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George JM, Cooke PV, Ilonzo N, Tadros RO, Grossi RJ. Management of Innominate Artery Occlusion With Severe Left Common Carotid Artery Stenosis. Cureus 2021; 13:e19592. [PMID: 34926061 PMCID: PMC8671066 DOI: 10.7759/cureus.19592] [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] [Accepted: 11/14/2021] [Indexed: 11/27/2022] Open
Abstract
Innominate artery occlusion is a rare entity, particularly when coupled with severe left common carotid artery stenosis. Innominate artery disease may present with varying degrees of symptomatology and can place patients at risk for both posterior fossa and hemispheric ischemic events. We present a symptomatic case of innominate artery occlusion with severe left common carotid disease. We reviewed the literature and current options for the treatment of innominate artery disease. The patient underwent successful hybrid repair with left carotid artery retrograde stenting and left carotid artery to right carotid artery bypass. She has been symptom and re-intervention free during her one-year follow-up. We describe a successful hybrid repair of symptomatic innominate artery occlusion with concomitant severe left carotid artery stenosis in a patient with a prohibitive open thoracic surgical risk.
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Affiliation(s)
- Justin M George
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Peter V Cooke
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Nicole Ilonzo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Weill Cornell, New York, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Robert J Grossi
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, USA
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Tesar J, Favot D, Williams L, Tesar P. Aorto-carotid bypass for orthostatic mediated hypoperfusion transient ischaemic attacks: A case report. Int J Surg Case Rep 2021; 81:105780. [PMID: 33756170 PMCID: PMC8020438 DOI: 10.1016/j.ijscr.2021.105780] [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: 02/16/2021] [Revised: 03/13/2021] [Accepted: 03/14/2021] [Indexed: 11/27/2022] Open
Abstract
Orthostatic mediated hypoperfusion transient ischaemic attack is a rare phenomenon. Aorto-carotid bypass is an uncommon procedure usually performed in the setting of dissections and vasculitis affecting the supra-aortic branch vessels. Aorto-carotid bypass can be considered in patients with symptomatic atherosclerotic disease of the supra-aortic branch vessels.
Introduction and importance Aorto-carotid bypass is a rare procedure. It is reported to be performed for management of cerebral malperfusion in the setting of supra-aortic branch vessel disease. Malperfusion requiring a bypass is largely secondary to dissection or vasculitis. Atherosclerotic disease of the supra-aortic branch vessels is commonly managed via an endovascular approach. We report a rare and atypical presentation of cerebral malperfusion in the setting of atherosclerotic disease of the innominate and carotid arteries managed with an aorto-carotid bypass graft. Case presentation A case report of an 80-year-old female presenting with orthostatic mediated hypoperfusion transient ischaemic attacks with episodes of limb shaking and unilateral weakness with postural changes. The malperfusion was in the setting of severe atherosclerotic disease of the innominate and carotid arteries. Clinical discussion and conclusion Our patient was not amendable to endovascular intervention or a less invasive open approach. The patient underwent an aorto-carotid bypass graft with complete resolution of symptoms. This case highlights a rare manifestation of orthostatic mediated cerebral malperfusion and a successful novel treatment method.
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Affiliation(s)
- Joshua Tesar
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Danella Favot
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Livia Williams
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
| | - Peter Tesar
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
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Chong JH, Harky A, Badran A, Panagiotopoulos N, Odurny A, Philips M, Livesey S, Pousios D. Aorto-innominate artery bypass for migrated stent. J Card Surg 2020; 36:312-314. [PMID: 33032362 DOI: 10.1111/jocs.15092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/05/2020] [Accepted: 09/22/2020] [Indexed: 11/28/2022]
Abstract
We report a case of a 64-year-old female who first presented with a transient ischemic attack in 2007 due to an innominate artery stenosis, which indicated an endovascular stent placement. In 2008, she presented with recurrence of symptoms and was diagnosed with in-stent restenosis alongside an unusual occurrence of retrograde migration into the ascending aortic arch. We performed an aorto-innominate bypass through a median sternotomy. The patient was discharged without any complications thereafter, and the graft has shown excellent patency. As of 2019, the patient remains well.
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Affiliation(s)
- Jun Heng Chong
- GKT School of Medical Education, King's College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Liverpool Center for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | - Abdul Badran
- Department Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK
| | | | - Allan Odurny
- Department of Interventional Radiology, Southampton General Hospital, Southampton, UK
| | - Michael Philips
- Department of Vascular Surgery, Southampton General Hospital, Southampton, UK
| | - Steven Livesey
- Department Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK
| | - Dimitrios Pousios
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK
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Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series. J Vasc Surg 2020; 71:2012-2020.e18. [DOI: 10.1016/j.jvs.2019.08.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 08/20/2019] [Indexed: 01/10/2023]
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The incidence and risk factors of stent fracture in patients treated for proximal common carotid artery stenosis. J Vasc Surg 2019; 71:824-831.e1. [PMID: 31405760 DOI: 10.1016/j.jvs.2019.04.492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/11/2019] [Indexed: 11/27/2022]
Abstract
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.
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Amuluru K, Al-Mufti F, Romero CE. Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting. INTERVENTIONAL NEUROLOGY 2018; 7:445-451. [PMID: 30410523 DOI: 10.1159/000490584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Background Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium. Summary To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions. Key Message In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.
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Affiliation(s)
- Krishna Amuluru
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
| | - Fawaz Al-Mufti
- Neuroendovascular Surgery and Neurocritical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Charles E Romero
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
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Mansukhani NA, Miller KR, Havelka GE, Russell HM, Eskandari MK. Aorta-innominate bypass through ministernotomy. J Vasc Surg 2018; 68:607-610. [DOI: 10.1016/j.jvs.2018.01.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/16/2018] [Indexed: 10/28/2022]
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Tang X, Long WA, Hu C, Tang F, Wang Q, Li L. The modified ‘no touch’ technique in the antegrade endovascular approach for left common carotid artery ostial stenosis stenting. J Neurointerv Surg 2016; 9:137-141. [DOI: 10.1136/neurintsurg-2016-012544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/20/2016] [Accepted: 07/29/2016] [Indexed: 11/04/2022]
Abstract
BackgroundOpen surgery and the retrograde endovascular approach via the distal left common carotid artery (LCCA) have some limitations in LCCA ostial stenosis treatment. The ‘no touch’ technique used in the renal artery was modified for this situation.MethodsFifteen selective LCCA stenosis patients were treated by the modified ‘no touch’ technique in the antegrade endovascular approach from March 2013 to March 2016. Thirteen underwent the transfemoral approach and the other two had the transbrachial approach due to a ‘bovine aortic arch’. Distal embolic protection devices were used in all cases. Follow-up included a neurological examination, carotid duplex scan, and office interview. Mean follow-up time was 18.2±11.5 months.ResultsThe initial technical success rate was 100%. The average procedure time was 84.0±16.3 min. There were no procedure-related deaths. No clinical neurological complications occurred during the in-hospital stay. No incidence of death or major stroke occurred during the follow-up period; 6.7% (1/15) of patients had a contralateral minor stroke, 66.7% (4/6) of symptomatic patients were relieved of initial symptoms, and the rest showed improvement. No patient developed new ipsilateral neurological symptoms and no in-stent restenosis occurred during the follow-up period. These results were confirmed by ultrasound.ConclusionsThe modified ‘no touch’ antegrade endovascular technique is a feasible method for treating LCCA ostial lesions with a satisfactory initial success rate, acceptable procedure time, and comparable mid- and long-term results. This technique could be considered as a complementary option for LCCA ostial stenosis in addition to open surgery and the retrograde endovascular approach.
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Juo YY, Ramirez LR, Ruben G. Innominate Artery Stenosis Presenting With Migratory Digital Ischemia. Vasc Endovascular Surg 2016; 50:411-4. [DOI: 10.1177/1538574416655892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events. Case Presentation: An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits. Conclusion: Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.
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Affiliation(s)
- Yen-Yi Juo
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Lisbi Rivas Ramirez
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Garry Ruben
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
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Baldawi M, Renno A, Abbas J, Nazzal M. Carotid artery pseudoaneurysm as a complication of carotid artery stenting. Ann Vasc Surg 2014; 29:363.e1-3. [PMID: 25462542 DOI: 10.1016/j.avsg.2014.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/01/2014] [Accepted: 08/21/2014] [Indexed: 11/29/2022]
Abstract
Carotid artery stenting (CAS) has been adopted more in the treatment of carotid artery stenosis recently. The vast majority of studies about this procedure have concentrated mainly on the short- and long-term clinical complications, that is, stroke, myocardial infarction, and restenosis. However, mechanical complications including both stent fracture and carotid pseudoaneurysm are under-reported. In the present report, we present a patient with a common carotid artery psuedoaneurysm as a complication of CAS.
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Affiliation(s)
- Mustafa Baldawi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH
| | - Anas Renno
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH
| | - Jihad Abbas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH
| | - Munier Nazzal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH.
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High frequency of brachiocephalic trunk stent fractures does not impair clinical outcome. J Vasc Surg 2014; 59:781-5. [DOI: 10.1016/j.jvs.2013.09.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/19/2013] [Accepted: 09/19/2013] [Indexed: 11/18/2022]
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Dayama A, Riesenman PJ, Cheek RA, Kasirajan K. Endovascular Management of Aortic Arch Vessel Occlusion. Vasc Endovascular Surg 2012; 46:273-6. [DOI: 10.1177/1538574411436330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 56-year-old female presented with pain in her bilateral upper extremities. Angiogram demonstrated occlusion of her left subclavian and innominate arteries (IAs). The patient’s left subclavian occlusion was successfully treated with percutaneous mechanical thrombectomy, angioplasty, and stenting. One month later, endovascular revascularization of the IA was performed. Initially the lesion could not be directly transversed from neither an antegrade nor a retrograde approach. Wires were passed from the brachial and femoral arteries into the right common carotid artery where the femoral wire was snared and brought out through the right brachial access. Over this through-and-through wire access, angioplasty and stenting of the IA was performed with an excellent angiographic result. In follow-up, the patient remained free of upper extremity symptoms. Occlusive lesions of the aortic arch vessels can be successfully managed with antegrade and retrograde endovascular techniques.
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Affiliation(s)
- Anand Dayama
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA, USA
| | - Paul J. Riesenman
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA, USA
| | - Rick A. Cheek
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA, USA
| | - Karthikeshwar Kasirajan
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA, USA
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Garcia-Toca M, Rodriguez HE, Naughton PA, Keeling A, Phade SV, Morasch MD, Kibbe MR, Eskandari MK. Are Carotid Stent Fractures Clinically Significant? Cardiovasc Intervent Radiol 2011; 35:263-7. [DOI: 10.1007/s00270-011-0149-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 02/25/2011] [Indexed: 11/28/2022]
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