Endovascular Repair of External Carotid Artery Disease

External carotid artery stenting in patients with ipsilateral internal carotid artery occlusion: Peri-operative and 12-month follow-up

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.

Duplex Criteria for Grading of External Carotid Stenosis

BACKGROUND

External carotid artery (ECA) stenosis is an independent mortality predictor. Additionally, concomitant ECA and internal carotid artery (ICA) stenosis progression has been associated with an increased risk of ipsilateral ischemic events in asymptomatic patients. Universally accepted ECA duplex velocity criteria, for the prediction of stenosis, do not exist.

METHODS

Consecutive patients undergoing angiography and carotid duplex assessments were compared (n = 140). ICA, common carotid artery (CCA), and ECA peak systolic velocities (PSVs) were recorded. ECA/CCA PSV ratio was calculated. These parameters were compared with angiographic ECA measurements. Receiver-operator curve analysis was used to determine optimal criteria in identifying ECA stenosis of >50%.

RESULTS

In patients with little ipsilateral ICA disease, for the detection of ECA stenosis of ≥50%, an ECA PSV >148 cm/sec provided a sensitivity of 80%, specificity of 76.2%, and an overall accuracy of 77.1%. An ECA/CCA PSV ratio of 1.45 demonstrated a sensitivity of 73.7%, specificity of 66.7%, and an accuracy of 68.2%.In patients with ICA stenosis ≥50%, for the detection of ECA stenosis of ≥50%, an ECA PSV >179 cm/sec provided a sensitivity of 50%, specificity of 79.6%, and overall accuracy of 71.3%. An ECA/CCA PSV ratio of ≥1.89 provided a sensitivity of 71.9%, specificity of 72.7%, and overall accuracy of 72.5%.

CONCLUSIONS

ECA PSV and ECA/CCA PSV ratios appear as useful metrics for the prediction of unilateral high-grade ECA stenosis.

Efficacy and Safety of Willis Covered Stent for Treatment of Internal Carotid Artery Aneurysms

OBJECTIVE

The purpose of this study was to evaluate the clinical and short-term outcome of patients who underwent covered stent treatment for internal carotid artery aneurysms.

METHODS

Twelve cases patients with internal carotid artery aneurysms were treated with Willis covered stents during the period from December 2010 to January 2016. The guiding catheter was placed as high as possible to facilitate the delivery of the covered stent system.

RESULTS

Covered stent placement was successful in 11 of 12 case patients (91.6%), embolization was successful in 11 of 12 patients (91.6%), the treatment in 1 patient of 12 cavernous aneurysms patients was performed covered stents +ONYX + plastic coil embolization, and the other was used Willis covered stents. The results indicated that only 1 of 12 patients underwent postoperative massive cerebral infarction, but was successfully rescued. The angiographic following-up of patients using covered stent suggested that 12 cases patients were complete occlusion and the parent artery patency. Clinical follow-up results also demonstrated that clinical neurologic symptoms fully recovered in 11 of 12 cases patients, another case improved and were not aggravated in any patient before discharge and had aggravated symptoms.

CONCLUSION

Willis covered stents are effective for treatment of internal carotid artery aneurysms with good safety and short-term outcomes.

Vascular Reconstruction for Radiation-induced Bilateral Internal Carotid Artery Occlusion and Unilateral External Carotid Artery Stenosis by a Combination of Surgical and Endovascular Method: Case Report

We present a case of a 63-year-old male presenting with right hemiparesis and diagnosed as cerebral infarction. He had a previous history of left pharyngeal carcinoma, which was treated by radial dissection and radiation therapy 10 years before. Magnetic resonance imaging (MRI) showed multiple cerebral infarction in the bilateral cerebral hemisphere, predominantly on the left. Cerebral angiography showed occlusion of bilateral internal carotid arteries and severe stenosis at the orifice of the left external carotid artery (ECA). Single photon emission tomography (SPECT) showed reduced cerebral blood flow and decreased cerebral vascular reserve in the bilateral anterior cerebral artery and left middle cerebral artery territories. He was successfully treated by a combination of carotid stenting for the left ECA and left superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. He did not have further ischemic symptom for more than 2 years. Radiation-induced carotid vasculopathy often involves multiple arteries and treatment is often complex and difficult. Safer and less invasive treatment strategy should be considered using both endovascular and direct surgery.