Carotid and cerebral angiography performed by cardiologists: cerebrovascular complications

Complications of Diagnostic Carotid/Cerebral Arteriography when Performed by a Vascular Surgeon

Carotid stenting has recently been considered as an alternative treatment to carotid endarterectomy for certain patients with carotid stenosis. Hence, performing carotid arteriography with minimal morbidity and mortality is essential. The purpose of this study was to audit complications of diagnostic carotid/cerebral arteriography performed by a vascular surgeon with experience in endovascular interventions. One hundred one consecutive patients underwent 4-vessel arch aortography with selective carotid, subclavian, and/or vertebral arteriography with use of the Seldinger technique. Demographic data, indications, procedure approach (transfemoral, brachial), number of arteries punctured, type of selective injection, contrast volume, and procedure time were analyzed. Minor complications were those that do not significantly alter the health or activity of the patient or require extra hospitalization or treatment. Other complications were defined as major complications. The technical success rate was 99% (100/101 patients). These included the following: 82 patients with right carotid artery, 82 with left carotid artery, 15 with right subclavian artery, 21 with left subclavian artery, 11 with right vertebral artery, and 17 with left vertebral artery (a total of 228 selective injections). Indications for procedures included the following: transient ischemic attack (TIA)/stroke symptoms in 66%, asymptomatic carotid stenosis in 22%, upper limb claudication in 4%, and vertebrobasilar insufficiency in 4%. Right femoral puncture was used in 79%, left femoral in 12%, and left brachial in 9%. The mean amount of contrast used was 101 cc (45-250 cc) and the mean procedure time was 46 minutes (22-132 minutes). There were 5 complications in the whole series: 3 major complications (3%), including 1 minor stroke (1%) with carotid injection, 1 TIA, and 1 major retroperitoneal bleeding; and 2 (2%) minor complications. The major complication rate in this series compares favorably to published rates of 5.7% to 9.1%. There was no association between complications and specific risk factors except for a longer catheterization time (66 minutes versus 45 minutes, p= 0.011). Carotid/cerebral arteriography can be done safely by experienced vascular surgeons with minimal perioperative complications that compare favorably with what has been reported in the radiology literature.

Effect of transfusion on dizziness in anemic patients after elective off-pump coronary artery bypass graft surgery

Background:

Neurological disorders are common complications following coronary artery bypass graft (CABG). Dizziness in convalescence period is of high importance because it can prolong patient's stay at the hospital and decrease in sense of rehealing. Transfusion indication is seen in hemoglobin levels <7 g/dl; however, dizziness has been frequently observed in patients with hemoglobin levels 7-10 g/dl and they have dramatic response to transfusion. Therefore, this study was designed to evaluate effect of transfusion on dizziness in hemoglobin levels of 7-10 g/dl to set a more accurate indication for transfusion in anemic patients after elective off-pump CABG.

Materials and Methods:

This clinical trial study was conducted on 90 patients undergoing elective off-pump CABG surgery from January to June 2011, in Afshar cardiovascular center, Yazd, Iran. Patients with hemoglobin levels of 7-10 g/ dl measured 48 h after CABG were included in this study and those who stayed in ICU more than 48 h were excluded. The subjects were randomly divided into two groups: the experimental group received packed cell according to study protocol while the control group did not receive packed cell. Hemoglobin concentration was measured at 48 h and 72 h after CABG and discharge time, respectively. Dizziness was evaluated 72 h after surgery. Data were analyzed by ANOVA, Chi-square, and Fisher's exact test for quantitative and qualitative variables.

Results:

The mean age of the patients was 63.5 ± 10.67 years, from all of patients in which 50 cases (55.6%) were males and 40 cases (44.4%) were females. Dizziness after surgery occurred in 35 cases (38.8%), of whom, 27 cases (62.8%) were in the control group and 8 cases (17%) were in the transfusion group. Significantly a difference in the incidence of dizziness was found between two groups (P= 0.001).

Conclusion:

Transfusion in hemoglobin levels of 7-10 g/dl can be useful to decrease dizziness in anemic patients after elective off-pump CABG; however, the guidelines in textbooks suggest transfusion after CABG to be in hemoglobin levels <7 g/dl.

Feasibility of the 3D RCA catheter to engage the brachiocephalic vessels during carotid angiography and stenting

BACKGROUND

Engagement of the brachiocephalic vessels during carotid angiography is performed using a JR-4, Vitek, or other catheters with variable success. These catheters require additional training for safe manipulation. In this study, we evaluated the feasibility of using the 3D RCA catheter which requires less manipulation in the aorta, and less training, to engage the brachiocephalic vessels.

METHODS

We prospectively studied consecutive high-risk patients undergoing carotid angiography and stenting from August 2005 to March 2009 at our institution. A baseline aortogram was performed to define the arch type in all patients. Engagement of the brachiocephalic vessels was initially attempted using the 3D RCA catheter using the following approach: The 3D RCA catheter is positioned in the ascending aorta beyond the brachiocephalic vessels take off. The natural curve of the catheter usually makes it point cephalad spontaneously in most patients and as it is gently withdrawn it engages the aortic arch vessels without much manipulation. Clinical follow-up with a neurological exam was performed at one month and six months.

RESULTS

A total of 52 patients were enrolled in this study. Baseline demographics and aortic arch types encountered are listed in Table I. The 3D RCA catheter readily engaged the brachiocephalic vessels in 50/52 patients (96.0 %) in our cohort of patients undergoing carotid angiography. Of the 52 patients, 43 subsequently underwent carotid stenting and shuttle sheath placement was facilitated by initial engagement of the relevant common carotid artery with the 3D RCA catheter. There was one transient neurologic complication that resolved by 5 days in a patient that underwent carotid stenting.

CONCLUSIONS

The 3D RCA catheter can be used with a high success rate to engage the brachiocephalic vessels in all 3 arch types, including a bovine arch during carotid angiography and facilitates shuttle sheath placement for carotid stenting. It requires less manipulation and therefore may be a more operator friendly approach. © 2010 Wiley-Liss, Inc.

Complication rate of diagnostic carotid angiography performed by interventional cardiologists

OBJECTIVE

The aim of this study was to evaluate the complication rate of diagnostic carotid angiography performed by interventional cardiologists and compare it to previously published data.

BACKGROUND

Percutaneous treatment for carotid artery stenosis is increasingly being performed. Previously published data describes the complication rate of diagnostic carotid angiography performed by radiologists and vascular surgeons, yet the information regarding interventional cardiologists is sparse. Currently in the United States, interventional cardiologists perform a great deal of diagnostic carotid angiograms.

METHODS

A retrospective analysis was done on 333 patients who underwent diagnostic carotid angiography at a single medical center from January 2000 to February 2007. Medical records were reviewed for cardiovascular risk factors, indications for the procedure, angiography technique and in-hospital complications. Complications were categorized as neurological and non-neurological. Neurological complications were further grouped into transient (<7 days) or permanent. Non-neurological complications were grouped into major (requiring additional treatment) or minor.

RESULTS

Three hundred and thirty-three patients underwent 347 diagnostic carotid angiograms. Twelve (3.5%) complications occurred in 12 patients. No cerebral vascular accidents occurred and only one (0.3%) transient ischemic attack occurred. Two patients required blood transfusions following the index procedure yielding a major non-neurological complication rate of 0.6%. Review of the literature revealed a transient neurological complication rate from 0 to 2.4% and a major non-neurological complication rate of 0.26-4.3%.

CONCLUSIONS

Neurological and non-neurological complication rates for carotid angiograms performed by interventional cardiologists are low and compare well with the literature. Interventional cardiologists can safely perform diagnostic carotid angiography with low complication rates.

Pediatric cerebral angiography: analysis of utilization and findings

Pediatric neuroendovascular procedures are being performed with increasing frequency, for various indications. Reported here is the experience of interventionally trained neurologists performing pediatric cerebral diagnostic angiography between August 1, 2005, and April 30, 2008, at a single tertiary institution. Data regarding patient demographics, diagnostic indication and angiographic diagnosis, procedural complications, and procedural specifications were recorded to assess practice patterns and to track procedural morbidity. In all, 42 patients had 46 procedures during the study period. Mean age was 9.97 years (standard deviation S.D. = 5.39; range, 0.3-18 years); 22/42 were male (52%). Known or suspected vascular malformation was the diagnostic indication for 20 patients; of these, 12 had an arteriovenous malformation, 5 had venous abnormalities, and 3 exhibited no angiographic vascular malformations. In 13 total procedures there was no angiographic pathology. General anesthesia was used in 29/46 procedures (63%). A total of 190 cerebral arteries were individually selected, with a mean number of vessels catheterized of 4.1 (S.D. = 1.7) per procedure. No procedural thromboembolic complications, iatrogenic arterial dissection, or neurologic or vascular access site complications occurred. In conclusion, pediatric cerebral angiography seems to be generally safe, although there should be a strong diagnostic indication, given the inherent procedural risk.

More coronary artery stenosis, more cerebral artery stenosis? A simultaneous angiographic study discloses their strong correlation

Cerebral artery stenosis (CAS) has the same pathogenesis as coronary artery disease (CAD), but the coexistence of these two diseases has been rarely reported. To detect coexistent CAS in CAD patients, we conducted a study of simultaneous coronary and cerebral angiography. Of the 663 consecutive newly diagnosed CAD patients who had not yet been explored to have CAS, 80 were admitted to undergo angiography of bilateral carotid and vertebral system during the same procedure. We defined significant vascular stenosis, either located intracranially or extracranially, as the lesions of diameter stenosis more than 50%. Association between carotid or vertebral stenosis and their potential risk factors were also analyzed. Of our patients, 18 (22.5%) had significant extracranial vascular stenosis, 14 (17.5%) suffered from intracranial stenosis, and 20 (25%) had both. Only 28 patients (35%) had no significant intracranial or extracranial stenosis. None of the demographic parameters as hypertension or diabetes showed significant differences between the cerebral patent group and the CAS group, except for the number of coronary stenotic vessels (1.71 +/- 0.81 versus 2.69 +/- 0.64, P < 0.001). The number of coronary stenotic vessels is correlated well to the number of cerebral stenotic lesions (r = 0.562, P < 0.001). Besides, 8 of the cerebral stenotic patients and 2 of the cerebral patent patients had ischemic stroke previously. We conclude the CAS is coexistent in more than half of the CAD patients in this study. Our study also implies a proportional increase in the severity of CAS to CAD severity.

Management of cerebrovascular accidents during cardiac catheterization

Ischemic cerebrovascular events are a rare complication of cardiac catheterization. Consequently a unique standard of management for these events is yet to be defined. Immediate cerebral angiography followed by local thrombolysis is an effective strategy and we report six cases for which this approach was successfully employed. In contrast the use of immediate neuroimaging by means of MRI or CT scan in two cases delayed the implementation of appropriate therapy.

Neuro-embolic protection during percutaneous balloon mitral valvuloplasty

This report describes the management of a patient with severe symptomatic mitral stenosis and a large mobile thrombus extending from the left atrial appendage that was resistant to warfarin therapy. Percutaneous balloon mitral valvuloplasty was performed with cerebral protection using bilateral internal carotid artery filters to minimize the risk of embolic stroke.

Initial Experience with Routine Selective Carotid Arteriography by Vascular Surgeons

We report the results of our first 2 years of experience with routine carotid angiography with an emphasis on technique and complications. We reviewed the hospital records, office charts, and prospective quality-assurance database records of 336 patients undergoing cerebrovascular arteriograms and collected data on the indications, complications, and technical aspects of the procedures. Indications for angiography included carotid stenosis in 331 (95%) patients, subclavian steal syndrome in 9 patients, vertebrobasilar insufficiency in 6 patients, and carotid body tumor in 2 patients. Selective catheterizations were performed on 654 common carotid arteries, 63 subclavian arteries, and 63 vertebral arteries. Both common carotid arteries were not selectively catheterized in 34 (9.8%) patients. Reasons for not selecting one or both common carotid arteries included physician choice to limit contrast administration in patients with renal insufficiency in 16 cases, proximal occlusion in 4 cases, proximal stenosis thought to be at risk of embolization if instrumented in 3 cases, imaging equipment malfunction in 2 cases, and in only 9 (2.6%) cases was selective carotid catheterization attempted but unsuccessful. There were no procedure-related deaths. Complications were documented in six (1.8%) patients, including cerebrovascular accident (CVA) in 1 (0.3%) patient. One hundred forty-two (41%) patients went on to carotid endarterectomy, and we performed 16 carotid bifurcation stents during the study period. Routine selective carotid angiography is a low-risk procedure that can be performed safely by vascular surgeons with catheter/guide wire skills.

Iatrogenic carotid artery injury in neurosurgery

Iatrogenic carotid artery injury (CAI) results from various neurosurgical procedures. A review of the literature was conducted to provide an update on the management of this potentially devastating complication. Iatrogenic CAIs are categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., anterior cervical spine surgery, central venous catheterization, chemical substances, chiropractic manipulation, diagnostic cerebral angiography, middle-ear surgery, percutaneous procedures for trigeminal neuralgia, radiation therapy, skull-base surgery, tracheostomy, and transsphenoidal surgery. The incidence, mechanisms of injury, diagnostic imaging modalities, and reparative procedures are discussed for each procedure. Iatrogenic CAI may be more prevalent than had previously been thought, mostly because of a heightened awareness on the part of physicians and the earlier detection of asymptomatic patients owing to sophisticated and less-invasive imaging modalities. Prevention is the best treatment for every iatrogenic injury, and it is expected that further accumulation of experience with and knowledge of iatrogenic CAI will result in further reduction of this complication. Although some CAIs, such as radiation-induced carotid artery stenosis, may not be preventable, earlier intervention before the patient becomes symptomatic may favorably alter the prognosis. Following the rapid development of endovascular techniques in recent years, surgically inaccessible lesions can be treated in a more reliable and safe manner than before.

Safety and efficacy of carotid arteriography in vascular surgery practice

OBJECTIVE

Carotid arteriography (CA) is an important method of assessing carotid artery occlusive disease and is the best method of planning for carotid angioplasty and stent placement (CAS). This study compared the results of CA performed by vascular surgeons in a contemporary series against widely recognized interdisciplinary quality standards for this procedure. Although many vascular surgeons perform CA, there is a paucity of data about its safety, efficacy, and compliance with quality standards in vascular practice. The importance of quality CA will likely increase as CAS emerges to assume a broader clinical role.

METHOD

Carotid arteriograms performed by seven vascular surgeons at three institutions from September 2000 to May 2004 were reviewed. These results were compared with quality standards for the performance of CA.

RESULTS

Five hundred three carotid arteriograms were performed over 45 months. Indications for the procedure were extracranial cerebrovascular disease (86%), trauma (5%), and other conditions (9%). Indications for the procedure were appropriate in 100% of patients (as determined by guidelines document) and exceeded the recommended standard of appropriate indications in 99%. All procedures successfully provided the information required, exceeding the threshold of 98% for procedural success. Reversible neurologic deficits occurred in 0.6% (two transient ischemic attacks and one stroke) compared with the threshold of 2.5%. A permanent neurologic deficit occurred in 0.2% (1 patient) compared with the published guideline of 1% after carotid arteriography. Major non-neurologic complications occurred in 1.2% (6 patients), less than the standard of 2.0%.

CONCLUSIONS

The safety and efficacy of a contemporary series of CA performed in vascular surgery practice compared favorably with recognized interdisciplinary quality standards for this procedure. Ensuring safe and effective CA is likely to support the successful growth of CAS as a treatment option.