients treated in a hybrid operating room, 10 were stented after CEA. All these cases were treated by retrograde stent placement in the proximal common carotid artery (CCA). Treatment was completed in all patients, and no cerebral infarction, myocardial infarction, or death was observed in the perioperative period. There were no cases of additional neurological events during the follow-up period, but asymptomatic restenosis was observed in one patient. Hybrid surgery combining CEA and CAS was considered to be an effective treatment for carotid artery stenosis with a large amount of vulnerable plaque.

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

ABSTRACTBACKGROUND AND PURPOSEThe effect of coronavirus disease 2019 (COVID‐19) pandemic on performance of neuroendovascular procedures has not been quantified.METHODSWe performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January‐April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID‐19 cases per 100,00 population‐into high and low prevalent regions.RESULTSBetween 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID‐19 prevalent regions. The procedural volume reduction was mainly observed in March‐April 2020.CONCLUSIONSWe provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

Intentional Stent Stenosis to Prevent Hyperperfusion Syndrome after Carotid Artery Stenting for Extremely High-Grade Stenosis

Intracranial hemorrhage due to hyperperfusion syndrome is a severe carotid artery stent placement complication of extremely high-grade stenosis, causing hemodynamic insufficiency. To prevent hyperperfusion syndrome, we attempted intentional residual stent stenosis and implemented "gentle" carotid artery stent placement, defined as carotid artery stent placement using a closed-cell stent coupled with slight balloon predilation, without balloon postdilation. Gradual stent expansion was expected. We investigated the incidence of hyperperfusion syndrome and long-term outcomes after gentle carotid artery stent placement.We included patients who underwent carotid artery stent placement for extremely high-grade stenosis from January 2015 to March 2019. We defined extremely high-grade stenosis as carotid stenosis with conventional angiographic "slow flow" and a reduced MCA signal intensity on MRA. A reduced MCA signal intensity was defined as MCA with a relative signal intensity of <0.9 in the ipsilateral compared with the contralateral MCA. We evaluated the stent diameter, CBF on SPECT, hyperperfusion syndrome, and intracranial hemorrhage. We defined hyperperfusion syndrome as a triad of ipsilateral headache, seizure, and hemiparesis.Twenty-eight of the 191 patients met our inclusion criteria. After carotid artery stent placement, their median minimal stent diameter was 2.9 mm, which expanded to 3.9 mm at 4 months. Neither cerebral hyperperfusion syndrome nor intracranial hemorrhage occurred.The gentle carotid artery stent placement strategy for intentional residual stent stenosis may prevent hyperperfusion syndrome in high-risk patients. Stents spontaneously dilated in 4 months.

Use of Cangrelor in Cervical and Intracranial Stenting for the Treatment of Acute Ischemic Stroke: A "Real Life" Single-Center Experience.

In cases of large-vessel-occlusion strokes due to an underlying tandem internal carotid artery occlusion or intracranial atherosclerotic disease, concomitant stent placement may be needed. Immediate platelet inhibition is necessary, but to date, a standardized approach for antiplatelet inhibition in acute settings is still missing. Here we report our single-center experience about the safety and efficacy of periprocedural administration of cangrelor in patients with acute ischemic stroke due to intracranial or cervical artery occlusion undergoing stent placement. We retrospectively evaluated all cases of acute ischemic stroke that needed acute stent implantation and were treated with periprocedural administration of cangrelor between January 2019 and April 2020 at our institution. All patients who needed either extracranial or intracranial artery stent placement (in either the anterior or posterior circulation) were included. We evaluated 38 patients in whom cangrelor was administered IV periprocedurally. Their mean age was 64 years (range, 26-85 years), with 25/38 male subjects and 13/38 female patients. In 26 patients (68.4%), a tandem occlusion was present and was treated with carotid artery stent placement, while 12 patients (31.6%) required an intracranial stent implantation. In 4 subjects (10.5%), an intracerebral hemorrhage occurred after the procedure. All patients in the series were alive 1 week after the procedure. Although larger, multicentric randomized studies are strongly warranted, our results support the hypothesis of a possible role of cangrelor as a valuable therapeutic option in the management of platelet inhibition in acute ischemic stroke procedures after intra- or extracranial stent placement.

Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease.

Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience. The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events. Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%. TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02536378.

Impact of Positive Stress Test on Postoperative Cardiac Events in Patients Undergoing Elective Carotid Revascularization

The purpose of this study is to explore the impact of postoperative cardiac events in patients undergoing elective carotid revascularization by three different modalities namely carotid endarterectomy (CEA), femoral access carotid artery stent (CAS) and open carotid stent placement (TCAR).

Relevance of Distal Arterial Collapse in Stenting of Atherosclerotic Near-Occlusion of the Carotid Artery.

Carotid near-occlusion has been subclassified into near-occlusion with and without collapse. We aimed to compare the technical success and perioperative complication rates of carotid artery stent placement with special attention to these subtypes to see whether there is a clinical relevance of this subclassification. From January 2014 to January 2018, we retrospectively evaluated all patients with atherosclerotic extracranial carotid stenosis treated by carotid artery stent placement. Patients with near-occlusion were identified based on DSA findings. Patient characteristics, the presence of criteria for near-occlusion and collapse, arterial diameters, technical success rate, and perioperative (≤30 days) complications were analyzed. We identified 59 near-occlusions in 58 (46 men, 11 with collapse) patients. Forty-one patients (70.7%) were symptomatic. Technical success rate was 98.3% (58 of 59 procedures). In 1 case of near-occlusion with collapse, we were not able to pass through the stenosis. Compared with patients without collapse (4.2% of 48 cases), those with collapse (30% of 10 stented patients) had significantly higher rates of postintervention hyperperfusion syndrome (P = .032). In the whole cohort, the permanent morbidity and mortality rate was 3.4% (1.7% permanent morbidity and 1.7% mortality). For asymptomatic and symptomatic near-occlusion groups, the rates were 0% and 4.9%, respectively. The composite risk of stroke, death, and myocardial infarction was similar between the groups with and without collapse (P = .682). Rate of hyperperfusion syndrome (with or without permanent deficit) was similar (P = 1) in preoperatively symptomatic patients versus asymptomatic patients (9.8% vs 5.9%). Internal carotid artery diameter consistently increased after carotid artery stent placement in patients with collapse and was not related to the development of hyperperfusion syndrome. Care should be taken to minimize hyperperfusion risk in patients with near-occlusion undergoing CAS, especially in the subgroup of patients with collapse and in patients with both symptomatic and asymptomatic carotid stenosis.

Carotid Artery Stent Placement via Radial Arterial Route (5529)

Carotid Artery Stent Placement via Radial Arterial Route (5529)

Abstract TP127: Periprocedual Risk of Treatment for Carotid Stenosis Complicated With Cardiac Disease - J-ASPECT Study

Background and Purpose: Heart disease is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS). However, the outcomes of patients with heart disease who were treated with CEA/CAS have not been fully examined. We investigated the impact of heart disease on outcomes of CEA and CAS in general practice using the Japanese nationwide data from J-ASPECT study. Methods: We analyzed data from 23,366 patients of CEA or CAS (CEA 8,514, CAS 14,809) who had been hospitalized in the period from April 2012 to March 2017. We extracted data from the Japanese nationwide DPC database for patients who underwent CEA or CAS which were identified from procedural coding with Japanese original K-codes (CEA: K6092, CAS: K609-2). For further categorization of carotid artery stenosis patients with or without heart disease, we used the ICD-10 code (ischemic heart disease, valvular disease cardiomyopathy, conduction disturbance, cardiac arrhythmia, atrial fibrillation/atrial flutter and heart failure) to identify the presence of heart disease. Outcome (death within 30days) was compared between the patient who underwent CEA or CAS and patient with or without heart disease after adjustment for patient characteristics by using the logistic regression analysis. Results: Of the patients who underwent CAS or CEA, 2495 (29.3%) in CEA and 3930 (26.5%) in CAS were complicated with heart disease. Heart disease was not associated with the risk of death within 30days in both patients undergoing CEA (OR, 1.38; 95% CI, 0.54-3.55, p=0.5) or CAS (OR, 1.42; 95% CI, 0.93-2.16, p=0.099). Among heart disease, valvular disease was associated with increased the risk of death within 30days in patients undergoing CEA (OR, 6.71; 95% CI, 1.89-23.77, p=0.0032) and CAS (OR, 2.94; 95% CI, 1.05-8.20, p=0.004) after adjustment for potential confounders. Especially of the patients with valvular disease, aortic valve disease was significantly increased the risk of death within 30days (CEA: OR, 11.2; 95% CI, 3.13-39.8, p=0.0002, CAS: OR, 3.53; 95% CI, 1.07-11.6, p=0.038). Conclusion: Patients who were complicated with valvular disease, especially aortic valve disease had a high risk of death within 30 days after CEA or CAS.

Abstract TP467: Effects of the Tortuosity of the Cervical Internal Carotid Artery on Procedural Outcomes of Stent Placement

Introduction: Severe tortuosity of the cervical internal carotid artery distal to the stenosis may prevent successful placement of distal protection device and increase the risk of dissection and/or ischemic stroke. Objective: To assess and categorize the effects of tortuosity of the cervical internal carotid artery distal on procedural times, and peri-procedural complications in patients treated with carotid artery stent placement. Material and Methods: We analyzed the angiographic images and clinical data for a consecutive series of patients treated with stent placement over an 18-month period and graded the tortuosity as follows: Grade 0 is no vessel turns; Grade 1 (MILD) is 1 vessel turn, &gt;90 degrees; Grade 2 (MODERATE) is 1 vessel turn, ≤90 degrees; Grade 3 (SEVERE) is 2 vessel turns, any angle; Grade 4 (SEVERE) is two vessel segments which are parallel to due to interspersed loop; Grade 5 (SEVERE) is a complete vessel loop (360 degrees). Technical complications including unsuccessful attempts to cross the stenosis with interventional devices, unutilized distal embolic protection, iatrogenic dissection, and ischemic events were ascertained. Results: A total of 80 patients were identified who underwent stent placement; mean (SD) 67.4 (8), 60 (75%) were men. Forty-three patients (53.8%) had evidence of stroke on non-invasive imaging prior to stent placement. In sixty-five cases, stent placement was performed electively (81.3%), emergently in fifteen cases (18.8%). The tortuosity was graded as 1 (46.2%), 2 (11.3%), 3 (15%), 4 (6.3%), and 5 (2.5%). Of the 80 patients, eighteen (22.5%) had severe tortuosity of grade 3 or higher. Mean procedural time (SD) was significantly greater with severe vessel tortuosity compared to mild to moderate vessel tortuosity (51.6 (6.2) versus 42.3 (5.2) minutes, p=.042). Technical complication rates were not significantly different with severe vessel tortuosity compared with mild to moderate vessel tortuosity (7% vs 9% p=.53). One intra-procedural dissection occurred in a case of severe tortuosity (grade 5). Conclusions: Severely tortuous internal carotid arteries distal to the stenosis can be seen in one fifth of patients undergoing carotid stent placement and is associated with increased procedural times.

Asymptomatic Cerebral Vasoconstriction after Carotid Artery Stenting.

Carotid artery stent placement is widely performed for treatment of carotid stenosis. The purpose of this study is to present our observations on cerebral vasoconstriction in ipsilateral anterior circulation during immediate poststenting angiography in patients with near-total occlusion of the proximal ICA. We retrospectively reviewed patient data from December 2008 to December 2018. There were 28 patients with carotid near-total occlusion. Two neuroradiologists reviewed the final cerebral angiographic finding of carotid artery stent placement to evaluate the presence of vasoconstriction or vasodilation. A total of 28 patients with near-total occlusion (mean ± standard deviation age, 69.0 ± 6.5 years; 92.9% male) were analyzed. Ten patients showed vasoconstriction in the treated territory, and 18 patients did not show vasoconstriction after carotid artery stenting. There were no statistically significant differences in comorbidity, frequency of symptomatic lesions, antiplatelet medication, mean procedure time, and initial NIHSS and baseline modified Rankin scale scores between the 2 groups. However, vasoconstriction is more likely to happen in patients with isolated territory from the contralateral anterior and posterior circulation (66.7% in the isolated territory group and 12.5% in the not-isolated territory group; P < .05). No headache or neurologic deficit was noted in all 10 patients with cerebral vasoconstriction. Cerebral vasoconstriction may occur after carotid artery stenting more frequently than expected. It occurs more frequently in patients with near-total occlusion and with isolation of the cerebral circulation. A large-scale study is necessary to assess the clinical implications of cerebral vasoconstriction after carotid artery stenting.

The learning curve of transcarotid artery revascularization

BackgroundIn the pivotal U.S. Food and Drug Administration approval trial, ROADSTER, transcarotid artery revascularization (TCAR) using the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical Inc, Sunnyvale, Calif) was shown to have one of the lowest reported complication rates, not only for carotid artery stent placement, but also for any carotid intervention, including endarterectomy. The number of cases required for a surgeon to gain the proficiency to realize these outcomes has not been studied. Our objective was to determine the learning curve for vascular surgeons performing the TCAR procedure. We examined the effect of surgeon procedural experience on intraoperative data and postoperative outcome. MethodsThis retrospective review analyzed data from a prospectively maintained database of 188 consecutive patients from three large academic centers who underwent TCAR. Procedures were ordered chronologically for each surgeon and grouped into bins of five. Operative times and flow reversal times were analyzed by analysis of variance. Results led to comparison of surgeons' early experience (cases 1-15) with their later experience (cases 16-50). The primary outcome was postoperative stroke and death. ResultsThe mean procedural time for all cases was 75.0 ± 23.8 minutes. When the procedural time of cases 1 through 15 (mean, 79.0 ± 28.3 minutes) were compared with cases 16 through 50 (mean, 71.8 ± 19.0 minutes), a significant difference was noted (P = .02). The mean flow reversal time was 10.6 ± 6.8 minutes. When flow reversal times were compared using analysis of variance testing, cases 1 through 15 were statistically similar and cases 11 through 50 were also similar, but the two groups differed from each other (P < .001). For flow reversal, cases 1 through 15 had mean reversal times of 13.3 ± 8.8 minutes compared with 8.5 ± 3.5 minutes for cases 16 through 50 (P < .001). Postoperative stroke rates were similar in the 1 through 15 and 16 through 50 case groups (2.4% vs 1.0%; P = .59), as were death rates (0.0% vs 1.0%; P > .99). The combined stroke/death rates were also comparable at 2.4% in the early cohort vs 1.9% in the late cohort (P > .99). ConclusionsThere seems to be a relatively short learning curve for the TCAR procedure. After 15 cases, surgeons are able to reduce procedural decrease by 10% (from 79.0 to 71.8 minutes), and flow reversal times by an average of 40% (from 13.3 to 8.5 minutes). More important, the rates of stroke and death do not differ between early and late experience with TCAR. The TCAR procedure may be quickly and safely adopted by vascular surgeons for carotid intervention.

Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment After Stroke: Early and 12-Month Outcomes in a Comprehensive Stroke Center

Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment After Stroke: Early and 12-Month Outcomes in a Comprehensive Stroke Center

Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke—Early and 12-Month Outcomes in a Comprehensive Stroke Center

PurposeTo compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center. Materials and MethodsRetrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed. ResultsSixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P = .08). Complication rates were similar between groups. mRS scores showed a significant improvement over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A subanalysis in patients with NIHSS scores ≥ 4 showed no differences in complication rate and outcome. ConclusionsCAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced centers, even after major atherosclerotic stroke.

Medical Therapy for Asymptomatic Patients and Stent Placement for Symptomatic Patients Presenting with Carotid Artery Near-Occlusion with Full Collapse

PurposeTo report long-term results of stent placement and medical therapy for symptomatic and asymptomatic patients, respectively, with carotid artery near-occlusion with full collapse. Materials and MethodsBetween January 2008 and December 2010, 204 carotid arteries diagnosed by duplex scanning as exhibiting complete occlusion were re-examined with CT angiography; 46 arteries in 46 patients were patent with threadlike lumens and were reclassified as exhibiting near-occlusion with full collapse. Asymptomatic patients (n = 22) received best medical therapy (BMT) alone, and symptomatic patients (n = 24) were referred for carotid artery stent (CAS) placement plus BMT. Patients underwent clinical follow-up for 63.9 months ± 23.6 and duplex surveillance. ResultsNone of the 22 asymptomatic patients treated with BMT alone experienced neurologic events during the follow-up interval. Four died of unrelated causes, resulting in a cumulative survival rate of 81.8%. Technical failure occurred in 5 of 24 symptomatic patients, but none had perioperative complications related to inability to cross the near-occlusion. Of the 19 patients with procedural success, 1 developed immediate upper limb monoparesis; none had periprocedural myocardial infarction, and none died. At 60-month follow-up, patients who underwent successful CAS placement had neurologic event–free and cumulative survival rates of 89.4% and 89.4%; patients with failed recanalization had neurologic event–free and cumulative survival rates of 0% and 40.0% (P = .01). ConclusionsAsymptomatic patients with carotid near-occlusion with full collapse experienced good outcomes with BMT alone. Symptomatic patients who underwent CAS placement demonstrated long-term survival and freedom from neurologic event rates comparable to those of asymptomatic patients.

Utility of carotid-enhanced ultrasonography for evaluating stent thrombosis after carotid artery stent placement

Utility of carotid-enhanced ultrasonography for evaluating stent thrombosis after carotid artery stent placement

Outcomes of mini-incision eversion carotid endarterectomy combined with nontouch isolation technique of the internal carotid artery

ObjectiveWe developed a mini-incision eversion carotid endarterectomy (CEA) procedure (the Jikei method CEA) to prevent perioperative embolic stroke. The aim of this study was to retrospectively analyze perioperative and midterm outcomes after the Jikei method CEA. MethodsWe evaluated patients with the Jikei method CEA at our institution between January 2006 and June 2014. The primary end point was a major adverse event, which included death, stroke, intracranial hemorrhage, and myocardial infarction, within 30 days of CEA. Secondary end points were postoperative ipsilateral stroke and restenosis. ResultsWe retrospectively studied 120 lesions in 110 patients. The mean age was 72.2 ± 8.0 years. With regard to the 120 lesions, 56 lesions (46.7%) were symptomatic and 73 lesions (60.8%) showed ≥90% severe stenosis. The mean length of the skin incision was 3.2 ± 0.5 cm. The mean operative time, volume of blood loss, and internal carotid artery clamp time were 171.0 ± 50.7 minutes, 161.6 ± 110.8 mL, and 35.7 ± 10.8 minutes, respectively. There were three perioperative major adverse events (2.5%), including two strokes (1.7%) and one intracranial hemorrhage (0.8%) resulting from hyperperfusion syndrome. The median postoperative hospital stay was 6 days (range, 2-303 days). The mean follow-up was 3.9 ± 2.2 years. There was no case of ipsilateral stroke during the follow-up period. The freedom from ipsilateral stroke at 5 years was 98.3%. Three lesions (2.5%) developed restenosis. The freedom from restenosis was 97.2% at 5 years. The freedom from reintervention at 5 years was 99.0% because carotid artery stent placement was necessary in one patient with severe restenosis. ConclusionsThe Jikei method CEA was safe and effective in preventing perioperative and midterm stroke.

The correlation of carotid artery structure characteristics and residual stenosis after stenting

Objective To analyze the correlation of characteristics of carotid artery structure and the incidence of residual stenosis after carotid artery stent (CAS) placement and its influencing factors using color Doppler flow imaging (CDFI). Methods Five hundred and ninety-six cases from January 2013 to December 2015 who underwent CAS (600 pieces of stent) were included in this study. All patients were examined by CDFI within 1 month before and 1 week after carotid artery stenting. The incidence of residual stenosis was analysed. The correlation of residual stenosis and the characteristics of carotid artery lesions and atherosclerotic plaque before stenting were analyzed respectively. Results There was positive correlation between the incidence rates of residual stenosis and irregularly shaped plaque (odd ratios, 9.02; 95% confidence interval, 5.21-15.59, P<0.05), the plaques with calcification in the surface(odd ratios, 2.55; 95% confidence interval, 1.45-4.49, P<0.05), the residual diameter of carotid stenosis less than 1.0 mm(odd ratios, 1.61; 95% confidence interval, 1.06-2.45, P<0.05), which were the independent risk factors for influencing residual stenosis after CAS. Conclusions Choosing a more adaptable stent based on the characteristics of carotid artery lesions and atherosclerotic plaque by CDFI before stenting may be useful for the patients to get best result of revascularization. The rate of residual stenosis may be decreased. Key words: Ultrasonography, Doppler, color; Carotid stenosis; Residual stenosis; Rish factors

Selective-versus-Standard Poststent Dilation for Carotid Artery Disease: A Systematic Review and Meta-Analysis.

The safety and efficacy of standard poststent angioplasty in patients undergoing carotid artery stent placement have not been well-established. We conducted a systematic review of the literature to evaluate the safety and efficacy of carotid artery stent placement and analyzed outcomes of standard-versus-selective poststent angioplasty. A systematic search of MEDLINE, EMBASE, Scopus, and the Web of Science was performed for studies published between January 2000 and January 2015. We included studies with >30 patients describing standard or selective poststent angioplasty during carotid artery stent placement. A random-effects meta-analysis was used to pool the following outcomes: periprocedural stroke/TIA, procedure-related neurologic/cardiovascular morbidity/mortality, bradycardia/hypotension, long-term stroke at last follow-up, long-term primary patency, and technical success. We included 87 studies with 19,684 patients with 20,378 carotid artery stenoses. There was no difference in clinical (P = .49) or angiographic outcomes (P = .93) in carotid artery stent placement treatment with selective or standard poststent balloon angioplasty. Both selective and standard poststent angioplasty groups had a very high technical success of >98% and a low procedure-related mortality of 0.9%. There were no significant differences between both groups in the incidence of restenosis (P = .93) or procedure-related complications (P = .37). No comparison to a patient group without poststent dilation could be performed. Our meta-analysis demonstrated no significant difference in angiographic and clinical outcomes among series that performed standard poststent angioplasty and those that performed poststent angioplasty in only select patients.

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience.

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.