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Plata-Bello J, Pérez-Lorensu PJ, Saponaro-González Á, Darias-Delbey B, Fariña-Jerónimo H, Domínguez-Lorenzo JM, Ucelay-Gómez R, González-Tabares EF, Ibrahim-Achi Z, Guerrero-Ramírez CS, Padrón-Encalada CE, Pérez-Burkhardt JL. Can NIRS be a surrogate indicator of elective shunt in carotid endarterectomy? A single-center observational retrospective study says no. J Clin Monit Comput 2024; 38:631-638. [PMID: 38064136 DOI: 10.1007/s10877-023-01114-1] [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: 08/05/2023] [Accepted: 11/23/2023] [Indexed: 06/11/2024]
Abstract
BACKGROUND Neuromonitoring during carotid endarterectomy (CEA) under general anesthesia is desirable and may be useful for preventing brain ischemia, but the selection of the most appropriate method remains controversial. PURPOSE To determine the effectiveness of near infrared spectroscopy (NIRS) compared to multimodality intraoperative neuromonitoring (IONM) in indicating elective shunts and predicting postoperative neurological status. METHODS This is a retrospective observational study including 86 consecutive patients with CEA under general anesthesia. NIRS and multimodality IONM were performed during the procedure. IONM included electroencephalography (EEG), somatosensory evoked potentials (SSEPs) and transcranial motor-evoked potentials (TcMEPs). Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated for each neuromonitoring modality. RESULTS NIRS presented a sensitivity and a specificity for detecting brain ischemia of 77.7% and 89.6%, respectively (PPV = 46.6% and NPV = 97.2%). In contrast, a 100% sensitivity and specificity for multimodality IONM was determined (PPV and NPV = 100%). No significant difference (in demographical or clinical data) between "true positive" and "false-positive" patients was identified. Among the methods included in multimodality IONM, EEG showed the best results for predicting postoperative outcome after CEA (PPV and NPV=100%). CONCLUSION NIRS is inferior to multimodality IONM in detecting brain ischemia and predicting postoperative neurological status during CEA under general anesthesia.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Carretera Ofra s/n La Cuesta. CP 38320. La Laguna, S/C de Tenerife, Santa Cruz de Tenerife, Spain.
| | | | | | - Beneharo Darias-Delbey
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
- Department of Vascular Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Helga Fariña-Jerónimo
- Department of Neurosurgery, Hospital Universitario de Canarias, Carretera Ofra s/n La Cuesta. CP 38320. La Laguna, S/C de Tenerife, Santa Cruz de Tenerife, Spain
| | | | - Roberto Ucelay-Gómez
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | - Zena Ibrahim-Achi
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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Chen YR, Li WQ, Liu JH. Differentiation Between Internal Carotid Artery Hypoplasia and Acquired Narrowing by Neurovascular Ultrasound: Case Series and Literature Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:765-776. [PMID: 35984092 DOI: 10.1002/jum.16083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 06/15/2023]
Abstract
Uniformly narrowed internal carotid artery (ICA) without proximal steno-occlusion or parietal anomalies is often subject to misdiagnosis due to lack of awareness. We combined our experiences of 4 cases with 29 previously published cases to form a retrospective series including 18 cases of ICA hypoplasia and 15 cases of ICA acquired narrowing. The ultrasonic manifestations of ICA acquired narrowing and ICA hypoplasia are extremely similar, but narrowed ICA without intracranial occlusion or bottle-neck-sign highly indicates ICA hypoplasia, whereas moyamoya vessels favor ICA acquired narrowing, thus promoting the understanding of and discriminability between the two on neurovascular ultrasound.
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Affiliation(s)
- Yan-Ru Chen
- Neurology Department, The Second Affiliated Hospital of Chongqing Medical University, Chonqing, China
| | - Wen-Qi Li
- Neurology Department, The Second Affiliated Hospital of Chongqing Medical University, Chonqing, China
| | - Ji-Hong Liu
- Neurology Department, The Second Affiliated Hospital of Chongqing Medical University, Chonqing, China
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Miceli G, Tuttolomondo A, Velardo M, Bencivinni F, Poma S, Pinto A. "The importance of being external": review of the literature of the rare phenomenon of common carotid occlusion with bulb reverse-crossed stenosis and external collaterals activation. Is still correct speaking about carotid steal? J Ultrasound 2022; 25:435-442. [PMID: 35032023 PMCID: PMC9402855 DOI: 10.1007/s40477-021-00644-1] [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: 07/13/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022] Open
Abstract
Common carotid artery occlusion (CCAO) is a rare phenomenon associated with the development of neurological symptoms. In CCAO, diversion of blood flow from the external carotid artery (ECA) to the internal carotid artery (ICA) via the carotid bulb (CB) may occur. This pathway activation has been called "carotid steal". Starting from a particular case we describe the ECD finding of a complete occlusion of CCA with patency of ICA and ECA. In case of occlusion of CCA, inversion of the ECA flow may occur, towards the ICA, and it can be damped by a significant stenosis crossed in retrograde direction that may concur to maintain the pressure balance between the two circulations. Usually, this particular compensation can guarantee normal flow velocities in middle cerebral arteries without signs of activation of anterior collateral pathways. In this review we underline the protective role of ECA and we propose a new definition for this phenomenon. The ECA may provide blood to the cerebral circulation through several anastomotic secondary channels. Finally, only with an extensive knowledge of hemodynamic information of all intracranial and extracranial arteries, including ECA, we can estimate cerebral ischemic risk of the patient and choose the correct management of this occlusion.
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Affiliation(s)
- Giuseppe Miceli
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), Università degli Studi di Palermo, piazza delle Cliniche 2, 90127, Palermo, Italy.
| | - Antonino Tuttolomondo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), Università degli Studi di Palermo, piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Mariachiara Velardo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), Università degli Studi di Palermo, piazza delle Cliniche 2, 90127, Palermo, Italy
| | | | - Sonia Poma
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), Università degli Studi di Palermo, piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Antonio Pinto
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), Università degli Studi di Palermo, piazza delle Cliniche 2, 90127, Palermo, Italy
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Overview and Diagnostic Accuracy of Near Infrared Spectroscopy in Carotid Endarterectomy: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2021; 62:695-704. [PMID: 34627675 DOI: 10.1016/j.ejvs.2021.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/29/2021] [Accepted: 08/14/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been estimated at 2% - 5%. Monitoring intra-operative cerebral oxygenation with near infrared spectroscopy (NIRS) has been assessed as a strategy to reduce intra- and post-operative complications. The aim was to summarise the diagnostic accuracy of NIRS to detect intra-operative ischaemic events, the values associated with ischaemic events, and the relative contribution of external carotid contamination to the NIRS signal in adults undergoing carotid endarterectomy. DATA SOURCES EMBASE, MEDLINE, Cochrane Centre Register of Controlled Trials, and reference lists through May 2019 were searched. REVIEW METHODS Non-randomised and randomised studies assessing NIRS as an intra-operative monitoring tool in carotid endarterectomy were included. Studies using NIRS as the reference were excluded. Risk of bias was assessed using the Newcastle Ottawa Scale, RoB-2, and QUADAS-2. RESULTS Seventy-six studies were included (n = 8 480), under local (n = 1 864) or general (n = 6 582) anaesthesia. Seven studies were eligible for meta-analysis (n = 524). As a tool for identifying intra-operative ischaemia, specificity increased with more stringent NIRS thresholds, while there was unpredictable variation in sensitivity across studies. A Δ20% threshold under local anaesthesia resulted in pooled estimates for sensitivity and specificity of 70.5% (95% confidence interval, CI, 54.1 - 82.9) and 92.4% (95% CI 85.5 - 96.1) compared with awake neurological monitoring. These studies had low or unclear risk of bias. NIRS signal consistently dropped across clamping and recovered to pre-clamp values upon de-clamp in most studies, and larger decreases were observed in patients with ischaemic events. The contribution of extracranial signal to change in signal across clamp varied from 3% to 50%. CONCLUSION NIRS has low sensitivity and high specificity to identify intra-operative ischaemia compared with awake monitoring. Extracranial signal contribution was highly variable. Ultimately, data from high quality studies are desperately needed to determine the utility of NIRS.
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Dong H, Jiang X, Zou Y, Chen Y, He J, Deng Y, Xu B, Gao R. External carotid artery stenting in patients with ipsilateral internal carotid artery occlusion: Peri-operative and 12-month follow-up. Catheter Cardiovasc Interv 2021; 97 Suppl 2:982-987. [PMID: 33600036 DOI: 10.1002/ccd.29563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/06/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study aimed to evaluate the safety and clinical efficacy of external carotid artery (ECA) stenting in patients with ipsilateral internal carotid artery (ICA) occlusion. BACKGROUND In patients with ICA occlusion, severe ipsilateral ECA stenosis may exacerbate pre-existing cerebral ischemia and cognitive impairment. It remains unclear whether ECA stenting to normalize ECA collaterals to the cerebralis alleviates cerebral ischemia and improves cognitive function. METHODS From January 2008 to June 2019, we retrospectively collected clinical data of 36 consecutive patients with ipsilateral ICA occlusion who had undergone ECA stenting (mean age, 66.7 ± 8.3 years; males, n = 26 [72.2%]). Neurocognitive test results, including Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) tests, symptom assessment, and adverse events were recorded. RESULTS ECA stenting was successful in all 36 patients. Intra-operatively, six (16.7%) patients experienced hemodynamic depression during balloon dilation and recovered completely within 2 days. Within a 12-month follow-up period, two patients experienced a transient ischemic attack, one patient had a contralateral minor stroke, and 33 patients remained asymptomatic. No other adverse events occurred in the peri-operative or follow-up periods. Compared with baseline, significant MMSE (25.3 ± 1.3 vs. 23.6 ± 1.7; p < .05) and MOCA (24.1 ± 1.3 vs. 22.8 ± 1.7; p < .05) test score improvements were observed 3 months post-operatively and were maintained throughout follow-up. CONCLUSIONS ECA stenting may improve cerebral ischemia and cognitive function in patients with severe ECA stenosis and ipsilateral ICA occlusion; however, further research is required to support our findings.
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Affiliation(s)
- Hui Dong
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiongjing Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yubao Zou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jining He
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Deng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Quintas-Neves M, Xavier SA, Santos MR, Silva AR, Alves JN, Rocha J, Amorim JM. External carotid artery stenting in symptomatic internal carotid artery occlusion. J Clin Neurosci 2020; 78:397-399. [PMID: 32402613 DOI: 10.1016/j.jocn.2020.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
We report the case of a patient with an anterior ischemic stroke due to tandem occlusion of the left M2 segment and ipsilateral internal carotid artery (ICA), with concomitant severe stenosis of the ipsilateral external carotid artery (ECA) and contralateral ICA, and moderate stenosis of the left vertebral artery (VA); as thrombectomy was not possible, stenting of the right ICA was performed. Two days after significant recovery, the patient showed neurological deterioration when in upright position, and brain magnetic resonance imaging confirmed decreased cerebral blood flow on the left hemisphere. Stenting of the left ECA and balloon angioplasty of the ipsilateral VA were performed in order to increase collateral flow, with an almost complete resolution of symptoms. This case highlights the importance of assessing the collateralization pattern when an ICA occlusion is present, and the potential need to revascularize an ipsilateral stenotic ECA.
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Affiliation(s)
- Miguel Quintas-Neves
- Neuroradiology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal.
| | - Sofia Almeida Xavier
- Neuroradiology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - Mariana Ribeiro Santos
- Neuroradiology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - Ana Rita Silva
- Neurology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - José Nuno Alves
- Neurology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - Jaime Rocha
- Neuroradiology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - José Manuel Amorim
- Neuroradiology Department, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
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Saqqur M, Khan K, Derksen C, Alexandrov A, Shuaib A. Transcranial Doppler and Transcranial Color Duplex in Defining Collateral Cerebral Blood Flow. J Neuroimaging 2018; 28:455-476. [DOI: 10.1111/jon.12535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/18/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Maher Saqqur
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
- Neuroscience Institute; Hamad General Hospital Doha Qatar
| | - Khurshid Khan
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Carol Derksen
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Andrei Alexandrov
- Department of Neurology; University of Tennessee Health Science Center; Memphis TN USA
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
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Kobayashi M, Yoshida K, Kojima D, Oshida S, Fujiwara S, Kubo Y, Ogasawara K. Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions. J Vasc Surg 2018; 69:454-461. [PMID: 29960793 DOI: 10.1016/j.jvs.2018.03.437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions. METHODS This was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery. RESULTS There were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively. CONCLUSIONS ECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.
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Affiliation(s)
- Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Daigo Kojima
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Sotaro Oshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yoshitada Kubo
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.
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Al Sultan AYA, Alsubhi AMA. Anesthetic Considerations for Carotid Endarterectomy: A Postgraduate Educational Review. Anesth Essays Res 2018; 12:1-6. [PMID: 29628544 PMCID: PMC5872842 DOI: 10.4103/aer.aer_217_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Carotid endarterectomy (CEA) has shown a significant benefit in preventing ipsilateral stroke when it is compared to conservative management. Surgical morbidity and mortality must be kept to a minimum to achieve this benefit. Neurological status of the CEA patients can be monitored easily during regional anesthesia depending on the awake testing (neurocognitive assessment) method of the CEA patients. In addition, specific parameters can help us to monitor and to predict the neurological status of the CEA patients during the procedures such as regional cerebral oxygen saturation (rSO2) and middle cerebral artery velocity (MCAv) changes. We conducted a computerized literature search involving humans, published in English until December 2017, and indexed through Medical Databases; MEDLINE/PubMed, EMBASE, and Web of Science. We reviewed articles performed for prospective and other types of studies related to CEA procedures and techniques which can predict patient's status during the procedure. Searching relevant articles and discussing the results to allow meaningful rate comparison, and to conclude a result view which benefits the CEA patients and the medical staff during the CEA procedures. In total, studies observed cerebral rSO2 and MCAv have significant value during CEA procedures. Patients with neurological symptoms during the procedures showed changes of cerebral rSO2 and MCAv more than the patients without neurological symptoms. Mentioned parameters (cerebral rSO2 and MCAv) showed significant increasing right after the procedure. Mostly, CEA surgeries under local anesthesia were observed, for monitoring patients' consciousness status and comparing it to patients who undergo general anesthesia, to view the reliability of these techniques during CEA procedures, and to predict and avoid intraoperative neurological symptoms.
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Domanin M, Lanfranconi S, Romagnoli S, Runza L, Cortini F, Comi GP, Gabrielli L. A Rare Cause of Juvenile Stroke: Extracranial Carotid Artery Aneurysm with Venous Complete Reconstruction of the Carotid Bifurcation. Pediatr Neurosurg 2018; 53:275-279. [PMID: 29694968 DOI: 10.1159/000487089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/21/2018] [Indexed: 11/19/2022]
Abstract
Extracranial carotid artery aneurysms (ECAA) are a rare cause of embolic stroke. The underlying etiology is variable, with atherosclerosis being the most common entity in older subjects. Several treatments have been developed over the last 20 years, but the preferred method remains unknown. Notwithstanding the widespread use of endovascular techniques, surgical reconstruction by means of a bifurcated venous bypass graft should be applied in younger patients. In this way, it is possible to avoid major concerns about the development of long-term intrastent restenosis, and also to spare the external carotid artery which represents the main branch for the ipsilateral cerebral and facial perfusion. We propose ECAA resection and interposition of the inverted great saphenous vein to both the internal and external carotid artery by means the use of a tributary, i.e., the Giacomini vein.
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Affiliation(s)
- Maurizio Domanin
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy.,Operative Unit of Vascular Surgery I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Lanfranconi
- Operative Unit of Neurology, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Romagnoli
- Operative Unit of Vascular Surgery I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letterio Runza
- Division of Pathology, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Cortini
- Genetics Laboratory, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Piero Comi
- Operative Unit of Neurology, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Livio Gabrielli
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy.,Operative Unit of Vascular Surgery I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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11
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Domanin M, Isalberti M, Romagnoli S, Rolli A, Sommaruga S. Acute hemifacial ischemia as a late complication of carotid stenting. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2017; 3:83-86. [PMID: 29349384 PMCID: PMC5757794 DOI: 10.1016/j.jvscit.2016.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/05/2016] [Indexed: 12/11/2022]
Abstract
Concerns about carotid artery stenting (CAS) center primarily on procedural complications like acute occlusion, stroke, and long-term intrastent restenosis. External carotid artery (ECA) thrombosis is observed during CAS follow-up, but it often remains asymptomatic or, at worst, results in jaw claudication. We report here a case of late occlusion of the ECA after CAS with symptoms of acute homolateral facial ischemia as well as pain, cyanosis, tongue numbness, and skin coldness. The patient was submitted to local thrombolysis and balloon angioplasty with regression of symptoms after recanalization. With this report, we add a caveat about blockage of the ECA ostium during CAS.
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Affiliation(s)
- Maurizio Domanin
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
- Operative Unit of Vascular Surgery, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Correspondence: Maurizio Domanin, MD, Department of Clinical Science and Community Health, University of Milan, Via Francesco Sforza 25, Milan 20122, ItalyDepartment of Clinical Science and Community HealthUniversity of MilanVia Francesco Sforza 25Milan20122Italy
| | - Maurizio Isalberti
- Operative Unit of Neuroradiology, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Romagnoli
- Operative Unit of Vascular Surgery, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Rolli
- Operative Unit of Vascular Surgery, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Sommaruga
- Operative Unit of Vascular Surgery, I.R.C.C.S. Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Spacek M, Stechovsky C, Horvath M, Hajek P, Zimolova P, Veselka J. Evaluation of cerebrovascular reserve in patients undergoing carotid artery stenting and its usefulness in predicting significant hemodynamic changes during temporary carotid occlusion. Physiol Res 2015; 65:71-9. [PMID: 26596325 DOI: 10.33549/physiolres.933077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We investigated the usefulness of cerebrovascular reserve (CVR) testing to predict severe hemodynamic changes during proximally protected carotid artery stenting. Of 90 patients referred, 63 eligible underwent complete evaluation of the extent of carotid artery disease and transcranial Doppler ultrasound (TCD) assessment of CVR by means of a breath-holding test and ophthalmic artery flow pattern evaluation. Periprocedural TCD monitoring of the ipsilateral middle cerebral artery flow was performed in 24 patients undergoing proximally protected procedure (requiring induction of flow arrest within internal carotid artery). Abnormal CVR was significantly less common in patients with unilateral compared to bilateral carotid artery disease (26.3 % vs. 76.9 %, p=0.02), while ophthalmic artery flow reversal was rare in patients with unilateral carotid artery disease (2.5 % vs. 42.9 %, p<0.01). During the induction of carotid flow arrest, the average mean flow velocity drop following external carotid artery occlusion was low (3.5 %, p=0.67) compared to the induction of complete flow arrest (32.8 %, p<0.01). Six patients had a total mean flow velocity drop >50 %, including 2 patients with normal pre-procedural CVR. Our results suggest that TCD evaluation of CVR is not a reliable predictor of hemodynamic changes induced during proximally protected carotid artery stenting in patients with unilateral carotid artery disease.
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Affiliation(s)
- M Spacek
- Department of Cardiology, Motol University Hospital, Second Medical School, Charles University, Prague, Czech Republic.
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Spacek M, Stechovsky C, Horvath M, Hajek P, Veselka J. Predicting Hemodynamic Changes of Cerebral Blood Flow during Temporal Carotid Occlusion: A Review of Current Knowledge with Implication for Carotid Artery Stenting. Int J Angiol 2015; 24:210-4. [PMID: 26417190 DOI: 10.1055/s-0035-1555132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Carotid artery disease (CAD) plays an important role in the stroke development and its prevalence increases with aging of the population. Its wide variability of clinical manifestation ranges from incidental asymptomatic finding to devastating or fatal stroke, although cerebral collateral circulation is considered one of the major modifying factors. Over time, carotid artery stenting (CAS) has evolved into a reputable method for the treatment of patients with severe CAD. With expanding use of proximal protection systems resembling surgical clamp, there is an increasing demand to understand collateral cerebral circulation to protect patients from periprocedural hypoperfusion, which increases the risk of cerebral events. Transcranial Doppler ultrasound (TCD) is a useful tool allowing monitoring in real time during procedure patient́s cerebral hemodynamic status providing the operator with valuable information. Its role in predicting periprocedural hypoperfusion is, however, less well established. In this article, we discuss the role of cerebral collateral circulation, summarize the current knowledge regarding its evaluation with TCD and suggest future implications for CAS.
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Affiliation(s)
- Miloslav Spacek
- Department of Cardiology, Motol University Hospital, 2nd Medical School, Charles University, V Úvalu, Prague, Czech Republic
| | - Cyril Stechovsky
- Department of Cardiology, Motol University Hospital, 2nd Medical School, Charles University, V Úvalu, Prague, Czech Republic
| | - Martin Horvath
- Department of Cardiology, Motol University Hospital, 2nd Medical School, Charles University, V Úvalu, Prague, Czech Republic
| | - Petr Hajek
- Department of Cardiology, Motol University Hospital, 2nd Medical School, Charles University, V Úvalu, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Motol University Hospital, 2nd Medical School, Charles University, V Úvalu, Prague, Czech Republic
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Siracuse JJ, Epelboym I, Li B, Hoque R, Catz D, Morrissey NJ. External carotid artery stenosis after internal and common carotid stenting. Ann Vasc Surg 2014; 29:443-6. [PMID: 25463339 DOI: 10.1016/j.avsg.2014.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/26/2014] [Accepted: 08/30/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The external carotid artery (ECA) can be an important collateral for cerebral perfusion in the presence of severe internal carotid artery (ICA) disease. ICA stenting that covers the ECA origin may put the ECA at increased risk of stenosis. Our objective was to determine the rate of ECA stenosis secondary to ICA stenting, determine predictive factors, and describe any subsequent associated symptoms. METHODS We retrospectively reviewed clinical data on all ICA stents crossing the origin of the ECA placed by vascular surgeons at our institution. We analyzed patient demographics, comorbidities, stent type and sizes, as well as medication profile to determine predictors of ECA stenosis. RESULTS Between 2005 and 2013, there were 72 (out of 119 total ICA stenting) patients (mean age 71, 68% male) who underwent placement of ICA stents that also crossed the origin of the ECA. Six patients (8.3%) had a significantly increased ECA stenosis postprocedure. There were no occlusions. All patients with ECA stenosis maintained patency of their ICA stent and were asymptomatic. Age, gender, comorbidities, stent type and size, and medication profile were not associated with ECA stenosis after stenting. CONCLUSIONS ECA stenosis after ICA stenting covering the ECA origin is uncommon and not clinically significant in patients with patent ICA stents. The clinical significance of concurrent ECA and ICA stenosis after stenting is unclear as it is not captured here. The potential for ECA stenosis should not deter stenting across the ECA origin if necessary. Patient and stent factors are not predictive of ECA stenosis.
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Affiliation(s)
- Jeffrey J Siracuse
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
| | - Irene Epelboym
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Boyangzi Li
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Rahima Hoque
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Diana Catz
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Nicholas J Morrissey
- Section of Vascular Surgery and Endovascular Interventions, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY
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Nielsen HB. Systematic review of near-infrared spectroscopy determined cerebral oxygenation during non-cardiac surgery. Front Physiol 2014; 5:93. [PMID: 24672486 PMCID: PMC3955969 DOI: 10.3389/fphys.2014.00093] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 02/21/2014] [Indexed: 02/02/2023] Open
Abstract
Near-infrared spectroscopy (NIRS) is used to monitor regional cerebral oxygenation (rScO2) during cardiac surgery but is less established during non-cardiac surgery. This systematic review aimed (i) to determine the non-cardiac surgical procedures that provoke a reduction in rScO2 and (ii) to evaluate whether an intraoperative reduction in rScO2 influences postoperative outcome. The PubMed and Embase database were searched from inception until April 30, 2013 and inclusion criteria were intraoperative NIRS determined rScO2 in adult patients undergoing non-cardiac surgery. The type of surgery and number of patients included were recorded. There was included 113 articles and evidence suggests that rScO2 is reduced during thoracic surgery involving single lung ventilation, major abdominal surgery, hip surgery, and laparoscopic surgery with the patient placed in anti-Tredelenburg's position. Shoulder arthroscopy in the beach chair and carotid endarterectomy with clamped internal carotid artery (ICA) also cause pronounced cerebral desaturation. A >20% reduction in rScO2 coincides with indices of regional and global cerebral ischemia during carotid endarterectomy. Following thoracic surgery, major orthopedic, and abdominal surgery the occurrence of postoperative cognitive dysfunction (POCD) might be related to intraoperative cerebral desaturation. In conclusion, certain non-cardiac surgical procedures is associated with an increased risk for the occurrence of rScO2. Evidence for an association between cerebral desaturation and postoperative outcome parameters other than cognitive dysfunction needs to be established.
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Affiliation(s)
- Henning B Nielsen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
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Reichmann B, Hellings W, van der Worp H, Algra A, Brown M, Mali W, Moll F, de Borst G. Flow Velocities in the External Carotid Artery Following Carotid Revascularization. Eur J Vasc Endovasc Surg 2013; 46:411-7. [DOI: 10.1016/j.ejvs.2013.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 07/02/2013] [Indexed: 11/30/2022]
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17
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de Borst GJ, Moll FL. Commentary: Selective Treatment of External Carotid Artery Stenosis. J Endovasc Ther 2012; 19:512-4. [DOI: 10.1583/12-3886c.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Kouvelos GN, Koutsoumpelis AC, Klonaris C, Matsagkas MI. Endovascular Repair of External Carotid Artery Disease. J Endovasc Ther 2012; 19:504-11. [DOI: 10.1583/jevt-12-3886r.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Al-Basheer M, Ferrar D, Nelson D, Vasudevan T. Outcome of the external carotid artery following carotid endarterectomy with added external carotid artery eversion endarterectomy. Ann Vasc Dis 2011; 4:225-8. [PMID: 23555457 DOI: 10.3400/avd.oa.11.00020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 05/17/2011] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To study the results of eversion endarteterctomy of the external carotid artery (ECA) performed as part of standard CEA at a tertiary referral center using duplex ultrasonography. MATERIALS AND METHODS Sixty patients (18 women and 42 men) who underwent 65 carotid endarterectomies at Waikato Hospital between January 2006 and July 2007 for significant internal carotid artery (ICA) disease were studied. The procedure also included eversion endarterectomy of the ECA with sharp transection at eversion end point. Preoperative and postoperative duplex scans were performed for all patients using Acuson (USA) ultrasound machine and by one sonographer. Postoperative follow-up scans at periods between 6 weeks and 18 months were reviewed and analyzed with Ascer et al. Doppler ultrasound-scan peak systolic velocity (PSV) criteria. RESULTS Preoperative scans revealed significant bifurcation disease involving both ICA and ECA in all patients. The first post operative scan, done six weeks post-operatively, revealed one incomplete ECA endarterectomy, resulting in moderate (50%-74%) stenosis, while the rest had no evidence of residual ECA disease at the site of ECA endarterectomy. Over the post-operative period, sixteen (24.6%) ECA lesions and no occlusions were reported. The degree of ECA stenosis ranged from moderate to severe with PSVs ranging from 120 to 461 cm per second. All ECA lesions were ostial. Only 3 (18.7%) lesions were detected in the first nine months post operatively. Fifteen lesions were smooth and regular on duplex, while one had features of irregular residual stenosis. Eight (50%) were isolated ECA lesions, while the rest was associated with either ICA restenosis or occlusion. CONCLUSION ECA disease progression detected by Duplex ultrasound following eversion endarterectomy, as a part of CEA, commonly happens after 9 months and results in recurrent ECA stenosis, in most cases. Timing and features of the lesions suggest an intimal reaction as the aetiology in most cases. Eversion endarterectomy of the ECA does not predispose to ECA occlusion.
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Affiliation(s)
- Mamoun Al-Basheer
- Department of vascular surgery, Waikato Hospital, Hamilton, New Zealand
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20
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Xu DS, Abruzzo TA, Albuquerque FC, Dabus G, Eskandari MK, Guterman LR, Hage ZA, Hurley MC, Hanel RA, Levy EI, Nichols CW, Ringer AJ, Batjer HH, Bendok BR. External Carotid Artery Stenting to Treat Patients With Symptomatic Ipsilateral Internal Carotid Artery Occlusion. Neurosurgery 2010; 67:314-21. [PMID: 20644416 DOI: 10.1227/01.neu.0000371728.49216.3b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
The external carotid artery (ECA) anastomoses in many distal territories supplied by the internal carotid artery (ICA) and is an important source of collateral circulation to the brain. Stenosis of the ECA in ipsilateral ICA occlusion can produce ischemic sequelae.
OBJECTIVE
To examine the effectiveness of ECA stenting in treating symptomatic ipsilateral ICA occlusion.
METHODS
We retrospectively reviewed patient databases from 5 academic medical centers to identify all individuals who underwent ECA stenting after 1998. For all discovered cases, coinvestigators used a common submission form to harvest relevant demographic information, clinical data, procedural details, and follow-up results for further analysis.
RESULTS
Twelve patients (median age, 66 years; range, 45–79 years) were identified for our cohort. Vessel disease involvement included severe ECA stenosis ≥ 70% in 11 patients and ipsilateral ICA occlusion in all patients. Presenting symptoms included signs of transient ischemic attack, stroke, and amaurosis fugax. ECA stenting was associated with preservation of neurological status in 11 patients and resolution of symptoms in 5 patients at a median follow-up time of 26 months (range, 1–87 months; mean, 29 months). Symptomatic in-stent restenosis did not occur within any patient during the follow-up course.
CONCLUSION
We found ECA stenting in symptomatic ipsilateral ICA disease to be a potentially effective strategy to preserve neurological function and to relieve ischemic symptoms. Further investigation with larger studies and longer follow-up periods is warranted to elucidate the true indications of this management strategy.
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Affiliation(s)
- David S. Xu
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Todd A. Abruzzo
- Departments of Neurology, Neurological Surgery, and Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Guilherme Dabus
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark K. Eskandari
- Department of Surgery, Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lee R. Guterman
- Department of Neurological Surgery, Buffalo Neurosurgery Group, West Seneca, New York
| | - Ziad A. Hage
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael C. Hurley
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ricardo A. Hanel
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Elad I. Levy
- Departments of Neurological Surgery and Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | | | - Andrew J. Ringer
- Departments of Neurological Surgery and Radiology, The Neuroscience Institute, University of Cincinnati College of Medicine and Mayfield Clinic, Cincinnati, Ohio
| | - H. Hunt Batjer
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bernard R. Bendok
- Departments of Neurological Surgery and Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ko JK, Lee SW, Lee TH, Choi CH. External carotid artery angioplasty and stenting followed by superficial temporal artery to middle cerebral artery anastomosis. J Korean Neurosurg Soc 2009; 46:488-91. [PMID: 20041061 DOI: 10.3340/jkns.2009.46.5.488] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 06/08/2009] [Accepted: 10/23/2009] [Indexed: 11/27/2022] Open
Abstract
A 31-year-old man presented with right hemiparesis, and magnetic resonance imaging revealed a small infarct at left basal ganglia. Digital subtraction angiography showed left cervical internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA) with collateral cerebral circulation fed by ECAs. Based on the results of a functional evaluation of cerebral blood flow, we performed preventive ECA angioplasty and stenting for advanced ECA stenosis to ensure sufficient blood flow to the superficial temporal artery. Eight weeks later, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was performed. His postoperative course was uneventful and no additional transient ischemic attacks have occurred. To our knowledge, this is the first report of preventive angioplasty and stenting for advanced narrowing of an ECA before STA-MCA anastomosis for ipsilateral ICA occlusion.
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Affiliation(s)
- Jun Kyeung Ko
- Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea
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22
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Casey K, Zhou W, Tedesco MM, Al-Khatib WK, Hernandez-Boussard T, Bech F. Fate of the external carotid artery following carotid interventions. Int J Angiol 2009; 18:173-6. [PMID: 22477547 DOI: 10.1055/s-0031-1278348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVE The external carotid artery (ECA) is an important collateral pathway for cerebral blood flow. Carotid artery stenting (CAS) typically crosses the ECA, while carotid endarterectomy (CEA) includes deliberate ECA plaque removal. The purpose of the present study was to compare the long-term patency of the ECA following CAS and CEA as determined by carotid duplex ultrasound. METHODS Duplex ultrasounds and hospital records were reviewed for consecutive patients undergoing CAS between February 2002 and April 2008, and were compared with those undergoing CEA in the same time period. Preoperative and postoperative ECA peak systolic velocities were normalized to the common carotid artery (CCA) as ECA/CCA ratios. A significant (80% or greater) ECA stenosis was defined as an ECA/CCA ratio of 4.0. A change of ratio by more than 1 was defined as significant. Data were analyzed using Student's t test and χ(2) analysis. RESULTS A total of 86 CAS procedures in 83 patients were performed (81 men, mean age 69.9 years). Among them, 38.4% of patients had previous CEA, 9.6% of whom had contralateral internal carotid artery occlusion. Sixty-seven CAS and 65 CEA patients with complete duplex data in the same time period were included in the analyses. There was no difference in the incidence of severe ECA stenosis on preoperative ultrasound evaluations. During a mean follow-up of 34 months (range four to 78 months), three postprocedure ECA occlusions were found in the CAS group. The likelihood of severe stenosis or occlusion following CAS was 28.3%, compared with 11% following CEA (P<0.025). However, 62% of CEA patients and 57% of CAS patients had no significant change in ECA status. Reduction in the patient's degree of ECA stenosis was observed in 9.4% of CAS versus 26.6% of CEA patients. Overall, immediate postoperative ratios of both groups were slightly improved, but there was a trend of more disease progression in the CAS group during follow-up. CONCLUSION CAS is associated with a higher incidence of post-procedure ECA stenosis. Despite the absence of neurological symptoms, a trend toward late disease progression of ECA following CAS warrants long-term evaluation.
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Affiliation(s)
- Kevin Casey
- Division of Vascular and Endovascular Surgery
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23
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Gilad R, Gandhi CD, Johnson DM, Patel AB. Hyperperfusion Syndrome after External Carotid Artery Stent Placement in a Case of Bilateral Internal Carotid Occlusion and External Carotid Stenosis. J Vasc Interv Radiol 2008; 19:1373-7. [DOI: 10.1016/j.jvir.2008.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2007] [Revised: 05/22/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022] Open
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Adel JG, Bendok BR, Hage ZA, Naidech AM, Miller JW, Batjer HH. External carotid artery angioplasty and stenting to augment cerebral perfusion in the setting of subacute symptomatic ipsilateral internal carotid artery occlusion. J Neurosurg 2007; 107:1217-22. [PMID: 18077961 DOI: 10.3171/jns-07/12/1217] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓The authors performed external carotid artery (ECA) angioplasty and stenting in a 45-year-old man who had presented with right hemispheric crescendo ischemic symptoms stemming from acute right internal carotid artery occlusion (ICAO). This unique application of ECA angioplasty and stenting augmented cerebral perfusion and improved clinical symptoms. In certain situations, ECA stenting can increase cerebral perfusion in the setting of ICAO and ECA stenosis. The authors are the first to describe this approach in this context.
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Affiliation(s)
| | | | | | - Andrew M. Naidech
- 3Neurology and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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25
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de Borst GJ, Vos JA, Reichmann B, Hellings WE, de Vries JPPM, Suttorp MJ, Moll FL, Ackerstaff RGA. The Fate of the External Carotid Artery after Carotid Artery Stenting. A Follow-up Study with Duplex Ultrasonography. Eur J Vasc Endovasc Surg 2007; 33:657-63. [PMID: 17337347 DOI: 10.1016/j.ejvs.2007.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 01/16/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the long-term effect of carotid angioplasty and stenting (CAS) of the internal carotid artery (ICA) on the ipsilateral external carotid artery (ECA). SUBJECTS AND METHODS We prospectively registered the pre- and post-interventional duplex scans obtained from 312 patients (mean age 70 years) who underwent CAS. Duplex scans were scheduled the day before CAS, 3 and 12 months post-procedurally and yearly thereafter, to study progression of obstructive disease in the ipsilateral ECA compared to the contralateral ECA. The duplex ultrasound criteria used to identify ECA stenosis >or=50% were Peak Systolic Velocities of >or=125 cm/s. RESULTS Preprocedural evaluation of the ipsilateral ECA demonstrated >or=50% stenosis in 32.7% of cases vs 30% contralateral. Both ipsilateral and contralateral 3 (1%) ECA occlusions were noted. After stenting 5 (1.8%) occlusions were seen vs 1% contralateral. No additional ipsilateral occlusions and 2 additional contralateral occlusions were noted at extended follow-up. The prevalence of >or=50% stenosis of the ipsilateral ECA (Kaplan-Meier estimates) progressed from 49.1% at 3, to 56.4%, 64.7%, 78.2%, 72.3%, and 74% at 12, 24, 36, 48, and 60 months respectively. Contralateral prevalences were 31.3%, 37.7%, 41.7%, 43.1%, 46.0%, and 47.2% respectively (p<0.001). Progression of stenosis was more pronounced in 234 patients (75%) with overstenting of the carotid bifurcation (p=0.004). CONCLUSION Our results show that significant progression of >or=50% stenosis in the ipsilateral ECA occurs after CAS. There was greater progression of disease in the ipsilateral compared with the contralateral ECA. Progression of disease in the ECA did not lead to the occurrence of occlusion during follow up.
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Affiliation(s)
- G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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Lee SJ, Ahn JY. Stenosis of the Proximal External Carotid Artery in an Adult With Moyamoya Disease: Moyamoya or Atherosclerotic Change? -Case Report-. Neurol Med Chir (Tokyo) 2007; 47:356-9. [PMID: 17721051 DOI: 10.2176/nmc.47.356] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 55-year-old woman presented with moyamoya disease manifesting as recurrent transient ischemic attacks despite taking aspirin and antihypertensive agent. Angiography showed the characteristic angiographic appearance with bilateral internal carotid artery occlusion and abnormal collateral vessels. Left external carotid angiography demonstrated moderate stenosis of the proximal external carotid artery (ECA). A self-expandable stent was successfully placed in the left ECA to improve ipsilateral cerebral perfusion. The patient had an uneventful outcome after a 1-year follow up. Involvement of the proximal ECA is very unusual in moyamoya disease, and might result from hemodynamic stress or degenerative atherosclerosis. Revascularization procedures for stenoses of proximal ECA may improve cerebral perfusion in patients with moyamoya disease.
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Affiliation(s)
- Seong Jun Lee
- Department of Neurosurgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, ROK
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Aleksic M, Matoussevitch V, Heckenkamp J, Brunkwall J. Changes in internal carotid blood flow after CEA evaluated by transit-time flowmeter. Eur J Vasc Endovasc Surg 2005; 31:14-7. [PMID: 16242979 DOI: 10.1016/j.ejvs.2005.08.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 08/31/2005] [Indexed: 11/15/2022]
Abstract
AIM The aim of this study was to investigate whether there was an association between the degree of the stenosis of the internal carotid artery (ICA) and post-operative increase of blood flow. METHODS AND MATERIALS In 200 out of 660 patients undergoing carotid endarteriectomy (CEA) for a high-degree ICA stenosis, pre-operatively a bilateral selective carotid and intracerebral angiography was performed. The degree of the ipsilateral and contralateral stenosis was digitally assessed by using computer software according to the CC-Index. Intraoperatively, the pressure ratio over the stenosis (ICA/CCA) was measured by direct arterial puncture. Blood flow in the ICA was measured before and after CEA with an ultrasound flowmeter using the transit-time principle. These findings were correlated to the degree of stenosis revealed by angiographic analysis and the pressure ratio. RESULTS Before CEA the median blood flow in the ICA was 171 ml/min (range 620 ml/min) with a significant (p<0.001) post-operative increase to 250 ml/min (range 875 ml/min). The median relative increase of flow (post-flow-pre-flow/pre-flow) was 42%. The pre-CEA flow volumes were dependent on the degree of stenosis and also the pressure ratio. The increase of flow following CEA correlated better with pressure ratio (r=-0.435, p<0.001), than the stenosis severity (r=0.319, p<0.001). Analysis of variance identified only the pressure gradient as an independent determinant of flow changes following CEA. CONCLUSIONS The blood flow increase following CEA is mainly determined by the pressure gradient across the stenosis.
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Affiliation(s)
- M Aleksic
- Division of Vascular Surgery, Department of Visceral- and Vascular Surgery, University of Cologne, Cologne, Germany.
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Murata Y, Katayama Y, Sakatani K, Fukaya C, Kano T. Evaluation of extracranial-intracranial arterial bypass function by using near-infrared spectroscopy. J Neurosurg 2003; 99:304-10. [PMID: 12924705 DOI: 10.3171/jns.2003.99.2.0304] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT It has been reported that extracranial-intracranial (EC-IC) arterial bypass surgery can be useful in preventing stroke in patients with hemodynamic compromise. Little is yet known, however, regarding the extent to which the bypass contributes to maintaining adequate cerebral blood oxygenation (CBO) and its temporal changes following surgery. The authors evaluated bypass function repeatedly by using near-infrared spectroscopy (NIRS) after surgery. METHODS The authors investigated 30 patients who had undergone EC-IC bypass surgery. Single-photon emission computerized tomography revealed a decrease in regional cerebral blood flow (rCBF) and a lowered rCBF response to acetazolamide. Changes in CBO were evaluated in the sensorimotor cortex during compression of the anastomosed superficial temporal artery (STA). When decreases in oxyhemoglobin (HbO2) and total hemoglobin (Hb) concentrations were observed, the bypass was considered to have maintained CBO in the sensorimotor cortex given that decreases in HbO2 and total Hb indicate cerebral ischemic changes. The bypass maintained CBO immediately after surgery in 36.7% of patients (Group I, 11 patients) and at some time after surgery, mostly within 1 year, in 43.3% of patients (Group II, 13 patients); however, it did not maintain it throughout the follow-up period in 20% of patients (Group III, six patients). Note that the preoperative rCBF in patients in Groups I and II was lower than that in patients in Group III (p < 0.004). In fact, the preoperative rCBF predicted whether a bypass would maintain CBO at a cutoff value of 24.5 to 25 ml/100 g/min. Among Groups I and II, 18 patients demonstrated an increase in deoxyhemoglobin during STA compression. The preoperative rCBF in these cases was lower than that in the six remaining patients (p < 0.006). Note that the preoperative rCBF predicted the postoperative deoxyhemoglobin response at a cutoff value of 22.2 to 24 ml/100 g/min. CONCLUSIONS The EC-IC bypass surgery can maintain CBO immediately after surgery or gradually within 1 year when the preoperative rCBF is below 24.5 to 25 ml/100 g/min. Furthermore, bypass flow plays a critical role in maintaining an adequate CBO when preoperative rCBF is below 22.2 to 24 ml/100 g/min.
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Affiliation(s)
- Yoshihiro Murata
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
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