External carotid artery angioplasty and stenting to augment cerebral perfusion in the setting of subacute symptomatic ipsilateral internal carotid artery occlusion

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.

External carotid artery stenting in symptomatic internal carotid artery occlusion

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.

External carotid stenting for symptomatic stenosis in a patient with patent EDAS for Moyamoya disease

BACKGROUND

Moyamoya disease is characterized by progressive narrowing of the internal carotid artery (ICA). Symptomatic patients typically undergo cerebrovascular intervention via extracranial-intracranial (EC-IC) bypass, most often with the use of the superficial temporal artery. This case of Moyamoya disease is of particular interest as the patient presented with a unilateral atherosclerotic external carotid artery (ECA) stenosis after EC-IC bypass that eliminated the benefit of his original surgery, resulting in a symptomatic presentation.

CLINICAL PRESENTATION

A 53-year-old man presenting with Moyamoya disease and known left ICA occlusion had received a bilateral encephaloduroarteriosynangiosis (EDAS) bypass 10 years previously. He re-presented complaining of right-sided tingling, weakness, and numbness radiating up the arm. CT angiography indicated significant stenosis of the left ECA. ECA angioplasty and stenting with a distal protection device resulted in resolution of his symptoms.

CONCLUSIONS

This case illustrates that a patient presenting with Moyamoya disease and concurrent symptomatic ECA stenosis post-EDAS can be effectively and safely treated with ECA stenting.

External carotid stenting for symptomatic stenosis in a patient with patent EDAS for Moyamoya disease

BACKGROUND

Moyamoya disease is characterized by progressive narrowing of the internal carotid artery (ICA). Symptomatic patients typically undergo cerebrovascular intervention via extracranial-intracranial (EC-IC) bypass, most often with the use of the superficial temporal artery. This case of Moyamoya disease is of particular interest as the patient presented with a unilateral atherosclerotic external carotid artery (ECA) stenosis after EC-IC bypass that eliminated the benefit of his original surgery, resulting in a symptomatic presentation.

CLINICAL PRESENTATION

A 53-year-old man presenting with Moyamoya disease and known left ICA occlusion had received a bilateral encephaloduroarteriosynangiosis (EDAS) bypass 10 years previously. He re-presented complaining of right-sided tingling, weakness, and numbness radiating up the arm. CT angiography indicated significant stenosis of the left ECA. ECA angioplasty and stenting with a distal protection device resulted in resolution of his symptoms.

CONCLUSIONS

This case illustrates that a patient presenting with Moyamoya disease and concurrent symptomatic ECA stenosis post-EDAS can be effectively and safely treated with ECA stenting.

Limb-shaking transient ischemic attacks successfully treated with external carotid artery stenting

The external carotid artery (ECA) is one of the most important extracranial-to-intracranial sources of collateral circulation, contributing significantly to the cerebral blood flow especially when perfusion through the internal carotid artery (ICA) is compromised. Most of the endovascular studies so far have been dedicated to ICA, with little focus on the ECA. Limb-shaking transient ischemic attacks (TIAs) are a relatively rare manifestation of carotid artery disease that may present with repetitive shaking movements of the affected limbs. We report a case of an 80-year-old male with bilateral internal and contralateral external carotid artery occlusion who developed limb-shaking TIAs as a result of significant stenosis of the right ECA. Percutaneous revascularization of the ECA was performed by angioplasty and stenting. At the follow-up 12 months later, the patient remained neurologically intact with complete resolution of his symptoms. Stenting of the ECA should be considered as a reasonable alternative to conventional open repair especially in patients with contralateral carotid stenosis, insufficient circle of Willis, and significant comorbidities.

Stenting in the remnant of the third aortic arch in a case of post-irradiation occluded internal carotid artery

Collateral networks between the external carotid artery and internal carotid arteries become crucial for cerebral perfusion after occlusion of internal carotid arteries. We report the first case of a patient who received percutaneous transluminal angioplasty and stenting in a collateral vessel between the external and internal carotid artery for treatment of radiation induced severe stenosis of the internal carotid artery in the context of a contralateral internal carotid artery occlusion.

Protection of anastomotic pathways to the vertebral artery during stenting of external carotid artery stenosis

A 61-year-old man presented with a severe external carotid artery (ECA) stenosis with concomitant ipsilateral internal carotid artery (ICA) occlusion manifesting as amaurosis fugax. The left ophthalmic artery was supplied from the left ECA. The left intracranial ICA was supplied by the collateral flow from the contralateral ICA and ipsilateral ECA through the ophthalmic artery. The left vertebral artery also participated in the latter collateral pathway through the left occipital artery and ascending pharyngeal artery. Percutaneous revascularization of the ECA was performed using a nitinol self-expanding stent. To prevent embolic complications through the ophthalmic or vertebral arteries, distal protection was performed using a balloon. During a 22-month follow-up period, the patient was completely free from any ocular or neurological symptoms. The present case of severe ECA stenosis with ipsilateral ICA occlusion showed that percutaneous balloon angioplasty with stenting is feasible and effective. This intervention requires cautious evaluation of the anastomotic pathways connecting the ECA to the cerebral circulation to avoid embolic complications.

External Carotid Artery Stenting to Treat Patients With Symptomatic Ipsilateral Internal Carotid Artery Occlusion

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.

Treatment of limb-shaking TIAs with external carotid artery stenting

Limb-shaking transient ischemic attacks (TIAs) occur when perfusion is reduced to the cortical territory associated with the transient movements. We present a case in which a patient with preexisting left internal carotid artery (ICA) occlusion developed limb-shaking TIAs secondary to severe stenosis of her left external carotid artery (ECA). After angioplasty and stenting of her left ECA, her symptoms resolved.