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Pini R, Gallitto E, Fronterrè S, Rocchi C, Lodato M, Shyti B, Faggioli G, Gargiulo M. Diagnosis and management of acute conditions of the extracranial carotid artery. Semin Vasc Surg 2023; 36:130-138. [PMID: 37330227 DOI: 10.1053/j.semvascsurg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
Symptomatic carotid stenosis and carotid dissection are acute conditions of extracranial cerebrovascular vessels determining transient ischemic attack or stroke. Medical, surgical, or endovascular management are different options to treat these pathologies. This narrative review focused on the management, from symptoms to treatment, of the acute conditions of extracranial cerebrovascular vessels, including post-carotid revascularization stroke. Symptomatic carotid stenosis (> 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria) with transient ischemic attack or stroke benefits from carotid revascularization-primarily with carotid endarterectomy associated with medical therapy-within 2 weeks from symptom onset to reduce the risk of stroke recurrence. Different from acute extracranial carotid dissection, medical management with antiplatelet or anticoagulant therapy can prevent new neurologic ischemic events, considering stenting only in case of symptom recurrence. Stroke after carotid revascularization can be associated with the following etiologies: carotid manipulation, plaque fragmentation, or clamping ischemia. Medical or surgical management is therefore influenced by the cause and timing of the neurologic events after carotid revascularization. Acute conditions of the extracranial cerebrovascular vessels include a heterogeneous group of pathologies and correct management can reduce symptom recurrence substantially.
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy.
| | - Enrico Gallitto
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Sara Fronterrè
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Cristina Rocchi
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Marcello Lodato
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Betti Shyti
- Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico University Hospital Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138, Bologna, Italy; Vascular Surgery, University of Bologna, Il Dipartimento di Scienze Mediche e Chirurgiche, Bologna, Italy
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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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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 218] [Impact Index Per Article: 218.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Lin MS, Chen YH, Chao CC, Lin CH, Li HY, Chao CL, Chen MF, Kao HL. Catheter-based neurosalvage for acute embolic complication during carotid intervention. J Vasc Surg 2010; 52:308-13. [PMID: 20591603 DOI: 10.1016/j.jvs.2010.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 03/10/2010] [Accepted: 03/12/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Iatrogenic emboli may be released during carotid intervention, causing permanent neurologic complications and catastrophic outcomes. This article reports the procedural details and clinical results of our series of neurosalvage techniques to manage thromboembolic events during carotid procedures. METHODS Between March 2003 and December 2007, 342 patients (283 men, 72.1 +/- 8.9 years old, 121 symptomatic) underwent percutaneous stent deployment in 407 cervical internal carotid arteries in our institution. Visible distal embolization with flow occlusion caused neurologic complications in 10 patients (2.5%), and a structured and stepwise neurosalvage approach was attempted. RESULTS Guidewire fragmentation and microcatheter injection of heparin and nitroglycerin were performed in all 10 patients as step 1. Intra-arterial thrombolysis was given in four patients and balloon angioplasty in five, as step 2. Intracranial stenting was done in one patient as the last step. Successful angiographic recanalization (Thrombolysis in Myocardial Infarction [TIMI] grade 2-3) occurred in 9 of 10 (90%). Residual neurologic sequel was observed in five, including three patients with hemorrhage complications (1 received emergent craniotomy). There was no neurologic mortality in this series. CONCLUSIONS Acute embolic complication during carotid artery stenting can be managed by catheter-based neurosalvage with effective angiographic recanalization and marginal clinical success.
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Affiliation(s)
- Mao-Shin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Bordes J, Boret H, Prunet B, Montcriol A, Goutorbe P. [Carotid dissection during angioplasty for vasospasm induced by subarachnoid haemorrhage. The use of multimodal cerebral monitoring]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:1023-1028. [PMID: 19945247 DOI: 10.1016/j.annfar.2009.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 09/30/2009] [Indexed: 05/28/2023]
Abstract
We report the case of a 54-year-old woman presenting subarachnoid haemorrhage. She experienced multiple vasospasms and treatment included triple-H (hypervolaemia, hypertension, and haemodilution) and endovascular therapies. Right internal carotid dissection complicated angioplasty of the right middle cerebral artery. Combined brain tissue partial pressure of oxygen monitoring and transcranial echo-Doppler could have facilitated early diagnosis. Despite successful revascularization of right internal carotid by stenting, this complication caused acute stroke with refractory intracranial hypertension.
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Affiliation(s)
- J Bordes
- Département d'anesthésie-réanimation, HIA Sainte-Anne, 2 boulevard Sainte-Anne, Toulon, France.
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