Synchronous Carotid Endarterectomy and Retrograde Endovascular Treatment of Brachiocephalic or Common Carotid Artery Stenosis

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.

Safety and durability of concomitant carotid endarterectomy with carotid-subclavian bypass grafting

BACKGROUND

Concomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution.

METHODS

Electronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group.

RESULTS

There were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%).

CONCLUSIONS

Concomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.

Results of subclavian to carotid artery bypass for occlusive disease of the common carotid artery: A retrospective cohort study

BACKGROUND

Optimal treatment of significant atherosclerosis of the common carotid artery (CCA) is not well-defined. The purpose of this study was to evaluate the long-term results of prosthetic subclavian to carotid bypass for occlusive disease of the CCA.

MATERIAL AND METHODS

From January 1994 to December 2015, 45 patients, mean age 67 years, underwent an ipsilateral subclavian to carotid bypass for occlusive disease of the CCA. Thirty-eight patients (84%) presented with neurologic symptoms, including transitory ischemic attacks in 29 cases and minor strokes in 9 cases. The graft material consisted of a 7 mm polytetrafluoroethylene conduit, and the distal anastomosis was done on the carotid bulb in 21 patients, on the internal carotid artery in 19 cases, and on the distal CCA in 5 cases. Median length of follow-up was 58 months. Study endpoints were the combined postoperative stroke/mortality rate, graft infection, overall late survival, freedom from ipsilateral stroke, and graft patency.

RESULTS

Postoperative stroke/mortality rate was 2%. No graft infection was observed throughout follow-up. At 60 months, overall survival, freedom from stroke, and graft patency were 71% (standard error [SE] = 0.07), 98% (SE = 0.02), and 95.5% (SE = 0.06), respectively.

CONCLUSIONS

Subclavian to carotid bypass allows very good patency rates and excellent protection from postoperative and late stroke, remaining a benchmark for any other treatment method.

The modified ‘no touch’ technique in the antegrade endovascular approach for left common carotid artery ostial stenosis stenting

Background

Open 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.

Methods

Fifteen 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.

Results

The 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.

Conclusions

The 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.

Combined Carotid Endarterectomy and Retrograde Stenting of the Supra-Aortic Trunk: Does Cervical Block Offer Advantages?

BACKGROUND

Atherosclerosis of the carotid artery is a major source of stroke. In some cases, atherosclerosis occurs at several positions within the carotid artery. Carotid endarterectomy (CEA) in combination with retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis has been described as efficacious and safe procedure to prevent stroke in these cases. The aim of this study was to analyze the impact of anesthetic techniques on hemodynamic factors, operation time, duration of clamping, and postoperative pain.

METHODS

A retrospective analysis of patients undergoing CEA in combination with retrograde stenting under either general anesthesia (GA) or cervical block (CB) was carried out. Preoperative risk factors were analyzed as well as operating and cross-clamping time, hemodynamic factors, perioperative complications, postoperative pain, application of pain killers, and duration of intensive care unit (ICU) and hospital stay.

RESULTS

Operating (GA: 193 ± 91 min vs. CB: 125 ± 52 min, P = 0.029) and cross-clamping time (GA: 34 ± 12 min vs. CB: 26 ± 9 min, P < 0.001) were shorter under CB. Patients under CB were hemodynamically more stable and required less norepinephrine (GA: 1.1 ± 0.6 mg vs. CB: 0.1 ± 0.1 mg, P < 0.001) and crystalloids (GA: 2,813 ± 1,173 mL vs. CB: 1,088 ± 472 mL, P < 0.001). Postoperative pain levels (GA: numeric rating scale 4.3/10 vs. 2.0/10; P = 0.004) and requirement of pain killers were also lower within the CB group.

CONCLUSIONS

Synchronous CEA and retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis under CB is associated with reduction of operating and cross-clamping time, improved hemodynamical stability, lower postoperative pain, shorter ICU and hospital stay, and it offers the advantage of a continuous neurological monitoring.

Endovascular Treatment of Proximal Aortic Arch Lesions through a Retrograde Approach

Tandem atherosclerotic lesions of the carotid bifurcation and the ipsilateral proximal common carotid artery (CCA) or innominate arteries (IA) can be challenging to treat. A surgical approach may treat the lesion at the carotid bifurcation, but proximal CCA or IA lesions require a major surgical exposure. An endovascular approach is challenging as well since anatomic variations, such as a type III aortic arch, can render navigation very difficult. We report our experience in the hybrid surgical and endovascular treatment of complex proximal CCA and IA lesions. Eleven patients who underwent hybrid procedures with surgical exposure (with or without endarterectomy) of the carotid artery and retrograde endovascular intervention of a proximal lesion were included in the study. The mean percentage of stenosis was 81%. Seven patients underwent a carotid endarterectomy (CEA), and 4 patients underwent only a surgical cutdown for retrograde endovascular access of the IA or left CCA. All procedures were technically successful. Eight patients had no symptoms within 30 days of the procedure. The hybrid retrograde endovascular approach through carotid exposure with or without CEA appears to be effective and safe in selected patients who have a high-risk complex anatomy of tandem lesions.

Percutaneous and open retrograde endovascular stenting of symptomatic high-grade innominate artery stenosis: technique and follow-up

BACKGROUND AND PURPOSE

Angioplasty and stenting of the IA have been reported with high technical and clinical success rates, low complication rates and good mid-term patency rates. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure of the CCA are used. The purpose of this study was to determine safety, efficacy and mid-term clinical and radiological outcome of the stent-assisted treatment of atherosclerotic stenotic disease of the IA with special focus on the different technical approaches.

MATERIALS AND METHODS

Between 1996 and 2008, 18 patients (12 men, 6 women) with symptomatic high-grade stenosis (>80%) of the IA were treated with endovascular stent placement. Their mean age was 60.4 years (range, 48-78 years). Mean angiographic and clinical follow-up was 2.7 years (range, 0.3-9.1 years). Clinical follow-up was performed by using the mRS at hospital discharge, routine follow-up controls, and a questionnaire. In 11 patients, a percutaneous approach was used. In 7 patients, the lesions were accessed retrogradely through a cervical cut-down with common carotid arteriotomy. In 2 patients, a simultaneous ipsilateral carotid endarterectomy was performed.

RESULTS

In all patients, primary stent placement was performed. There were 2 procedure-related transient complications (11.1%) due to cerebral embolism without permanent morbidity or mortality. During the follow-up, all patients showed improvement of the preprocedural symptoms. At the latest clinical follow-up (mean, 2.7 years), all patients showed an excellent or good outcome (mRS, 0 or 1). In 2 patients (11.1%), a secondary stent placement was needed due to a significant symptomatic in-stent stenosis.

CONCLUSIONS

Percutaneous and open retrograde stenting of high-grade stenosis of the IA is a viable less invasive alternatives to open bypass surgery with good midterm clinical results and patency rates.

Retrograde Supra-Aortic Stent Placement Combined With Open Carotid or Subclavian Artery Revascularization

Purpose: To review the outcomes of retrograde supra-aortic vessel stent (RSAS) placement combined with open carotid or subclavian artery revascularization. Methods: Retrospective review of all consecutive patients between 1995 and 2010, excluding transfemoral procedures or isolated retrograde stent placement. Results: There were 11 patients (9 females, mean age 65 years). Open revascularization included carotid endarterectomy in 6 patients, carotid-subclavian bypass in 3, and carotid-carotid bypass in 2 patients. There were no operative deaths or neurological events. All symptomatic patients improved. Over a mean follow-up of 24 months, One patient developed common carotid artery (CCA) in-stent dissection and symptomatic restenosis treated with subclavian-carotid bypass. Another 3 patients had asymptomatic restenosis of the carotid bifurcation but required no intervention. Conclusions: Retrograde stenting of the common carotid or innominate artery is a safe and effective method to provide inflow in selected patients with severe supra-aortic vessel disease who require concomitant open carotid or subclavian artery reconstructions.

Combined surgical and endovascular approach to treat symptomatic in-stent occlusion of the left common carotid artery origin

Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.

Hybrid treatment of common carotid artery occlusion with ring-stripper endarterectomy plus stenting

Symptomatic occlusion of the common carotid artery with preserved circulation in the internal carotid artery is an uncommon occurrence. We describe a hybrid technique whereby a patient was treated with eversion carotid bifurcation endarterectomy, fluoroscopically guided retrograde ring-stripper common carotid endarterectomy, and stenting of residual stenosis in the disobliterated artery. Successful recanalization was achieved without adverse anatomic or neurologic sequelae. The patient remains asymptomatic with a radiographically patent reconstruction at 1 year. This combination of endovascular and open surgery enables the surgeon to address long occlusions of the common carotid arteries with control of the distal and proximal endarterectomy margins and obviates the need for general anesthesia or sternotomy.

Cerebral protection during open retrograde angioplasty/stenting of common carotid and innominate artery stenoses

Background

This was a retrospective study of the effectiveness of open, retrograde angioplasty/stenting of supra-aortic arterial stenoses combined with transcranial Doppler-directed dextran therapy in preventing perioperative embolization.

Methods

Eight patients underwent angioplasty/stenting of the proximal common carotid (synchronous carotid endarterectomy (CEA) in six), while four underwent angioplasty/stenting of the innominate artery (synchronous CEA in one). Open exposure of the carotid bifurcation enabled temporary carotid clamping to protect the brain from procedural embolization. Dextran was administered to patients with a high rate of embolization on transcranial Doppler after the operation.

Results

No emboli were recorded in the cerebral circulation during the actual angioplasty procedure when the internal carotid artery was clamped. After operation three patients developed high-rate embolization and received dextran. No strokes or deaths occurred within 30 days of treatment. One patient developed symptoms and a recurrent stenosis greater than 50 per cent during follow-up and was treated by redo angioplasty.

Conclusion

Retrograde angioplasty/stenting with or without synchronous CEA offers an alternative approach to treating patients with supra-aortic inflow disease.