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Pagliariccio G, Di Sario I, Capoccia L, D'Elia M, Bafile G, Leopardi M, Fiore F, Palmieri A, Antico L, Antico A. Carotid Near-Occlusion: Surgical or Conservative Management? Retrospective Multicenter Study. Ann Vasc Surg 2024; 102:133-139. [PMID: 38408393 DOI: 10.1016/j.avsg.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse. METHODS Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments. RESULTS In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm. CONCLUSIONS According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse.
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Affiliation(s)
| | | | - Laura Capoccia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Marcello D'Elia
- Vascular Surgery Department, Avezzano Hospital, Avezzano, Italy
| | - Gennaro Bafile
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Marco Leopardi
- Vascular Surgery Department, L'Aquila Hospital, L'Aquila, Italy
| | - Franco Fiore
- Vascular Surgery Department, Chieti Hospital, Chieti, Italy
| | | | - Lorenzo Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
| | - Antonio Antico
- Vascular Surgery Department, Pescara Hospital, Pescara, Italy
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Holmgren M, Henze A, Wåhlin A, Eklund A, Fox AJ, Johansson E. Phase-contrast magnetic resonance imaging of intracranial and extracranial blood flow in carotid near-occlusion. Neuroradiology 2024; 66:589-599. [PMID: 38400954 PMCID: PMC10937755 DOI: 10.1007/s00234-024-03309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Compare extracranial internal carotid artery flow rates and intracranial collateral use between conventional ≥ 50% carotid stenosis and carotid near-occlusion, and between symptomatic and asymptomatic carotid near-occlusion. METHODS We included patients with ≥ 50% carotid stenosis. Degree of stenosis was diagnosed on CTA. Mean blood flow rates were assessed with four-dimensional phase-contrast MRI. RESULTS We included 110 patients of which 83% were symptomatic, and 38% had near-occlusion. Near-occlusions had lower mean internal carotid artery flow (70 ml/min) than conventional ≥ 50% stenoses (203 ml/min, P < .001). Definite use of ≥ 1 collateral was found in 83% (35/42) of near-occlusions and 10% (7/68) of conventional stenoses (P < .001). However, there were no differences in total cerebral blood flow (514 ml/min vs. 519 ml/min, P = .78) or ipsilateral hemispheric blood flow (234 vs. 227 ml/min, P = .52), between near-occlusions and conventional ≥ 50% stenoses, based on phase-contrast MRI flow rates. There were no differences in total cerebral or hemispheric blood flow, or collateral use, between symptomatic and asymptomatic near-occlusions. CONCLUSION Near-occlusions have lower internal carotid artery flow rates and more collateral use, but similar total cerebral blood flow and hemispheric blood flow, compared to conventional ≥ 50% carotid stenosis.
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Affiliation(s)
- Madelene Holmgren
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Alexander Henze
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Anders Wåhlin
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
- Department of Applied Physics and Electronics, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
| | - Elias Johansson
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden.
- Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
- Neuroscience and Physiology, Gothenburg University, Göteborg, Sweden.
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Henze A, Fox AJ, Johansson E. High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery. Neuroradiology 2024; 66:349-352. [PMID: 38191868 PMCID: PMC10859336 DOI: 10.1007/s00234-024-03283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024]
Abstract
We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2 days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28 days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0 mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.
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Affiliation(s)
- Alexander Henze
- Institution of Radiation Sciences, Department of Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Center, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Institution of Clinical Science, Department of Neurosciences, Umeå University, Umeå, Sweden.
- Wallenberg Center of Molecular Medicine, Umeå University, Umeå, Sweden.
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden.
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Holmgren M, Henze A, Wåhlin A, Eklund A, Fox AJ, Johansson E. Diagnostic separation of conventional ⩾50% carotid stenosis and near-occlusion with phase-contrast MRI. Eur Stroke J 2024; 9:135-143. [PMID: 38032058 PMCID: PMC10916822 DOI: 10.1177/23969873231215634] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION The aim of this study was to assess sensitivity, specificity and interrater reliability of phase-contrast MRI (PC-MRI) for diagnosing carotid near-occlusion. PATIENTS AND METHODS Prospective cross-sectional study conducted between 2018 and 2021. We included participants with suspected 50%-100% carotid stenosis on at least one side, all were examined with CT angiography (CTA) and PC-MRI and both ICAs were analyzed. Degree of stenosis on CTA was the reference test. PC-MRI-based blood flow rates in extracranial ICA and intracranial cerebral arteries were assessed. ICA-cerebral blood flow (CBF) ratio was defined as ICA divided by sum of both ICAs and Basilar artery. RESULTS We included 136 participants. The ICAs were 102 < 50% stenosis, 88 conventional ⩾50% stenosis (31 with ⩾70%), 49 near-occlusion, 12 occlusions, 20 unclear cause of small distal ICA on CTA and one excluded. For separation of near-occlusion and conventional stenoses, ICA flow rate and ICA-CBF ratio had the highest area under the curve (AUC; 0.98-0.99) for near-occlusion. ICA-CBF ratio ⩽0.225 was 90% (45/49) sensitive and 99% (188/190) specific for near-occlusion. Inter-rater reliability for this threshold was excellent (kappa 0.98). Specificity was 94% (29/31) for cases with ⩾70% stenosis. PC-MRI had modest performance for separating <50% and conventional ⩾50% stenosis (highest AUC 0.74), and eight (16%) of near-occlusions were not distinguishable from occlusion (no visible flow). CONCLUSION ICA-CBF ratio ⩽0.225 on PC-MRI is an accurate and reliable method to separate conventional ⩾50% stenosis and near-occlusion that is feasible for routine use. PC-MRI should be considered further as a potential standard method for near-occlusion detection, to be used side-by-side with established modalities as PC-MRI cannot separate other degrees of stenosis.
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Affiliation(s)
- Madelene Holmgren
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Alexander Henze
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Anders Wåhlin
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
- Department of Applied Physics and Electronics, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Center, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
- Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden
- Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
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Saba L, Scicolone R, Johansson E, Nardi V, Lanzino G, Kakkos SK, Pontone G, Annoni AD, Paraskevas KI, Fox AJ. Quantifying Carotid Stenosis: History, Current Applications, Limitations, and Potential: How Imaging Is Changing the Scenario. Life (Basel) 2024; 14:73. [PMID: 38255688 PMCID: PMC10821425 DOI: 10.3390/life14010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/24/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Carotid artery stenosis is a major cause of morbidity and mortality. The journey to understanding carotid disease has developed over time and radiology has a pivotal role in diagnosis, risk stratification and therapeutic management. This paper reviews the history of diagnostic imaging in carotid disease, its evolution towards its current applications in the clinical and research fields, and the potential of new technologies to aid clinicians in identifying the disease and tailoring medical and surgical treatment.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Roberta Scicolone
- Department of Radiology, University of Cagliari, 09042 Cagliari, Italy;
| | - Elias Johansson
- Neuroscience and Physiology, Sahlgrenska Academy, 41390 Gothenburg, Sweden;
| | - Valentina Nardi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, 26504 Patras, Greece;
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Andrea D. Annoni
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy; (G.P.); (A.D.A.)
| | | | - Allan J. Fox
- Department of Medical Imaging, Neuroradiology Section, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
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Nordanstig A, Gu T, Henze A, Wester P, Fox AJ, Johansson E. Risk of Stroke Recurrence After Intravenous Thrombolysis in Patients with Symptomatic Carotid Stenosis. Can J Neurol Sci 2023:1-8. [PMID: 37681233 DOI: 10.1017/cjn.2023.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To assess if intravenous thrombolysis (IVT) affects the risk of recurrent preoperative cerebrovascular events before carotid surgery or stenting in patients with symptomatic ≥ 50% carotid stenosis. METHODS Three cohorts of symptomatic ≥ 50% carotid stenosis patients were merged. To make the control group relevant, we excluded patients not presenting with stroke on the day of symptom onset. The risk of preoperative cerebrovascular events up to 30 days was compared between the IVT-treated and non-IVT-treated. RESULTS In total, 316 patients were included, 64 (20%) treated with IVT. Those treated with IVT had similar risk of recurrent ipsilateral ischemic stroke or retinal artery occlusion (12% at day 7, 12% at day 30) as those not treated (9% at day 7, 15% at day 30; adjusted HR 0.9, 95% CI 0.4-2.2). There was a tendency (p = 0.09) towards time-dependency in the data where the recurrence risk was higher in IVT-treated at day 0 (6% in IVT-treated, 1% in non-IVT-treated, OR 5.5, 95% CI 1.2-25.4, p = 0.03). This was not significant when adjusting for co-factors (adjusted OR 4.4, 95% CI 0.9-21.8, p = 0.07) and was offset by a later risk decrease, with no remaining risk difference between IVT-treated and non-IVT-treated at day 7. CONCLUSIONS Intravenous thrombolysis treatment does not seem to affect the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic ≥50% carotid stenosis: The risk is high in both IVT-treated and non-IVT-treated. However, there might be a risk increase on the day of IVT treatment that is offset by a risk decrease during the first week.
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Affiliation(s)
- Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Thomas Gu
- Department of Neurosciences, Institution of Clinical Science, Umea University, Umea, Sweden
| | - Alexander Henze
- Department of Diagnostic Radiology, Institution of Radiation Sciences, Umea University, Umea, Sweden
| | - Per Wester
- Institution of Public Health and Clinical Medicine, Umea University, Umea, Sweden
- Department of Clinical Sciences, Danderyds hospital Karolinska Institute, Stockholm, Sweden
| | - Allan J Fox
- Department of Medical Imaging, Sunnybrook health Science Center, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Neurosciences, Institution of Clinical Science, Umea University, Umea, Sweden
- Wallenberg Center of Molecular Medicine, Umea University, Umea, Sweden
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 205] [Impact Index Per Article: 205.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Kellomäki E, Gu T, Fox AJ, Johansson E. Symptomatic and asymptomatic carotid near-occlusions have very similar angiographic appearance on CT-angiography. Neuroradiology 2022; 64:2203-2206. [PMID: 36129513 PMCID: PMC9576665 DOI: 10.1007/s00234-022-03054-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 10/25/2022]
Abstract
The aim of this study was to compare the angiographic appearance of symptomatic and asymptomatic carotid near-occlusion. We have found no such previous study. The study hypothesis was that among symptomatic patients with ≥ 50% carotid stenosis, near-occlusion is more common and near-occlusions are more severe than among asymptomatic persons with ≥ 50% carotid stenosis. We reassessed consecutive CTAs from 4042 persons, 645 had ≥ 50% carotid stenosis, and 385 (60%) symptomatic. Near-occlusion was similarly common in symptomatic (105, 27%) and asymptomatic (56, 24%) cases. Among near-occlusions, the angiographic appearance was very similar between symptomatic and asymptomatic cases: mean stenosis lumen diameter (0.7 mm), distal ICA diameter (2.1 mm), and ECA ratio (0.79) were the same in both groups. Mean ICA ratio (0.46 and 0.48) and share of full collapse was very similar (45% and 42%). These findings add to the pathophysiological understanding of carotid near-occlusion.
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Affiliation(s)
- Elisa Kellomäki
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Thomas Gu
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Allan J Fox
- Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - Elias Johansson
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden. .,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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Johansson E, Holmgren M, Henze A, Fox AJ. Diagnosing carotid near-occlusion is a difficult task-but it might get easier. Neuroradiology 2022; 64:1709-1714. [PMID: 35829763 DOI: 10.1007/s00234-022-03007-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Elias Johansson
- Clinical Science, Umeå University, Neurosciences, Umeå, Sweden. .,Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
| | | | | | - Allan J Fox
- Sunnybrook Health Science Center, University of Toronto, Toronto, Canada
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The periprocedural and 30-day outcomes of carotid stenting in patients with carotid artery near-occlusion. Sci Rep 2021; 11:21876. [PMID: 34750446 PMCID: PMC8575776 DOI: 10.1038/s41598-021-01286-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/21/2021] [Indexed: 12/24/2022] Open
Abstract
The safety of endovascular revascularization in patients with carotid artery near occlusion (CANO) is unknown. We aimed to evaluate the peri-procedural risk in CANO patients receiving carotid artery stenting (CAS). A prospective data base with retrospective review was performed to identify patients who underwent CAS with CANO from July 2006 to July 2020, and had at least 1-month clinical follow-up data. The primary endpoints were stroke, hyperperfusion syndrome, and death within 30 days after CAS. A total of 198 patients with carotid artery stenosis were enrolled including 92 patients with CANO and 106 age and sex-matched patients with 70–99% conventional carotid stenosis. Full distal carotid collapse was found in 45 CANO patients (45/92, 49%). The technical success rate was 100%. The CANO patients had significantly longer lesion lengths compared with those of the non-CANO group. The incidence of hyperperfusion syndrome was comparable (CANO: 2.2%, non-CANO: 0.9%, P = 0.598). The risks of ischemic stroke and death within 30 days were 1.1% and 0% in the CANO group; and 1.9% and 0.9%, in the non-CANO group, respectively, without statistical difference. In conclusion, CAS is safe for patients with CANO, with a similar low 30-day peri-procedural event rate comparable to those of non-CANO.
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