Treatment Of Internal Carotid Artery Research Articles

Efficacy and safety of surgical treatment of patients with pathological tortuosity of the internal carotid artery

Of the study is to improve the results of surgical treatment in patients with pathological tortuosity of the internal carotid artery. The study included 119 patients (41 (34%) men and 78 (66%) women) with PI ICA aged 34 to 71 years (average age 53.2±7.5 years) divided into 2 groups. 64 patients (54%) of group I underwent BSA resection with lower mouth and 55 patients (46%) of group II underwent BSA prosthetics. Depending on the degree of neurological disorders, patients were distributed according to the classification of A.V. Pokrovsky. In the early postoperative period, TIA was noted in one patient, and transient lesions of the cranial nerves were observed in 5 patients. During 5 years of follow-up, none of the patients developed TIA, IS or other vascular events. In the early surgical period, there were no significant differences in effectiveness between the groups of patients. In the long-term period (5 years after surgery), a higher frequency of asymptomatic patients was noted in group I. Resection and replacement of a pathologically tortuous internal carotid artery (ICA) is a safe and effective surgical treatment. A multicenter randomized trial should be conducted to compare the effectiveness of surgical treatment of PI ICA with a conservative approach to effectively treat patients.

Abstract 1122‐000078: C‐Guard Stent for the Treatment of Cervical Internal Carotid Artery Aneurysms: Report of 2 Cases

Introduction : C‐Guard carotid stent is a self‐expandable open cell stent covered with a double‐layer mesh which was developed for the treatment of internal carotid artery disease. Lower procedural and complications rates, as well as lower post‐operative infarctions are some advantages of this device. Nevertheless, the use of C‐Guard in the treatment of cervical internal carotid artery (ICA) aneurysms is scarce. Therefore, we present two cases in which the C‐Guard stent achieved complete angiographic occlusion at follow‐up. Methods : We identified two cases in which the C‐Guard carotid stent was used to treat symptomatic cervical ICA aneurysms. Angiographic follow‐up was performed. Results : Case 1: 47‐yo female presented left‐sided motor deficit. CT showed ischemic areas in the right hemisphere and CTA demonstrated an unruptured aneurysm in the C1 segment of the right ICA. The patient started dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. A 6mm x 40 mm C‐Guard carotid stent was deployed without complications. One‐year follow‐up CTA showed complete obliteration of the aneurysm with reconstruction of the ICA. Case 2: 38‐yo male presented decreased left visual acuity. CTA and DSA showed an unruptured aneurysm in the C1 segment of the ICA. The patient started DAPT with aspirin and clopidogrel. A 7mm x 30 mm C‐Guard carotid stent was deployed without complications. Three‐month follow‐up DSA showed complete obliteration of the aneurysm with adequate filling of distal vessels. Conclusions : C‐Guard stent is a potential alternative to conventional carotid stents in the treatment of cervical ICA aneurysms with high obliteration rates at follow‐up.

Tandem Lesions in Anterior Circulation Stroke: Analysis of the German Stroke Registry-Endovascular Treatment.

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Effect of Carotid Siphon Anatomy on Aneurysm Occlusion After Flow Diversion for Treatment of Internal Carotid Artery Aneurysms.

Flow diversion (FD) is effective for treatment of intracranial internal carotid artery (ICA) aneurysms. To determine whether carotid siphon (CS) geometry influences the efficacy of FD when employed for ICA aneurysms. Outcomes of a consecutive series of patients with ICA aneurysms treated with FD were retrospectively reviewed. CS anatomy was quantified through measurement of the posterior, anterior, and anterosuperior bend angles in accordance with previously described methodology. The relationship of CS geometry to likelihood of incomplete aneurysm occlusion at 1 yr after treatment was assessed with multivariate logistic regression analysis. There were 167 ICA aneurysms in 164 patients treated with FD during the study period. The mean age of our cohort was 55.7 yr (standard deviation [SD]: 12.3) and a majority of patients were female (145/164, 86.8%). Anterior (47.4 degrees vs 8.5, P<.001) and anterosuperior bend angles (100.9 vs 76.5, P=.002) were significantly greater in aneurysms that required repeat FD after initial treatment. On multivariate logistic regression analysis, increasing patient age (unit odds ratio [OR]: 1.05, 95% confidence interval [CI] 1.01-1.08; P=.003) and anterior bend angle ≥-3.5 (OR: 2.47, 95% CI 1.04-5.86; P=.046) were associated with increased odds of incomplete aneurysm occlusion at 1 yr after treatment. These findings suggest that variations in CS anatomy may influence the efficacy of FD treatment and should be analyzed prior to offering FD for treatment of ICA aneurysms. Further investigation into the hemodynamic effects of CS geometry is warranted.

Preliminary application of one-step hybrid operation in the treatment of carotid artery occlusion

Objective: To evaluate the prognosis and surgical complication of the recanalization treatments for internal carotid artery (ICA) occlusion by using one-step hybrid carotid endarterectomy and endovascular surgery. Methods: Retrospective analysis was performed on the clinical data and follow-up data of 22 patients with occluded ICA treated by one-step hybrid surgery. Difference in Barthel score and occurrence of ischemic stroke were compared with surgical group and conventional group which was treated by oral taking anti-platelet drugs. Further, the complications were analyzed to evaluate the safety and effectiveness of the surgery. Results: The difference in ischemic event rate and Barthel scores improvement between the two groups were significant. Occlusive ICAs in 19 cases were recanalized successfully. The possibility of brain hyperperfusion related to the surgery was 10.5% (2/19) while the possibility of carotid artery cavernous fistula was 9.1% (2/22). We also observed rare dissecting ICA caused by the treatment (4.5%) and distal restenosis (5.3%). Conclusions: One-step hybrid carotid endarterectomy and endovascular surgery could help recanalize the ICA, improve the blood supply and improve the prognosis. It's a safe and effective treatment for ICA occlusion.

A Newly-Developed Flow Diverter (FloWise) for Internal Carotid Artery Aneurysm: Results of a Pilot Clinical Study.

We report the results of a pilot clinical study that evaluated the safety and efficacy of a newly-developed, retrievable flow diverter (FloWise; Taewoong Medical) for the treatment of internal carotid artery (ICA) aneurysm. A total of 10 patients were enrolled. Inclusion criteria were 1) unruptured aneurysm with a dome size of ≥ 8 mm and a neck size of ≥ 4 mm at the ICA, or 2) two or more unruptured aneurysms of any size able to be spanned by a single FloWise at the ICA. Co-primary effectiveness end points were technical success of FloWise placement, and a 50% or greater decrease in aneurysm volume at the 6-month follow-up angiogram. The primary safety end point was the new development of neurological deficits persisting for more than 1-month post-treatment. Ten patients harboring 14 ICA aneurysms (median diameter, 9.4 mm; range, 2.3-31.0 mm) were enrolled between January 2016 and July 2017. FloWise placement was successful in all patients. There were no newly-developed neurological deficits during the 6-month clinical follow-up period. One patient did not receive follow-up imaging due to pregnancy. Nine patients with 12 aneurysms received a 6-month angiographic follow-up. Ten aneurysms (83.3%) showed decreases in volume greater than 50% (mean volume decrease, 82.8 ± 32.9%), of which 8 (66.7%, 95% confidence interval, 35.4-98.0%) showed complete occlusion. One patient was retreated due to mass symptom aggravation. In this pilot study, FloWise appeared to be safe and effective for ICA aneurysm treatment. A prospective multicenter study to validate the effectiveness and safety of FloWise would be worthwhile.

EXPERIENCE OF EXTRACRANIAL-INTRACRANIAL BYPASS WITH USING MAXILLARY ARTERY

Objective is to present the first experience of creating extracranial-intracranial (EC-IC) bypass using the maxillary artery (MA) as an arterial donor for treatment of giant intracranial aneurysms (GIA), as well as for treatment of internal carotid artery (ICA) occlusion. Materials and methods. We performed EC-IC bypasses using MA at 4 patients: at 3 patients with GIA of the anterior part of the Willis circle (giant fusiform aneurysm of the М1 segment of middle cerebral artery (MCA), giant fusiform aneurysm of the supraclinoid part of ICA, giant ICA bifurcation aneurysm) and at patient with ICA occlusion. All patients with aneurysms had tumor-like clinical manifestation. Patient with ICA occlusion had crescendo ipsilateral MCA transient ischemic attacks. Creation of the traditional EC-IC bypass was impossible because of superficial temporal artery injury as result of prior surgery in other hospital. Results. We used transzygomatic pterional craniotomy, MA as a donor artery, M2 segment of MCA as a recipient artery and radial artery as an interposition graft in all cases. At patient with ICA occlusion surgical treatment included bypass creation, at all patients with GIA after bypass creation we performed aneurysm trapping (distal clipping of М1 segment at patient with MCA aneurysm, cervical ICA ligation at patient with supraclinoid ICA GIA, temporary trapping, thrombectomy and aneurysm clipping at patient with bifurcation ICA GIA). We confirmed bypass patency by intraoperative Doppler sonography and flowmetry and computed tomography or magnetic resonance imaging in postoperative period. In all cases bypasses were patent with flow 33–57 ml per min. Patient with ICA bifurcation GIA suffered from contralateral hemiparesis due to ischemia in anterior choroid artery territory in early postoperative period, which partially regressed at discharge. In other cases there were not any complications. Conclusion. EC-IC bypasses with using MA as a donor and radial artery as an interposition graft can provide sufficient replacement blood flow in the MCA territory in cases of giant cerebral aneurysms and in patients with occlusion of the ICA. This type of bypasses is less traumatic compared with high-flow bypasses. Given the shorter length and less tortuosity of the graft, its more secure localization, we can assume a lower risk of bypass thrombosis in the early and late postoperative periods and higher patency of the graft.

Real-world experience of treatment decision-making in carotid stenosis in a neurovascular board.

To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option. We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases. Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis. Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.

Efficacy and Safety of Willis Covered Stent for Treatment of Internal Carotid Artery Aneurysms

The purpose of this study was to evaluate the clinical and short-term outcome of patients who underwent covered stent treatment for internal carotid artery aneurysms. Twelve cases patients with internal carotid artery aneurysms were treated with Willis covered stents during the period from December 2010 to January 2016. The guiding catheter was placed as high as possible to facilitate the delivery of the covered stent system. Covered stent placement was successful in 11 of 12 case patients (91.6%), embolization was successful in 11 of 12 patients (91.6%), the treatment in 1 patient of 12 cavernous aneurysms patients was performed covered stents +ONYX + plastic coil embolization, and the other was used Willis covered stents. The results indicated that only 1 of 12 patients underwent postoperative massive cerebral infarction, but was successfully rescued. The angiographic following-up of patients using covered stent suggested that 12 cases patients were complete occlusion and the parent artery patency. Clinical follow-up results also demonstrated that clinical neurologic symptoms fully recovered in 11 of 12 cases patients, another case improved and were not aggravated in any patient before discharge and had aggravated symptoms. Willis covered stents are effective for treatment of internal carotid artery aneurysms with good safety and short-term outcomes.

Surgical Treatment of Residual Distal Intimal Flap during Eversion Carotid Endarterectomy

Eversion carotid endarterectomy (ECEA) is an effective surgical technique for the treatment of internal carotid artery (ICA) stenosis. However, a residual distal intimal flap may determine a higher rate of neurological complications. The treatment of DIF may be challenging, and no definitive approach has been described. We describe a simple surgical option for the treatment of DIF. After internal ECEA has been performed, stitches are positioned at the side of intimal flap. Suture sequence is performed from internal-external-external-internal artery wall including the everted ICA, maintaining the suture thread inside the vessel. Once the ICA is correctly repositioned, the suture thread is pulled out. Once the standard carotid anastomosis has been performed, the flap is finally tacked. Fifteen patients have undergone surgical repair of DIF with the modified technique. No patients developed neurological complications after the surgical procedure, and all patients are still alive at last follow-up visit. This simple technique seems a safe and feasible surgical option to correct DIF, avoiding challenging surgical procedures that may increase operative and clamping time.

POSSIBILITIES OF SURGICAL CORRECTION OF INTERNAL CAROTID ARTERY THROMBOSIS IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Objective. To estimate the efficacy of surgical treatment of internal carotid artery (ICA) thrombosis in patients suffered from acute ischemic stroke (AIS). Material and methods. Author operated 25 patients suffered from AIS and ICA thrombosis from 01 Feb, 2014 till 31 Aug, 2016 in Neurosurgical Department of N.V. Sklifosovsky Research Institute for Emergency Medicine. Among them, 15 patients had total thrombosis of ICA and were operated on, 10 patients had partial mural thrombosis or floating thrombus (6 patients were operated on). There were 7 thrombectomies with the removal of intima, 13 superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses, 1 ICA stent installation. Results. The excellent outcomes were seen in 7 (33.4%) patients, good outcomes — in 11 (52.3%) and satisfactory outcomes were observed in 3 (14.3%) patients. The improvement of functional deficit in the early post-operative period was 4.85 scores according to NIHSS, 1.2 scores according to Rankin scale and 2.3 scores according to Rivermead mobility index. The regress of neurological deficit was more significant among patients with severe focal disturbances; better outcomes were among patients operated on within first 3 days from an onset of the disease. There was no significant improvement among non-operated patients at the moment of discharge from hospital. Thrombectomy with the removal of intima performed in 2 (40%) patients with partial mural thrombosis was complicated by repeated thrombosis of ICA. The improvement of cerebral blood supply was verified in 16 (76.2%) operated patients according to the data of cerebral perfusion examination. Conclusions. The early surgical treatment is indicated for patients with acute total thrombosis of ICA. It is possible to perform STA-MCA bypass in case of inability to perform endovascular thrombextraction or open thrombectomy with the removal of intima. The conservative treatment is indicated for patients with partial mural thrombosis while urgent operation is necessary among patient with floating thrombus to decrease the risk of cerebral embolism.

Surgical Treatment of Complex Cerebral Aneurysms Using Interposition Short Vein Graft.

Cerebral revascularization strategies may become necessary in select patients who present with challenging cerebral aneurysms. In this study, we present the techniques of a moderate-flow extra-intracranial bypass using a short interposition vein graft and concurrent aneurysm management. The short interposition vein graft was used for the reconstruction of complex cerebral aneurysms in nine patients. In eight of them, the superficial temporal artery (STA) main trunk was used as a donor site for the anastomosis of a short interposition vein graft, and an extracranial vertebral artery (VA) was used in one case. The vein grafts were implanted into the M2 of the middle cerebral artery (MCA) for the adjunctive treatment of internal carotid artery (ICA) aneurysms in three patients, into the A3 of the anterior cerebral artery (ACA) in one patient, into the P2 of the posterior cerebral artery (PCA) for the adjunctive treatment of complex PCA aneurysms in three patients, into the P3 of the PCA for the adjunctive treatment of a basilar artery (BA) trunk giant aneurysm in 1 patient, and into the postero-inferior cerebellar artery (PICA) for the adjunctive treatment of the VA dissecting aneurysm in one patient. All of the bypasses were patent. Intraoperative flow measurements confirmed a moderate flow-carrying capacity of the short interposition short vein graft (30-70 ml; mean: 43 ml/min). The STA main trunk to proximal MCA/PCA bypass and the extracranial VA to PICA bypass using short interposition vein grafts can provide sufficient blood flow and may be a reasonable alternative to the conventional EC-IC bypass/high-flow bypass.

Endovascular Management of Iatrogenic Vascular Injury in the Craniocervical Region.

To evaluate iatrogenic vascular injuries in the craniocervical region and their endovascular management. Twenty-one patients (9 women, 12 men) with a mean age of 53.6 years (range 16-87 years), who underwent endovascular embolization for iatrogenic vascular injury in the craniocervical region between December 2000 and October 2015, were included in this retrospective study. Types of iatrogenic injuries, etiologies that caused these injuries and details of endovascular managements were reported. The etiologies of the vascular injuries were as follows: transsphenoidal surgery (n=9), skull-base surgery (n=2), cholesteatoma surgery (n=1), tracheostomy (n=2), central venous catheterization (n=2), oropharyngeal tumor operation (n=1), endovascular treatment of internal carotid artery (ICA) stenosis (n=1), suprasellar epidermoid tumor operation (n=1), sphenoid sinus tumor surgery (n=1), and speech prosthesis device placement (n=1). The types of vascular injuries diagnosed at the time of angiography were; 2 occlusions, 2 stenoses, 2 dissections, 1 carotid cavernous fistula, 8 artery rupture with extravasation, and 9 pseudoaneurysms. Endovascular management of these vascular injuries were; parent artery occlusion (PAO) (n=15), aneurysm occlusion (n=3), covered stent (n=1) and conservative management (n=2). All patients except two were successfully treated. No patient had bleeding within a 30-day period after angiography. Long-term follow-up was available in all patients without occurrence of re-bleeding. One patient died due to complications related to primary vascular injury. Although iatrogenic vascular injuries are rare, early diagnosis and management may be lifesaving. Endovascular techniques are reliable and safe in most of the patients.

Impact of Endovascular Technique on Fluoroscopy Usage: Stent-Assisted Coiling versus Flow Diversion for Paraclinoid Internal Carotid Artery Aneurysms.

Flow diversion is increasingly being utilized for the treatment of internal carotid artery (ICA) aneurysms. The purpose of this study was to evaluate the impact of endovascular technique--flow diversion versus stent-assisted coiling (SAC) on fluoroscopy time in patients treated for wide-neck paraclinoid ICA aneurysms. A retrospective review identified the 20 most recent consecutive patients treated for wide-neck paraclinoid ICA aneurysms by flow diversion and SAC respectively. Fluoroscopy time, cumulative dose area-product (DAP), contrast usage, intra-procedural complications, and total procedure time were collected and compared between the two treatment techniques. Treatment groups were comparable in terms of demographics, contrast usage, and clinical and angiographic outcomes. Flow diversion was associated with a significant reduction in fluoroscopy time (52.0 minutes versus 77.4 minutes), and demonstrated a strong trend towards shorter total procedure time (172 minutes versus 202 minutes). Average patient radiation exposure as measured by DAP was lower in the flow diversion group, 13225 mGy(x)cm(2) versus 15124 mGy(x)cm(2), although this finding was not statistically significant. There was no significant difference in contrast usage between the two groups, 152 ml and 159 (flow diversion and SAC respectively). The rate of complete aneurysm occlusion was higher in the flow diversion group (80% versus 60%). Endovascular treatment of paraclinoid ICA aneurysms with flow diversion is associated with shorter fluoroscopy times compared to stent-assisted coiling. There is also a likely reduction in overall procedure time. These results should be considered when recommending a treatment course for patients with such lesions.

Peri-procedural outcome of series of 104 carotid artery stenting procedures

Abstract Background Management of carotid artery stenosis is considered an important strategy for stroke prevention. Carotid artery stenting (CAS) has been introduced as an acceptable alternative to surgical carotid endarterectomy (CEA) in the treatment of internal carotid artery (ICA) stenosis. Objective Assessment of peri-procedural outcome of CAS in 104 consecutive procedures. Methods The study included 104 consecutive CAS procedures. Included patients had ⩾50% ICA stenosis in the symptomatic group and ⩾70% stenosis in the asymptomatic group. Procedures were performed in cath. labs of Catania and Ragusa hospitals-Italy. Results Included procedures were done in 100 consecutive eligible patients with ICA stenosis. Four patients had undergone CAS procedures in both sides in 2 separate sessions. Patients were 71 males and 29 females, mean age was 71.9 ± 7.85 years, and 21 patients were ⩾80 years old (octogenarians). The majority of patients had asymptomatic ICA stenosis (76%) and was diagnosed accidentally during medical checkup. Twenty-four patients had symptomatic ICA stenosis (ipsilateral TIA or stroke). Technical success was obtained in 103 procedures (99%). Embolic protection devices were used in all succeeded cases. Combined cerebrovascular events had occurred in 5 patients with estimated rate = 4.8%. No cases of amaurosis fugax, MI or death had occurred. Adverse events was 4.1% in the symptomatic group and 1.3% in the asymptomatic group with no significant statistical difference ( P = 0.064). Conclusion CAS with EPDs seems a feasible and safe procedure and could be performed with an acceptable rate of periprocedural adverse events.

E-042 Case Based Review of the Pathophysiology of Internal Carotid Artery Pseudoaneurysm Coil Migration

Learning ObjectivesReview the pathophysiology and risk factors of internal carotid artery (ICA) pseudoaneurysm formation.Evaluate imaging of coil migration following endovascular treatment of internal carotid artery pseudoaneurysm.Discuss treatment options of coil...

高位病変CEAに対する3D-CTA＋2D-CT合成画像支援の有用性と限界

Carotid endarterectomy (CEA) is a standard treatment for internal carotid artery (ICA) stenosis. The level of carotid bifurcation of Japanese is reportedly higher than that of Europeans. Therefore, it is somewhat difficult to develop an operative field on the distal side of ICA stenosis. We conducted of this study to clarify the usefulness and feasibility of 3D-CTA and 2D-CT imaging using 16-raw CT for CEA with a high-positon ICA stenosis. Between 2006 and 2010, 51 CEAs for 50 consecutive patients with ICA stenosis were performed in our institutes. Thirteen of these were high-position ICA stenosis. For CEA with high-position ICA stenosis, we tried to visualize the anatomical structures of the retromandibular space using 3D-CTA with 2D-CT, which is perpendicular to the operative approach, at the three depths of the sternocleidomastoid muscle, jugular vein, and carotid bifurcation. In all 13 patients, the parotid gland, jugular vein, and plaque position could be visualized. However, in one of the 13 patients, the distal side of the ICA stenosis could not be visualized, and we unexpectedly needed to cut the occipital artery, and in six of the 13 patients, the common facial vein could not be observed. In the last 10 patients, the MRI diffusion image revealed no additional ischemic lesion. In our series, no persistent morbidity or mortality was observed. Preoperative simulation using 3D-CTA+2D-CT might be useful for CEA with high-position ICA stenosis, despite the limitation of the visualization of the common facial vein.

Internal Carotid Artery Stenting in Patients over 80 Years of Age: Single‐Center Experience and Review of the Literature

Thirty percent to 40% of strokes in the elderly are secondary to carotid bifurcation disease. The treatment of internal carotid artery (ICA) stenosis in this patient population is a clinical dilemma. Age more than 80 years is a risk factor for carotid endarterectomy (CEA). Carotid artery stenting (CAS) may be also associated with increased peri-procedural complications in this age group. This study was a single-center, retrospective database analysis evaluating CAS in patients more than 80 years old. Primary outcome included death, myocardial infarction (MI), or ipsilateral stroke. Secondary outcome included re-stenosis at 30 days, 6 months, and 1-year post-procedure. Between March 2001 and March 2004, CAS was performed in 178 patients. Twenty-four patients were more than 80 years old (range 80-91), and 16 men, 70.8%, were symptomatic. Success rate was 100% with residual stenosis of <20%. At the 30 days follow-up there was 1 non-Q wave MI (4.2%), 1 transitory ischemic attack (TIA), and 1 femoral occlusion in the symptomatic group. There were no deaths at 1-year follow-up evaluation as well as no ICA re-stenosis. CAS can be performed in patients more than 80 years old. Complications may be higher than in younger patients. However, because of the high prevalence of stroke in octogenarians, randomized trials should include this patient population.

Competitive strategies for surgery in the treatment of primary internal carotid artery (ICA) stenosis

BACKGROUND: Surgery remains the gold standard in the treatment of internal carotid artery (ICA) stenosis. In the last 10 years endovascular treatment of ICA lesions by carotid artery stenting (CAS) has become increasingly popular. The aim of this study is to assess the arguments of carotid endarterectomy (CEA) adversaries (increased physical stress for the patient, complicated procedure, higher mortality, etc.) and to present modern strategies, by which CEA as competitive treatment modality is able to withstand the current trend towards endovascular management of ICA stenosis. METHODS: Medline (1995–2007) and Cochrane Electronic Databases (2007) were searched for prospectively randomized publications, dealing with surgical and endovascular treatment of ICA stenosis. The results have been evaluated in terms of a meta-analysis and compared according to their different domains (mortality, stroke rate, complications, hospital stay, and costs). Corresponding to these data strategies for successful and safe carotid surgery have been developed. RESULTS: Whereas CEA has proved its efficacy in the treatment of ICA stenosis by large randomized multicenter trials, same Level I data are lacking on endovascular management. Some studies comparing CEA with CAS had to be terminated prematurely because of significant higher rates of neurological complications in the CAS arm. At present there exist no prospectively randomized trials which favour CAS over CEA. CONCLUSIONS: Eversion CEA as fast, safe, relatively easy, and economic procedure in locoregional anesthesia fulfils most demands of modern and competitive surgery. Additionally the length of hospital stay can be reduced significantly. Endovascular treatment of ICA stenosis represents an alternative to CEA only in patients with recurrent ICA stenosis and with hostile necks.

Carotid artery dissection: Endovascular treatment. Report of 12 patients

The purpose of this article is to report our experience with endovascular treatment of internal carotid artery (ICA) dissection with the use of stents. Carotid dissection is an important cause of ischemic stroke in young and middle-aged patients. There are some patients in whom invasive management is recommended. Twelve patients (eight females, four males), mean age of 50 years (range 35-80 years) with ICA dissection, were treated with the endovascular approach during a 24-month period. Patients included in this study underwent magnetic resonance (MR) and digital subtraction angiography (DSA) for diagnosis. Over this time period, 162 patients with ICA dissections were seen at our institution. Indications for endovascular treatment were: recurrent ischemic events despite adequate anticoagulant treatment in seven cases, contraindication to anticoagulation in four cases, and one case with significant mismatch between diffusion and perfusion weighted MR. Eleven dissections were spontaneous and one was traumatic. The follow-up was performed clinically with Doppler ultrasound (US) and MR at 6, 12, and 24 months. Stent deployment was successful in all cases. Acute symptoms were resolved in 66.7% of patients. No patients deteriorated their neurological status. There were no new clinical events, stent stenosis or occlusion on 24 months follow-up. Our results showed an excellent clinical outcome of the treated patients. This suggests promising results with the use of endovascular treatment in selected patients.