Analysis of anatomic factors and age in patients undergoing carotid angioplasty and stenting

Comparison of treatment outcomes and complications of coil embolization in elderly and very elderly patients with cerebral aneurysms: a propensity score matching analysis

PURPOSE

This single center study aims to compare the treatment outcomes and procedure-related complications of coil embolization in elderly patients (60-79 years) and very elderly patients (aged 80 years or older) with cerebral aneurysms.

METHODS

Data was collected from 504 elderly patients aged 60 years or older who underwent coil embolization for intracranial aneurysms from 2018 to 2021. The study evaluated patient-related and anatomical factors and assessed various outcomes, comparing results between groups using statistical analysis and propensity score matching.

RESULTS

A total of 503 cerebral aneurysms were analyzed from individuals aged 60-79 years (n = 472) and those aged 80 years or older (n = 31). The majority of the aneurysms were unruptured with an average size of 3.5 mm in height and 3.4 mm in width. The patients were compared using 1:1 propensity score matching, and no significant differences were found in factors other than age and aortic elongation. Logistic analysis revealed that being over 80 years old and having a severe aortic arch elongation were identified as risk factors for procedure-related events in both total and unruptured cases.

CONCLUSIONS

The study compared coil embolization treatment for cerebral aneurysms in patients aged 60-79 and over 80, finding no significant difference in treatment outcomes except for procedure-related events. Procedure-related events were associated with severe aortic arch elongation and being over 80 years old. Coil embolization can be considered safe and effective for patients over 80, but further trials are needed for accurate conclusions.

Optimal guiding catheter position during advancement of the guiding catheter into the carotid artery from the aortic arch via transfemoral approach

BACKGROUND

Guiding catheter (GC) advancement into the target carotid artery is a crucial step in neuroendovascular therapy. In difficult anatomies, alternative methods have been reported to overcome difficult carotid access for swift GC advancement. However, studies focusing on the positional relationship between the GC and inner catheter (IC) at the aortic arch are lacking.

METHODS

We evaluated the impact of the positional relationship between the GC and IC on whether the GC position affects catheter support or system straightening. We retrospectively reviewed 89 patients who underwent neuroendovascular therapy. We assessed the time to carotid access across difficult arch anatomies. The GC position was divided into Position 1, descending aorta level; Position 2, aortic arch level; and Position 3, origin of the left common carotid artery or innominate artery. We also evaluated the GC support and straightening effects in an in vitro vascular model study.

RESULTS

The coaxial catheter flexion angle at the aortic arch was significantly larger when the GC was set to Position 3 (p < 0.0001). A significantly shorter time to carotid access was observed with Positions 2 and 3 than with Position 1 in the difficult arch anatomy group. In the in vitro vascular model evaluation, the catheter support effect significantly increased as the GC position became closer to the IC tip (p < 0.0001) and straightening effect significantly increased as the GC moved to Position 2 from Position 1 (p < 0.0001).

CONCLUSION

During GC advancement, the GC positional relationship changed the support of the coaxial system with system straightening. The optimal GC position, Position 3, facilitated swift GC advancement.

Patient Selection Criteria and Procedural Standardization for Carotid Artery Stenting-A Single Center Experience

The gold standard for the treatment of carotid artery stenosis is the carotid endarterectomy (CEA). According to current guidelines, carotid artery stenting (CAS) is an alternative. Randomized control trials (RCTs) show significantly higher rates of peri-interventional strokes after CAS compared to CEA. However, these trials were usually characterized by a great heterogeneity in the CAS procedure. In this retrospective analysis from 2012 to 2020, 202 symptomatic and asymptomatic patients were treated with CAS. Patients were carefully pre-selected according to anatomical and clinical criteria. In all cases, the same steps and material were used. All interventions were performed by five experienced vascular surgeons. Primary endpoints of this study were perioperative death and stroke. Asymptomatic carotid stenosis was present in 77% of the patients and symptomatic in 23%. The mean age was 66 years. The average degree of stenosis was 81%. The CAS technical success rate was 100%. Periprocedural complications occurred in 1.5% of cases, including one major stroke (0.5%) and two minor strokes (1%). The results of this study indicate that through a strict patient selection based on anatomical and clinical criteria, CAS can be performed with very low complication rates. Furthermore, standardization of the materials and the procedure itself is crucial.

Aortic arch types and postoperative outcomes after carotid artery stenting in asymptomatic and symptomatic patients

BACKGROUND

The aim of this study was to investigate the influence of the aortic arch type on technical and clinical success of carotid artery stenting (CAS) procedure.

METHODS

Clinical and anatomical data of consecutive patients who underwent CAS from 2010 to 2018 were prospectively collected and retrospectively analyzed. Primary outcome was technical success, define as successful stent delivery and deployment and <30% residual carotid stenosis. Secondary outcomes were death, stroke, myocardial infarction (MI) and transient ischemic attack (TIA) rates at 30 days after CAS. Subgroups analysis with asymptomatic and symptomatic patients were also performed.

RESULTS

During the study period, 523 patients were enrolled and analyzed. Among these, 176 (33.6%) had Type I, 227 (43.4%) had Type II and 120 (23.0%) had Type III or bovine aortic arch (BAA) type. Technical success rate was achieved in 96.0% of cases. At 30 days, if compared with Type I or II, patient with Type III or BAA experienced a higher death rate (0 vs. 0 vs. 1.8%, respectively; P=0.056) and combined postoperative stroke/TIA rate (3% vs. 2.8% vs. 9.9%, respectively; P=0.012). No differences for same outcomes between asymptomatic and symptomatic patients were described, although the latter group experienced more postoperative MI. A multivariate analysis revealed Type III or BAA as an independent risk factor for postoperative stroke/TIA (HR 3.23, IC95% 1.40-7.45; P=0.006).

CONCLUSIONS

In this cohort of patients, death and postoperative neurological complications rates were associated with Type III or BAA, irrespective of symptomatic patients' status. Extremely attention is required during perioperative period in patients who were candidate to CAS and with challenging aortic arch anatomy.

The management of asymptomatic carotid stenosis: Is there a benefit to operate elderly patients?

BACKGROUND

We present a retrospective study of a series of 40 patients over the age of 75 operated for an asymptomatic carotid stenosis. The results were evaluated during an average of 3 years of follow-up.

MATERIAL AND METHOD

The study is retrospective and monocentric. The series includes 40 patients aged over 75 years and with an average age of 78.5 years (range 75-82). Patients underwent surgery for an asymptomatic carotid stenosis of more than 80%. The technique in all case was a carotid endarterectomy.

RESULTS

There have been no postoperative deaths or neurological adverse events. During an average follow-up of 3 years, there was one death secondary to colon cancer. However, 5 patients were lost to follow-up.

CONCLUSION

Carotid surgery in elderly patients may have a benefit. However, our study has shortcomings. It is retrospective and the patient cohort is reduced. A randomized, prospective study, comparing surgery or angioplasty with the best medical treatment, is necessary to choose the most effective and safest treatment to offer to an elderly patient with asymptomatic carotid stenosis.

Type III Arch Configuration as a Risk Factor for Carotid Artery Stenting: A Systematic Review of Contemporary Guidelines on Management of Carotid Artery Stenosis

BACKGROUND

Type III arch configuration is frequently reported as a stroke risk factor for carotid angioplasty and stenting (CAS). We reviewed contemporary guidelines on management of carotid artery stenosis to assess the clinical relevance attributed to this anatomic feature in current clinical practice.

METHODS

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The PubMed, EMBASE, and Web of Science databases were searched to identify all guidelines on extracranial carotid disease published between January 2008 and March 2020. A total of 435 articles were screened. For multiple guidelines from the same writing group, only the most recent updated version was considered. Eighteen documents were identified for qualitative analysis.

RESULTS

Four guidelines specifically reported type III arch as a predictive factor of periprocedural complications after CAS. Two of them also provided a low level of evidence of their recommendation. None of the documents indicated the exact criteria for aortic arch classification. Three different methods to describe type III arch configuration were identified.

CONCLUSIONS

Type III arch configuration is inconsistently included among stroke risk factors for CAS in contemporary guidelines, and variably defined. Further studies on the level of concordance between the 3 existing definition criteria are warranted.

Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Arterial access is a technical consideration of mechanical thrombectomy that may affect procedural time, but few studies exist detailing the relationship of anatomy to procedural times and patient outcomes. We sought to investigate the respective impact of aortic arch and carotid artery anatomy on endovascular procedural times in patients with large-vessel occlusion.

MATERIALS AND METHODS

We retrospectively reviewed imaging and medical records of 207 patients from 2 academic institutions who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion from January 2015 to July 2018. Preintervention CTAs were assessed to measure features of the aortic arch and ipsilateral great vessel anatomy. These included the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch and the takeoff angle of the respective great vessel from the arch. mRS scores were calculated from rehabilitation and other outpatient documentation. We performed bootstrap, stepwise regressions to model groin puncture to reperfusion time and binary mRS outcomes (good outcome, mRS ≤ 2).

RESULTS

From our linear regression for groin puncture to reperfusion time, we found a significant association of the great vessel takeoff angle (P = .002) and caudal distance from the origin of the innominate artery to the top of the aortic arch (P = .05). Regression analysis for the binary mRS revealed a significant association with groin puncture to reperfusion time (P < .001).

CONCLUSIONS

These results demonstrate that patients with larger takeoff angles and extreme aortic arches have an association with longer procedural times as approached from transfemoral access routes.

Intracranial Stenting: Is It Still an Option for Treatment of Patients With Intracranial Atherosclerosis?

Intracranial atherosclerotic disease (ICAD) is considered a major cause of recurrent cerebrovascular events. ICAD continues to be a disease without an effective method of reducing the risk of recurrent stroke and death, even with aggressive, highly monitored medical treatment. We reviewed data from three randomized controlled studies that published data comparing intracranial stenting vs. medical treatment for symptomatic severe-ICAD. Ethnic, demographic, clinical, and procedural differences were observed among the data from these trials that might influence their results. Future research should aim at establishing refined selection criteria that can identify high-risk ICAD patients who may benefit from intracranial stenting.

Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis

Background and Purpose- Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods- We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results- Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9-3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9-1.9; interaction P=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions- The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated. Clinical Trial Registration- URL: https://clinicaltrials.gov . Unique identifier: NCT00190398. URL: http://www.isrctn.com . Unique identifier: ISRCTN57874028. URL: http://www.isrctn.com . Unique identifier: ISRCTN25337470. URL: https://clinicaltrials.gov . Unique identifier: NCT00004732.

Vascular Anatomy and Not Age is Responsible for Increased Risk of Complications in Symptomatic Elderly Patients Undergoing Carotid Artery Stenting

BACKGROUND

Various studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy.

METHODS

A retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (<80 years).

RESULTS

The study included 447 patients: 335 patients (75%) <80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P < 0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P < 0.01, respectively), higher percentage of tortuous carotid vessels (P < 0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02).

CONCLUSIONS

Complex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.

Feasibility of Using Neck Extension to Overcome a Difficult Aortic Arch and Gain Access to the Carotid Artery

OBJECTIVE

The purpose of this study was to investigate neck movement and various conditions of the aortic arch that may hinder access to the carotid artery during neurointerventional procedures.

METHODS

We reviewed 230 patients who underwent internal carotid artery angiography between February 2016 and October 2016. Use of a Davis catheter (DC) was first attempted and if not possible, movement (right, left, flexion, and extension) of the patient's head was tried before catheter exchange. We analyzed the success rate after neck motion in relation to various aortic arch factors.

RESULTS

Only extension of the patient's neck was effective. Of the 209 patients with right side angiography, 23 had failed access with a DC, but neck extension was effective in 3 patients (13%). Failure to insert a DC was significantly correlated with age, male sex, acute angle, arch elongation, aortic calcification, and carotid artery angulation on the right side, whereas access was not gained in 24 out of 208 patients who underwent left side angiography, and neck extension was successful in 7 patients (29.2%). Also, significant factors determining the catheter exchange were age, male sex, acute angle, arch elongation, and aortic calcification.In the DC access failure group, neck extension was significantly more effective for younger aged patients (P = 0.011).

CONCLUSIONS

Factors such as older age, acute arch angle, higher elongation type, arch calcification, and carotid artery angulation were verified as factors affecting access by a simple catheter; however, neck extension was shown to facilitate access in about 10%-30% of patents.

Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal

OBJECTIVE

We report the 1-year outcomes of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial. This trial introduced a novel transcarotid neuroprotection system (NPS), the ENROUTE transcarotid NPS (Silk Road Medical Inc, Sunnyvale, Calif). Postoperative results demonstrated that the use of the ENROUTE transcarotid NPS is safe and effective. The aim of this study was to evaluate the safety of transcarotid artery revascularization (TCAR) and to present the 1-year outcomes.

METHODS

This study is a prospective, single-arm clinical trial. Current enrollment occurs in 14 centers. Primary end points were incidence rates of ipsilateral stroke at 1 year after TCAR. Occurrence of stroke was ascertained by an independent Clinical Events Committee. Patients with anatomic or medical high-risk factors for carotid endarterectomy (CEA) were eligible to be enrolled in the ROADSTER trial.

RESULTS

Overall, 165 patients were included in the long-term follow-up (112 of 141 patients from the pivotal phase and 53 of 78 patients from the extended access). Mean age was 73.9 years (range, 42.1-91.3 years). Patients aged 75 years and older were 43.3% of the cohort. The majority of patients were white (92.7%) and male (75.2%). Most patients were asymptomatic (79.9%). Anatomic risk factors were distributed as follows: contralateral carotid artery occlusion (11.0%), tandem stenosis of >70% (1.8%), high cervical carotid artery stenosis (25.0%), restenosis after CEA (25.6%), bilateral stenosis requiring treatment (4.3%), and hostile neck (14.6%). Medical high-risk criteria included two-vessel coronary artery disease (14.0%) and severe left ventricular dysfunction with ejection fraction <30% (1.8%). In general, 43.3% of patients had at least one anatomic high-risk factor, whereas 29.9% of patients had medical high-risk factors. Both subsets of factors were present simultaneously in 26.8% of the cohort. At 1-year follow-up, ipsilateral stroke incidence rate was 0.6%, and seven patients (4.2%) died. None of the deaths were neurologic in origin.

CONCLUSIONS

TCAR with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to 1 year after TCAR as illustrated in this analysis. The promising results from the ROADSTER trial likely stem from the novel cerebral protection provided through the ENROUTE transcarotid NPS in comparison to distal embolic protection devices as well as the transcarotid approach's circumventing diseased aortic arch manipulation and minimizing embolization. TCAR offers a safe and durable revascularization option for patients who are deemed to be at high risk for CEA.

Unfavorable Vascular Anatomy Is Associated with Increased Revascularization Time and Worse Outcome in Anterior Circulation Thrombectomy

BACKGROUND

Reperfusion time influences patient outcome in mechanical thrombectomy for large vessel occlusion. We analyzed anatomic features that could be used to make preoperative and intraoperative decisions to minimize revascularization time.

METHODS

We reviewed a prospectively maintained database for patients with stroke evaluated from February 2015 to July 2016. Patients received a score based on bovine arch, aortic arch, and internal carotid artery dolichoarteriopathy (B.A.D. score), which we correlated with procedural times and outcomes. Univariate analysis was performed to identify predictors of procedural times, revascularization, complications, and outcome. Relevant variables were assessed via multivariate regression.

RESULTS

We identified 61 patients (31 men) who underwent transfemoral thrombectomy. Mean puncture to reperfusion time was 46 minutes. Age >75 years (odds ratio [OR] = 3.98; 95% confidence interval [CI], 1.17-13.54; P = 0.027) and high B.A.D. score (OR = 2.55; 95% CI, 1.17-5.57; P = 0.019) were significant predictors of puncture to reperfusion time >40 minutes. Mean puncture to first-pass time was 24 ± 14.2 minutes. Age >65 years (OR = 4.68; 95% CI, 1.07-20.55; P = 0.041) and high B.A.D. score (OR = 2.84; 95% CI, 1.18-6.85; P = 0.020) were independently predictive of time to first pass >20 minutes. Lower scores predicted higher Thrombolysis In Cerebral Infarction score (OR = 0.07; 95% CI, 0.01-0.81; P = 0.033). Higher scores predicted hemorrhagic transformation (OR = 4.8; 95% CI, 1.19-12.29; P = 0.024) and modified Rankin Scale score >4 (OR = 3.0; 95% CI, 1.15-7.92; P = 0.025) after thrombectomy.

CONCLUSIONS

Bovine variation, aortic arch type, and internal carotid artery dolichoarteriopathy are associated with increased revascularization time and poor outcomes in thrombectomy. We developed the B.A.D. score to predict reperfusion time and outcomes, demonstrating need for preoperative anatomic evaluation to guide treatment.

Takeoff orientation of the major aortic arch branches irrespective of arch type: Ramifications for brachiocephalic interventions including carotid stenting

Background:

Our previous work demonstrating great ease and predictability of cannulation of the major aortic arch branches with an upwardly pointing 3DR catheter, irrespective of aortic arch type, led us to hypothesize that centering or “cresting” of these vessels must occur along the superior most aspect of the aortic arch in a curvilinear fashion.

Methods:

We retrospectively analyzed 111 computed tomographic scans of the chest and thoracic aorta with intravenous contrast performed at our hospital between April 2011 and May 2012 utilizing TeraRecon image reconstruction software. Four studies were excluded due to poor image quality and/or surgical changes to native aortic architecture.

Results:

Of the 107 studies included, 104 (97.2%) demonstrated centering of the major aortic arch branches on a curvilinear line “cresting” the superior most aspect of the aortic arch irrespective of arch type. Of the three studies that did not demonstrate this “cresting,” two were found to have aberrant right subclavian arteries associated with a type I aortic arch, and one had an aberrant right common carotid associated with a type II aortic arch.

Conclusion:

Operators engaging major aortic arch branches need to be mindful of the fact that these vessels are indeed centered on a line “cresting” along the superior most aspect of the aortic arch, and any algorithm that, by taking this information into account, reduces catheter manipulation in the aortic arch could potentially result in a reduction in distal atheroembolic events.

[Carotid endarterectomy and stenting in patients with internal carotid artery stenosis and contralateral occlusion]

AIM

To determine surgical risk factors and to compare early outcomes after carotid endarterectomy and carotid stenting in patients with internal carotid artery stenosis and contralateral occlusion.

MATERIAL AND METHODS

132 patients were enrolled. 62 and 70 patients underwent carotid endarterectomy and carotid stenting respectively. Early postoperative results were compared depending on type of surgical intervention and presence of risk factors.

RESULTS

Significant difference between groups was only found for incidence of neuropathy of the cranial nerves. It was established that cardiac comorbidities are risk factors for adverse events after carotid endarterectomy. Stable (homogeneous) atherosclerotic plaque with clear contour and no ulceration is optimal for carotid stenting.

The effect of demographic features on aortic arch anatomy and its role in the etiology of cerebrovascular disease

PURPOSE

The aim of this study was to retrospectively evaluate the distribution of aortic arches, the relationship with demographic characteristics, and the results of carotid and vertebral artery stenting procedures in patients diagnosed with cerebrovascular disease through the intra-arterial digital subtraction angiography (DSA) technique.

METHODS

A retrospective examination was performed on 288 patients diagnosed with cerebrovascular disease, who underwent DSA in the Department of Neurology of Gaziantep University Medical Faculty and Kahramanmaraş¸ Sütçü Imam University Medical Faculty. The patients were examined in respect of demographic features and aortic arch anatomic structure characteristics. All demographic characteristics, DSA, carotid, and vertebral artery stent results were recorded.

RESULTS

The patients comprised 60.1% males and 39.9% females with a mean age of 58.25 years. Type 2 aortic arch was found in 175 (60.7%) patients, Type 2 aortic arch in 99 (34.3%) patients, and Type 3 aortic arch in 14 (4.8%) patients. The right carotid artery stenosis rate was found to be higher in patients with Type 2 aortic arch (P=0.013). When the patients were evaluated according to the presence of a bovine arch, there was no significant difference in terms of age, carotid, and vertebral artery lesions (P>0.05).

CONCLUSION

The aortic arch and its branching properties were not found to have a direct effect on increased risk of cerebrovascular disease or stenting rates. This study can be considered to raise awareness for new studies to demonstrate the effect of aortic arch anatomic differences on cerebrovascular diseases.

Transradial Approach for Deployment of a Flow Diverter for an Intracranial Aneurysm in a Patient with a Type-3 Aortic Arch

BACKGROUND

Flow diversion with the Pipeline embolization device (PED) is an effective treatment for giant and wide-neck intracranial aneurysms, but the standard transfemoral approach may not be feasible in patients with Type-3 aortic arches.

CASE REPORT

An 84-year-old woman presented with a right internal carotid artery (ICA) giant aneurysm and a Type-3 aortic arch, necessitating a transradial approach for access to the right common carotid artery. A triaxial catheter system made for a stable platform for the deployment of two telescoping PEDs to treat the patient's right ICA giant aneurysm. The procedure was technically successful, and there were no immediate complications.

CONCLUSION

The transradial approach allows for carotid access in patients with challenging aortic arches, and this report demonstrates its effectiveness for deployment of flow diverters, especially with a triaxial catheter system. The peripheral access point facilitates hemostasis, which is of great importance in patients on antiplatelet medications to prevent thrombotic complications of flow diverters.

Influence of carotid tortuosity on internal carotid artery access time in the treatment of acute ischemic stroke

Purpose Carotid artery anatomy is thought to influence internal carotid artery access time (ICA-AT) in patients requiring mechanical thrombectomy for acute ischemic stroke. This study investigates the association between ICA-AT and carotid anatomy. Material and methods Computed tomography angiography (CTA) data of 76 consecutive patients presenting with acute ischemic stroke requiring mechanical thrombectomy for middle cerebral artery or carotid T occlusion were evaluated. The supraaortic extracranial vasculature was analyzed regarding take-off angles and curvature of the affected side. Digital subtraction angiography data were primarily analyzed regarding ICA-AT and secondarily regarding recanalization time and radiographic result. Results ICA-AT was significantly influenced by vessel tortuosity. Take-off angle of the left common carotid artery ( p = 0.001) and the brachiocephalic trunk ( p = 0.002) as well as the tortuosity of the common carotid artery ( p = 0.002) had highest impact on ICA-AT. For recanalization time, however, we found only the take-off angle of the left common carotid artery to be of significance ( p = 0.020). There was a tendency for ICA-AT to correlate with successful (mTICI ≥ 2 b) revascularization (average time of successful results was 24.3 minutes, of unsuccessful was 35.6 minutes; p = 0.065). Every evaluated segment with less carotid tortuosity showed a carotid AT below 25 minutes. Conclusion Supraaortic vessel tortuosity significantly influences ICA-AT in mechanical thrombectomy for an acute large vessel. There furthermore was a trend for lower successful recanalization rates with increasing ICA-AT.

Carotid artery stenting in clinical practice depending on patient age

BACKGROUND

The age-dependent outcome of carotid artery stenting (CAS) outside of randomized controlled trials is largely unknown. Therefore, we assessed acute and long-term results of CAS in a single-center real-world registry.

METHODS

All symptomatic and asymptomatic patients who consecutively underwent CAS were enrolled into the present analysis. The population was divided into three groups dependent on patients' age (<65, 65-74, and ≥75 years).

RESULTS

Between 1999 and 2015, a total of 878 patients (24%, <65 years; 40%, 65-74 years; and 36%, ≥75 years) underwent CAS. The rate of the primary endpoint (30-day composite of death, stroke, and myocardial infarction [MACCE] plus long-term ipsilateral stroke) was higher in patients aged ≥75 years compared to the middle-age group (hazard ratio [HR] 2.30, confidence interval [CI] 1.22-4.36; P = 0.001). Similarly, the rate of the stroke endpoint (30-day any stroke plus long-term ipsilateral stroke) was higher in patients aged ≥75 years compared to patients aged 65-74 years (HR 2.03, CI 1.01-4.10; P = 0.04). There was no significant age-dependent difference of the primary endpoint and stroke endpoint in the subset of asymptomatic patients. Furthermore, age had no influence on the risk of stroke beyond the periprocedural period.

CONCLUSIONS

Patients aged ≥75 years had poorer outcomes after CAS compared to younger patients. Importantly, age did not influence the outcome in asymptomatic patients and the risk for stroke beyond the periprocedural period.

Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy

BACKGROUND AND PURPOSE

Complex vascular anatomy might increase the risk of procedural stroke during carotid artery stenting (CAS). Randomized controlled trial evidence that vascular anatomy should inform the choice between CAS and carotid endarterectomy (CEA) has been lacking.

METHODS

One-hundred eighty-four patients with symptomatic internal carotid artery stenosis who were randomly assigned to CAS or CEA in the ICSS (International Carotid Stenting Study) underwent magnetic resonance (n=126) or computed tomographic angiography (n=58) at baseline and brain magnetic resonance imaging before and after treatment. We investigated the association between aortic arch configuration, angles of supra-aortic arteries, degree, length of stenosis, and plaque ulceration with the presence of ≥1 new ischemic brain lesion on diffusion-weighted magnetic resonance imaging (DWI+) after treatment.

RESULTS

Forty-nine of 97 patients in the CAS group (51%) and 14 of 87 in the CEA group (16%) were DWI+ (odds ratio [OR], 6.0; 95% confidence interval [CI], 2.9-12.4; P<0.001). In the CAS group, aortic arch configuration type 2/3 (OR, 2.8; 95% CI, 1.1-7.1; P=0.027) and the degree of the largest internal carotid artery angle (≥60° versus <60°; OR, 4.1; 95% CI, 1.7-10.1; P=0.002) were both associated with DWI+, also after correction for age. No predictors for DWI+ were identified in the CEA group. The DWI+ risk in CAS increased further over CEA if the largest internal carotid artery angle was ≥60° (OR, 11.8; 95% CI, 4.1-34.1) than if it was <60° (OR, 3.4; 95% CI, 1.2-9.8; interaction P=0.035).

CONCLUSIONS

Complex configuration of the aortic arch and internal carotid artery tortuosity increase the risk of cerebral ischemia during CAS, but not during CEA. Vascular anatomy should be taken into account when selecting patients for stenting.

CLINICAL TRIAL REGISTRATION

URL: http://www.isrctn.com/ISRCTN25337470. Unique identifier: ISRCTN25337470.

Initial experience with a multiple parallel guidewire support system for complex tortuous aortic arch navigation and great vessel catheterization: technical note

The ability to traverse an anatomically challenging and complex arch is paramount to the success of any neuroendovascular procedure. With age, the aortic arch becomes elongated, calcified, and less compliant. The authors present the initial experience with a multiple parallel guidewire system (ZigiWire Mode 3) for catheterization through a complex tortuous aortic arch to access extracranial vessels. The ZigiWire is an organized guidewire system that uses consecutive delivery of 3 small-diameter (0.014-inch) guidewires that are progressively advanced in parallel to secure support-wire access. The authors have found it useful in situations in which traditional methods for great-vessel access have failed. Moreover, the progressive construction of a large wire from smaller wires prevents "kickback" force from a single larger guidewire, allowing stable distal access. The authors have been able to advance different diagnostic and guide catheters over the ZigiWire. This guidewire has allowed them to successfully complete neuroendovascular procedures in patients who were previously considered unsuitable for the procedure because of tortuous vascular access.

Long-Term Outcomes of Carotid Artery Stenting in Clinical Practice

Background—

There is a lack of long-term data and data outside of controlled clinical trials in carotid artery stenting. Thus, we sought to evaluate the long-term effectiveness in stroke prevention by carotid artery stenting in a large number of patients in a real-world setting.

Methods and Results—

The present work represents an all-comer registry with a strict, prospectively designed, follow-up protocol, including an independent pre- and postprocedural neurological assessment. Between November 1999 and March 2015, 1000 procedures in 901 patients were consecutively performed in a single center. Mean age was 71±9 years, and symptomatic stenosis was present in 262 patients (29.1%). The population was also characterized by a high comorbidity: 289 patients (32.1%) would have been excluded according to the CREST protocol (Carotid Revascularization Endarterectomy Versus Stent Trial). The median length of follow-up was 5.5 (interquartile range, 2.6–7.9) years and complete in 93% of the patients. The rate of the primary end point (composite of stroke, death, and myocardial infarction [major adverse cardiac or cerebrovascular event] by day 30 plus ipsilateral stroke beyond 30 days) was 6.9% (9.9% in symptomatic versus 5.7% in asymptomatic patients; P =0.03). The rate was higher in CREST ineligible than in CREST eligible patients (11.4% versus 4.9%; P =0.001).

Conclusions—

Long-term stroke prevention by carotid artery stenting is effective in experienced centers. A high percentage of patients who would have been excluded from controlled clinical trials undergoes carotid artery stenting in daily clinical practice. However, these patients have a substantially higher risk for an acute major adverse cardiac or cerebrovascular event.

Factors associated with successful revascularization using the aspiration component of ADAPT in the treatment of acute ischemic stroke

Introduction

ADAPT (a direct aspiration first pass technique) has been shown to be fast, cost-effective, and associated with excellent angiographic and clinical outcomes in the treatment of acute ischemic stroke (AIS).

Objective

To identify any and all preoperative factors that are associated with successful revascularization using aspiration alone.

Methods

A retrospective review of 76 patients with AIS treated with thrombectomy was carried out. Cohort 1 included cases in which aspiration alone was successful (Thrombolysis in Cerebral Infarction 2b or 3). Cohort 2 included cases in which aspiration was unsuccessful or could not be performed despite an attempt.

Results

There was no difference between cohorts in gender, race, medications, National Institute of Health Stroke Scale score, IV tissue plasminogen activator, site or side of the occlusion, dense vessel sign, aortic arch type, severe stenosis, clot length, operator years of experience, and guide/aspiration catheters used. Patients in cohort 1 were on average younger (66.5 vs 74.1 years, p=0.025). There was a trend for more patients in cohort 2 to have atrial fibrillation/arrhythmias (62.5% vs 45.5%, p=0.168) and have a cardiogenic stroke etiology (78.1% vs 56.8%, p=0.086). There was also a trend for more reverse curves (2.3 vs 1.7, p=0.107), larger vessel diameter (3.26 mm vs 2.88 mm, p=0.184), larger vessel-to-catheter ratio (2.09 vs 1.87, p=0.192), and worse clot burden score (5.38 vs 6.68, p=0.104) in cohort 2.

Conclusions

Aspiration success was associated with younger age. Our findings suggest that ADAPT can be used for the vast majority of patients but it may be beneficial to use a different method first in the elderly.

Carotid stent-assisted thrombectomy in acute ischemic stroke

Acute carotid occlusion or near-occlusion with concomitant intracranial embolism cause severe acute ischemic strokes in patients. These concomitant occlusions have suggested poor response to intravenous thrombolysis and complicate endovascular treatment. Nevertheless, endovascular stent-assisted thrombectomy may improve outcome in patients but the treatment is not without concerns. Required antiplatelet therapy to prevent stent thrombosis may increase the rate of intracranial hemorrhage, especially after recent thrombolysis. Furthermore, technical difficulties in access of the intracranial vasculature may cause adverse events, even in the hands of experienced interventionalists. These concerns currently defy the treatment in being recommended for general use and only on a compassionate basis. However, recent patient series have suggested reasonable safety and efficacy for carotid stent-assisted thrombectomy.

High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection

BACKGROUND:

Demographics and vascular anatomy may play an important role in predicting periprocedural complications in symptomatic patients undergoing carotid artery stenting (CAS).

OBJECTIVE:

To predict factors associated with increased risk of complications in symptomatic patients undergoing CAS and to devise a CAS scoring system that predicts such complications in this patient population.

METHODS:

A retrospective study was conducted that included patients who underwent CAS for symptomatic carotid stenosis during a 3-year period. Demographics and anatomic characteristics were subsequently correlated with 30-day outcome measures.

RESULTS:

A total of 221 patients were included in the study. The cumulative rate of periprocedural complications was 7.2%, including stroke (3.2%), myocardial infarction (3.2%), and death (1.4%). Renal disease increased the risk of all complications. National Institutes of Health Stroke Scale score ≥10 at presentation, difficult femoral access, and diseased calcified aortic arch increased the risk of stroke and all complications. Type III aortic arch correlated with increased risk of stroke. Pseudo-occlusion and concentric calcification of the carotid artery increased the risk of myocardial infarction, death, and all complications. Carotid tortuosity and anatomy hostile to the deployment of distal protection devices increased the risk of stroke, myocardial infarction, death, and all complications.

CONCLUSION:

Our results suggest that CAS should be avoided in patients with multiple anatomic risk factors. High presenting National Institutes of Health Stroke Scale score and renal disease also increase the complication risk. The CAS scoring system devised here is simple, reproducible, and clinically valuable in predicting complications risk in symptomatic patients undergoing CAS.

Carotid Artery Angioplasty and Stenting for Patients Less than 70 Years-of-Age

Background:

Recent studies have suggested that carotid artery angioplasty and stenting (CAS) is a safe alternative to carotid endarterectomy (CEA) in average risk patients <70 years of age. We examined a consecutive series of patients who underwent CAS in order to determine the influence of patient age on outcome.

Methods:

A retrospective, longitudinal cohort study of consecutive patients who underwent CAS at St. Michael's Hospital, Canada between January 2001 and November 2010 was performed. The outcome measures were 30-day stroke and 30-day composite death, stroke and acute myocardial infarction (MI). Patients were stratified based on age <70 and ≥70 years.

Results:

One hundred and fifty-nine patients underwent 165 CAS procedures. The 30-day risk of stroke was 3.8% while the composite outcome of death/stroke/MI was 8.2%. When stratified by age <70 and ≥70 years, the 30-day stroke rate was 0% versus 7.4% (p=0.03), and the composite outcome of death/stroke/MI was 2.6% versus 13.6% (p=0.02), respectively.

Conclusions:

Patients <70 years of age undergoing CAS have a low rate of major complications, comparing favourably with historical CEA adverse event rates, and supporting the recent carotid stenosis literature that in the younger population CAS has a similar complication rate compared to CEA.

Carotid artery stenting: current and emerging options

Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.

Carotid artery stenting is safe and associated with comparable outcomes in men and women

OBJECTIVE

Historically, large randomized controlled studies looking at carotid endarterectomy (CEA) have indicated an increased perioperative risk for women when gender subgroup analysis was performed. However, the outcomes of carotid stenting in women as compared to men have not been adequately investigated. We sought to compare the safety and efficacy of carotid angioplasty and stenting (CAS) when performed in women as compared to men.

METHODS

Procedures, complications, demographics, co-morbidities, and follow-up data from carotid stenting procedures performed in a bi-campus division were entered into a prospective database and then retrospectively supplemented with stored angiographic image data and reviewed. Arterial anatomic characteristics evaluated using angiographic images were: common carotid/internal carotid lesion length ratio, common carotid/internal carotid diameter, index lesion length, common carotid/internal carotid artery tortuosity, and lesion and aortic arch calcification. Outcomes compared included groin complications, postoperative pressor requirements, length of stay, restenosis, stroke, myocardial infarction (MI), and death.

RESULTS

Between 2003 and 2008, 228 patients underwent 238 procedures. Cerebral protection devices and self-expanding stents were placed in all patients. A total of 97 percutaneous interventions performed in 93 women were compared with 141 interventions in 135 men. Mean age in women was 71.8 +/- 9.2 years, in men was 72.2 +/- 9.1 years (P > .99); 44.3% of women and 34.7% of men had symptomatic disease (P = .14). Preoperative demographics and co-morbidities did not differ significantly between genders, with the exception of hypertension (83.0% of males vs 96.7% of females, P = .001), and history of coronary artery bypass grafting (31.8% of males vs 16.1% of females, P = .01). There were no significant differences seen in anatomic arterial characteristics, though there was a trend towards women having larger internal carotid to common carotid diameter ratios (0.65 vs 0.62) and more plaques isolated to the common carotid segment (9.5% vs 6.9%). There were no significant differences seen in overall 30-day peri-procedural stroke rate (2.1% in women and 4.2% in men, P = .48), death rate (0 % vs 0.7%, P > .99), or cardiac events (3.2% vs 0.7%, P = .3). The combined 30-day stroke, death, and MI rate was 5.7% for males compared to 5.4% for females (P > .99). There were no differences observed in the long-term survival, stroke-free survival, or restenosis between genders.

CONCLUSION

Despite previous concerns over adverse outcomes in women undergoing carotid endarterectomy, from our data, carotid stenting appears to be a safe modality in women with equivalent outcomes when compared to men.

Impact of aortorenal morphology on renal artery stent procedures: significance of aortic tortuosity and renal artery derivation

PURPOSE

To clarify the impact of aortorenal morphology on renal artery stenting procedures.

METHODS

A retrospective study evaluated 142 consecutive renal artery stenting procedures performed for de novo atherosclerotic renal artery stenosis in 119 patients (62 men; mean age 72±9 years, range 41-93). All procedures were done via a transfemoral approach without distal protection. Aortorenal morphology was classified into 3 types based on the relationship between abdominal aortic tortuosity and renal artery derivation. Using a straight reference line centered on the most angulated point of the inner curve of the infrarenal abdominal aorta, type 1 referred to a renal artery ostium that was more than half of the aortic diameter distance from the reference line in the greater curvature and less than half in the lesser curvature. Type 2 referred to a renal artery ostium that was less than half of the aortic diameter distant from the reference line in the greater curvature and more than half in the lesser curvature. Type 3 referred to a renal artery ostium that was beyond the reference line in the greater curvature or more than one aortic diameter from the reference line in the lesser curvature. The technical success rate, procedure time, final engagement technique, shape of the guide catheter used, and any adverse events were analyzed.

RESULTS

Type 1 aortorenal morphology was observed in 91 cases, type 2 in 30, and type 3 in 21. All cases were successfully treated; there were no technical complications, in-hospital cardiovascular events, or deaths. Procedure time differed significantly (p<0.001) among the 3 types (type 1: 19.6±5.6 minutes, type 2: 23.3±6.8 minutes, and type 3: 32.3±9.6 minutes; p<0.05 for type 1 vs. 2, p<0.001 for type 2 vs. 3, and p<0.001 for type 1 vs. 3). There were also significant differences among types in terms of engagement technique and guide catheter shape.

CONCLUSION

Aortorenal morphology was significantly associated with procedure time and the selection of engagement technique and guide catheter shape.

Carotid Wallstent placement difficulties encountered in carotid artery stenting

Purpose

The present study aimed to identify the types of curved lesions that are difficult to place Carotid Wallstent (CWS).

Materials and methods

The study targeted 31 consecutive carotid artery (CA) stenosis underwent carotid artery stenting using CWS. CWS placement success rate, stenosis location, lesion tortuosity, and relationship with stent placement failures were investigated. Lesion tortuosity was defined as the angle formed by 2 tangential lines between internal CA and common CA from the inflection point (IP) was defined as the center of lesion curvature. Stenosed lesions were classified into type A or B. Type A was defined as if the distal end of the stenosis was located proximal to the IP at a distance ≥0.5 of a vertebral body based on the posterior height of the 3rd vertebral body, otherwise was type B.

Results

The stent placement success rate was 93.5% (29/31). The 2 unsuccessfully stented lesions, both lesions were significantly different from other lesions by having a lesion tortuosity less than 90° and by belonging to type B.

Conclusion

Since CWS placement is difficult in patients with CA stenosis located close to the IP at a lesion tortuosity ≤90°, open-cell stents should be considered as an alternative.

Incidence and risk factors for medical complications and 30-day end points after carotid artery stenting

With the extensive use of carotid artery stenting (CAS) surgeries, scholars are paying more attention to the safety and efficiency of CAS. Our study aims to analyze the clinical efficiency, safety, and technical feasibility of CAS surgery in the treatment of carotid artery stenosis. A total of 379 cases of CAS were collected and retrospectively analyzed. The outcomes were summarized according to decrease in stenosis extent, incidence of early complications after procedure, 30-day end point events, and the follow-up data. Logistic regression was employed to analyze the correlations between risk factors and complications within 30 days and 30-day end points of stroke, myocardial infarctions (MIs), and mortality. The average extent of stenosis reduced from preoperative (81% ± 17%) to postoperative (26% ± 17%). In all, 53 patients had 72 medical complications, including 6 (1.58%) cerebral hemorrhage, 7 (1.85%) cerebral infarction, 5 (1.32%) transient ischemic attack (TIA), 5 (1.32%) heart failure, 10 (2.63%) symptomatic hypertension, 21 (5.54%) symptomatic hypotension, 10 (2.63%) symptomatic bradycardia, and 8 other complications; 15 patients had at least 2 complications. Advanced age, diabetes, and heart failure were associated with the high incidence of early complications (P < .05). Asymptomatic stenosis (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.131-1.131, P = .0426) and diabetes (OR = 3.38, 95% CI: 1.340-8.574, P = .0099) were correlated with the incidence of 30-day end point events. Diabetes and symptomatic stenosis are independent risk factors for 30-day end point events of CAS. Advanced age, hypertension, and vascular unstable plaque will increase the risk of postoperative complications.

Results of carotid angioplasty and stenting are equivalent for critical versus high-grade lesions in patients deemed high risk for carotid endarterectomy

BACKGROUND

To examine outcomes of carotid angioplasty and stenting (CAS) in patients with critical carotid stenosis who are deemed high risk for carotid endarterectomy.

METHODS

Medical records were retrospectively analyzed for patients undergoing CAS between September 2002 and March 2011 at a single institution. Patients were classified as having either critical (≥ 90%) or high-grade (70%-89%) carotid stenosis based on angiography. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke during the follow-up period.

RESULTS

A total of 245 patients underwent 257 CAS procedures during the study period. Fifty-one percentage (n = 130) of cases involved critical stenosis (66.2% male; mean age, 71 ± 10 y), with the remaining group (n = 127) involving high-grade stenosis (67.7% male; mean age, 71 ± 9 y). Symptomatic carotid disease was present in 25% of the critical stenosis and 31% of the high-grade stenosis groups (P = 0.33). Chronic obstructive pulmonary disease was more commonly found in the high-grade stenosis group (20% versus 8%, P = 0.01). No difference was observed between the groups relative to other baseline demographic characteristics, presence of contralateral carotid occlusion, stent diameter or length, maximum balloon diameter or length, use of embolic protection device, or procedural duration. Technical success was achieved in all cases. There was no difference in the need to predilate before the introduction of the filter or stent based on the degree of stenosis. We found no difference in the primary composite end point between the high-grade or critical stenosis groups (7.1% versus 7.7%, P = 0.74), or there were no differences between the individual components of the composite end point. Mid-term survival was similar between the two groups at a mean follow-up period of 2.4 y.

CONCLUSIONS

Despite concerns regarding the potential for increased neurologic complications, our data demonstrate that patients with high-grade and critical stenosis are able to safely undergo CAS and achieve similar periprocedural outcomes and mid-term prognosis.

Is age of 80 years a threshold for carotid revascularization?

Background and purpose:

Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.

Methods:

Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.

Results:

After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.

A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%)

Conclusions:

MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years

BACKGROUND

Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA.

METHODS

Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures.

RESULTS

The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years.

CONCLUSIONS

In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.

Carotid artery stenting for primary and secondary stroke prevention

BACKGROUND

Carotid artery disease is a major cause of the disability and mortality associated with strokes. Ischemic stroke remains the major cause of adult disability and third-leading cause of adult mortality, and carotid revascularization currently remains the principal surgical tool in the prophylaxis of this disease.

METHODS

The literature representing the current body of evidence for carotid revascularization and the authors' current practices in the management of this disease are summarized in this review.

RESULTS

We provide an evidence-based narration of the development and current status of carotid artery stenting (CAS) by reviewing 1) the evidence for carotid revascularization from early carotid endarterectomy (CEA) trials; 2) the randomized trials comparing CEA and CAS, with a special emphasis on the recently published results of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which have been a "game-changer," tipping the balance towards accepting CAS as a safe, equally effective, and durable alternative to CEA for all patients requiring carotid revascularization; and 3) the technical advances in CAS after enrollment of patients in the CREST.

CONCLUSIONS

CAS and CEA are complementary procedures. Judicious selection of the procedure is made on a case-by-case basis.

Age-related complications following endovascular treatment of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

The factors that led us to do the research for this paper was a desire to see if elderly patients did as well as non-elderly patients during endovascular intracranial aneurysm treatment. By doing this research, we could better stratify the most appropriate treatment for each patient with an aneurysm. The purpose of this study was to determine whether the incidence of procedural complications was greater in the elderly, defined as patients older than 65 years of age, compared with nonelderly patients undergoing elective endovascular treatment for intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review was performed in patients undergoing elective endovascular treatment of intracranial aneurysms between 2000 and 2010 at 1 institution. "Minor complications" were defined as those resulting in minimal or no loss of function that resolved before dismissal; "major complications" were complications that resulted in loss of function or complications that required a subsequent invasive therapy. Major complications were further stratified into those with and without neurologic disability, defined as an mRS score of >3. T tests and χ(2) analyses were used to compare groups.

RESULTS

Three hundred fifty-five patients underwent 394 endovascular procedures treating 75 aneurysm recurrences and 319 untreated aneurysms. One hundred eight (30%) were elderly. There was no significant difference in the rate of complications in the elderly compared with the nonelderly (33% versus 26%, respectively; P = .18). Major complications were significantly more prevalent in the elderly than in the nonelderly (17% versus 7.4%, respectively, P = .004). Major complications with neurologic disability were also significantly more prevalent in the elderly compared with the nonelderly (8.2% versus 1.8%, respectively, P = .004).

CONCLUSIONS

Major functional complications were markedly more common in the elderly compared with the nonelderly.

Carotid artery stenting: what you need to know

Carotid stenting has become an accepted alternative in patients with carotid stenosis. The purpose of this article is to review the relevant trials, describe the different devices available for stenting, the devices for cerebral protection, as well as describe techniques and tricks for successful carotid artery stenting. Understanding how to appropriately preoperatively evaluate patients and intra- and postoperative procedures, carotid artery stenting can be a safe procedure.

Carotid Tortuosity in Patients With Prior Cervical Radiation

Introduction: Anatomic distortion associated with radiation-induced tissue changes may pose challenges for patients with prior cervical irradiation undergoing carotid stenting. We sought to evaluate the effect of these changes on carotid intervention. Methods: Carotid angioplasty and stenting (CAS) for high-grade stenosis was performed in 203 patients. In all, 12 consecutive patients with prior ipsilateral cervical irradiation were age-/sex-matched to 24 controls. Degree of internal carotid (IC) tortuosity was assessed by 4 methods: ( a) deviation of IC from common carotid (CCA) axis, ( b) number of intersections between this axis and the course of the IC, ( c) total degrees of angulation along the course of the extracranial IC, and ( d) the IC length to straight-line distance ratio. Results: Carotid angioplasty and stenting was successful in all patients. Mean age was 72.8 ± 10 years; 58.4% were male. Twenty-nine percent were symptomatic (14.4% transient ischemic attack [TIA], 8.5% cardiovascular accident [CVA], and 6.5% amaurosis). Comorbidities were similar between the entire cohort and the subgroups of irradiated/control patients. The IC revealed a higher degree of deviation from the axis of the CCA in the previously irradiated patients compared to those without radiation (29.2° ± 4.5° vs 13.0° ± 2.0°, P = .001) and was more likely to intersect this axis in those with a history of cervical irradiation (83.3% vs 14.3%, P < .05). Irradiated patients also exhibited a significantly greater degree of tortuosity versus nonirradiated patients when assessed by total angulation along the course of the carotid (171.8° ± 26.0° vs 74.2° ± 20.2°, P = .014) and by the IC length:distance ratio (1.14 ± 0.05 vs 1.04 ± 0.03, P = .020). Despite increased IC tortuosity in patients with prior irradiation, all procedures were successfully completed and there did not appear to be a predilection for a specific filter type. Conclusions: A history of cervical irradiation is associated with increased tortuosity of the IC, leading to potential challenges for filter and stent deployment. However, this increased procedural complexity did not affect technical success rate or device selection in this series.

Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review

BACKGROUND AND PURPOSE

The purposes of this study were to assess the relationships between anatomic and technical factors and the 30-day risk of stroke or death after carotid angioplasty and stenting in the Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial and to perform a systematic review of the literature.

METHODS

We included patients from EVA-3S in whom carotid stenting was attempted irrespective of allocated treatment. Two radiologists blinded to clinical data independently assessed the aortic arch and carotid arteries on procedural angiograms. In addition, we performed a systematic review of studies that reported 30-day risk of stroke or death in relation with arterial anatomy and technique. Outcomes were stroke or death and stroke occurring within 30 days of the carotid angioplasty and stenting procedure.

RESULTS

Two hundred sixty-two patients from EVA-3S fulfilled the inclusion criteria (including 1 initially allocated to surgery and 13 in whom stent insertion failed).Within 30 days after the procedure, 25 (9.5%) patients had a stroke or had died. The risk of stroke or death was higher in patients with internal carotid artery-common carotid artery angulation ≥60° (relative risk, 4.96; 2.29 to 10.74) and lower in those treated with cerebral protection devices (relative risk [RR], 0.38; 0.17 to 0.85). In the systematic review (56 studies; 34 398 patients), the risk of stroke or death was higher in patients with left-sided carotid angioplasty and stenting (RR, 1.29; 1.05 to 1.58), increased internal carotid artery-common carotid artery angulation (RR, 3.41; 1.52 to 7.63), and when the target internal carotid artery stenosis was >10 mm (RR, 2.36; 1.28 to 3.38). There was no significant increase in risk of stroke or death in patients with Type III aortic arch, aortic arch calcification, or with ostial involvement, calcification, ulceration or degree of stenosis of the target internal carotid artery stenosis. The use of a cerebral protection device was associated with a lower risk of stroke or death (RR, 0.55; 0.41 to 0.73). Risk was not related with stent or cerebral protection device type.

CONCLUSIONS

Our results strongly suggest that some technical and anatomic factors, especially extreme angulation of the carotid artery, have an impact on the risks of carotid angioplasty and stenting.