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A Systematic Review of the Causes and Management of Nonthrombotic Embolic Stroke of Tissue Origin. Stroke Res Treat 2018; 2018:8092862. [PMID: 29854382 PMCID: PMC5941808 DOI: 10.1155/2018/8092862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/28/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction Various bodily tissues have been reported to enter the arterial circulation and embolize to the brain resulting in ischemic stroke. Most frequently nonthrombotic embolic stroke (NTES) of tissue origin is iatrogenic or related to an underlying disease process. With the increase in elective surgery and intravascular procedures, NTES may increase in prevalence. Aim To compile a summary of the background, incidence, presentation, and treatment of NTES of tissue origin, by conducting a systematic review of the current literature. Summary of Review We searched EMBASE and MEDLINE for articles on NTES of tissue origin published in English with no restriction on publication date (search date June 2017). 800 articles were identified and screened and 159 articles were ultimately reviewed in full text and included in qualitative analysis. Articles deemed relevant were assessed by a second reviewer to confirm compatibility with the inclusion criteria. References of included articles were reviewed for relevant publications. We categorized the pathology of the emboli into the following groups: amniotic fluid (4 publications), tumour (60 publications), fat (43 publications), cholesterol (19 publications), and intravascular debris (12 publications). We then summarized the available literature on each cause of NTES. Conclusions NTES of tissue origin is an uncommon but important diagnosis to consider particularly in younger stroke patients and in certain clinical settings. Treatment for NTES is currently anecdotal and based on small case series. Embolectomy may emerge as the therapy of choice due to the longer treatment timeframe and heterogeneity of the emboli.
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Ledwoch J, Staubach S, Segerer M, Strohm H, Mudra H. Incidence and risk factors of embolized particles in carotid artery stenting and association with clinical outcome. Int J Cardiol 2016; 227:550-555. [PMID: 27829527 DOI: 10.1016/j.ijcard.2016.10.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 07/22/2016] [Accepted: 10/30/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND One of the mechanisms for periprocedural neurologic events in carotid artery stenting (CAS) is catheter manipulation within the aorta and supraaortic arteries causing plaque embolization. Therefore, the present analysis sought to determine risk factors for embolic particle dimensions and their relationship with adverse clinical events after CAS. METHODS Between 1999 and 2015 embolic protection devices (EPD) of a total of 944 CAS procedures were evaluated regarding the occurrence and size of captured particles. RESULTS Particles were found in 819 of 944 (87%) EPDs. Larger particles were detected in procedures using open cell stents (150±282μm vs. 107±177μm; p=0.005) and longer stents (≥40mm) (165±315μm vs. 122±215μm; p=0.026). With increasing learning curve, particle size was continually reduced (168±282μm in the first third of the cohort vs. 127±309μm in the second third vs. 108±114μm in the last third; p=0.009). Longer stents and use of Acculink stent were found to be independent predictors for particle diameter. In patients who died or sustained a stroke during long-term follow-up (median 5.5years [IQR 2.6-7.9]) significantly larger particles were captured during CAS compared to those patients with an uneventful follow-up (160±330μm vs. 121±195μm; p=0.047). CONCLUSIONS In the vast majority of CAS procedures particles could be retrieved from the EPDs used. Procedural characteristics such as stent type and stent length were associated with larger particles.
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Affiliation(s)
- Jakob Ledwoch
- Städtisches Klinikum München GmbH, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany
| | - Stephan Staubach
- Städtisches Klinikum München GmbH, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany
| | - Manuela Segerer
- Städtisches Klinikum München GmbH, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany
| | - Henning Strohm
- Städtisches Klinikum München GmbH, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany
| | - Harald Mudra
- Städtisches Klinikum München GmbH, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany.
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Brinjikji W, Lehman VT, Huston J, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. The association between carotid intraplaque hemorrhage and outcomes of carotid stenting: a systematic review and meta-analysis. J Neurointerv Surg 2016; 9:837-842. [PMID: 27540090 DOI: 10.1136/neurintsurg-2016-012593] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this systematic review and meta-analysis was to determine whether carotid stenting patients with intraplaque hemorrhage (IPH) identified on preoperative MRI were more likely to suffer perioperative ischemic complications compared with patients without IPH. METHODS We conducted a comprehensive literature search of studies published between January 1, 2005 and December 31, 2015 reporting perioperative outcomes of carotid stenting among patients with and without IPH on hemorrhage sensitive carotid MRI sequences. Clinical outcomes included perioperative (≤30 days post-stenting) minor stroke, major stroke, death, and a composite outcome combining stroke, death, and myocardial infarction (MI). We also compared the rate of silent ischemia on diffusion weighted imaging (DWI) between groups. Statistical analysis was performed using a random effects meta-analysis. RESULTS 9 studies with 491 unique patients (198 in the IPH group and 293 in the non-IPH group) were included. The rate of the composite outcome of any stroke, death, or MI within 30 days was 8.1% (13/160) in the IPH group and 2.1% (5/239) in the non-IPH group (OR=4.45, 95% CI 1.61 to 12.30, p<0.01). There were no significant differences between groups in the rates of minor stroke, major stroke, or death when considered individually. The rate of postoperative infarct on DWI was 49.7% (75/161) for the IPH group and 33.6% (81/241) for the non-IPH group (OR=2.01, 95% CI 1.31 to 3.09, p<0.01). CONCLUSIONS Our systematic review and meta-analysis demonstrated that patients with IPH on pre-carotid stenting MRI had higher rates of silent ischemia as well as of a composite outcome of perioperative stroke, death, and MI compared with those without IPH.
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Affiliation(s)
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Bouchez L, Lovblad KO, Kulcsar Z. Pretherapeutic characterization of the clot in acute stroke. J Neuroradiol 2016; 43:163-6. [DOI: 10.1016/j.neurad.2016.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
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Pelz DM, Lownie SP, Lee DH, Boulton MR. Plaque morphology (the PLAC Scale) on CT angiography: predicting long-term anatomical success of primary carotid stenting. J Neurosurg 2015; 123:856-61. [DOI: 10.3171/2014.9.jns14811] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT
Carotid angioplasty and stenting has emerged as an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid stenosis. Primary carotid stenting, performed using self-expanding stents alone without deliberate use of embolic protection devices and balloon angioplasty, has been shown to be effective and faster, cheaper, and potentially safer than conventional techniques. However, the long-term morphological results of this technique have not been established. The aim of this study was to determine whether preprocedural carotid plaque imaging at the site of maximal stenosis by using CT angiography (CTA) could predict the long-term morphological outcome of primary carotid stenting.
METHODS
One hundred eighty-one patients were treated over an 11-year period. Preprocedural CTA was performed in 102 of these. A morphological scale (the Predicting Long-term outcome with Angioplasty of the Carotid artery [PLAC] Scale), with grades from 0 to 4 and A or B, was used to evaluate the circumferential degree of plaque calcification, and the presence or absence of soft plaque. All patients were followed using duplex carotid ultrasound and plain radiographs. Satisfactory morphological outcome was defined as a peak systolic velocity < 120 cm/s and internal carotid artery/common carotid artery ratio < 1.4.
RESULTS
The average follow-up duration was 29.7 months (median 24.5 months, range 0.3–87 months). Univariate logistic regression demonstrated that a low calcification grade (p < 0.001), less thick calcification (p < 0.001), and moderate amounts of soft plaque (p < 0.001) are factors that are highly associated with good long-term outcome. Multivariate analyses confirmed that these factors are independent of each other in predicting outcome.
CONCLUSIONS
The long-term morphological outcome of primary carotid stenting was predicted with considerable accuracy by using a straightforward CTA carotid plaque grading scale.
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Lanzer P, Widimský P. Ischaemic stroke and ST-segment elevation myocardial infarction: fast-track single-stop approach. Eur Heart J 2015; 36:2348-55. [DOI: 10.1093/eurheartj/ehv217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/04/2015] [Indexed: 11/14/2022] Open
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Paraskevas KI, Veith FJ. Thrombolysis May Reduce the Incidence/Extent of Postprocedural Ischemic Strokes Associated With Carotid Artery Stenting: A Hypothesis. Angiology 2014; 66:604-6. [PMID: 25168957 DOI: 10.1177/0003319714549370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA
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Pini R, Faggioli G, Fittipaldi S, Pasquinelli G, Tonon C, Beltrandi E, Mauro R, Stella A. Inflammatory mediators and cerebral embolism in carotid stenting: new markers of risk. J Endovasc Ther 2014; 20:684-94. [PMID: 24093322 DOI: 10.1583/13-4354r.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate serological predictors of risk for cerebral embolism after carotid artery stenting (CAS). METHODS Twenty consecutive symptomatic and asymptomatic patients (13 men; mean age 74 years) with carotid artery stenosis undergoing standardized filter-protected CAS (Wallstent) were preoperatively evaluated to identify unstable plaque (duplex ultrasound), complicated aortic plaque (transesophageal echocardiography), and inflammatory status [high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA) serum levels]. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing the number, volume, and side (ipsilateral and non-ipsilateral) of preoperative and postoperative cerebral lesions detected on diffusion-weighted resonance magnetic imaging (DW-MRI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS. RESULTS All CAS procedures were completed with no complications. All patients had a negative preoperative DW-MRI, but at least 1 asymptomatic cerebral lesion appeared on DW-MRI after the procedure in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 for men, p=0.03). Carotid plaque morphology, supra-aortic vessel anatomy, and procedure complexity did not correlate with number or volume of new cerebral lesions. Complicated aortic plaque was associated with a higher volume of non-ipsilateral cerebral lesions than uncomplicated plaque (235.0±259.3 vs. 63.6±63.2 mm(3), respectively; p=0.02). Hs-CRP ≥5 mg/L and SAA ≥10 mg/L were significantly associated with a higher number of new cerebral lesions [16.2±10.7 vs. 4.3±3.4 for hs-CRP <5 mg/L (p=0.02) and 14.8±10.3 vs. 2.8±3.4 for SAA <10 mg/L (p=0.006), respectively]. Hs-CRP ≥5 mg/L and SAA ≥10 mg/L also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis [37.0% (5.1%) vs. 26.9% (2.5%) for hs-CRP <5 mg/L, p=0.004; 35.9% (13.5%) vs. 22.2% (6.9%) for SAA <10 mg/L, p=0.02]. CONCLUSION In addition to female gender and the presence of complicated aortic plaque, inflammatory status can be a predictor of cerebral embolism in CAS.
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Affiliation(s)
- Rodolfo Pini
- 1 Cardio-Thoraco-Vascular Department, S. Orsola-Malpighi Polyclinic, University of Bologna, Italy
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Youn SW, Kim HK, Kim HT, Han SM, Do JK, Do YR, Lee HJ, Lee J, Lim JH. Propagation-based phase-contrast X-ray microtomography of a cerebral protection device retrieved after carotid artery stenting. JOURNAL OF SYNCHROTRON RADIATION 2014; 21:215-222. [PMID: 24365939 DOI: 10.1107/s1600577513023862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 08/25/2013] [Indexed: 06/03/2023]
Abstract
Phase-contrast synchrotron X-ray microtomography (pcSyncX) based on the highly coherent X-ray beam has previously been used to visualize the microstructures of biologic specimens, but it has never been used to evaluate embolic debris adherent on a cerebral protection device (CPD). The purpose of this study was to demonstrate the feasibility of pcSyncX for evaluating embolic debris during carotid artery stenting (CAS). Five patients (four males, age range 67-77 years) with severe carotid artery stenosis underwent CAS. The retrieved CPD was exposed to synchrotron radiation and 1000 pcSyncX projection images were obtained by rotating the CPD through 180°. An X-ray shadow of a CPD was converted into a visual image by the scintillator. After microtomographic reconstruction, the three-dimensionally reconstructed images were further segmented into the embolic debris and CPD. The total volume of emboli was calculated by summing the volume at each scanning level. The number of membrane pores covered by emboli as seen from the outer surface was counted and the percentage of covered area was calculated. Embolic debris was clearly demonstrated not only on the inner surface and within pores but also on the outer surface of the CPD. The mean total volume of embolic debris was 0.538 × 10(-6) mm(3) (range 0.225-0.965 × 10(-6) mm(3)). Most (61.5%) of the debris was located at the apical one-third of the CPD and 20.8% of the pore area was covered by debris.
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Affiliation(s)
- Sung Won Youn
- Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Ho Kyun Kim
- Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Hong Tae Kim
- Department of Anatomy, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Sung Mi Han
- Department of Anatomy, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Jin Kuk Do
- Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Young Rok Do
- Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Hui Joong Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jongmin Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jae Hong Lim
- X-ray Imaging Group, Beamline Division, Pohang Accelerator Laboratory, POSTECH, Pohang, Gyungbuk, Republic of Korea
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Melfi R, Patti G, Di Sciascio G. The protective effect of clopidogrel and atorvastatin in patients undergoing carotid stenting. Interv Cardiol 2013. [DOI: 10.2217/ica.13.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Song TJ, Suh SH, Min PK, Kim DJ, Kim BM, Heo JH, Kim YD, Lee KY. The influence of anti-platelet resistance on the development of cerebral ischemic lesion after carotid artery stenting. Yonsei Med J 2013; 54:288-94. [PMID: 23364958 PMCID: PMC3575994 DOI: 10.3349/ymj.2013.54.2.288] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Cerebral ischemic lesions are frequently observed after carotid artery stenting (CAS), and anti-platelet agents are used to prevent stent thrombosis and peri-procedural complications. However, despite the premedication, cerebral ischemic lesions are observed, suggesting that they may rather be related to anti-platelet resistance. We, therefore, investigated the effects of anti-platelet resistance on the development of cerebral ischemic lesions after CAS. MATERIALS AND METHODS We retrospectively reviewed patients who received CAS and selected patients for whom brain MRI was performed within 24 hours after CAS and for whom anti-platelet resistance was checked. Anti-platelet resistance was examined by the VerifyNow system. We analyzed the correlation between anti-platelet resistance and cerebral ischemic lesions detected on follow-up MRI. RESULTS Among 76 patients, 45 (59.2%) developed new ischemic lesions after CAS. Twelve (15.8%) patients showed aspirin resistance and 50 (65.8%) patients showed clopidogrel resistance. Patients with a new ischemic lesion demonstrated a significantly greater frequency of clopidogrel resistance than those who had no new ischemic lesion (82.2% versus 41.9%, p=0.001). The frequency of aspirin resistance was not significantly different between the groups of patients with and without new ischemic lesions (20.0% versus 9.7%, p=0.340). In multivariate analysis, clopidogrel resistance was a significant risk factor for post-procedural cerebral ischemia. CONCLUSION Anti-platelet resistance can be used to predict new ischemic lesions after CAS. Anti-platelet resistance should be evaluated in all patients prior to CAS to prevent ischemic complications related to CAS.
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Affiliation(s)
- Tae-Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Pil-Ki Min
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University, Seoul, Korea
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Van der Heyden J, Wolters FJ, Garin N, Blant SA, Inglin M, Bal ET, Suttorp JM. The role of embolic protection devices during carotid stenting prior to cardiac surgery in asymptomatic patients: empty filters? Catheter Cardiovasc Interv 2012; 80:112-9. [PMID: 21953787 DOI: 10.1002/ccd.23383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/03/2011] [Accepted: 09/09/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze the debris captured in the distal protection filters used during carotid artery stenting (CAS). BACKGROUND CAS is an option available to high-risk patients requiring revascularization. Filters are suggested for optimal stroke prevention during CAS. METHODS From May 2005 to June 2007, filters from 59 asymptomatic patients who underwent CAS were collected and sent to a specialized laboratory for light-microscope and histological analysis. Peri- and postprocedural outcomes were assessed during 1-year follow-up. RESULTS On the basis of biomedical imaging of the filter debris, the captured material could not be identified as embolized particles from the carotid plaque. On histological analysis the debris consisted mainly of red blood cell aggregates and/ or platelets, occasionally accompanied by granulocytes. We found no consistent histological evidence of embolized particles originating from atherosclerotic plaques. Post-procedure, three neurological events were reported: two (3.4%) transient ischemic attacks (TIA) and one (1.7%) ipsilateral minor stroke. CONCLUSION The filters used during CAS in asymptomatic patients planned for cardiac surgery often remained empty. These findings may be explained by assuming that asymptomatic patients feature a different atherosclerotic plaque composition or stabilization through antiplatelet medication. Larger, randomized trials are clearly warranted, especially in the asymptomatic population.
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Affiliation(s)
- Jan Van der Heyden
- Department of Interventional Cardiology, St-Antonius Hospital, Nieuwegein, The Netherlands.
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Hayase H, Tokunaga K, Nakayama T, Sugiu K, Nishida A, Arimitsu S, Hishikawa T, Ono S, Ohta M, Date I. Computational fluid dynamics of carotid arteries after carotid endarterectomy or carotid artery stenting based on postoperative patient-specific computed tomography angiography and ultrasound flow data. Neurosurgery 2012; 68:1096-101; discussion 1101. [PMID: 21221041 DOI: 10.1227/neu.0b013e318208f1a0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There are significant differences in the postoperative morphological and hemodynamic conditions of the carotid arteries between carotid artery stenting (CAS) and endarterectomy (CEA). OBJECTIVE To compare the postoperative rheological conditions after CAS with those after CEA with patch angioplasty (patch CEA) through the use of computational fluid dynamics (CFD) based on patient-specific data. METHODS The rheological conditions in the carotid arteries were simulated in 2 patients after CAS and in 2 patients after patch CEA by CFD calculations. Three-dimensional reconstruction of the carotid arteries was performed with the images obtained with computed tomography angiography. The streamlines and wall shear stress (WSS) were calculated by a supercomputer. Adequate boundary conditions were determined by comparing the simulation results with ultrasound flow data. RESULTS CFD was successfully calculated for all patients. The differences between the flow velocities of ultrasound data and those of the simulation results were limited. In the streamline analysis, the maximum flow velocities in the internal carotid artery after patch CEA were around two-thirds of those after CAS. Rotational slow flow was observed in the internal carotid artery bulb after patch CEA. WSS analysis found regional low WSS near the outer wall of the bulb. High WSS was observed at the distal end of the arteriotomy after patch CEA and at the residual stenosis after CAS. CONCLUSION CFD of postoperative carotid arteries disclosed the differences in streamlines and WSS between CAS and patch CEA. CFD may allow us to obtain adequate rheological conditions conducive to achieving the best clinical results.
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Affiliation(s)
- Hitoshi Hayase
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Piñero González de la Peña P, González García A, Moniche Álvarez F, Mayol Deyá A, González Marcos J, Cayuela Domínguez A, Gil Peralta A. Filter content after carotid angioplasty and stenting: Relation to ischemic lesions in diffusion-weighted imaging. RADIOLOGIA 2012. [DOI: 10.1016/j.rxeng.2012.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Jiang L, Ling F, Wang B, Miao Z. Insight into the periprocedural embolic events of internal carotid artery angioplasty. A report of four cases and literature review. Interv Neuroradiol 2011; 17:452-8. [PMID: 22192549 DOI: 10.1177/159101991101700409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 10/16/2011] [Indexed: 11/17/2022] Open
Abstract
Thromboembolism is a major risk of carotid angioplasty and stenting (CAS). Although the incidence of distal embolism has been documented by MRI and TCD studies, the mechanisms and management of this complication are rarely reported. Here we describe four patients with periprocedural embolic events to demonstrate the mechanisms of thromboembolism in CAS. Different remedies were applied to these patients according to the underlying mechanisms of thromboembolism and good clinical outcomes were achieved.
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Affiliation(s)
- L Jiang
- Department of Neurosurgery, Xuanwu hospital, Capital Medical University, Beijing, China
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16
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Piñero González de la Peña P, González García A, Moniche Álvarez F, Mayol Deyá A, González Marcos JR, Cayuela Domínguez A, Gil Peralta A. [Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]. RADIOLOGIA 2011; 54:155-64. [PMID: 21530991 DOI: 10.1016/j.rx.2010.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 12/28/2010] [Accepted: 12/29/2010] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. MATERIAL AND METHODS We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 μl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. RESULTS Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. CONCLUSIONS Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.
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Affiliation(s)
- P Piñero González de la Peña
- Unidad de Neurorradiología Diagnóstica, Servicio de Radiodiagnóstico, Hospitales Universitarios Virgen del Rocío, Sevilla, España.
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Sorimachi T, Nishino K, Shimbo J, Morita K, Ito Y, Fujii Y. Routine Use of Debris Aspiration Before Retrieval of Distal Filter Protection Devices in Carotid Arterial Stenting: Analysis of Captured Debris and Evaluation of Clinical Results. Neurosurgery 2010; 67:1260-7; discussion 1267. [PMID: 20871452 DOI: 10.1227/neu.0b013e3181ef5e85] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Distal filter protection allows for continuous cerebral perfusion during carotid artery stenting (CAS), although a higher risk of debris migrating into the cerebral arteries compared with other protection systems has been reported.
OBJECTIVE:
To improve the extent of debris capture, we used routine aspiration of blood located proximal to the filter in the internal carotid artery blood column before retrieval of the filter device.
METHODS:
Of 71 CAS procedures with distal filter protection, routine aspiration was performed in 41 procedures. The size and number of debris particles in each aspirated blood sample were measured under a stereoscopic microscope in 30 consecutive procedures with routine aspiration. Occurrence of periprocedural neurological events was compared between 41 procedures with routine aspiration and the other 30 without routine aspiration.
RESULTS:
In the aspirated blood, debris particles ≥500 μm and ≥1000 μm in the longest diameter were observed in 30 (100%) and 28 (93.3%) procedures, respectively. The number of particles ≥1000 μm was significantly larger in the second through fourth blood aspirates vs the first aspirate (P < .05). Occurrence of periprocedural neurological events was significantly less frequent in the routine aspiration group (0 of 41 procedures) than in the conventional method group (7 of 30 procedures) (P < .05).
CONCLUSION:
The use of routine aspiration during CAS with distal filter protection possibly reduced periprocedural neurological events by increasing the proportion of debris captured. To improve the capture of debris particles, at least 4 repeated aspirations are advisable during each CAS procedure.
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Affiliation(s)
- Takatoshi Sorimachi
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
| | - Kazuhiko Nishino
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
| | - Junsuke Shimbo
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
| | - Kenichi Morita
- Department of Neurosurgery, Niigata City General Hospital, Niigata, Japan
| | - Yasushi Ito
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan
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