Outcomes of the Endovascular Treatment for the Supra-Aortic Trunks Occlusive Disease: A 14-Year Monocentric Experience

Challenging the Controversy Surrounding Percutaneous Brachial Artery Access Related Complications: A Systematic Review and Meta-Analysis

BACKGROUND

Endovascular therapy has become increasingly preferred in the diagnosis and treatment of various conditions. The choice of arterial access usually depends on the type of procedure being performed with most via the common femoral artery and increasingly via the radial artery. Percutaneous access via the brachial artery has however been approached with caution due to the perceived increased risk for development of complications. Percutaneous brachial artery access (pBAA) has insufficient evidence when compared to femoral and radial access, with no large-scale studies available. The objective of this study is to review the literature and report the clinical and radiological complications associated with pBAA.

METHODS

EMBASE, EMCARE, CINAHL and Medline were searched for existing data on the complications associated with pBAA. Systematic review and meta-analysis were carried out on the data of 31 studies.

RESULTS

The results of this systematic review and meta-analysis indicates that the probability of post procedural haematoma was 4.76%, haemorrhage 1.43%, perforation 1.11% pseudoaneurysm 1.06%, spasm 0.9%, thrombus 0.55%, neuropathy 0.53%, occlusion 0.51%, ischaemia 0.37% and infection 0.24 %. Non-target vessel puncture, stenosis and stroke had a 0% incidence among the assessed population.

CONCLUSION

This study provides evidence to support clinical decision making when it comes to the utility of pBAA in endovascular diagnosis or therapy. The results demonstrate that pBAA is relatively safe with a low incidence of serious complications and thereby provide the clinician with the option of an alternate access point when planning treatment.

Length and location of post-PIRCS predict percutaneous transluminal angioplasty and stenting-related restenosis in nasopharyngeal cancer

PURPOSE

Post-irradiated carotid stenosis (PIRCS) commonly occurs in patients with nasopharyngeal cancer (NPC) after receiving radiotherapy. A high in-stent restenosis (ISR) is observed in these patients after percutaneous transluminal angioplasty and stenting (PTAS) for PIRCS. Risk factors for ISR in these patients remain unclear.

METHODS

Data were retrospectively analyzed from 68 NPC patients with 70 lesions treated with PTAS for PIRCS. The median follow-up was 40 months (range: 4-120). Evaluations of demographic and clinical characteristics included stenotic severity, stenotic lesion length (SLL), stenotic lesion location, and ISR-related stroke during follow-up. The risk for ISR was evaluated using multiple Cox regression analysis.

RESULTS

The median age of the patients was 61 (35-80) years and 94.1% were male. The median stenosis was 80% (60-99%) and the median SLL was 2.6 cm (0.6-12.0 cm) before PTAS. Compared to those without ISR, patients with longer SLL were at significantly greater risk of developing significant ISR, defined as > 50% after PTAS (hazard ratio [HR] and 95% confidence interval [CI]: 2.06 [1.30-3.28]). PTAS for lesions from the internal carotid artery (ICA) to common carotid artery (CCA) was associated with a significantly greater risk of ISR than lesions located only in the ICA (HR: 9.58 [1.79-51.34]). The baseline cut-off value for SLL that best predicted significant ISR was 1.6 cm (area under the curve 0.700, sensitivity 83.3% and specificity 62.5%).

CONCLUSION

Stenotic lesions located from the ICA to CCA with longer SLL at baseline appear to predict ISR in NPC patients with PIRCS after PTAS. Intensive post-procedural follow-up is advised for this patient population.

Transbrachial Access Site Complications in Endovascular Interventions: A Systematic Review of the Literature

The transfemoral approach (TFA) or transradial approach (TRA) serves as the primary technique for most endovascular cases; however, the transbrachial (TBA) route is an alternative access site used when TFA and TRA are contraindicated. Although TBA has advantages over TRA, such as the ability to accommodate large guide catheters and devices, there is some apprehension in implementing TBA due to perceived access site complication rates. This article aims to glean the rate of access site complication from current literature. Relevant studies were identified using the following search terms: ((access site complications) AND ((endovascular AND brachial) OR (percutaneous brachial access) OR (brachial))) OR (endovascular AND (percutaneous brachial access)); endovascular + brachial artery; endovascular + brachial artery + access site; and endovascular + brachial artery + access site complications. Articles published after 2008 addressing major complication rates from percutaneous TBA interventions were included. Fifteen studies out of 992 total articles met the inclusion criteria. The major access site complication rate was 75/1,424 (5.27%). Patients who underwent hemostasis with a vascular closure device (VCD) had a major complication rate of 13/309 (4.21%) compared to a major complication rate of 65/1122 (5.79%) for patients who underwent hemostasis with manual compression (MC). The major access site complication rate associated with TBA was 5.27%, which is relatively high compared to the complication rate in TFA or TRA. More prospective trials are needed to fully understand the access site complication rate in TBA interventions.

Middle and Distal Common Carotid Artery Stenting: Long-Term Patency Rates and Risk Factors for In-Stent Restenosis

PURPOSE

In the absence of literature data, we aimed to determine the long-term patency rates of middle/distal common carotid artery (CCA) stenting and to investigate predisposing factors in the development of in-stent restenosis (ISR).

MATERIALS AND METHODS

Fifty-one patients (30 males, median age 63.5 years), who underwent stenting with 51 self-expandable stents for significant (≥ 60%) stenosis of the middle/distal CCA, were analyzed retrospectively. Patient (atherosclerotic risk factors, comorbidities, medications), vessel (elongation), lesion (stenosis grade, length, calcification, location), and stent characteristics (material, diameter, length, fracture) were examined. Duplex ultrasonography was used to monitor stent patency. The Mann-Whitney U and Fisher's exact tests, Kaplan-Meier analyses, and a log-rank test were used statistically.

RESULTS

The median follow-up time was 35 months (interquartile range, 20-102 months). Significant (≥ 70%) ISR developed in 14 patients (27.5%; stenosis, N = 10; entire CCA occlusion, N = 4). Primary patency rates were 98%, 92%, 83%, 73%, and 61% at 6, 12, 24, 60, and 96 months, respectively. Reintervention was performed in six patients (11.8%) with nonocclusive ISR. Secondary patency rates were 100% at 6 and 12 months and 96% at 24, 60, and 96 months. In-stent restenosis developed more frequently (P < .001) in patients with hyperlipidemia; primary patency rates were also significantly worse (Chi-square, 11.08; degrees of freedom, 1; P < .001) in patients with hyperlipidemia compared to those without.

CONCLUSION

Stenting of the middle/distal CCA can be performed with acceptable patency rates. If intervention is unequivocally needed, patients with hyperlipidemia will require closer follow-up care.

LEVEL OF EVIDENCE

Level 3, Local non-random sample.

The Current Status of Endovascular Treatment for Extracranial Steno-occlusive Diseases in Japan: Analysis Using the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3)

Endovascular treatment of extracranial steno-occlusive lesions is an alternative to direct surgery. There is no consensus regarding the natural course and standard treatment of these lesions. The aim of this study was to identify the current status of endovascular treatment for extracranial steno-occlusive lesions. A total of 1154 procedures for extracranial steno-occlusive lesions, except for internal carotid artery stenosis, were collected from the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3). Atherosclerotic lesions were most frequent (1021 patients, 88.5%). Endovascular treatment was performed for 456 (39.5%) patients with subclavian artery, 349 (30.2%) with extracranial vertebral artery, 172 (14.9%) with the origin of common carotid artery, and 38 (3.3%) with innominate artery stenosis; the overall technical success rate was 98.0%. Percutaneous transluminal angioplasty was performed in 307 patients (26.6%) and stenting in 838 (72.6%). An embolic protection device (EPD) was used in 571 patients (49.5%), and procedure under general anesthesia was performed in 168 (14.6%). Preoperative antiplatelet therapy was administered in 1091 procedures (94.5%). A good outcome was obtained for 962 patients (83.4%). Complications were observed in 89 patients (7.7%). The procedure under general anesthesia was statistically significant factors (P <0.01), and also after multivariable adjustment (odds ratio 2.29; 95% confidence interval 1.25–4.17; P <0.01). Comparisons between JR-NET3 and previous cohorts (JR-NET1&2), the utilization of EPD and complications increased significantly, and the type of antiplatelet therapy changed markedly. Based on the results of this study, endovascular treatment for extracranial steno-occlusive lesions is relatively safe. Further prospective studies are necessary to validate the beneficial effects.

The incidence and risk factors of stent fracture in patients treated for proximal common carotid artery stenosis

OBJECTIVE

Our aim was to identify the incidence of and predictors for common carotid artery (CCA) stent fractures (SFs) and to examine the effect of SFs on the development of in-stent restenosis (ISR).

METHODS

Seventy patients (37 women; median age, 60.9 years) who were stented for significant (≥60%) proximal CCA stenosis from 2006 to 2016 and revisited us to determine SF using fluoroscopy in 2018 were evaluated. Seventy stents were deployed; among them 87.1% were balloon-expandable and 12.9% were self-expandable. SFs were classified as type I (fracture of one strut), type II (fracture of multiple struts without stent deformity), type III (fracture of multiple struts with stent deformity), type IV (complete fracture of the stent without a gap), and type V (complete fracture of the stent with a gap). Duplex ultrasound examination was used for monitoring stent patency. Mann-Whitney U and Fisher's exact tests, Kaplan-Meier and logistic regression analyses, and a log-rank test and a gamma correlation analysis were applied as statistical methods.

RESULTS

The patients were followed for 75.5 months (range, 47-109 months). Significant (≥70%) ISR was observed in eight patients (11.4%). Reintervention was performed in four cases (5.7%). Twenty-seven SFs (38.6%; type I, 8; type II, 10; type III, 4; type IV, 2; and type V, 3) were found. Calcification was shown to be a significant predictor for SF (odds ratio, 13.2; 95% confidence interval, 3.9-45.1; P < .001). There was no significant difference between the fractured and the nonfractured group regarding the number of patients with ISR and reintervention (P = .701 and P = .636, respectively). Neither did the primary patency rates differ significantly (P = .372) in patients with and without SF.

CONCLUSIONS

Fractures frequently occur in a wide variety of stent devices deployed in the proximal CCA, but SFs seem to have no effect on ISR and reintervention.

Total arch replacement as treatment for repeated cerebral infarctions due to unstable plaque simultaneously in the innominate artery and left subclavian artery: a case report

We report a case of total arch replacement in a patient who suffered repeated cerebral infarctions due to unstable plaque simultaneously in the innominate and left subclavian arteries.

Amaurosis fugax associated with congenital vascular defect

A 68-year-old female with no significant past medical history presented with loss of vision in the lower half of her left eye that lasted <5 minutes. No abnormalities were found on ocular or physical exam. Computed tomography angiography and carotid ultrasound were performed, which confirmed the diagnosis as amaurosis fugax with two abnormalities leading to the transient retinal vessel occlusion. First, it was found that the patient has a congenital vascular anomaly, which consisted most notably of a right-sided aortic arch. This vascular anomaly also consisted of abnormal branching of the left subclavian and common carotid arteries, predisposing the patient to turbulent blood flow and increased risk of the formation of an atherosclerotic plaque at the origin of the common carotid artery. This is an abnormal location for a plaque leading to amaurosis fugax compared to the most common location at the carotid bifurcation. Endarterectomy was not performed because of the difficult location of the plaque and tortuosity of the vessel. Rather, medical intervention with antiplatelet and lipid-lowering therapy was initiated to lower the risk of future retinal or cerebral thromboembolic events.