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Wu CH, Lin TM, Chung CP, Yu KW, Tai WA, Luo CB, Lirng JF, Chang FC. Prevention of in-stent restenosis with drug-eluting balloons in patients with postirradiated carotid stenosis accepting percutaneous angioplasty and stenting. J Neurointerv Surg 2023; 16:73-80. [PMID: 36914246 PMCID: PMC10804009 DOI: 10.1136/jnis-2022-019957] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/19/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To investigate the technical safety and outcome of in-stent restenosis (ISR) prevention with drug-eluting balloon (DEB) in patients with postirradiated carotid stenosis (PIRCS) undergoing percutaneous angioplasty and stenting (PTAS). METHODS Between 2017 and 2021, we prospectively recruited patients with severe PIRCS for PTAS. They were randomly separated into two groups based on endovascular techniques performed with and without DEB. Preprocedural and early postprocedural (within 24 hours) MRI, short-term ultrasonography (6 months after PTAS), and long-term CT angiography (CTA)/MR angiography (MRA), 12 months after PTAS, were performed. Technical safety was evaluated based on periprocedural neurological complications and the number of recent embolic ischemic lesions (REIL) in the treated brain territory on diffusion-weighted imaging of early postprocedural MRI. RESULTS Sixty-six (30 with and 36 without DEB) subjects were enrolled, with one failure in techniques. For 65 patients in the DEB versus conventional groups, technical neurological symptoms within 1 month (1/29 (3.4%) vs 0/36; P=0.197) and REIL numbers within 24 hours (1.0±2.1 vs 1.3±1.5; P=0.592) after PTAS showed no differences. Peak systolic velocity (PSVs) on short-term ultrasonography was significantly higher in the conventional group (104.13±42.76 vs .81.95±31.35; P=0.023). The degree of in-stent stenosis (45.93±20.86 vs 26.58±8.75; P<0.001) was higher, and there were more subjects (n=8, 38.9% vs 1, 3.4%; P=0.029) with significant ISR (≥ 50%) in the conventional group than in the DEB group on long-term CTA/MRA. CONCLUSIONS We observed similar technical safety of carotid PTAS with and without DEBs. The number of cases of significant ISR were fewer and the degree of stenosis of ISR was less in primary DEB-PTAS of PIRCS than for conventional PTAS in the 12-month follow-up.
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Affiliation(s)
- Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Te-Ming Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Ping Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kai-Wei Yu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-An Tai
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
- Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Jiing-Feng Lirng
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Kim SM, Ryu JC, Koo S, Kim JS, Kim BJ. Low-Density Lipoprotein Cholesterol Levels Are Associated With Subsequent Stented-Territory Ischemic Stroke After Carotid Artery Stenting: A Single Center Retrospective Study. J Lipid Atheroscler 2023; 12:175-188. [PMID: 37265854 PMCID: PMC10232219 DOI: 10.12997/jla.2023.12.2.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/12/2023] [Accepted: 04/13/2023] [Indexed: 06/03/2023] Open
Abstract
Objective The role of low-density lipoprotein cholesterol (LDL-C) after carotid artery stenting (CAS) is not well known with respect to stented-territory infarction (STI) and in-stent restenosis (ISR). We hypothesized that LDL-C levels after CAS might be independently associated with STI and ISR. Methods We conducted a retrospective study for patients with significant extracranial carotid stenosis who were subjected to CAS between September 2013 and May 2021. LDL-C levels were measured after 6 and 12 months following CAS. The association between STI and ISR, and LDL-C was explored using Cox proportional-hazard model. Results Of 244 patients enrolled, STI and ISR were observed in 11 (4.5%) and 10 (4.1%) patients, respectively. In multivariable analysis, higher white blood cell count (hazard ratio [HR], 1.408 per 103/mm3; 95% confidence interval [CI], 1.085-1.828; p=0.010), higher LDL-C levels after 12 months (HR, 1.037 per 1 mg/dL; 95% CI, 1.011-1.063; p=0.005), and ISR (HR, 13.526; 95% CI, 3.405-53.725; p<0.001) were independent predictors of STI. Diabetes (HR, 4.746; 95% CI, 1.026-21.948; p=0.046), smaller stent diameter (HR, 0.725 per 1 mm; 95% CI, 0.537-0.980; p=0.036), and higher LDL-C levels after 12 months (HR, 1.031 per 1 mg/dL; 95% CI, 1.007-1.055; p=0.011) were independent predictors of ISR. Conclusion We showed that LDL-C levels after 12 months independently predict STI and ISR after CAS. It is necessary to investigate the optimal target LDL-C level for STI prevention through well designed research in the future.
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Affiliation(s)
- Seung Min Kim
- Department of Neurology, Veterans Health Service Medical Center, Seoul, Korea
| | - Jae Chan Ryu
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sujin Koo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S. Kim
- Department of Neurology, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Roh J, Baik SK, Yeom JA, Park KP, Ahn SH, Park MG. Usefulness of cone-beam computed tomography to predict residual stenosis after carotid artery stenting. Interv Neuroradiol 2022:15910199221143259. [PMID: 36523192 DOI: 10.1177/15910199221143259] [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: 02/17/2024] Open
Abstract
OBJECTIVES The long-term durability of carotid artery stenting (CAS) may be determined by various factors; however, residual stenosis is a known risk factor for in-stent restenosis. The authors of this article utilized cone-beam computed tomography (CBCT) in angiosuite to investigate plaque features affecting the character and quality of stent expansion after CAS. METHODS Forty-two CAS cases with both pre- and post-CAS CBCT evaluations were included in this retrospective analysis. Five features derived from pre-CAS images were tested: (1) eccentricity, (2) overballoon, (3) maximum plaque thickness, (4) calcification barrier, and (5) stenotic degree. For post-CAS CBCT, stent configuration was assessed if the stent was expanded and oval or round in shape as well as outward or inward in orientation. Variables were tested if they were associated with oval expansion, outward expansion, and 20% residual stenosis after CAS. RESULTS Oval or outward expansion is directly related to residual stenosis. The oval expansion was associated with maximum plaque thickness, and outward expansion was associated with the presence of a calcification barrier. Variables related to > 20% residual stenosis were the maximum plaque thickness, calcification barrier, and pre-CAS stenotic degree. CONCLUSIONS CBCT for carotid stenosis may provide valuable information about plaque features, especially calcification features that may interfere with the angioplasty effect, as well as the characteristics and quality of stent expansion. Residual stenosis > 20% was associated with calcification barrier, maximum plaque thickness, and pre-CAS stenotic degree.
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Affiliation(s)
- Jieun Roh
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Seung Kug Baik
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Jeong A Yeom
- Department of Radiology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Kyung-Pil Park
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Sung-Ho Ahn
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Min-Gyu Park
- Department of Neurology, 194197Pusan National University Yangsan Hospital, Yangsan-si, South Korea
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Sýkora J, Zeleňák K, Vorčák M, Števík M, Sýkorová M, Sivák J, Rovňák M, Zapletalová J, Mužík J, Šinák I, Kurča E, Meyer L, Fiehler J. Comparison of Restenosis Risk in Single-Layer versus Dual-Layer Carotid Stents: A Duplex Ultrasound Evaluation. Cardiovasc Intervent Radiol 2022; 45:1257-1266. [PMID: 35798859 DOI: 10.1007/s00270-022-03200-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/04/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE The aim of this study was to report intermediate-term results of duplex ultrasound follow-up of carotid artery stenting performed with the dual-layer stent as compared to concurrent patients treated with other commercially available single-layer carotid stents. MATERIALS AND METHODS A single centre, retrospective, nonrandomized study including 162 non-consecutive patients with 199 implanted carotid stents treated over a 7-year period was conducted. Patients with at least one ultrasound examination after treatment were included. Procedural and follow-up data for patients treated with the dual-layer stent implantation (83 stents) vs first-generation carotid stents implantations (116 stents) were compared. RESULTS The median follow-up time was 24.0 months (IQR 10-32 months) for dual-layer stents and 27.5 months (IQR 10.3-59 months) for single-layer stents. The rate of severe restenosis was significantly higher in the dual-layer stent group than in the single-layer group (13.3% [11/83] vs 3.4% [4/116], p = 0.01). Seven reinterventions were performed in 5 patients with dual-layer stents. The rate of reintervention was significantly higher compared to no reinterventions in single-layer stents (6% [5/83] vs 0% [0/116], p = 0.012). Patients with restenosis had significantly higher presence of dyslipidaemia (100% [12/12] vs 63.3% [95/150], p = 0.009). CONCLUSIONS In this real-world cohort of patients undergoing carotid artery stenting, the patients treated with low-profile dual-layer micromesh stent showed higher rates of restenosis and reinterventions compared to first-generation single-layer stents.
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Affiliation(s)
- Ján Sýkora
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.,Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.
| | - Martin Vorčák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martin Števík
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Martina Sýkorová
- Vaša Ambulancia, s. r. o., Prieložtek 1, 036 01, Martin, Slovakia
| | - Jozef Sivák
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, I. P. Pavlova 185/6, 77520, Olomouc, Czech Republic.,Middle-Slovak Institute of Cardiovascular Diseases, Cesta k nemocnici 1, 974 01, Banská Bystrica, Slovakia
| | - Marek Rovňák
- Orthopedic Clinic, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Jana Zapletalová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 976/3, 775 15, Olomouc, Czech Republic
| | - Juraj Mužík
- Department of Geotechnics, Faculty of Civil Engineering, University of Žilina, Univerzitná, 8215/1, 010 26, Žilina, Slovakia
| | - Igor Šinák
- Department of Vascular Surgery, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Egon Kurča
- Clinic of Neurology, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Jens Fiehler
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
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Factors contributing to restenosis after carotid artery stenting and the usefulness of magnetic resonance plaque imaging: A study of 308 consecutive patients. Eur J Radiol 2022; 154:110398. [DOI: 10.1016/j.ejrad.2022.110398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/29/2022] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
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Hemodynamic Impact of Stenting on Carotid Bifurcation: A Potential Role of the Stented Segment and External Carotid Artery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:7604532. [PMID: 34868344 PMCID: PMC8642019 DOI: 10.1155/2021/7604532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
Carotid stenting near the bifurcation carina is associated with adverse events, especially in-stent restenosis, thrombosis, and side branch occlusion in clinical data. This study is aimed at determining the potential biomechanical mechanisms for these adverse events after carotid stenting. The patient-specific carotid models were constructed with different stenting scenarios to study the flow distribution and hemodynamic parameters, such as wall shear stress (WSS), flow velocity, relative residence time (RRT), and oscillating shear index (OSI) in the carotid bifurcation. The results suggested that the existing stents surely reduced blood flow to the external carotid artery (ECA) but enhanced local flow disturbance both in ECA and stented internal carotid artery (ICA), and the inner posterior wall of the stented ICA and the outer posterior wall of ECA might endure a relatively low level of WSS and remarkably elevated OSI and RRT. In addition, the implanted stent leads to more ECA adverse flow than ICA after stenting. While disturbed flow near the strut increased as stent length increased, blood flow and areas of local flow disturbance in ECA slightly decreased as stent length increased. In conclusion, the results revealed that ECA might be in relatively high levels of abnormal local hemodynamics after stenting, followed by stented ICA, leading to potential adverse events after intervention.
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Optimal Management of Carotid Artery Restenosis. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ösken A, Akdeniz E, Keskin M, Öz A, Ipek G, Zehir R, Barutça H, Çam N, Şahin S. Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents. Angiology 2021; 72:762-769. [PMID: 33966501 DOI: 10.1177/00033197211014684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.
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Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Evliya Akdeniz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Başkent University Faculty of Medicine, Istanbul, Turkey
| | - Muhammed Keskin
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Öz
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Göktürk Ipek
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Regayip Zehir
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey.,Department of Cardiology, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey
| | - Hakan Barutça
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
| | - Sinan Şahin
- Department of Radiology, 111319Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey
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Armstrong EJ, Kokkinidis DG. Restenosis After Carotid Artery Stenting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 24:70-71. [PMID: 33468421 DOI: 10.1016/j.carrev.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale New Haven Hospital, Yale University School of Medicine, CT, USA
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Veselka J, Hajek P, Štěchovský C, Horváth M, Adlová R, Roland R, Homolová I, Hansvenclová E, Zimolová P. Long-term survival of carotid stenting patients with regard to single- or double-vessel carotid artery disease: a propensity score matching analysis. Arch Med Sci 2021; 17:849-855. [PMID: 34336012 PMCID: PMC8314408 DOI: 10.5114/aoms.2020.98167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/18/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is lack of long-term data outside of controlled clinical trials in carotid artery stenting (CAS). In this study, we compared the short-term outcome, long-term survival, and rate of re-interventions for restenosis in patients after CAS, related to the extent of carotid atherosclerosis classified as single-vessel (unilateral) or double-vessel (bilateral) carotid artery disease. MATERIAL AND METHODS We retrospectively evaluated 599 patients with significant carotid artery stenosis, who underwent 763 CAS procedures, and used the propensity score to match 226 pairs (452 patients) in the single- or double-vessel carotid disease. RESULTS There was no significant difference in the occurrence of in-hospital major adverse events (3.5% vs. 3.1% of patients in the double-vessel carotid group vs. the single-vessel carotid group; p = 1) The mean follow-up was 6.1 ±4.0 years, and a total of 181 (40%) deaths occurred during 2759 patient-years, which translates into 7.8 and 5.3 deaths per 100 patient-years in the double-vessel carotid group and the single-vessel carotid group, respectively (p < 0.01). The survival in the double-vessel carotid group vs. the single-vessel carotid group at 10 years was 46% (95% CI: 38-54%) vs. 55% (95% CI: 47-63%) (p < 0.01). Twenty-four (11%) patients and 6 (3%) patients underwent re-interventions for restenosis in the double-vessel and the single-vessel carotid disease group, respectively (p < 0.01). CONCLUSIONS Patients with CAS and significant double-vessel carotid artery disease had similar peri-procedural risk, but had a worse long-term survival, and a higher rate of re-interventions for restenosis compared to the single-vessel carotid artery disease patients.
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Affiliation(s)
- Josef Veselka
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Petr Hajek
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Cyril Štěchovský
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Martin Horváth
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Radka Adlová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Robert Roland
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Ingrid Homolová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Eva Hansvenclová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Petra Zimolová
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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11
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Beeman BR, Kuhn BA, Recht MH, Muck PE, Schneider PA. Duplex Ultrasound Surveillance after Transcarotid Artery Revascularization (TCAR) in Clinical Practice. Ann Vasc Surg 2020; 72:330-339. [PMID: 33245990 DOI: 10.1016/j.avsg.2020.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To propose a protocol for the routine clinical use of duplex ultrasound (DUS) assessment after transcarotid artery revascularization (TCAR) procedures, with its specific point of vascular access, based on DUS data from routine clinical practice. METHODS DUS data were retrospectively collected at 2 centers from a total of 97 patients who underwent a TCAR procedure with at least 30-day and up to 12-month follow-up. Peak systolic velocity (PSV), end diastolic velocity (EDV), and the internal carotid artery (ICA)/common carotid artery (CCA) PSV ratio were collected at baseline (≤30 days after the procedure) and compared with subsequent measurements. RESULTS Baseline data were established within 30 days after the procedure. There were no access site stenoses, pseudoaneurysms, or dissections detected in follow-up. Average hemodynamics measurements at 12 months after the procedure (36% of patients reached this time point to date) were PSV 167 ± 153 cm/sec, EDV 51 ± 55 cm/sec, and ICA/CCA PSV 2.3 ± 1.9. Five patients (5.2%) exhibited velocities indicative of ≥80% in-stent restenosis (ISR) at 12 months after the procedure. Two patients (2.1%) underwent repeat intervention for ISR based on high velocities and before significant clinical consequence. The other 3 patients (3.1%) were asymptomatic and are being managed medically and monitored for neurological symptoms. One intraprocedural stroke (1.0% of total treated) was observed. CONCLUSIONS This protocol not only illustrates the utility of using the CCA for the arterial access sheath for carotid stenting, but also successfully identifies patients with clinically significant restenosis >80%-99%. A surveillance regimen of baseline at ≤30 days after the procedure, followed by assessment at 6 and 12 months, and yearly thereafter appears to be a safe and effective protocol, based on the data available to date. A PSV >340 cm/sec and ICA/CCA ratio >4.15 is consistent with an 80-99% restenosis after TCAR. Although a small number, this study serves as a starting point for those who perform TCAR to specifically look at the CCA access site to rule out these potential pitfalls which did occur in the early trials.
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Affiliation(s)
- Brian R Beeman
- Carle Heart and Vascular Institute, Carle Foundation Hospital, Urbana, IL.
| | - Brian A Kuhn
- TriHealth/Good Samaritan Hospital, Cincinnati, OH
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12
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Wang C, Zhao P, Sun T, Han M, Wang Y, Wu W, Li X, Wang D. Hybrid Recanalization for the Treatment of Carotid/Vertebral In-stent Restenosis or Occlusion: Pilot Surgery Experiences From One Single Center. Front Neurol 2020; 11:604672. [PMID: 33329364 PMCID: PMC7732432 DOI: 10.3389/fneur.2020.604672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background : The hybrid recanalization of internal carotid artery (ICA) and vertebral artery (VA) in-stent restenosis or occlusion using a combination of endarterectomy and endovascular intervention has achieved technical success. We present our surgical experiences to further evaluate the safety and efficacy of the hybrid technique for the treatment of in-stent restenosis and occlusion. Methods : A cohort of 12 refractory patients with in-stent restenosis or occlusion who underwent hybrid recanalization, a combination of endarterectomy and endovascular intervention, were retrospectively analyzed. Medical records, including presenting symptoms, comorbidities, contralateral ICA/VA findings, use of antiplatelet drugs, postoperative complications, and angiographic outcomes, were collected. Results : Among 415 consecutive patients with ICA, common carotid artery, and V1 segment lesions, 12 refractory patients (2.89%) with 13 cases were enrolled in our study (1 female and 11 male). All patients underwent successful hybrid recanalization. There were no cases of postoperative stroke or death. Only two patients sustained hoarseness, but it resolved within 2 weeks after surgery. Three patients were treated with dual antiplatelet (aspirin and clopidogrel), seven with single antiplatelet (aspirin), one with single antiplatelet (clopidogrel), and one with single antiplatelet (ticagrelor). All patients were followed up in the outpatient department according to the protocol, with a mean follow-up period of 13 months (range, 6-24 months). No death or recurrent symptoms occurred during the regular follow-up period. Conclusion : The hybrid technique maybe a safe and feasible treatment option to recanalize in-stent restenosis or occlusion with acceptable complications.
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Affiliation(s)
- Chao Wang
- School of Clinical Medicine, Shandong University, Jinan, China.,Dezhou City People's Hospital, Dezhou, China.,Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Peng Zhao
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Tao Sun
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Mengtao Han
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Xingang Li
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
| | - Donghai Wang
- School of Clinical Medicine, Shandong University, Jinan, China.,Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
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13
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Kang Z, Cao Y, Li L, Zhang G. The Association Between Apolipoprotein E Gene Polymorphism and In-Stent Restenosis After Extracranial and Intracranial Artery Stenting. J Stroke Cerebrovasc Dis 2020; 30:105424. [PMID: 33221611 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Neo-atherosclerosis plays a vital role in the incidence of in-stent restenosis (ISR) after extracranial and intracranial artery stenting, and Apolipoprotein (ApoE) gene polymorphism has been reported to be closely related to the occurrence and development of atherosclerosis. The present study aims to investigate the association between ApoE gene polymorphism and ISR after extracranial and intracranial artery stenting. METHODS A total of 169 patients with successful stent implantation were included in this study. ApoE genotypes were obtained during the postoperative follow-up. Color Doppler ultrasonography of cervical artery or head and neck CT angiography (CTA) was performed on the 1,3,6 and 12 months and then yearly in the clinical follow-up. Multivariate Cox regression analysis of independent risk factors was performed to evaluate the ISR. Kaplan-Meier curves were generated to compare the restenosis -free rate among the patients with different ApoE genotypes. RESULTS Of the 169 patients, 43 (43/169, 25.4%) developed ISR after a mean follow-up period of 10.4 months (1-35 months). Multivariate analysis showed that genotype E4/E4 (hazard ratio 3.305, P = 0.031, 95% confidence interval 1.118-9.773) and degree of stenosis >90% (hazard ratio 5.083, P = 0.001, 95% confidence interval 1.938-13.327) were significant determinants of ISR. CONCLUSION ApoE gene polymorphism is closely related to the incidence of ISR after extracranial and intracranial artery stenting, and the genotype E4/E4 is an independent risk factor for ISR.
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Affiliation(s)
- Zhoucheng Kang
- Department of Neurology, Xijing Hospital, The Fourth Military Medical University, 15 Changle West Road, Xi'an, Shanxi 710032, P.R. China
| | - Yuhong Cao
- Department of Neurology, Air Force Medical Center, 30 Fucheng Road, Haidian District, Beijing 100142, P.R. China.
| | - Li Li
- Department of Neurology, Air Force Medical Center, 30 Fucheng Road, Haidian District, Beijing 100142, P.R. China.
| | - Guangyun Zhang
- Department of Neurology, Air Force Medical Center, 30 Fucheng Road, Haidian District, Beijing 100142, P.R. China.
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14
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Takao N, Hagiwara Y, Shimizu T, Soga K, Tsuchihashi Y, Otsubo H, Tatsuno K, Takaishi S, Usuki N, Yoshie T, Takada T, Ueda T, Hasegawa Y, Yamano Y. Preprocedural Carotid Plaque Echolucency as a Predictor of In-Stent Intimal Restenosis after Carotid Artery Stenting. J Stroke Cerebrovasc Dis 2020; 29:105339. [PMID: 33032020 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES In-stent intimal restenosis (ISR) caused by neointimal hyperplasia can develop <24 months after carotid artery stenting (CAS). The utility of plaque imaging by carotid ultrasonography (US) or magnetic resonance imaging (MRI) has been investigated for the prediction of ipsilateral stroke. We aimed to investigate whether these imaging techniques are useful for detecting carotid plaques prone to ISR. MATERIALS AND METHODS We examined 133 patients (mean age of 72.1 ± 8.4 years old) that received CAS at a single hospital from 2014 to 2018. A pre-CAS carotid plaque evaluation was performed by carotid angiography, duplex carotid US, and black-blood carotid artery MRI (BB-MRI). The mean stenosis rate was 71.0 ± 12.3% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Follow-up carotid angiography was performed 6 months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosed based on the NASCET criteria. The selection of the stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis. RESULTS Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than two stents were deployed. Univariate logistic regression analyses demonstrated echolucent lesion, floating plaque, complete occlusive or pseudo-occlusive lesion, and closed-cell stent use as significantly associated with ISR (>50%). Multivariate logistic regression analysis demonstrated that echolucent lesion (OR 4.667, 95% CI 1.849-11.779) and closed-cell stent use (OR .378, 95% CI .148-.968) were significantly associated with ISR. CONCLUSIONS Preprocedural plaque characterization by carotid US appeared to be useful to predict ISR 6 months after CAS.
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Affiliation(s)
- Naoki Takao
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yuta Hagiwara
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
| | - Takahiro Shimizu
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Kaima Soga
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yoko Tsuchihashi
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Haruki Otsubo
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Noriko Usuki
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Tomohide Yoshie
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Tatsuro Takada
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan; Department of Rare Diseases Research, Institute of Medical Science, St. Marianna University School of Medicine, Kawasaki, Japan
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15
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Stilo F, Montelione N, Calandrelli R, Distefano M, Spinelli F, Di Lazzaro V, Pilato F. The management of carotid restenosis: a comprehensive review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1272. [PMID: 33178804 PMCID: PMC7607074 DOI: 10.21037/atm-20-963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.
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Affiliation(s)
- Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nunzio Montelione
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rosalinda Calandrelli
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Marisa Distefano
- UOC Neurologia e UTN, Ospedale Belcolle, Strada Sammartinese 01100 Viterbo, Viterbo, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology, and Neurobiology Unit, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, UOC Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e della Testa-collo, Roma, Italy
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16
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Fuse Y, Kojima T, Shintai K, Seki Y. Long-term Outcomes of Carotid Artery Stenting: A Single-center Experience. Neurol Med Chir (Tokyo) 2020; 60:121-125. [PMID: 31902874 PMCID: PMC7073700 DOI: 10.2176/nmc.oa.2019-0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The long-term prophylactic effect of carotid artery stenting (CAS) remains incompletely elucidated. We evaluated outcomes of CAS at our institution to determine the safety and efficacy of CAS in real-world settings. We retrospectively analyzed 73 patients who underwent CAS from 2006 to 2013. Periprocedural results were compared between asymptomatic and symptomatic carotid stenosis groups. The primary endpoint was a composite of ipsilateral stroke, death, and carotid artery restenosis beyond 30 days and within 5 years after the first procedure. The average age was 72.2 years with a majority of male subjects (84.9%). Twenty-seven patients (37%) were asymptomatic. Incidence of periprocedural adverse events and mRS ≤2 at 30 days after CAS were not significantly different between groups (P = 0.14 and 0.07, respectively). CAS was unsuccessful in three patients and one post-procedural minor stroke occurred. Therefore, 69 patients were included in the long-term study. The rate of occurrence of the primary endpoint was 21.7%. Ipsilateral ischemic stroke occurred in one patient, which was due to cardiogenic embolus. Nine patients died, and cancer was the most frequent cause. Five in-stent restenoses were observed. All patients with restenosis underwent additional CAS without any occurrence of stroke. This study revealed the safety and long-term efficacy of CAS in a real-world setting. Routine follow-up is also important for detecting carotid artery restenosis.
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Affiliation(s)
- Yutaro Fuse
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| | - Takao Kojima
- Department of Neurosurgery, Fukushima Medical University
| | - Kazunori Shintai
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
| | - Yukio Seki
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital
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17
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Kang K, Gao F, Mo D, Yang M, Liu Y, Yang B, Chen X, Gu W, Ma G, Zhao X, Miao ZR, Ma N. Outcome of endovascular recanalization for intracranial in-stent restenosis. J Neurointerv Surg 2020; 12:1094-1098. [PMID: 32034104 DOI: 10.1136/neurintsurg-2019-015607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/16/2020] [Accepted: 01/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE In-stent restenosis (ISR) is one of the long-term adverse outcomes of endovascular angioplasty and stenting for symptomatic intracranial arterial stenosis. In this study, we try to evaluate the safety and efficacy of endovascular treatment for intracranial ISR. METHODS We retrospectively collected patients with intracranial ISR who underwent endovascular treatment from June 2012 to August 2019 at a high-volume stroke center. Successful recanalization was defined as ≤30% residual stenosis. Stroke, myocardial infarction, and death after stenting within 30 days were used to evaluate periprocedural safety. Recurrent stroke in the territory of the culprit vessel and re-ISR in patients with clinical and vascular imaging follow-up data were used to evaluate the long-term outcome. RESULTS 32 patients (59.6±7.2 years old) with ISR were recruited, including 22 patients (68.8%) treated with balloon dilatation, 8 patients (25%) with stenting, and 2 patients (6.3%) with failed procedures. Successful recanalization was achieved in 71.9% (23/32) of patients. There was no stroke, myocardial infarction or death within 30 days after the procedure. Recurrent stroke was found in 10.7% (3/28) of the patients, and re-ISR was found in 42.1% (8/19) of the patients. The re-ISR rate was lower in patients with stenting than in those with balloon dilatation (0% vs 57.1%, p=0.090), and in patients with successful recanalization than in those with unsuccessful recanalization (33.3% vs 75.0%, p=0.352), but with no statistically significant difference. CONCLUSIONS The periprocedural safety of endovascular treatment for intracranial ISR may be acceptable, but the long-term rates of recurrent stroke and re-ISR remain at high levels.
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Affiliation(s)
- Kaijiang Kang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Yang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yifan Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Yang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing Chen
- Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Weibin Gu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guofeng Ma
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhong-Rong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Severe, recurrent in-stent carotid restenosis: endovascular approach, risk factors. Results from a prospective academic registry of 2637 consecutive carotid artery stenting procedures (TARGET-CAS). ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:465-471. [PMID: 31933663 PMCID: PMC6956450 DOI: 10.5114/aic.2019.90221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/09/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Optimal management of severe carotid in-stent restenosis remains unknown. Prevalence and risk factors of first and recurrent carotid in-stent restenosis in the multi-stent approach have not been established yet. Aim To evaluate the safety of different methods of endovascular treatment of carotid in-stent restenosis/recurrent restenosis and to establish its rate and risk factors. Material and methods Between January 2001 and June 2016, 2637 neuroprotected carotid artery stenting (CAS) procedures were performed in 2443 patients (men: 67.0%; mean age: 67.9 ±8.8 years, symptomatic: 45.5%). Doppler ultrasound (DUS) evaluation was performed at discharge, after 3-6 months, 12 months, and then annually. Peak systolic velocity of 2-3 and > 3.0 m/s as well as end diastolic velocity of 0.5-0.9 and > 0.9 m/s were DUS criteria for 50-69% and ≥ 70% carotid in-stent restenosis (ISR) respectively. For angiographically confirmed ≥ 70% stenosis balloon re-angioplasty was first line treatment. Results Out of 95 DUS detected > 50% ISR (95/2637; 3.6%), 53 were confirmed in angiography as ≥ 70% (53/2637; 2.0%, one total occlusion). All patients were treated with bare balloon (n = 19), drug-eluting balloon (n = 27) or stent-supported (n = 6) angioplasty. One procedure was complicated with stroke (1.9%). Angiographic diameter stenosis (DS) was reduced from 83 ±8.3% to 13 ±7.6% (p < 0.001). There were 13 cases of ≥ 70% recurrent ISR. Bilateral and high-grade stenosis were independent risk factors of restenosis. Initial Carotid Wallstent implantation was a risk factor of first and recurrent in-stent restenosis. Conclusions Endovascular treatment of carotid in-stent restenosis is safe. Bilateral and high-grade carotid artery stenosis may increase the risk of restenosis. Initial Carotid Wallstent implantation may increase the risk of first and recurrent restenosis.
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19
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Yao X, Dai Z, Zhang X, Gao J, Xu G, Cai Y, Li Z. Carotid Geometry as a Predictor of In-Stent Neointimal Hyperplasia - A Computational Fluid Dynamics Study. Circ J 2019; 83:1472-1479. [PMID: 31061352 DOI: 10.1253/circj.cj-18-1152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carotid angioplasty and stenting (CAS) is emerging as an alternative treatment for carotid stenosis, but neointimal hyperplasia (NIH) remains a drawback of this treatment strategy. This study aimed to evaluate the effect of variations of carotid bifurcation geometry on local hemodynamics and NIH.Methods and Results:Hemodynamic and geometric effects on NIH were compared between 2 groups, by performing computational fluid dynamics (CFD) simulations both on synthetic models and patient-specific models. In the idealized models, multiple regression analysis revealed a significant negative relationship between internal carotid artery (ICA) angle and the local hemodynamics. In the patient-derived models, which were reconstructed from digital subtraction angiography (DSA) of 25 patients with bilateral CAS, a low time-average wall shear stress (TAWSS) and a high oscillatory shear index (OSI) were often found at the location of NIH. Larger difference values of the OSI percentage area (10.56±20.798% vs. -5.87±18.259%, P=0.048) and ECA/CCA diameter ratio (5.64±12.751% vs. -3.59±8.697%, P=0.047) were detected in the NIH-asymmetric group than in the NIH-symmetric group. CONCLUSIONS Changes in carotid bifurcation geometry can make apparent differences in hemodynamic distribution and lead to bilateral NIH asymmetry. It may therefore be reasonable to consider certain geometric variations as potential local risk factors for NIH.
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Affiliation(s)
- Xinke Yao
- School of Biological Science & Medical Engineering, Southeast University
| | - Zhengze Dai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University.,Department of Neurology, Nanjing Pukou Hospital
| | - Xu Zhang
- School of Biological Science & Medical Engineering, Southeast University
| | - Jie Gao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University
| | - Gelin Xu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University.,Department of Neurology, Jinling Hospital, Medical School of Nanjing University
| | - Yan Cai
- School of Biological Science & Medical Engineering, Southeast University
| | - Zhiyong Li
- School of Biological Science & Medical Engineering, Southeast University.,School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology
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20
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Dulai M, Tawfick W, Hynes N, Sultan S. Female Gender as a Risk Factor for Adverse Outcomes After Carotid Revascularization. Ann Vasc Surg 2019; 60:254-263. [PMID: 31200032 DOI: 10.1016/j.avsg.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 02/20/2019] [Accepted: 03/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND We aim to identify gender differences in complications after carotid surgery. Our primary endpoint is the incidence of perioperative stroke, myocardial infarction, and mortality. Secondary endpoints include restenosis and reintervention rates. METHODS All patients undergoing carotid endarterectomy from July 2003 to May 2016 were reviewed. The Society for Vascular Surgery carotid reporting standards were used as a guideline for data collection. RESULTS Over 13 years, 9,585 patients with carotid disease were referred to our institution. A total of 690 procedures were performed (633 carotid endarterectomies, 54 carotid angioplasties and stenting, and 3 bypasses). Of these 633 carotid endarterectomy procedures, 31.8% (201) were in women and 68.2% (432) were in men. In the perioperative period, female gender was found to be an independent predictor of stroke (odds ratio [OR]: 8.597, 95% confidence interval [CI]: 0.967-76.429, P = 0.041), restenosis (OR: 2.103, 95% CI: 1.445-3.060, P < 0.001), and reintervention (OR: 6.448, 95% CI: 1.313-31.667, P = 0.019). Mortality and cardiac morbidity did not significantly differ between genders. Ten-year stroke-free survival was 98.0% in women and 99.1% in men (logrank P = 0.259). Ten-year restenosis-free survival was 77.6% (45 of 201) in women and 89.4% (45 of 425) in men (logrank P < 0.001). Ten-year reintervention-free survival was 97.0% in women and 99.5% in men (logrank P = 0.008). Female gender was not an independent predictor of myocardial infarction (P = 0.713) and mortality (P = 0.856), respectively. The mean follow-up time was 47.06 ± 37.48 months with a median follow-up time of 43 months (interquartile range: 14.0-72.5). CONCLUSIONS Female gender was an independent predictor of postoperative stroke, restenosis, and reintervention. Symptom status at the time of surgery and type of closure of the arteriotomy did not influence development of stroke in female patients.
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Affiliation(s)
- Makinderjit Dulai
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland
| | - Wael Tawfick
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland
| | - Sherif Sultan
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland; Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.
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21
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In-stent restenosis associated with dual-layer Roadsaver carotid artery stent: a retrospective single-center study. LA RADIOLOGIA MEDICA 2019; 124:704-709. [DOI: 10.1007/s11547-019-01019-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/25/2019] [Indexed: 11/26/2022]
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22
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Cotter R, Kokkinidis DG, Choy HH, Singh GD, Rogers RK, Waldo SW, Laird JR, Armstrong EJ. Long-term outcomes of carotid artery stenting in patients with a contralateral carotid artery occlusion. Catheter Cardiovasc Interv 2018; 93:E49-E55. [DOI: 10.1002/ccd.27918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/09/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Ryan Cotter
- Division of Cardiology; Denver VA Medical Center and University of Colorado; Denver Colorado
| | - Damianos G. Kokkinidis
- Division of Cardiology; Denver VA Medical Center and University of Colorado; Denver Colorado
| | - Ho-Hin Choy
- Vascular Center and Division of Cardiology; UC Davis Medical Center; California
| | - Gagan D. Singh
- Vascular Center and Division of Cardiology; UC Davis Medical Center; California
| | - R. Kevin Rogers
- Division of Cardiology; Denver VA Medical Center and University of Colorado; Denver Colorado
| | - Stephen W. Waldo
- Division of Cardiology; Denver VA Medical Center and University of Colorado; Denver Colorado
| | - John R. Laird
- Vascular Center and Division of Cardiology; UC Davis Medical Center; California
| | - Ehrin J. Armstrong
- Division of Cardiology; Denver VA Medical Center and University of Colorado; Denver Colorado
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Li J, Hua Y, Needleman L, Forsberg F, Eisenbray JR, Li Z, Liu R, Tian X, Jiao L, Liu JB. Arterial occlusions increase the risk of in-stent restenosis after vertebral artery ostium stenting. J Neurointerv Surg 2018; 11:574-578. [PMID: 30337379 DOI: 10.1136/neurintsurg-2018-014243] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The study was designed to investigate if vascular occlusion in the internal carotid artery (ICA) or the contralateral vertebral artery (VA) contribute to developing in-stent restenosis (ISR) in patients with vertebral artery ostium stenosis (VAOS). METHODS 420 consecutive patients treated with VAOS stents (from a population of 8145 patients with VAOS) from January 2013 to December 2014 were analyzed in this retrospective study; 216 with drug eluted stents and 204 with bare metal stents. Based on pre-stent DSA findings, patients were divided into four groups: both carotid and vertebral arteries patent (PAT), ICA occlusion (ICA-OCC), contralateral VA occlusion (CVA-OCC), and combined occlusions (C-OCC). The incidence of ISR (stenosis >50%) was compared between groups using Cox regression analysis. RESULTS Of the 420 patients, the mean incidence of ISR was 36.4%, with a median 12 months of follow-up (IQR 3-12). Logistic regression analysis showed that drug eluting stent had less ISR than bare metal stent (OR=0.38, 95% CI 0.19 to 0.75, P=0.01). Cox regression analysis showed that CVA-OCC (HR=1.63, P=0.02) and C-OCC (HR=3.30, P=0.001) were risk factors for ISR but not ICA-OCC (P=0.31). In the CVA-OCC and C-OCC groups, in-stent peak systolic velocity (PSV) ≥140 cm/s, 1 day after successful stenting, was associated with subsequent development of ISR (OR=2.81, 95% CI 1.06 to 7.43, P=0.04). CONCLUSION Contralateral VA occlusion at the time of stenting increased the risk of ISR, especially if stent PSV on day 1 was >140 cm/s. Bare metal stents had more ISR than drug eluting stents.
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Affiliation(s)
- Jingzhi Li
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Laurence Needleman
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John R Eisenbray
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Zhaojun Li
- Department of Ultrasound, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ran Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Tian
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ji-Bin Liu
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Recurrent stenosis following carotid artery stenting treated with a drug-eluting balloon: a single-center retrospective analysis. Neuroradiology 2017; 60:81-87. [DOI: 10.1007/s00234-017-1935-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
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25
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Abstract
As a common etiology for ischemic stroke, atherosclerotic carotid stenosis has been targeted by vascular surgery since 1950s. Compared with carotid endarterectomy, carotid angioplasty and stenting (CAS) is almost similarly efficacious and less invasive. These advantages make CAS an alternative in treating carotid stenosis. However, accumulative evidences suggested that the long-term benefit-risk ratio of CAS may be decreased or even neutralized by the complications related to in-stent restenosis (ISR). Therefore, investigating the mechanisms and identifying the influential factors of ISR are of vital importance for improving the long-term outcomes of CAS. As responses to intrinsic and extrinsic injuries, intimal hyperplasia and vascular smooth muscle cell proliferation have been regarded as the principle mechanisms for ISR development. Due to the lack of consensus-based definition and consistent follow-up protocol, the reported incidences of ISR after CAS varied widely among studies. These variations made the inter-study comparisons of ISR largely illogical. To eliminate restenosis after CAS, both surgery and endovascular procedures have been attempted with promising results. For preventing ISR, drug-eluting stents and antiplatelets have been proposed as potential solutions.
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Affiliation(s)
- Zhengze Dai
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Pukou Hospital, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Kammler J, Blessberger H, Lambert T, Kellermair J, Grund M, Nahler A, Lichtenauer M, Schwarz S, Reiter C, Steinwender C, Kypta A. In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort. Clin Res Cardiol 2017; 106:493-500. [DOI: 10.1007/s00392-017-1078-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/10/2017] [Indexed: 11/28/2022]
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Di Gioia G, Scordino D, Campanale CM, Miglionico M, Creta A, Proscia C, Ragni L, Colaiori I, Di Sciascio G. In-Stent Restenosis After Carotid Artery Stenting: From Diagnosis to Treatment. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10312518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Although carotid artery stenting is a safe and effective treatment for preventing ischaemic stroke in significant carotid atherosclerotic disease, it can be complicated by in-stent restenosis (ISR). Factors involved in the ISR process are both mechanical and patient-related, but the most important is the neointimal thickening within stent struts, leading to lumen reduction. Overall incidence of carotid ISR is low and related embolic risk seems to be lower than native disease. Digital subtraction angiography is the gold standard for diagnosis. Nowadays, Doppler ultrasound should be considered the first-line investigation, due to its non-invasiveness and reproducibility. Computed tomography angiography remains useful when Doppler ultrasound is inconclusive. Indication and modality of treatment of ISR are still debated: both surgery (carotid endarterectomy with stent removal in most cases) or interventional procedures such as percutaneous transluminal angioplasty with simple balloon, cutting-balloon, drug-eluting balloon, and stenting, showed safety and efficacy in follow-up. Surgery is currently reserved for selected cases. Carotid ISR is an overall rare complication which can be easily identified at routine follow-up. This paper is a literature review and state-of-the-art assessment of ISR, clinical features, diagnosis, and treatment.
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Affiliation(s)
- Giuseppe Di Gioia
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Domenico Scordino
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Cosimo Marco Campanale
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Marco Miglionico
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Antonio Creta
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Claudio Proscia
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Laura Ragni
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Iginio Colaiori
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Germano Di Sciascio
- Department of Medicine and Surgery, Unit of Cardiology, Campus Bio-Medico University of Rome, Rome, Italy
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Zhou ZH, Peng J, Meng ZY, Chen L, Huang JL, Huang HQ, Li L, Zeng W, Wei Y, Zhu CH, Chen KN. Novel A20-gene-eluting stent inhibits carotid artery restenosis in a porcine model. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:2341-51. [PMID: 27540277 PMCID: PMC4982496 DOI: 10.2147/dddt.s94984] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Carotid artery stenosis is a major risk factor for ischemic stroke. Although carotid angioplasty and stenting using an embolic protection device has been introduced as a less invasive carotid revascularization approach, in-stent restenosis limits its long-term efficacy and safety. The objective of this study was to test the anti-restenosis effects of local stent-mediated delivery of the A20 gene in a porcine carotid artery model. Materials and methods The pCDNA3.1EHA20 was firmly attached onto stents that had been collagen coated and treated with N-succinimidyl-3-(2-pyridyldithiol)propionate solution and anti-DNA immunoglobulin fixation. Anti-restenosis effects of modified vs control (the bare-metal stent and pCDNA3.1 void vector) stents were assessed by Western blot and scanning electron microscopy, as well as by morphological and inflammatory reaction analyses. Results Stent-delivered A20 gene was locally expressed in porcine carotids in association with significantly greater extent of re-endothelialization at day 14 and of neointimal hyperplasia inhibition at 3 months than stenting without A20 gene expression. Conclusion The A20-gene-eluting stent inhibits neointimal hyperplasia while promoting re-endothelialization and therefore constitutes a novel potential alternative to prevent restenosis while minimizing complications.
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Affiliation(s)
- Zhen-Hua Zhou
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - Jing Peng
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - Zhao-You Meng
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - Lin Chen
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - Jia-Lu Huang
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - He-Qing Huang
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
| | - Li Li
- Department of Anatomy, Key Laboratory for Biomechanics of Chongqing, Third Military Medical University, Chongqing, People's Republic of China
| | - Wen Zeng
- Department of Anatomy, Key Laboratory for Biomechanics of Chongqing, Third Military Medical University, Chongqing, People's Republic of China
| | - Yong Wei
- Department of Anatomy, Key Laboratory for Biomechanics of Chongqing, Third Military Medical University, Chongqing, People's Republic of China
| | - Chu-Hong Zhu
- Department of Anatomy, Key Laboratory for Biomechanics of Chongqing, Third Military Medical University, Chongqing, People's Republic of China
| | - Kang-Ning Chen
- Department of Neurology, Cerebrovascular Disease Research Institute, Southwest Hospital
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Musialek P, Mazurek A, Trystula M, Borratynska A, Lesniak-Sobelga A, Urbanczyk M, Banys RP, Brzychczy A, Zajdel W, Partyka L, Zmudka K, Podolec P. Novel PARADIGM in carotid revascularisation: Prospective evaluation of All-comer peRcutaneous cArotiD revascularisation in symptomatic and Increased-risk asymptomatic carotid artery stenosis using CGuard™ MicroNet-covered embolic prevention stent system. EUROINTERVENTION 2016; 12:e658-70. [DOI: 10.4244/eijy16m05_02] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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Misaki K, Uchiyama N, Mohri M, Hayashi Y, Ueda F, Nakada M. Prediction of carotid artery in-stent restenosis by quantitative assessment of vulnerable plaque using computed tomography. J Neuroradiol 2015; 43:18-24. [PMID: 26603106 DOI: 10.1016/j.neurad.2015.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 09/09/2015] [Accepted: 09/14/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE To assess the relationship between plaque volume evaluated by multidetector computed tomographic angiography (MDCT) and in-stent restenosis (ISR) after carotid artery stenting (CAS). MATERIALS AND METHODS From a retrospectively maintained database, data were collected for 52patients with carotid artery stenosis treated with CAS between 2007 and 2012. We defined ISR of≥50% as a peak systolic velocity≥200cm/s on echo-duplex scan. Carotid plaques were subdivided into four components according to radiodensity in Hounsfield units (HU) as follows: <0, 0-60, 60-130, and>600HU. Risk factors that influenced ISR were compared using univariate and multivariate Cox regression analyses. RESULTS During a median follow-up period of 36months, ISR of≥50% was detected in five patients (9.6%). In the univariate Cox proportional hazard regression analysis, renal insufficiency, coronary artery disease, total plaque volume, and plaque volumes with radiodensities<0 and≥600HU increased the risk for ISR (P<0.10). When the significant risk factors determined from the univariate analysis were subjected to a multivariate analysis, only the volumes of the plaque components with radiodensities<0 HU independently predicted the development of ISR (hazard ratio: 1.041; 95% confidence interval: 1.006-1.078; P=0.021). CONCLUSION Our data suggest that the high volume of the plaque components with radiodensities<0HU was independently associated with the increased risk of ISR after CAS. Quantitative and qualitative tissue characterizations of carotid plaques using MDCT might be a useful predictive tool of the development of ISR.
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Affiliation(s)
- Kouichi Misaki
- Kanazawa University, Graduate School of Medical Science, Division of Neuroscience, Department of Neurosurgery, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan.
| | - Naoyuki Uchiyama
- Kanazawa University, Graduate School of Medical Science, Division of Neuroscience, Department of Neurosurgery, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan
| | - Masanao Mohri
- Kanazawa University, Graduate School of Medical Science, Division of Neuroscience, Department of Neurosurgery, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan
| | - Yutaka Hayashi
- Kanazawa University, Graduate School of Medical Science, Division of Neuroscience, Department of Neurosurgery, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan
| | - Fumiaki Ueda
- Kanazawa University, Graduate School of Medical Science, Division of Cardiovascular Medicine, Department of Radiology, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan
| | - Mitsutoshi Nakada
- Kanazawa University, Graduate School of Medical Science, Division of Neuroscience, Department of Neurosurgery, 13-1 Takara-machi, Kanazawa, 920-8641 Ishikawa, Japan
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Liu R, Jiang Y, Xiong Y, Li M, Ma M, Zhu W, Yin Q, Li W, Xu G, Liu X. An Optical Coherence Tomography Assessment of Stent Strut Apposition Based on the Presence of Lipid-Rich Plaque in the Carotid Artery. J Endovasc Ther 2015; 22:942-9. [PMID: 26464412 DOI: 10.1177/1526602815610116] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the rate of stent malapposition, plaque prolapse, and fibrous cap rupture detected by optical coherence tomography (OCT) after carotid artery stenting (CAS) based on the presence of lipid-rich plaque, which may be associated with acute stent thrombosis. Methods: A retrospective study was conducted involving 26 consecutive patients who underwent CAS with OCT imaging acquired before stent deployment and after stent dilation. Adequate imaging quality could not be obtained in 6 patients (out-of-screen images and residual blood), which left 20 patients (mean age 63 years; 13 men) for analysis. Plaque characteristics were determined from 500 selected OCT cross sections; a lipid-rich plaque was defined by lipid present in ≥2 quadrants. Cross-sectional OCT images within the stented segment were evaluated at 1-mm intervals for the presence of malapposition, plaque prolapse, and fibrous cap rupture. The data were compared between patients with and without lipid-rich plaques. The patients were examined at 6 months to determine the degree of in-stent restenosis (ISR). Results: Patients with lipid-rich plaque demonstrated a higher rate of embedded stent struts (29.4% vs 23.7%, p<0.001) and a lower rate of well apposed struts (54.6% vs 59.6%, p<0.001) compared to patients with non–lipid-rich plaque. Rates of plaque prolapse (65.5% vs 49.1%, p<0.001) and fibrous cap rupture (65.5% vs 49.1%, p<0.001) were significantly higher in patients with lipid-rich plaque. ISR ranged from none to 42% in 12 patients; malapposed stent struts and fibrous cap ruptures were not more frequent in the patients with obvious ISR. The 8 patients with no obvious restenosis still had malapposed struts, embedded struts, plaque prolapse, and fibrous cap rupture. Conclusion: Embedded stent struts, plaque prolapse, and fibrous cap rupture were more frequent and well-apposed stent struts were less frequent after CAS in patients with lipid-rich plaque.
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Affiliation(s)
- Rui Liu
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Yongjun Jiang
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Yunyun Xiong
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Min Li
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Minmin Ma
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Wusheng Zhu
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Qin Yin
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Wei Li
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, China
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Daou B, Chalouhi N, Starke RM, Dalyai R, Polifka A, Sarkar K, Jabbour P, Rosenwasser R, Tjoumakaris S. Predictors of restenosis after carotid artery stenting in 241 cases. J Neurointerv Surg 2015; 8:677-9. [DOI: 10.1136/neurintsurg-2015-011783] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 05/29/2015] [Indexed: 11/03/2022]
Abstract
BackgroundVariable rates of restenosis after carotid artery stenting (CAS) have been reported, and few predictors have been suggested. Because CAS is being performed with increasing frequency, more data are needed to evaluate the rate and predictors of restenosis and possibly identify new risk factors for restenosis after CAS. The aim of this study was to analyze the rate and predictors of restenosis after CAS.Methods241 patients with carotid artery stenosis treated with stenting were analyzed retrospectively to identify patients who had restenosis after stenting. Univariate analysis and multivariate logistic regression were conducted to determine the predictors of restenosis.ResultsMean patient age was 67.5 years. 8.3% of patients who underwent CAS had carotid restenosis of ≥50% during follow-up. 3.7% of patients required retreatment. Mean duration from CAS to retreatment was 11 months. In multivariate analysis, the predictors of restenosis included history of cardiovascular disease (OR=8.88, p<0.001) and having a cerebrovascular accident (CVA) prior to stenting (OR=1.87, p=0.034). A higher percentage of preoperative carotid stenosis was associated with higher odds of restenosis in univariate analysis (p=0.04, OR stenosis ≥80%=5.7).ConclusionsOur results suggest that the rate of carotid restenosis after stenting is low. Patients with cardiovascular disease, patients who had a CVA prior to stenting, and patients with higher percentages of preoperative stenosis had higher odds of restenosis. Higher rates of restenosis should be kept in mind when opting for CAS in these patients.
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Šedivý P, El Samman K, Přindišová H, Štádler P. The importance of and current trends in the endovascular program - A single center experience. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2015.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Miyazaki Y, Mori T, Iwata T, Aoyagi Y, Tanno Y, Kasakura S, Yoshioka K. Continuous daily use of cilostazol prevents in-stent restenosis following carotid artery stenting: serial angiographic investigation of 229 lesions. J Neurointerv Surg 2015; 8:471-5. [PMID: 25829365 DOI: 10.1136/neurintsurg-2014-011565] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/13/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Several studies have reported that cilostazol (CLS) may reduce in-stent restenosis (ISR) after carotid artery stenting (CAS). However, it is not known for how long CLS must be continued to prevent ISR. METHODS We retrospectively reviewed a prospectively collected database of patients who underwent elective CAS and follow-up angiography at 3 months and 1 year after the procedure. ISR was defined as stenosis of 50% or greater on digital subtraction angiography. The cumulative incidence rates of angiographic ISR were compared between the three groups, divided according to duration of CLS use : (1) patients who were maintained on CLS for 12 months or more after CAS (12M CLS group, n=70), (2) patients who were treated with CLS for the first 3 months after CAS (3M CLS group, n=23), and (3) patients who did not receive CLS (no CLS group, n=136). RESULTS A total of 229 lesions in 199 patients were included in our analysis. During a median follow-up of 365 days, ISR was detected in 15 lesions. The cumulative ISR rates overall and in the 12M CLS, 3M CLS, and no CLS groups were 5.6%, 0%, 5.0%, and 8.4%, respectively, at 1 year, and the log rank test showed that there was a significant difference between the three groups (p<0.05). Cox regression analysis demonstrated that the 12M CLS group had a significantly lower risk of ISR than the 3M CLS group (adjusted relative risk (aRR) 3.06e-10, 95% CI 0 to 0.51, p<0.05) and the no CLS group (aRR 1.41e-10, 95% CI 0 to 0.15, p<0.001), whereas no difference was found between the 3M CLS group and the no CLS group. CONCLUSIONS An overall cumulative ISR rate of 5.6% was documented angiographically at 1 year after CAS. Continuous daily use of CLS (for at least 1 year) may have a beneficial effect on long term prevention of ISR.
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Affiliation(s)
- Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takahisa Mori
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Tomonori Iwata
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yoshinori Aoyagi
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yuhei Tanno
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Shigen Kasakura
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Kazuhiro Yoshioka
- Department of Stroke Treatment, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
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Del Giudice C, Pellerin O, Gandini R, Sapoval M. Commentary: drug-coated balloon angioplasty to improve carotid stenting outcomes after postendarterectomy restenosis: fad or an answer to the problem of recurrent restenosis? J Endovasc Ther 2015; 22:217-9. [PMID: 25809365 DOI: 10.1177/1526602815573728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Olivier Pellerin
- Hôpital Européen Georges-Pompidou, Université Paris V-Paris Descartes, Paris, France
| | | | - Marc Sapoval
- Hôpital Européen Georges-Pompidou, Université Paris V-Paris Descartes, Paris, France
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Lucatelli P, Fanelli F, Cirelli C, Sacconi B, Anzidei M, Montisci R, Sanfilippo R, Tamponi E, Catalano C, Saba L. Carotid endarterectomy versus stenting: Does the flow really change? An Echo-Color-Doppler analysis. Int J Cardiovasc Imaging 2015; 31:773-81. [PMID: 25697722 DOI: 10.1007/s10554-015-0623-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 02/16/2015] [Indexed: 11/26/2022]
Abstract
To assess potential hemodynamic differences after carotid endarterectomy (CEA) and carotid artery stenting (CAS) and their eventual impact on clinical management. Between July 2012 and October 2013 two groups of 30 patients each referred for CEA or CAS were prospectively enrolled in two tertiary hospital care centers. Pre-procedural imaging assessment of carotid artery disease was performed with Echo-Color-Doppler (ECD) and computed tomography angiography (CTA). ECD was repeated within 24 h and 1, 6 and 12 months after surgical/endovascular procedures. Peak systolic velocity (PSV) and end diastolic velocity (EDV) were assessed at two standard sites: common carotid artery (CCA) and distal internal carotid artery (ICA). Twenty-four hours ECD findings highly differ between the two populations. CCA PSV in the CEA and CAS groups was respectively 44.88 ± 9.16 and 69.20 ± 20.04 cm/s (p = 0.002); CCA EDV was 16.11 ± 2.29 and 19.13 ± 6.42 cm/s (p = 0.065); ICA PSV was 46.11 ± 7.9 and 94.02 ± 57.7 cm/s (p = 0.0012); ICA EDV was 20.22 ± 4.33 and 30.47 ± 18.33 cm/s (p = 0.025). One month, 6 months and 1 year findings confirmed the different trend in the two cohorts; in particular, at 1 year: CCA PSV was 50.94 ± 12.44 and 60.59 ± 26.84 cm/s (p = 0.181); CCA EDV was 17.11 ± 3.46 and 19 ± 16.35 cm/s (p = 0.634); ICA PSV was 51.66 ± 10.1 and 70.86 ± 20.64 cm/s (p = 0.014); ICA EDV was 25.05 ± 8.65 and 32.66 ± 13 cm/s (p = 0.0609). ECD follow-up of patients undergone CEA or CAS may play a critical role in the clinical management. Strict surveillance of blood flow velocities allows reducing false positive re-stenosis diagnosis and choosing the best anti-aggregation therapies. Within the first month CEA patients benefit from a lower risk condition in comparison with CAS patients, due to a significantly faster PSV drop; moreover, long-term CCA PSV after CEA could be used as a surrogate marker of neointima formation.
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MESH Headings
- Aged
- Angioplasty/adverse effects
- Angioplasty/instrumentation
- Blood Flow Velocity
- Carotid Artery, Common/diagnostic imaging
- Carotid Artery, Common/physiopathology
- Carotid Artery, Common/surgery
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/physiopathology
- Carotid Artery, Internal/surgery
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/physiopathology
- Carotid Stenosis/surgery
- Carotid Stenosis/therapy
- Endarterectomy, Carotid/adverse effects
- Female
- Humans
- Italy
- Male
- Middle Aged
- Predictive Value of Tests
- Prospective Studies
- Recurrence
- Regional Blood Flow
- Severity of Illness Index
- Stents
- Tertiary Care Centers
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Ultrasonography, Doppler, Color
- Vascular Patency
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Affiliation(s)
- Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy,
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Siracuse JJ, Epelboym I, Li B, Hoque R, Catz D, Morrissey NJ. External carotid artery stenosis after internal and common carotid stenting. Ann Vasc Surg 2014; 29:443-6. [PMID: 25463339 DOI: 10.1016/j.avsg.2014.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/26/2014] [Accepted: 08/30/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The external carotid artery (ECA) can be an important collateral for cerebral perfusion in the presence of severe internal carotid artery (ICA) disease. ICA stenting that covers the ECA origin may put the ECA at increased risk of stenosis. Our objective was to determine the rate of ECA stenosis secondary to ICA stenting, determine predictive factors, and describe any subsequent associated symptoms. METHODS We retrospectively reviewed clinical data on all ICA stents crossing the origin of the ECA placed by vascular surgeons at our institution. We analyzed patient demographics, comorbidities, stent type and sizes, as well as medication profile to determine predictors of ECA stenosis. RESULTS Between 2005 and 2013, there were 72 (out of 119 total ICA stenting) patients (mean age 71, 68% male) who underwent placement of ICA stents that also crossed the origin of the ECA. Six patients (8.3%) had a significantly increased ECA stenosis postprocedure. There were no occlusions. All patients with ECA stenosis maintained patency of their ICA stent and were asymptomatic. Age, gender, comorbidities, stent type and size, and medication profile were not associated with ECA stenosis after stenting. CONCLUSIONS ECA stenosis after ICA stenting covering the ECA origin is uncommon and not clinically significant in patients with patent ICA stents. The clinical significance of concurrent ECA and ICA stenosis after stenting is unclear as it is not captured here. The potential for ECA stenosis should not deter stenting across the ECA origin if necessary. Patient and stent factors are not predictive of ECA stenosis.
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Affiliation(s)
- Jeffrey J Siracuse
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
| | - Irene Epelboym
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Boyangzi Li
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Rahima Hoque
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Diana Catz
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Nicholas J Morrissey
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
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Kono K, Shintani A, Terada T. Non-enhanced magnetic resonance angiography can evaluate restenosis after carotid artery stenting with the Carotid Wallstent. Acta Neurochir (Wien) 2014; 156:1713-9. [PMID: 24890936 DOI: 10.1007/s00701-014-2142-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) requires follow-up imaging to assess in-stent restenosis (ISR). This study aimed to determine whether non-enhanced magnetic resonance angiography (NE-MRA) is useful for evaluating ISR. METHOD Between 2009 and 2013, we performed 118 consecutive CAS procedures using the Precise stent (n = 78) and the Carotid Wallstent (n = 40). We reviewed 1.5 T NE-MRA and examined visualization of the stent lumen and the degree of ISR if present. Other imaging modalities were used as references. RESULTS NE-MRA performed just after CAS was not able to visualize the stent lumen in all patients because of metal artifacts. In the Carotid Wallstent group, follow-up NE-MRA was available in 22 patients. The stent lumen was visible more than three months after CAS in all patients. Among them, >40 % ISR was observed by other modalities in eight lesions. The degree of restenosis measured by NE-MRA (y%) had a linear relationship with that measured by conventional angiography (x%) (y = 0.97x-0.4, r = 0.79, P = 0.021). In one case among 17 without ISR (6 %), NE-MRA showed false ISR. In the Precise stent group, NE-MRA did not visualize the stent lumen in the follow-up period. CONCLUSIONS NE-MRA can visualize the stent lumen in the Carotid Wallstent more than three months after CAS, but not in the Precise stent at follow-up. This delayed visualization might depend on endothelialization of the stent lumen. The degree of ISR measured by NE-MRA is comparable to that by conventional angiography. NE-MRA can evaluate ISR after CAS with the Carotid Wallstent (100 % sensitivity and 94 % specificity).
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Affiliation(s)
- Kenichi Kono
- Department of Neurosurgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, 640-8505, Japan,
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Abstract
Cerebrovascular diseases are one of the favorite topics of manuscripts submitted to the Journal of Neurology. In this summary paper, we briefly present those manuscripts that in our opinion were most relevant in selected areas of vascular diseases of the brain.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal,
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Brown K, Itum DS, Preiss J, Duwayri Y, Veeraswamy RK, Salam A, Dodson TF, Brewster LP. Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy. J Vasc Surg 2014; 61:119-24. [PMID: 25064529 DOI: 10.1016/j.jvs.2014.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/08/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The external carotid artery (ECA) can be an important source of cerebral blood flow in cases of high-grade internal carotid artery stenosis or occlusion. However, the treatment of the ECA is fundamentally different between carotid endarterectomy (CEA) and carotid artery stenting (CAS). CEA is routinely associated with endarterectomy of the ECA, whereas CAS excludes the ECA from direct flow. We hypothesize that these differences make ECA occlusion more common after CAS. Further, the impact of CAS on blood flow into the ECA is interesting because the flow from the stent into the ECA is altered in a way that may promote local inflammation and may influence in-stent restenosis (ISR). Thus, our objective was to use our institutional database to identify whether CAS increased the rate of ECA occlusion and, if it did, whether ECA occlusion was associated with ISR. METHODS Patients undergoing CAS or CEA from February 2007 to February 2012 were identified from our institutional carotid therapy database. Preoperative and postoperative images of patients who followed up in our institution were included in the analysis of ECA occlusion and rates of ISR. RESULTS There were 210 (67%) CAS patients and 207 (60%) CEA patients included in this analysis. Despite CAS patients being younger (68 vs 70 years), having shorter follow-up (12.5 vs 56.2 months), and being more likely to take clopidogrel (97% vs 35%), they had an increased rate of ECA occlusion (3.8%) compared with CEA patients (0.4%). CAS patients who went on to ECA occlusion had an increased incidence of prior neck irradiation (50% vs 15%; P = .03), but we did not identify an association of ECA occlusion with ISR >50%. CONCLUSIONS Whereas prior publications have identified increased rates of external carotid stenosis, this is the first demonstration of increased ECA occlusion after CAS. However, ECA occlusion is uncommon (∼4%) and did not have an association with ISR >50%. Future work modeling ECA flow patterns before and after CAS will be used to further test this interaction.
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Affiliation(s)
- Kevin Brown
- Department of Vascular Surgery, Emory University/Atlanta VA Medical Center, Atlanta, Ga
| | - Dina S Itum
- Department of Vascular Surgery, Emory University, Atlanta, Ga
| | - Joshua Preiss
- Department of Vascular Surgery, Emory University, Atlanta, Ga
| | - Yazan Duwayri
- Department of Vascular Surgery, Emory University, Atlanta, Ga
| | | | - Atef Salam
- Department of Vascular Surgery, Emory University/Atlanta VA Medical Center, Atlanta, Ga
| | - Thomas F Dodson
- Department of Vascular Surgery, Emory University, Atlanta, Ga
| | - Luke P Brewster
- Department of Vascular Surgery, Emory University/Atlanta VA Medical Center, Atlanta, Ga.
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Brown KA, Itum DS, Duwayri Y, Reeves JG, Rajani R, Veeraswamy RK, Arya S, Salam A, Dodson TF, Brewster LP. Influence of the hostile neck on restenosis after carotid stenting. Ann Vasc Surg 2014; 29:9-14. [PMID: 24930975 DOI: 10.1016/j.avsg.2014.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/25/2014] [Accepted: 06/03/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) for carotid stenosis is favored over carotid endarterectomy (CEA) in patients with a hostile neck from prior CEA or cervical irradiation (XRT). However, the restenosis rate after CAS in patients with hostile necks is variable in the literature. The objective of this study was to quantify differences in the in-stent restenosis (ISR)/occlusion and reintervention rates after CAS in patients with and without a hostile neck. Here we hypothesize that patients with hostile necks have an increased ISR, and that this increase may add morbidity to these patients. MATERIALS AND METHODS All patients undergoing CAS from 2007 to 2013 for carotid artery stenosis with follow-up imaging at our institution were queried from our carotid database (n = 236). Patients with hostile necks, including both CAS after prior CEA (n = 65) and prior XRT (n = 37), were compared with patients who underwent CAS for other reasons including both anatomical (n = 46) and medical comorbidities (n = 88). The primary end points were ISR, repeat intervention, and stent occlusion. Secondary end points of the study were stroke/myocardial infarction (MI)/death at 30 days, perioperative cardiovascular accident, transient ischemic attack, MI, groin access complications, hyperperfusion syndrome, and periprocedural hypotension or bradycardia. RESULTS Despite the hostile neck cohort being younger and having lower incidence of chronic obstructive pulmonary disease, coronary artery disease, and renal insufficiency, they had a greater incidence of ISR (11% vs. 4%; P = .03) and required more reinterventions (8% vs. 2%; P = .04). Stent occlusion and periprocedural morbidity/mortality were not different between groups. CONCLUSIONS Patients with hostile necks have increased risk of restenosis and need for reinterventions after CAS compared with patients without a hostile neck. However, they do not appear to have higher rates of stent occlusion or per-procedural events.
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Affiliation(s)
- Kevin A Brown
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Dina S Itum
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Yazan Duwayri
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - James G Reeves
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Ravi Rajani
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | | | - Shipra Arya
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Atef Salam
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Thomas F Dodson
- Department of Surgery, Emory University Hospital, Atlanta, GA
| | - Luke P Brewster
- Department of Surgery, Emory University Hospital, Atlanta, GA.
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Yu SCH, Zou WXY, Soo YOY, Wang L, Hui JWY, Chan AYY, Lee KT, Ip VHL, Fan FSY, Chan ALC, Wong LKS, Leung TW. Evaluation of carotid angioplasty and stenting for radiation-induced carotid stenosis. Stroke 2014; 45:1402-7. [PMID: 24699055 DOI: 10.1161/strokeaha.113.003995] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate the procedural safety, clinical, and angiographic outcome of carotid angioplasty and stenting for high-grade (≥70%) radiation-induced carotid stenosis (RIS) using atherosclerotic stenosis (AS) as a control. METHODS In this 6-year prospective nonrandomized study, we compared the carotid angioplasty and stenting outcome of 65 consecutive patients (84 vessels) with RIS with that of a control group of 129 consecutive patients (150 vessels) with AS. Study end points were 30-day periprocedural stroke or death, ipsilateral ischemic stroke, technical success, procedural characteristics, instent restenosis (ISR; ≥50%) and symptomatic ISR. RESULTS The median follow-up was 47.3 months (95% confidence interval, 26.9-61.6). Imaging assessment was available in 74 vessels (RIS) and 120 vessels (AS) in 2 years. Comparing RIS group with AS group, the rates of periprocedural stroke or death were 1.5% (1/65) versus 1.6% (2/129; P=1); ipsilateral ischemic stroke rates were 4.6% (3/65) versus 4.7% (6/129; P=1); the annual risks of ipsilateral ischemic stroke were 1.2% (3 patient/254.7 patient year) versus 1.2% (6 patient/494.2 patient year; P=0.89); technical success rates were both 100%. Stenting of common carotid artery and the use of multiple stents was more common in the RIS group (P=0 in both cases); ISR rates were 25.7% (19/74) versus 4.2% (5/120; P<0.001); symptomatic ISR rates were 6.8% (5/74) versus 0.8% (1/120; P=0.031). CONCLUSIONS The safety, effectiveness, and technical difficulty of carotid angioplasty and stenting for RIS are comparable with that for AS although it is associated with a higher rate of ISR. CLINICAL TRIAL REGISTRATION This trial was not registered as enrollment started in 2006.
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Affiliation(s)
- Simon C H Yu
- From the Department of Imaging and Interventional Radiology, Prince of Wales Hospital (S.C.H.Y., J.W.Y.H., K.T.L.), Vascular and Interventional Radiology Foundation Clinical Science Center (S.C.H.Y., J.W.Y.H., K.T.L., T.W.L.), and Department of Medicine and Therapeutics, Prince of Wales Hospital (W.X.Y.Z., Y.O.Y.S., L.W., A.Y.Y.C., V.H.L.I., F.S.Y.F., A.L.C.C., L.K.S.W., T.W.L.), The Chinese University of Hong Kong, Hong Kong, China
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Lin YJ, Li JW, Zhang MJ, Qian L, Yang WJ, Zhang CL, Shao Y, Zhang Y, Huang YJ, Xu Y. The association between CYP2C19 genotype and of in-stent restenosis among patients with vertebral artery stent treatment. CNS Neurosci Ther 2013; 20:125-30. [PMID: 24330577 DOI: 10.1111/cns.12173] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/04/2013] [Accepted: 08/06/2013] [Indexed: 11/30/2022] Open
Abstract
AIMS Preventing stroke through endovascular treatment with vertebral artery stent remains a great challenge due to the occurrence of an in-stent restenosis. MATERIALS & METHODS In this study, a retrospective analysis was conducted in 90 patients who had been treated with VAS between 2004 and 2011 in Nanjing Drum Tower Hospital. Patients were followed up at 3 months, 6 months,and 1 year after VAS treatment and annually thereafter. For each time point, neurological function tests, vessel ultrasound and computer tomography angiography were performed to preliminarily screen the vessel stenosis. Digital subtraction angiography was used to verify the narrow sign on CTA or ultrasound. Clinical features of each patient including clopidogrel metabolization genes (CYP2C19, CYP3A4, and P2Y12) were recorded with purpose to investigate the possible risk factors for the development of ISR. RESULTS Single factor analysis dem-onstrated that hyperlipidemia (P < 0.05) and CYP2C19 (P < 0.01) loss-of-function geno-type increased the likelihood of ISR. A multiple logistic cox regression analysis also showed that stroke patients with hyperlipidemia (HR 3.719, 95% CI: 1.094-12.637, P = 0.035), and CYP2C19 loss-of-function genotype (HR 2.959, 95% CI: 1.325-6.610, P = 0.008) were more likely to suffer from ISR. Furthermore, CYP2C19 alleles were mainly divided into three groups: wt/wt (CYP2C19 *1/*1), wt/m (CYP2C19 *1/*2 and *1/*3), and m/m (CYP2C19 *2/*2,*2/*3 and*3/*3). Recurrent rate of ischemic stroke in m/m and wt/m groups was higher than the wt/wt group (OR: 0.141, 95% CI: 0.016-1.221, P = 0.042). CONCLUSION The study leads to the conclusion that hyperlipidemia and CYP2C19 impotency are possible risk factors for the development of ISR in VAS-treated patients with ischemic. Moreover, VAS-treated patients with CYP2C19 impotency were susceptible to recurrent stroke during our 54-month follow-up.
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Affiliation(s)
- Yong-Juan Lin
- Department of Neurology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; Stroke Center for Diagnosis and Therapy in Jiangsu province, Nanjing, China
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Wasser K, Karch A, Gröschel S, Witzenhausen J, Gröschel K, Bähr M, Liman J. Plaque morphology detected with Duplex ultrasound before carotid angioplasty and stenting (CAS) is not a predictor of carotid artery in-stent restenosis, a case control study. BMC Neurol 2013; 13:163. [PMID: 24191865 PMCID: PMC4228234 DOI: 10.1186/1471-2377-13-163] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background In-stent restenosis (ISR) is an important factor endangering the long-term safety and efficacy of carotid artery angioplasty and stenting (CAS). It is plausible that soft vulnerable plaques are more likely to be injured during CAS procedure and are therefore more likely to initiate the cascade finally leading to ISR. The aim of this study was to investigate if plaque morphology detected by a simple applicable Duplex ultrasound score before CAS can be used as a predictor for ISR. Methods Within a prospectively collected single-centre CAS database of 281 patients (comprising 300 arteries) with high-grade carotid artery stenosis, who underwent CAS between May 2003 and January 2013, we conducted a nested case–control study. Plaque morphology before CAS was analysed by a blinded investigator and each parameter of the Total Plaque Risk Score (TPRS) as well as the whole score was evaluated with regard to its diagnostic validity for ISR. Results We analysed the data of 10 patients with ISR and 50 patients without ISR. There were no significant differences with respect to baseline characteristics, vascular risk factors, and degree of stenosis between patients with and without ISR. The duration of follow-up was longer in patients with ISR (p = 0.024) and these patients were more likely to show increased PSV (p = 0.012) immediately after CAS than patients without ISR. Neither individual parameters of the TPRS score nor the score as a whole were suitable as a diagnostic test for ISR development. Conclusions In the present study we could demonstrate that the non-contrast enhanced DUS of the pre-interventional plaque formation cannot be used as a predictor for the development of ISR. Evaluating a more sophisticated, but not routinely available approach e.g. by ultrasound based plaque perfusion imaging or CT based plaque analysis could be helpful in the future in order to assess the role of plaque morphology in the context of ISR development.
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Affiliation(s)
| | | | | | | | | | | | - Jan Liman
- Department of Neurology, University of Göttingen, Robert-Koch-Str, 40, 37075 Göttingen, Germany.
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Pizzolato R, Hirsch JA, Romero JM. Imaging challenges of carotid artery in-stent restenosis. J Neurointerv Surg 2013; 6:32-41. [DOI: 10.1136/neurintsurg-2012-010618] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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