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Pini R, Faggioli G, Paraskevas KI, Campana F, Sufali G, Rocchi C, Palermo S, Gallitto E, Gargiulo M. Carotid Artery Stenting With Double-Layer Stent: A Systematic Review and Meta-Analysis. J Endovasc Ther 2024; 31:339-349. [PMID: 36214459 PMCID: PMC11110467 DOI: 10.1177/15266028221126940] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) in the treatment of significant stenosis is a cause of stroke due to both plaque prolapse and cerebral embolization. New types of stents with a double-layer structure have been designed to minimize plaque prolapse and embolization; these double-layer stents (DLSs) should be able to reduce the stroke risk; however, definite data on their performance are scarce in the literature. METHODS A systematic search was performed through PubMed, Scopus, and Cochrane Library, according to PRISMA guidelines; all studies on CAS with DLS (Roadsaver/Casper or CGuard) up to January 1, 2022, with a cohort of at least 20 patients were considered eligible. The present meta-analysis was approved and registered on PROSPERO register (CRD42022297512). Patients with tandem lesions or complete carotid occlusion were excluded from the study. The 30-day stroke rate after CAS was analyzed evaluating the preoperative symptomatic status and DLS occlusion. The estimated pooled rate of events was calculated by random effect model and moderators were evaluated. RESULTS A total of 14 studies were included in the meta-analysis for a total of 1955 patients. The estimated overall (95% confidence interval [CI]) stroke rate was 1.4% (0.9%-2.2%, I2 = 0%), which was not influenced by the type of DLS used: CGuard 0.8% (0.4%-1.8%, I2 = 0%) versus Roadsaver/Casper 1.5% (0.7%-3.2%, I2 = 0%), p=0.30. The 30-day estimated stroke rate was 1.5% (0.8%-2.9%, I2 = 0%) in asymptomatic and 1.9% (1.0%-3.6%, I2 = 0%) in symptomatic patients, with no influence by moderators. The 30-day DLS occlusion rate was 0.8% (0.4%-1.8%, I2 = 0%). The publication bias assessment identified asymmetry in the asymptomatic populations. CONCLUSION The overall 30-day stroke rate in CAS with DLS is low (1.4%), with similar results in symptomatic and asymptomatic patients. Acute occlusion of DLS is rare (0.8%). Further studies are necessary to reduce the publication bias for asymptomatic patients. CLINICAL IMPACT CAS with DLS is associated to a low rate of 30-day stroke in both symptomatic (1.9%) and asymptomatic (1.5%) patients. The type of DLS (CGuard or Roadsaver/Casper) did not affect the 30-day stroke rate.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | | | - Federica Campana
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Gemmi Sufali
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Cristina Rocchi
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Sergio Palermo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna and Policlinico Sant’Orsola Malpighi, Bologna, Italy
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Spiliopoulos S, Blanc R, Gandini R, Müller-Hülsbeck S, Reith W, Moschovaki-Zeiger O. CIRSE Standards of Practice on Carotid Artery Stenting. Cardiovasc Intervent Radiol 2024; 47:705-716. [PMID: 38683353 PMCID: PMC11164804 DOI: 10.1007/s00270-024-03707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis. PURPOSE This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure. METHODS The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022. RESULTS Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.
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Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - Roberto Gandini
- Diagnostic and Interventional Radiology/Neuroradiology, University of Rome "Tor Vergata", Rome, Italy
| | - Stefan Müller-Hülsbeck
- Diagnostic and Interventional Radiology/Neuroradiology, DIAKO Hospital, Flensburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University, Homberg, Germany
| | - Ornella Moschovaki-Zeiger
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Fan YM, Liu HY, Xue YY. Mechanical thrombectomy for symptomatic stent thrombosis after carotid artery stenting. Front Neurol 2023; 14:1277366. [PMID: 38020615 PMCID: PMC10663350 DOI: 10.3389/fneur.2023.1277366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background As there is still no consensus on the treatment of carotid stent thrombosis (CST), we would like to describe our experience with the revascularization of CST by mechanical thrombectomy. Methods We retrospectively studied patients who underwent mechanical thrombectomy after CST at Xuzhou Municipal First People's Hospital and Xuzhou Central Hospital between January 2020 and November 2022. The results of the procedures, complications, and clinical and imaging follow-up were recorded. Results A total of six patients were included in this study. The stenosis grade before stent implantation was ≥85% in all patients, and the stenosis length ranged from 7 to 20 mm. Patients experienced CST within 6 days to 45 months after carotid artery stenting (CAS); the median admission on the National Institutes of Health Stroke Scale (NIHSS) at CST was 12 (range 8-25). Mechanical thrombectomy was successfully performed in all patients. There was no periprocedural death, and the modified Rankin Scale (mRS) at the 3-month follow-up was 0-2. All patients showed recovery from their neurological deficits. Conclusion The treatment of symptomatic CST with mechanical thrombectomy resulted in satisfactory clinical outcomes. This regimen could be effective and safe, and future prospective and randomized studies are warranted.
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Affiliation(s)
- You-Min Fan
- Department of Neurology, Xuzhou Municipal First People’s Hospital, Xuzhou, China
| | - Han-Yang Liu
- Department of Interventional Radiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yu-Yang Xue
- Department of Interventional Radiology, Xuzhou Municipal First People’s Hospital, Xuzhou, China
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Okumura E, Onodera S, Jimbo H. Subacute In-Stent Occlusion 2 Weeks after CASPER Rx Stenting: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:173-179. [PMID: 37609575 PMCID: PMC10442173 DOI: 10.5797/jnet.cr.2023-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/03/2023] [Indexed: 08/24/2023]
Abstract
Objective CASPER Rx stent (Terumo, Tokyo, Japan) is one of the dual-layer micromesh stents for carotid artery stenosis. Although it is expected to be safe and efficacious even for vulnerable plaque, we report a case of in-stent occlusion 2 weeks after stenting with CASPER Rx stent. Case Presentation The patient was a 78-year-old man with a symptomatic, severely stenosed lesion of the cervical internal carotid artery (ICA). He had an unstable plaque and underwent carotid artery stenting with the CASPER Rx stent. There were no problems with the procedure or the patient's subsequent course, and he was discharged home 1 week after the procedure. However, on postoperative day 14, the patient had a transit ischemic attack and imaging showed acute occlusion due to thrombus in the stent and in the distal part of the ICA. Mechanical thrombectomy was performed and good recanalization was achieved, but postoperative cerebral infarction was observed and the patient was transferred to other hospital with modified Rankin Scale 2. Conclusion We experienced a case of in-stent occlusion 2 weeks after stenting with the CASPER Rx stent.
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Affiliation(s)
- Eitaro Okumura
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Sho Onodera
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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5
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Wang H, Xu L, Qin Y, Xiao G. Revascularization of acute stent thrombosis caused by diarrhea after carotid artery stenting in an intermediate clopidogrel metabolizer. BMC Neurol 2023; 23:260. [PMID: 37415135 DOI: 10.1186/s12883-023-03293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023] Open
Abstract
Carotid artery stenting (CAS) is an alternative treatment to carotid endarterectomy for carotid artery stenosis. Acute stent thrombosis (ACST) is an extremely rare complication but can have devastating consequences. Although many cases have been reported, the best treatment is still uncertain. In this study, we report the treatment of ACST caused by diarrhea in an intermediate clopidogrel metabolizer. We also review the literature and discuss appropriate treatment strategies for this rare event.
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Affiliation(s)
- Huaishun Wang
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Longdong Xu
- fifth People's Hospital of Changshu, Suzhou, 215004, China
| | - Yan Qin
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China.
| | - Guodong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China.
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Lu J. Rescue of immediate post-transcarotid artery revascularization carotid stent thrombosis due to clopidogrel resistance using flow-reversal and aspiration thrombectomy. J Vasc Surg Cases Innov Tech 2023; 9:101205. [PMID: 37274441 PMCID: PMC10238582 DOI: 10.1016/j.jvscit.2023.101205] [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] [Received: 02/16/2023] [Accepted: 04/14/2023] [Indexed: 06/06/2023] Open
Abstract
An 84-year-old patient developed immediate thrombosis of his carotid stent in recovery after transcarotid artery revascularization. In the present report, the technical details about intraoperative management for neurovascular rescue using the transcarotid artery revascularization flow-reversal system are described. The patient was determined to have clopidogrel resistance. Intraoperative medical management is also discussed. The current alternative intravenous and oral antiplatelet therapies such as glycoprotein IIb/IIIa and P2Y12 inhibitors are explored. The debate regarding preoperative antiplatelet resistance testing remains ambiguous, and increasing studies have demonstrated the safety and efficacy of alternatives to clopidogrel. Despite an unpredictable and devastating complication, the patient's outcome was successful using contemporary strategies.
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Affiliation(s)
- Joyce Lu
- Correspondence: Joyce Lu, MD, South Valley Vascular Associates, Division of BASS Medical Group, 820 S. Akers St., Suite 120, Visalia 93277, CA
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Ishikawa T, Yamanouchi T, Kabeya R. A Case of Acute In-Stent Mobile Plaque after Carotid Artery Stenting Aspirated with a Distal Access Catheter. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:107-113. [PMID: 37546543 PMCID: PMC10400897 DOI: 10.5797/jnet.cr.2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 08/08/2023]
Abstract
Objective Carotid artery stenting (CAS) is common procedure for carotid stenosis, but sometimes acute in-stent thrombosis or plaque protrusion after CAS leads to postoperative stroke. There are few reports of aspiration of in-stent plaque protrusion. This paper reports a case of acute in-stent mobile plaque aspirated with a distal access catheter. Case Presentation A 74-year-old male underwent CAS for symptomatic internal carotid artery stenosis and postoperative course was thought to be good, but in-stent mobile plaque was detected by carotid duplex at postoperative day 6. As mobile plaque is a high risk for stroke, we performed plaque aspiration with a distal access catheter, without neurological deficit or a new cerebral lesion in magnetic resonance imaging. We present a case report, including a literature review, of acute thrombosis or in-stent plaque protrusion. Conclusion Aspiration removal may be effective for in-stent mobile plaque, which is expected to be fragile, avoiding the disadvantages of increasing stents.
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Affiliation(s)
- Takayuki Ishikawa
- Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Takashi Yamanouchi
- Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
| | - Ryusuke Kabeya
- Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, Aichi, Japan
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Allard J, Delvoye F, Pop R, Labreuche J, Maier B, Marnat G, Sibon I, Zhu F, Lapergue B, Consoli A, Spelle L, Denier C, Richard S, Piotin M, Gory B, Mazighi M, Redjem H, Escalard S, Dessilles JP, Delvoye F, Smajda S, Maier B, Solène H, Mazighi M, Obadia M, Sabben C, Pierre S, Igor R, Corabianu O, de Broucker T, Manchon E, Taylor G, Maacha MB, Thion LA, Augustin L, Julien S, Wang A, Evrard S, Tchikviladze M, Ajili N, WeisenburgerLile D, Gorza L, Buard G, Coskun O, Di Maria F, Rodesh G, Zimatore S, Leguen M, Gratieux J, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Marinier S, Barreau X, Berge J, Menegon P, Lucas L, Olindo S, Renou P, Sagnier S, Poli M, Debruxelles S, Rouanet F, Tourdias T, Liegey JS, Briau P, Pangon N, Coussy A, Papillon L, Papaxanthos J, Detraz L, Daumas-Duport B, Alexandre PL, Roy M, Lenoble C, Desal H, Guillon B, de Gaalon S, Preterre C, Bracard S, Anxionnat R, Braun M, Derelle AL, Tonnelet R, Liao L, Zhu F, Schmitt E, Planel S, Humbertjean L, Lacour JC, Riou-Comte N, Voicu M, Alb L, Reitter M, Brezeanu M, Masson A, Tabarna A, Podar I, Macian-Montoro F, Saleme S, Mounayer C, Rouchaud A, Costalat V, Arquizan C, Dargazanli C, Gascou G, Lefèvre PH, Derraz I, Riquelme C, Gaillard N, Mourand I, Corti L, Cagnazzo F, Ter Schiphorst A, Ferre JC, Raoult H, Ronziere T, Lassale M, Paya C, Gauvrit JY, Tracol C, Langnier-Lemercier S. 24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study. Stroke 2023; 54:124-131. [PMID: 36542074 DOI: 10.1161/strokeaha.122.039797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Management of extracranial internal carotid artery steno-occlusive lesion during endovascular therapy remains debated. Stent occlusion within 24 hours of endovascular therapy is a frequent event after acute carotid artery stenting, and we currently lack large population results. We investigated the incidence, predictors, and clinical impact of stent occlusion after acute carotid artery stenting in current clinical practice. METHODS Patients treated by endovascular therapy with acute carotid artery stenting between 2015 and 2019 in 5 large-volume endovascular-capable centers were retrospectively analyzed. Patients were separated in 2 groups according to the stent patency at 24 hours after carotid artery stenting. We compared baseline characteristics, treatment modalities, and clinical outcome depending on 24-hour stent patency. Primary end point was favorable outcome, defined as a modified Rankin Scale score 0-2 at 3 months. RESULTS A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7-17] versus 18 [12-21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y12 antagonists at the acute phase (odds ratio [OR]' 2.95 [95% CI' 1.10-7.91]; P=0.026) and treated with angioplasty (OR' 2.42 [95% CI' 1.24-4.67]; P=0.008). A better intracranial angiographic reperfusion was observed in patients with 24-hour stent patency compared with patients without stent patency (OR' 8.38 [95% CI' 3.07-22.78]; P<0.001). Patients with a stent patency at 24 hours had a higher chance of favorable outcome (OR' 3.29 [95% CI, 1.66-6.52]; P<0.001) and a lower risk of death (OR' 0.32 [95% CI, 0.13-0.76]; P=0.009). CONCLUSIONS One out of 5 patients treated with carotid artery stenting during endovascular therapy presented a stent occlusion within 24 hours. This event was associated with worse functional outcome. Stroke etiology, P2Y12 antagonist administration, quality of intracranial reperfusion, and angioplasty were associated with 24-hour stent patency.
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Affiliation(s)
- Julien Allard
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,University of Paris' France (J.A., M.M.)
| | - François Delvoye
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Raoul Pop
- Department of Neuroradiolology, CHU Strasbourg, France (R.P.).,Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France (R.P.).,University of Strasbourg, INSERM UMR-S1255, France (R.P.)
| | - Julien Labreuche
- Department of Biostatistics, CHU Lille, University of Lille, France (J.L.)
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.)
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (G.M.)
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, France (I.S.)
| | - François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (B.L.)
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (A.C.)
| | - Laurent Spelle
- Department of Neuroradiolology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (L.S.)
| | - Christian Denier
- Department of Neurology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (C.D.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, France (S.R.).,CIC-P 1433, INSERM U1116, CHRU-Nancy, France (S.R.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (B.G.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.).,University of Paris' France (J.A., M.M.)
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Zhang JB, Fan XQ, Chen J, Liu P, Ye ZD. Acute carotid stent thrombosis: A case report and literature review. World J Clin Cases 2022; 10:9310-9317. [PMID: 36159434 PMCID: PMC9477654 DOI: 10.12998/wjcc.v10.i26.9310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/10/2021] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute carotid stent thrombosis (ACST) is a rare but devastating complication in the carotid artery stenting (CAS) procedure. The aim of this article is to report a case and review cases of ACST reported in the literature, and investigate risk factors and management strategies for ACST.
CASE SUMMARY We reviewed the treatment process of a patient with ACST after CAS. Then multiple databases were systematically searched to identify studies reporting ACST from 2005 to 2020. The demographic data, risk factors, treatment strategies, and prognosis were extracted and analyzed.
CONCLUSION The reason for ACST is multifactorial. Proper patient selection, normative anti-platelet treatment, and perfect technical detail may decrease the incidence of ACST. Several treatment strategies such as thrombolysis, mechanical thrombectomy, and open surgery may be options for the treatment of ACST. Limited data have shown that carotid endarterectomy is effective with favorable results.
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Affiliation(s)
- Jian-Bin Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xue-Qiang Fan
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jie Chen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhi-Dong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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Low M, Gray B, Dicks A, Ochiobi O, Blas J, Gandhi S, Carsten C. Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wei W, Wang Y, Wang P, Li Z. Revascularization of acute stent thrombosis after carotid artery stenting in a CYP2C19*2 heterozygote patient. J Int Med Res 2021; 49:3000605211001191. [PMID: 33745326 PMCID: PMC7989125 DOI: 10.1177/03000605211001191] [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
Carotid artery stenting (CAS) is an alternative strategy to carotid endarterectomy for the prevention of ischemic stroke. Acute carotid stent thrombosis (ACST) is an extremely rare but devastating complication of CAS. Although cases of successful recanalization have been reported, there is still a lack of experience regarding the choice of ACST treatment methods and the timing of such treatments, especially when patients are confirmed CYP2C19*2 heterozygotes. Here, we report a case of successful revascularization after ACST in a patient with CYP2C19*2 heterozygosity. We also review the literature and discuss appropriate treatment strategies for this devastating and rare event.
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Affiliation(s)
- Wei Wei
- Department of Emergency, Chengdu Second People's Hospital, Chengdu, China
| | - Yan Wang
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Pian Wang
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Zheng Li
- Department of Neurology, Chengdu Fifth People's Hospital, Chengdu, China
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Mouawad NJ, Hui S. Mechanical Thrombectomy of Symptomatic Acute Carotid Stent Thrombosis Using Transcarotid Artery Revascularization Neuroprotection Flow Reversal Technique. Ann Vasc Surg 2020; 70:565.e15-565.e19. [PMID: 32502681 DOI: 10.1016/j.avsg.2020.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/23/2020] [Accepted: 05/21/2020] [Indexed: 12/17/2022]
Abstract
Carotid artery stent thrombosis is a relatively rare yet devastating complication of endovascular carotid interventions and manifests as ipsilateral neurological aberrancies such as transient ischemic attack or cerebrovascular accident. Prompt evaluation is necessary, and appropriate imaging is warranted to ascertain the urgency for intervention. Traditionally, anticoagulation with stent explantation and associated thrombectomy is performed. With patients presenting with more high-risk criteria and medical comorbidities, we describe the successful use of transcarotid artery revascularization flow reversal technique with the Penumbra mechanical thrombectomy device to extirpate the thrombus.
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Affiliation(s)
| | - Samuel Hui
- Vascular & Endovascular Surgery, McLaren Bay Region, Bay City, MI
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Murray NM, Wolman DN, Marks M, Dodd R, Do HM, Lee JT, Heit JJ. Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty. Cureus 2020; 12:e7997. [PMID: 32523851 PMCID: PMC7274505 DOI: 10.7759/cureus.7997] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Acute carotid stent occlusion (CSO) is a rare complication of endovascular carotid stent placement that requires emergent intervention. We describe angioplasty or combined angioplasty and aspiration thrombectomy as a new endovascular technique for CSO treatment. The technique is compared to others previously described in the literature. Methods We performed a retrospective cohort study of all patients who underwent endovascular treatment (ET) of acute symptomatic CSO from January 2008 to March 2018 at our neurovascular referral center. Patient demographics, endovascular treatment details, and outcome data were determined from the electronic medical record. Primary outcome was successful stent recanalization and cerebral reperfusion (modified thrombolysis in cerebral infarction (mTICI) score IIB-III). Secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) shift from presentation to discharge, mortality, and modified Rankin Scale (mRS) score at 3 months. Additionally, a literature review (years 2008-2019) was performed to characterize other techniques for ET of CSO. Results Four patients who underwent ET of acute CSO were identified. ET treatment by angioplasty (n = 1) or combined aspiration thrombectomy and angioplasty (n = 3) resulted in carotid stent recanalization in all patients. Tandem intracranial occlusions were present in three patients (75%), and successful cerebral reperfusion was achieved in all patients. Patient symptoms improved (mean NIHSS shift -5.3 ± 7.2 at discharge). One patient died of a symptomatic reperfusion hemorrhage and another died of cardiac complications by 3-month follow-up. The mRS scores of the surviving patients were 1 and 3. Previously described studies (n = 14) using different and varied techniques had moderate recanalization rates and outcomes. Conclusion Combined aspiration thrombectomy and angioplasty for the neurointerventional treatment of acute CSO leads to high rates of stent recanalization and cerebral reperfusion. The recanalization rate here is improved compared to previously reported techniques. Further multicenter studies are required to risk-stratify patients for specific ET interventions.
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Affiliation(s)
| | | | | | - Robert Dodd
- Neurosurgery/ Cerebrovascular and Skull Base Surgery, Stanford University Medical Center, Palo Alto, USA
| | - Huy M Do
- Radiology, Stanford University School of Medicine, Stanford, USA
| | - Jason T Lee
- Vascular Surgery, Stanford University, Stanford, USA
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Toljan K, Jovanović I, Starčević K, Ljevak J, Blažević N, Radoš M, Poljaković Z. Acute Carotid Stent Thrombosis in an Ultrarapid Clopidogrel Metabolizer: Case Report and Literature Review. Vasc Endovascular Surg 2019; 53:602-605. [PMID: 31272299 DOI: 10.1177/1538574419857965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Carotid angioplasty and stenting (CAS) represents an effective procedure for treating carotid artery disease. The acute in-stent thrombosis is an extremely rare complication of CAS especially when it occurs postprocedurally during the first 24 hours. Improper antiplatelet therapy or poor response to antiplatelet medications is known to be associated with a higher risk of in-stent thrombosis during early postprocedural period following a successful intervention. MATERIAL AND METHODS A patient who experienced acute carotid in-stent thrombosis in early postprocedural period is described. He had been taking dual antiplatelet therapy for 2 weeks before undergoing a successful CAS. Moreover, pharmacogenetics studies showed the patient to be a clopidogrel ultrarapid metabolizer, which theoretically confers hyperresponsivity to medication. Alongside the report itself, a brief literature review of relevant sources pertinent to the case has been conducted. RESULTS According to the available literature, this is the first case report describing an ultrarapid clopidogrel metabolizer who underwent an uneventful CAS but experienced acute carotid in-stent thrombosis in early postprocedural period. A rescue procedure included an endovascular intervention consisting of thrombectomy and local alteplase application, followed by postprocedural administration of intravenous eptifibatide. At discharge, patient's dual antiplatelet therapy included ticagrelor instead of clopidogrel. CONCLUSION Acute carotid in-stent thrombosis is a highly unexpected complication of CAS and can occur despite ultrarapid clopidogrel metabolism trait.
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Affiliation(s)
- Karlo Toljan
- 1 Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ivan Jovanović
- 2 Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Katarina Starčević
- 1 Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Josip Ljevak
- 1 Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikola Blažević
- 1 Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marko Radoš
- 2 Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia.,3 School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zdravka Poljaković
- 1 Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia.,3 School of Medicine, University of Zagreb, Zagreb, Croatia
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Lazaro T, Srinivasan VM, Cooper P, Phillips M, Garcia R, Chen SR, Johnson J, Collins DE, Kan P. A new set of eyes: development of a novel microangioscope for neurointerventional surgery. J Neurointerv Surg 2019; 11:1036-1039. [PMID: 30878951 DOI: 10.1136/neurintsurg-2018-014610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endovascular technological advances have revolutionized the field of neurovascular surgery and have become the mainstay of treatment for many cerebrovascular pathologies. Digital subtraction angiography (DSA) is the 'gold standard' for visualization of the vasculature and deployment of endovascular devices. Nonetheless, with recent technological advances in optics, angioscopy has emerged as a potentially important adjunct to DSA. Angioscopy can offer direct visualization of the intracranial vasculature, and direct observation and inspection of device deployment. However, previous iterations of this technology have not been sufficiently miniaturized or practical for modern neurointerventional practice. OBJECTIVE To describe the evolution, development, and design of a microangioscope that offers both high-quality direct visualization and the miniaturization necessary to navigate in the small intracranial vessels and provide examples of its potential applications in the diagnosis and treatment of cerebrovascular pathologies using an in vivo porcine model. METHODS In this proof-of-concept study we introduce a novel microangioscope, designed from coherent fiber bundle technology. The microangioscope is smaller than any previously described angioscope, at 1.7 F, while maintaining high-resolution images. A porcine model is used to demonstrate the resolution of the images in vivo. RESULTS Video recordings of the microangioscope show the versatility of the camera mounted on different microcatheters and its ability to navigate external carotid artery branches. The microangioscope is also shown to be able to resolve the subtle differences between red and white thrombi in a porcine model. CONCLUSION A new microangioscope, based on miniaturized fiber optic technology, offers a potentially revolutionary way to visualize the intracranial vascular space.
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Affiliation(s)
- Tyler Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | - Robert Garcia
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Stephen R Chen
- Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Dalis E Collins
- Center for Comparative Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Coelho AP, Lobo M, Nogueira C, Gouveia R, Campos J, Augusto R, Coelho N, Semião AC, Canedo A. Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades. J Vasc Surg 2019; 69:952-964. [DOI: 10.1016/j.jvs.2018.09.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/20/2018] [Indexed: 10/27/2022]
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Kargiotis O, Safouris A, Magoufis G, Georgala M, Roussopoulou A, Stamboulis E, Moulakakis KG, Lazaris A, Geroulakos G, Vasdekis S, Tsivgoulis G. The Role of Neurosonology in the Diagnosis and Management of Patients with Carotid Artery Disease: A Review. J Neuroimaging 2018; 28:239-251. [DOI: 10.1111/jon.12495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
| | | | | | - Maria Georgala
- Department of Clinical NeurophysiologyMetropolitan Hospital Piraeus Greece
| | - Andromachi Roussopoulou
- Second Department of NeurologyMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
| | | | - Konstantinos G. Moulakakis
- Department of Vascular SurgeryMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
| | - Andreas Lazaris
- Department of Vascular SurgeryMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
| | - George Geroulakos
- Department of Vascular SurgeryMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
| | - Spyros Vasdekis
- Department of Vascular SurgeryMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
| | - Georgios Tsivgoulis
- Second Department of NeurologyMedical SchoolNational and Kapodistrian University of Athens“Attikon” University Hospital Athens Greece
- Department of NeurologyThe University of Tennessee Health Science Center Memphis TN
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Moulakakis KG, Lazaris AM. Emergent Carotid Stent Removal after Carotid Stent Thrombosis. Ann Vasc Surg 2017; 46:401-406. [PMID: 28887238 DOI: 10.1016/j.avsg.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/22/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Acute carotid stent thrombosis in patients undergoing CAS is a relatively rare and potentially devastating complication influencing significantly the quality of life. With the increasing use of stenting in clinical practice, it is expected to represent a more often encountered complication for physicians performing CAS. Emergent removal of the thrombosed stent and endarterectomy is indicated when the intrastent thrombosis is not associated with intracranial carotid branch thrombosis. METHODS The technique and its peculiarities and tip and tricks of this carotid operation have not been described meticulously. We describe the steps of the surgical technique in detail, and we analyze crucial issues associated with the technique. RESULTS We have performed this emergency operation in 2 patients with acute early stroke after CAS. Both patients presented recovery of their previous neurologic deficits and had uneventful postoperative course. CONCLUSIONS We illustrate the technique of emergent removal of the thrombosed stent after CAS. If carotid stent thrombosis with no distal extension is documented post procedurally, emergency stent removal and endarterectomy is the preferred strategy. Special care should be taken to avoid risk of clot dislocation and consequent cerebral embolization during the surgical exposure of the carotid bifurcation and placement of the vascular clamps.
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Affiliation(s)
- Konstantinos G Moulakakis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece.
| | - Andreas M Lazaris
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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