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Batista S, Oliveira LDB, Sousa MP, Pinheiro AC, Borges J, Santana L, Bertani R, Andreão FF, Simões A, Almeida Filho JA. Transradial artery access for carotid artery stenting: A pooled analysis. Neuroradiol J 2024:19714009231224410. [PMID: 38171509 DOI: 10.1177/19714009231224410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Carotid artery stenting (CAS) through transradial access (TRA) is emerging as an alternative to carotid endarterectomy. However, the current evidence base is limited, mainly comprising single-center studies. OBJECTIVE This systematic review and meta-analysis aim to assess the safety and effectiveness of TRA for CAS, providing evidence to support clinical decisions. METHODS We conducted searches on PUBMED, Cochrane Library, Embase, and Web of Science databases, including studies on TRA for CAS. Studies with fewer than 20 patients, non-primary outcomes, and non-full-text articles were excluded. RESULTS We analyzed 14 studies involving 1,166 patients who underwent CAS via TRA. Procedural success rate was high in 13 studies, with a 95% rate (95% CI; 92%-98%). Crossover to TFA access was observed in 12 studies at 6% (95% CI: 3%-9%). Transradial access failure was reported in four studies, with a rate of 0% (95% CI: 0%-0%). Cannulation failure resulted in a rate of 4% (95% CI: 2%-7%). Asymptomatic radial artery occlusion (ARAO) occurred at a rate of 2% based on eight studies (95% CI: 0%-5%). Forearm hematoma was reported in 10 studies, with an occurrence of 1% (95% CI: 0%-2%). Cerebral vascular attacks (CAV) within 30 days were assessed in 13 studies, indicating a 2% occurrence (95% CI: 1%-2%). CONCLUSION The findings suggest that TRA for CAS yields promising outcomes with high success rates and low complication rates. Further research should focus on randomized controlled trials and long-term outcomes to validate and extend findings.
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Affiliation(s)
- Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Marcelo Porto Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Agostinho C Pinheiro
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Laís Santana
- Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adria Simões
- Department of Neurosurgery, Hospital Geral de Palmas, Tocantins, Brazil
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Yamamoto Y, Okawa M, Suzuki K, Tateya I, Yoshimura M, Fushimi Y, Kato ET, Yoshida K, Miyamoto S. Continuous and Early Progression of Carotid Intima-Media Thickness after Radiotherapy for Head and Neck Cancer: 5-Year Prospective Observational Study. Cerebrovasc Dis 2023; 52:543-551. [PMID: 36716719 PMCID: PMC10627489 DOI: 10.1159/000528622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/28/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Radiation-induced carotid artery stenosis (RI-CS) is known as one of long-term side effects of radiotherapy for head and neck cancer (HNC). However, the clinical time course after irradiation has been poorly understood. We aimed to investigate the natural history of radiation-induced carotid atherosclerosis, comparing the patients who received radiotherapy for HNC with the patients who were treated without radiotherapy. METHODS The patients who received treatment of HNC at Department of Otolaryngology, Head and Neck Surgery of Kyoto University Hospital, from November 2012 to July 2015 were enrolled. The patients were assigned into the RT group and the control group, depending on whether radiotherapy was planned or not. Annual carotid ultrasound was performed from the enrollment to 5 years. The increase of mean intima-media thickness (IMT) at common carotid artery from the enrollment (Δmean IMT) was evaluated. RESULTS Fifty-six patients in the RT group and 25 patients in the control group were enrolled. From 5-year follow-up data, the significant higher increase of Δmean IMT was consistently observed in the RT group than in the control group after 2 years. The RT group presented a 7.8-fold increase of mean IMT compared to the control group (0.060 mm per year in the RT group and 0.008 mm per year in the control group). Cumulative incidence curves obtained from the analysis of all vessels revealed that the RT group presented higher incidence of Δmean IMT ≥0.25 mm than the control group (p < 0.01). In the RT group, the patients with mean IMT ≥1.0 mm at enrollment exhibited significantly higher incidence of Δmean IMT ≥0.25 mm than the patients with mean IMT <1.0 mm (p < 0.01). DISCUSSION Radiotherapy for HNC induces continuous carotid mean IMT progression. The irradiated carotid arteries with mean IMT ≥1.0 mm before radiotherapy presented earlier IMT progression than those with mean IMT <1.0 mm.
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Affiliation(s)
- Yu Yamamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurosurgery, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keita Suzuki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ichiro Tateya
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Eri Toda Kato
- Department of Clinical Laboratory Medicine Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Deng XJ, Lin X, Zhou L, Ji Z. Mechanical thrombectomy combined with stenting for radiation-induced carotid stenosis-related stroke with high-load embolization: A case report. Radiol Case Rep 2022; 17:4453-4458. [PMID: 36164288 PMCID: PMC9507989 DOI: 10.1016/j.radcr.2022.08.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 12/08/2022] Open
Abstract
Radiation therapy in patients with nasopharyngeal carcinoma can cause chronic progressive carotid artery injury, but acute ischemic stroke caused by carotid artery high-load thrombosis rarely occurs in patients with tandem lesions. We performed carotid mechanical thrombectomy combined with angioplasty in a 57-year-old man who received radiotherapy for nasopharyngeal carcinoma more than 10 years before presentation. He presented with acute-onset left hemiplegia, confusion, and mixed aphasia. Head CT revealed a hyper-dense sign in the right middle cerebral artery M1 region, and angiography disclosed occlusion in the right internal carotid artery C5 region with extremely severe stenosis in the middle C1 region. Intra-arterial mechanical thrombectomy with carotid stenting was performed, and re-canalization was achieved. Re-examination angiography after 3 months revealed worsening of ulcerative plaques and pseudoaneurysms in the left common carotid artery. Consequently, we performed carotid stenting over the left common carotid artery, and the patient recovered well postoperatively. Our experience suggests that early detection of large blood vessel damage and intervention are necessary to prevent large-vessel ischemic stroke in patients who received radiotherapy for nasopharyngeal carcinoma.
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Kang J, Woo SY, Yang SS, Park YJ, Kim DI, Jeon P, Kim GM, Kim YW. Treatment results of carotid endarterectomy and carotid artery stenting for patients with radiation-induced carotid stenosis. Ann Surg Treat Res 2022; 103:112-118. [PMID: 36017138 PMCID: PMC9365643 DOI: 10.4174/astr.2022.103.2.112] [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: 04/14/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Exposure to ionizing radiation over the head and neck accelerates atherosclerotic changes in the carotid arteries. Owing to the characteristics of radiation-induced carotid stenosis (RICS), the results regarding the optimal revascularization method for RICS vary. This study compared treatment outcomes between carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RICS. Methods This was a single-center retrospective review of consecutive patients who underwent CEA or CAS for carotid stenosis. RICS was defined as carotid stenosis (>50%) with the prior neck irradiation for cancer treatment on either side. For the analyses, demographics, comorbid conditions, carotid lesion characteristics based on imaging studies, surgical complications, neurologic outcomes, and mortality during the follow-up period were reviewed. To compare CEA and CAS results in RICS, a 1:1 propensity score matching was applied. Results Between November 1994 and June 2021, 43 patients with RICS and 2,407 patients with non-RICS underwent carotid revascularization with CEA or CAS. RICS had fewer atherosclerotic risk factors and more frequent severe carotid stenosis and contralateral carotid occlusions than non-RICS. CAS was more commonly performed than CEA (22.9% vs. 77.1%) for RICS due to more frequent unfavorable carotid anatomy (0 vs. 16.2%). Procedure-related complications were more common in the CEA than in the CAS. However, there was no significant difference in neurologic outcomes and restenosis rates between CEA and CAS in RICS. Conclusion Considering its lesion characteristics and cumulative incidence, RICS requires more attention than non-RICS. Although CAS has broader indications for RICS, CEA has shown acceptable results if selectively performed.
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Affiliation(s)
- Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nasr B, Crespy V, Penasse E, Gaudry M, Rosset E, Feugier P, Gouëffic Y, Maurel B, Hostalrich A, Alric P, Sadaghianloo N, Settembre N, Chevallier J, Ben Ahmed S, Gouny P, Steinmetz E. Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis. J Endovasc Ther 2022; 29:921-928. [PMID: 35012391 DOI: 10.1177/15266028211068757] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis. METHODS All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization. RESULTS One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1-141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years. CONCLUSION This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.
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Affiliation(s)
- Bahaa Nasr
- CHU Brest, Hôpital Cavale Blanche, Brest, France
| | | | | | | | - Eugenio Rosset
- CHU Clermont-Ferrand, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | | | - Yann Gouëffic
- Centre Casculaire, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | - Pierre Alric
- CHU Montpellier, Hôpital Lapeyronie, Montpellier, France
| | | | | | | | | | - Pierre Gouny
- CHU Brest, Hôpital Cavale Blanche, Brest, France
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Minc SD, Thibault D, Marone L. Outcomes of carotid artery stenting in patients with radiation arteritis compared with those with atherosclerotic disease. J Vasc Surg 2021; 75:1286-1292. [PMID: 34861360 DOI: 10.1016/j.jvs.2021.11.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Head and neck malignancies are often treated with radiotherapy (RT). Nearly 80% of patients who have undergone RT will develop carotid radiation arteritis to some degree and 29% will develop stenosis >50%. Surgery in a radiated neck has higher rates of complications, and carotid artery stenting (CAS) has become the primary therapy. The outcomes for CAS in patients with radiation arteritis have not been rigorously evaluated. The objective of the present study was to evaluate the differences in perioperative outcomes, restenosis rates, the need for reintervention, and freedom from mortality between RT patients and patients with atherosclerotic disease who had undergone CAS. METHODS The national Vascular Quality Initiative CAS dataset from 2016 to 2019 comprised the sample for analyses (n = 7343). The primary independent variable was previous head and/or neck RT. The primary endpoint was the interval to mortality. The secondary endpoints were the cumulative incidence of restenosis (>50% and >70% by duplex ultrasound) and reintervention. We also examined the following secondary perioperative endpoints: myocardial infarction, in-hospital mortality (death before discharge), neurologic events, ipsilateral stroke, and contralateral stroke. Kaplan-Meier and multivariable Cox proportional hazard models were used to assess for mortality, and cumulative incidence function estimates were used for the nonfatal endpoints. RESULTS Of the 7218 patients, 1199 (17%) had undergone prior RT. We found a significant difference in the 3-year estimates of mortality for those with and without prior RT (9.4% and 7.5%, respectively; P = .03). Furthermore, on adjusted analysis, we observed a 58% increase in the risk of mortality for those with prior RT (adjusted hazard ratio, 1.58; 95% confidence interval, 1.13-2.21). We did not observe any differences in the risk of perioperative complications (myocardial infarction, in-hospital mortality, ipsilateral or contralateral stroke), restenosis (>50% or >70%), or reintervention for the prior RT group compared with those without RT. CONCLUSIONS The CAS patients with RT had significantly greater mortality at all time points compared with those without RT, even after adjusting for other covariates. No significant difference was found in the incidence of perioperative complications, reintervention, or restenosis between the two groups. The present study is unique because of the large sample size and length of follow-up. The results suggest that for this high-risk group, CAS provides the same patency as it does for atherosclerotic carotid stenosis and avoids potentially morbid cranial nerve injury and wound healing complications.
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Affiliation(s)
- Samantha Danielle Minc
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WVa.
| | - Dylan Thibault
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WVa
| | - Luke Marone
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WVa
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Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions. J Vasc Surg 2021; 75:915-920. [PMID: 34560219 DOI: 10.1016/j.jvs.2021.08.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 08/23/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Limited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. METHODS Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. RESULTS A total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). CONCLUSIONS RICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.
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Yang EH, Marmagkiolis K, Balanescu DV, Hakeem A, Donisan T, Finch W, Virmani R, Herrman J, Cilingiroglu M, Grines CL, Toutouzas K, Iliescu C. Radiation-Induced Vascular Disease-A State-of-the-Art Review. Front Cardiovasc Med 2021; 8:652761. [PMID: 33860001 PMCID: PMC8042773 DOI: 10.3389/fcvm.2021.652761] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
Since the 1990s, there has been a steady increase in the number of cancer survivors to an estimated 17 million in 2019 in the US alone. Radiation therapy today is applied to a variety of malignancies and over 50% of cancer patients. The effects of ionizing radiation on cardiac structure and function, so-called radiation-induced heart disease (RIHD), have been extensively studied. We review the available published data on the mechanisms and manifestations of RIHD, with a focus on vascular disease, as well as proposed strategies for its prevention, screening, diagnosis, and management.
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Affiliation(s)
- Eric H Yang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Dinu V Balanescu
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States
| | - Abdul Hakeem
- Division of Cardiovascular Diseases & Hypertension, Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Teodora Donisan
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States
| | - William Finch
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Renu Virmani
- CVPath Institute, Gaithersburg, MD, United States
| | - Joerg Herrman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Mehmet Cilingiroglu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,University of Hawaii John Burns School of Medicine, Honolulu, HI, United States
| | - Cindy L Grines
- Cardiovascular Institute, Northside Hospital, Atlanta, GA, United States
| | | | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Erben Y, Franco-Mesa C, Miller D, Lanzino G, Bendok BR, Li Y, Sandhu SJS, Barrett KM, Freeman WD, Lin M, Huang JF, Huynh T, Farres H, Brott TG, Hakaim AG, Brigham TJ, Todnem ND, Tawk RG, Meschia JF. Higher Risk for Reintervention in Patients after Stenting for Radiation-Induced Internal Carotid Artery Stenosis: A Single-Center Analysis and Systematic Review. Ann Vasc Surg 2020; 73:1-14. [PMID: 33373766 DOI: 10.1016/j.avsg.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/11/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS). METHODS We performed a single-center, multisite case-control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS. RESULTS There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9 ± 15.6 Gy, and the time from radiation to CAS was 175.3 ± 140.4 months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7 ± 11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio = 7.1, 95% confidence interval = 2.1-32.8; P = 0.004). The mean follow-up was 33.7 ± 36.9 months, and the mortality across groups was no different (P = 0.12). CONCLUSIONS In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
| | - Camila Franco-Mesa
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | | | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ
| | | | | | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, FL
| | | | - Thien Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Albert G Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Nathan D Todnem
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Zheng Z, Zhao Q, Wei J, Wang B, Wang H, Meng L, Xin Y, Jiang X. Medical prevention and treatment of radiation-induced carotid injury. Biomed Pharmacother 2020; 131:110664. [PMID: 32861067 DOI: 10.1016/j.biopha.2020.110664] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/06/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022] Open
Abstract
Radiotherapy has significantly improved the survival of cancer patients but is also associated with several adversities, including radiation-induced carotid injury (RICI). The RICI mechanisms are complex, including vessel inflammatory injury, carotid atherosclerosis, intimal proliferation, media necrosis, and peri-adventitial fibrosis. The main manifestation and adverse consequence of RICI is carotid artery stenosis (CAS), which can lead to stroke and transient ischemic attack. Currently, carotid artery injury is primarily diagnosed via color-coded duplex sonography. Early detection of traumatic changes in the carotid artery depends on measurements of carotid intima-media thickness; serum biomarker testing also shows great potential. CAS is mainly treated with carotid endarterectomy or carotid angioplasty and stent implantation. Notably, bone marrow mesenchymal stem cells are advantageous in RICI treatment and reduce carotid inflammation, oxidative stress, and delaying atherosclerosis. This review summarizes the mechanisms, examination methods, and latest treatments for RICI to provide data for its clinical prevention and treatment.
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Affiliation(s)
- Zhuangzhuang Zheng
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
| | - Qin Zhao
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
| | - Jinlong Wei
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
| | - Bin Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
| | - Huanhuan Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
| | - Lingbin Meng
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, Tampa, FL, 33612, USA.
| | - Ying Xin
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun, 130021, China.
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China; Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun, 130021, China; NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun, 130021, China.
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11
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Jones RW, Conant M, Tanious A, Armstrong P, Moudgill N, Back M, Illig K, Brooks J. Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer. Ann Vasc Surg 2020; 70:230-236. [PMID: 32795652 DOI: 10.1016/j.avsg.2020.07.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor. The purpose of this study was to review long-term results of CAS in veteran patients with a prior history of treatment for head and/or neck cancer. METHODS This is a retrospective review of a veteran patient population from 1998 to 2016. All patients at our institution with a prior history of treatment for head and/or neck cancer who underwent CAS were included in the analysis. During this time period, 44 patients met inclusion criteria and were treated with 57 carotid stenting interventions. The Kaplan-Meier analysis was used to determine survival and primary patency. The secondary aims were to analyze early outcomes and to identify predictive risk factors for mortality and reintervention. RESULTS The mean follow-up was 42.9 ± 36.6 months. The cumulative survival at 1, 5, and 10 years was 91%, 67%, and 48%, respectively. The primary patency at 1, 5, and 10 years was 95%, 86%, and 86%, respectively. The reintervention rate was 11% (n = 6) with an assisted primary patency rate of 100%. No neurologic events occurred within 30 days. There were 3 strokes in late follow-up and no stroke-related deaths. Eighteen patients (41%) died during the follow-up period, 15 of whom died during the first 5 years of follow-up. Ten (66%) of those patients died of recurrent or active index cancer. On univariate analysis, tumor, node, metastasis stage IV was significantly associated with death (P = 0.02). Multivariate models were not statistically significant for predicting mortality or reintervention CONCLUSIONS: On the basis of the results in this series, CAS can be performed in these patients with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is poor, which is consistent with other published series of patients undergoing CAS for head/neck cancer with at least 5-year follow-up. In this specific patient population, a more critical analysis of the patient's overall prognosis, especially as related to cancer, should be undertaken before offering CAS.
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Affiliation(s)
- Roy W Jones
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Mark Conant
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Paul Armstrong
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Neil Moudgill
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Martin Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Karl Illig
- Department of Surgery, Regional Medical Center, Orangeburg, SC
| | - James Brooks
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
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12
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Cardiovascular Complications Associated with Mediastinal Radiation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:31. [DOI: 10.1007/s11936-019-0737-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
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Patel NS, Carlson ML, Pollock BE, Driscoll CLW, Neff BA, Foote RL, Lohse CM, Link MJ. Long-term tumor control following stereotactic radiosurgery for jugular paraganglioma using 3D volumetric segmentation. J Neurosurg 2019; 130:379-387. [PMID: 29652232 DOI: 10.3171/2017.10.jns17764] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 10/02/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The morbidity of gross-total resection of jugular paraganglioma (JP) is often unacceptable due to the potential for irreversible lower cranial neuropathy. Stereotactic radiosurgery (SRS) has been used at the authors' institution since 1990 for the treatment of JP and other benign intracranial tumors. Conventional means of assessing tumor progression using linear measurements or elliptical approximations are imprecise due to the irregular shape and insinuating growth pattern of JP. The objective of this study was to assess long-term tumor control in these patients by using slice-by-slice 3D volumetric segmentation of serial MRI data. METHODS Radiographic data and clinical records were reviewed retrospectively at a single, tertiary-care academic referral center for patients treated from 1990 to 2017. Volumetric analyses by integration of consecutive tumor cross-sectional areas (tumor segmentation) of serial MRI data were performed. Tumor progression was defined as volumetric growth of 15% or greater over the imaging interval. Primary outcomes analyzed included survival free of radiographic and clinical progression. Secondary outcomes included new or worsened cranial neuropathy. RESULTS A total of 85 patients were treated with Gamma Knife radiosurgery (GKRS) for JP at the authors' institution over the last 27 years. Sixty patients had pretreatment and serial posttreatment contrast-enhanced MRI follow-up suitable for volumetric analysis. A total of 214 MR images were analyzed to segment tumor images in a slice-by-slice fashion to calculate integral tumor volume. The median follow-up duration was 66 months (range 7-202 months). At 5 years the tumor progression-free survival rate was 98%. Three tumors exhibited progression more than 10 years after GKRS. Estimated survival free of radiographic progression rates (95% confidence interval [CI]; n = number still at risk) at 5, 10, and 15 years following radiosurgery were 98% (95% CI 94%-100%; n = 34), 94% (95% CI 85%-100%; n = 16), and 74% (95% CI 56%-98%; n = 6), respectively. One patient with tumor progression required treatment intervention using external beam radiation therapy, constituting the only case of clinical progression. Two patients (3%) without preexisting lower cranial nerve dysfunction developed new ipsilateral vocal fold paralysis following radiosurgery. CONCLUSIONS SRS achieves excellent long-term tumor control for JP without a high risk for new or worsened cranial neuropathy when used in primary, combined modality, or recurrent settings. Long-term follow-up is critical due to the potential for late radiographic progression (i.e., more than 10 years after SRS). As none of the patients with late progression have required salvage therapy, the clinical implications of this degree of tumor growth have yet to be determined.
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15
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Lee HJ, Chang FC, Luo CB, Guo WY. Influence of stenting with open-cell stents vs close-cell stents on the outcomes of patients with bilateral carotid stenosis. J Chin Med Assoc 2019; 82:66-71. [PMID: 30839407 DOI: 10.1097/jcma.0000000000000006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Carotid artery stenting (CAS) is an effective way to prevent stroke in patients with severe carotid stenosis. However, several studies comparing the outcomes of stenting with open-cell stents (OCS) vs closed-cell stents (CCS) have yielded inconclusive results. This study aimed to compare the outcomes of CAS with OCS vs CCS in the same patients. METHODS From year 2000 to 2016, we included 52 patients with severe bilateral carotid stenosis who underwent OCS deployment in one artery and CCS deployment in the contralateral artery. Stents were selected according to arterial anatomy and lesion morphology, and the peri-procedural and long-term outcomes of treatment with OCS vs CCS, were compared in terms of rates of ischemic spot development on early post-procedural diffusion-weighted imaging (ISDWI), in-stent restenosis (ISR), and recurrent stroke. RESULTS After stenting with OCS vs CCS, the number (rate) of arteries with no lesion, < 5 lesions, and ≥ 5 lesions on DWI was 9 (32%) vs 8 (27%), 8 (29%) vs 17 (57%), and 11 (39%) vs 5 (17%) (p = .10); number (rate) of arteries with 0%, < 50%, and >50% ISR was 34 (65%) vs 34 (65%), 9 (17%) vs 11 (21%), and 9 (17%) vs 7 (13%) (p = .71); number (rate) of recurrent strokes after CAS was 2 (4%) vs 0 (0%). CONCLUSION The rates of peri-procedural cerebral ischemic insult, long-term stent patency, and stroke recurrence indicate that no one carotid stent cell design is superior to the other. We suggest both OCS and CCS are reasonable options for the treatment of severe carotid stenosis.
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Affiliation(s)
- Han-Jui Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Fernández-Alvarez V, López F, Suárez C, Strojan P, Eisbruch A, Silver CE, Mendenhall WM, Langendijk JA, Rinaldo A, Lee AWM, Beitler JJ, Smee R, Alvarez J, Ferlito A. Radiation-induced carotid artery lesions. Strahlenther Onkol 2018; 194:699-710. [DOI: 10.1007/s00066-018-1304-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/10/2018] [Indexed: 11/24/2022]
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Choy HHK, Kokkinidis DG, Cotter R, Singh GD, Rogers RK, Waldo SW, Laird JR, Armstrong EJ. Long-term outcomes after carotid artery stenting of patients with prior neck irradiation or surgery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:327-332. [DOI: 10.1016/j.carrev.2017.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/18/2017] [Indexed: 11/25/2022]
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Ohshima T, Yamamoto T, Goto S, Ishikawa K, Nishizawa T, Shimato S. Crevice sign as an indicator of plaque laceration associated with postoperative severe thromboembolism after carotid artery stenting: a case report. NAGOYA JOURNAL OF MEDICAL SCIENCE 2017; 79:559-564. [PMID: 29238112 PMCID: PMC5719215 DOI: 10.18999/nagjms.79.4.559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Carotid artery stenting (CAS) is increasingly utilized in patients with carotid artery stenosis. Various intraprocedural and postprocedural complications have been reported in the literature. We present a case of symptomatic major thromboembolism after CAS. The intraprocedural angiogram showed extraordinary slow filling of the contrast medium into the plaque, which we named as "crevice sign." An 83-year-old man presented repeat right amaurosis fugax for 6 months. The radiological examinations revealed 85% stenosis of the origin of the right internal carotid artery. The patient underwent right CAS. The procedure was performed without any problems; however, the angiogram showed slow filling of contrast medium into the carotid plaque through the stent (crevice sign). Sixty minutes later in the ward, the patient presented sudden onset of left hemiparesis and aphasia. Emergency catheter angiography did not show in-stent thrombus, major artery occlusion, or the crevice sign. Magnetic resonance imaging on the next day revealed wide acute infarction of the right cerebral hemisphere. Physicians should be aware of the intraprocedural crevice sign so that a subsequent catastrophic ischemic event can be prevented.
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Affiliation(s)
- Tomotaka Ohshima
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Taiki Yamamoto
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Shunsaku Goto
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Kojiro Ishikawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
| | | | - Shinji Shimato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
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