Hybrid Interventions in the Case of Combined Stenosis of the Carotid Bifurcations and Supra-Aortic Arteries

Management and Treatment of Tandem Carotid Lesions

BACKGROUND

Tandem lesions of the proximal aortic branch vessels and carotid bifurcation are uncommon. While management strategies vary, a hybrid approach of carotid endarterectomy with retrograde common carotid artery (CCA) or innominate artery (IA) stenting has become a mainstay of treatment. The purpose of this article was to provide a review of the literature, discuss alternative treatment modalities, and highlight technical considerations of the hybrid approach.

METHODS

We performed a systematic review of the literature by searching relevant key words in the Cochrane Library, PubMed/Medline, and Embase. The primary endpoints of this study were stroke and all-cause mortality at 30 days. Secondary outcomes included rate of technical success, re-stenosis and need for re-intervention, and stroke and all-cause mortality at 1 year.

RESULTS

We identified 15 retrospective cohort studies with a cumulative 242 patients who underwent hybrid repair. The average technical success rate of hybrid repair for the management of tandem carotid lesions was high (98.8%). Multiple studies reported zero events. The average 30-day mortality rate across all studies was 0.6% (pooled: 3/242, 1.2%) and average 30-day stroke rate across all studies was 0.9% (pooled: 7/242, 2.9%). Of the studies that reported rates of re-stenosis and need for re-intervention, the average re-stenosis rate was 9.6% (pooled 34/209; 16.3%). The most common area of re-stenosis was the proximal carotid CCA/IA (61.7%). The average reintervention rate across all studies was 4.5% (pooled 13/209; 6.2%).

CONCLUSIONS

A hybrid approach of carotid endarterectomy with retrograde CCA/IA stenting is a safe and effective treatment modality for tandem carotid disease. However, there remains a paucity of high-level data as single-center studies are subject to publication bias. This study highlights the critical need for a prospective registry to prognosticate the risk of stroke and mortality for patients with asymptomatic versus symptomatic tandem carotid lesions.

Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions

INTRODUCTION

Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis.

METHODS

Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined.

RESULTS

We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA.

CONCLUSIONS

Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

A systematic review and meta-analysis of combined carotid endarterectomy with ipsilateral proximal intervention (hybrid approach) for tandem carotid artery lesions

OBJECTIVE

The safety and effectiveness of using the hybrid approach to treat tandem carotid lesions is controversial, and the clinical significance of the technical variants on the perioperative outcomes has not been evaluated. The present meta-analysis was performed to evaluate the technique, safety, effectiveness, and long-term outcomes of the hybrid approach.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched to identify studies from January 1, 1996 to January 11, 2020. The baseline patient characteristics, comorbidities, procedural details, and perioperative and long-term outcomes were collected and analyzed. A pooled overall survival curve was drawn. Univariate analysis was performed to compare the perioperative stroke risk between subgroups.

RESULTS

Overall, 275 patients (mean age, 66.94 years) from 15 studies were included. All the patients had presented with tandem stenosis of ≥50%, and 67.2% were symptomatic. The overall technical success rate was 99.8% (95% confidence interval [CI], 98.0%-100.0%). The pooled perioperative complications rates were as follows: death, 1.5% (95% CI, 0.0%-2.9%); stroke, 2.6% (95% CI, 0.7%-4.4%); combined stroke/death, 3.3% (95% CI, 1.2%-5.4%); and myocardial infarction, 3.2% (95% CI, 0.7%-9.1%). The overall primary patency rates were 99.2% (95% CI, 96.0%-100.0%) and 88.2% (95% CI, 78.8%-95.4%) at 1 and 2 years, respectively. Reintervention was performed in 6.6% of the patients (95% CI, 3.0%-11.2%). The pooled overall survival rates were 89.9% (95% CI, 83.7%-96.7%), 83.7% (95% CI, 75.9%-92.2%), and 75.9% (95% CI, 66.5%-86.7%) at 1, 3, and 5 years, respectively. Operations in which carotid endarterectomy was performed first carried a significantly greater risk of perioperative stroke compared with those in which proximal intervention had been performed first (5.7% vs 0.0%; P = .01). No difference was found in perioperative stroke risk between the subgroups of baseline symptomatic status (asymptomatic, 5.1%; symptomatic, 1.9%; P = .32), preoperative antiplatelet therapy (dual, 3.6%; single, 5.8%; P = .79), and carotid clamping during intervention (clamping, 2.8%; unclamping, 6.3%; P = .40).

CONCLUSIONS

For patients with a presumed high risk of neurologic events because of carotid tandem lesions, the hybrid approach could be considered a reasonable option with high technical success and acceptable perioperative and long-term results. Performing carotid artery stenting before carotid endarterectomy and administering perioperative dual antiplatelet therapy should be considered to promote technical success and better outcomes. Prospective and randomized controlled studies are needed to confirm the results and provide recommendations on patient selection for the hybrid approach.

The role of stump pressure and cerebral oximetry in predicting ischaemic brain damage during carotid endarterectomy

Objective is to compare the predictive value of stump pressure (SP) and cerebral oximetry (rSO2) levels in the evaluation of ischaemic injury of the cerebrum during clamping of the carotid artery (CCA) without temporary shunt (TS). Methods We included 84 patients with an asymptomatic stenosis (>70%) of the internal carotid artery (ICA) who underwent carotid endarterectomy (CEA) under GA. Cerebral ischaemic tolerance (CIT) was determined on the basis of SP, rSO2 and ∆rSO2 (↓rSO2 from baseline) during CCA. The levels of S100 protein (S100) and neuron-specific enolase (NSE) were measured on each stage of the study. MRI was performed for all patients. Results There were no perioperative strokes and myocardial infarctions during the study. Temporary shutdown of blood flow in CAs during CEA is accompanied by a significant elevation of S100, NSE concentration with their subsequent restoration (three days after surgery). ROC analysis showed that none of the methods for CIT assessment (SP, rSO2 and ∆rSO2) was a valuable predictor of cerebral damage during CEA. Conclusion SP with a threshold value of ≤40 mmHg has an average quality of prediction (AUC = 63). ∆rSO2 of ≥20% and a threshold value of rSO2 ≤ 40% have an unsatisfactory quality of prediction (AUC < 60).

Endovascular Treatment of the Subclavian Artery Steno-Occlusive Disease

OBJECTIVE

The aim of our study was to compare immediate and long-term results of endovascular interventions for the treatment of steno-occlusive disease of subclavian arteries (SAs) depending on the length of lesion.

MATERIALS AND METHODS

Between 2010 and 2013, we performed 245 endovascular procedures to treat patients with atherosclerotic steno-occlusive disease of SAs. All patients were examined and subdivided according to the received results into 2 groups: 125 patients with stenosis of SA were included in the first group and 120 patients with occlusion of SA were included in the second group. The patients were then followed up at 6, 12, 24, 36, and 48 months after endovascular interventions. Follow-up visits contained symptomatic evaluation, clinical assessment with physical examination, complete neurological evaluation, and serial color Doppler ultrasonography.

RESULT

Transitory ischemic attacks in the vertebrobasilar system were intraoperatively developed by 1 patient from the first group (.8%) and 3 patients from the second group (2.5%). Reinterventions in the long-term period were carried out in 9 (7.2%) cases in the first group and 12 (10%) cases in the second group (P = .43). The cumulative primary stent patency at 4 years was 89.8% in the first group and 87% in the second group (P = .4).

CONCLUSIONS

In the case of SA occlusion on the first stage, it is expedient to carry out endovascular recanalization followed by stenting. Our study revealed an increased risk of stent thrombosis or in-stent restenosis in patients with stents >40 mm.