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Václavík D, Pakizer D, Hrbáč T, Roubec M, Procházka V, Jonszta T, Herzig R, Školoudík D. Changes in Cognitive Functions after Carotid Endarterectomy and Carotid Stenting: A Decade-Apart Comparison. Biomedicines 2023; 12:13. [PMID: 38275374 PMCID: PMC10813376 DOI: 10.3390/biomedicines12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates changes in cognitive function in patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) and carotid stenting (CAS) over two decades. METHODS We compared cognitive function within 30 days after the procedure in 267 patients (first 100 each for CEA and CAS in two periods: 2008-2012 and 2018-2022) in a single institution. Assessments used Adenbrooke's Cognitive Examination-Revised (ACE-R), the Mini-Mental State Examination (MMSE), Speech Fluency Test (SFT), and Clock Drawing Test (CDT), conducted before and 30 ± 2 days after surgery. RESULTS Patients (mean age 67.2 years, 70%+ carotid stenosis) exhibited different cognitive changes over periods. In 2008-2012, significant declines in MMSE (CEA, p = 0.049) and CDT (CAS, p = 0.015) were observed among asymptomatic patients. On the contrary, in 2018-2022, improvements were observed in ACE-R and MMSE for symptomatic and asymptomatic patients undergoing CEA and CAS. CONCLUSION Over a decade, advances in interventional techniques and patient management have reduced risks of cognitive decline in patients with asymptomatic carotid stenosis and also have improved cognitive functions in both symptomatic and asymptomatic individuals.
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Affiliation(s)
- Daniel Václavík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
- Stroke Centre, Department of Neurology, Hospital Agel Ostrava Vitkovice, 703 00 Ostrava, Czech Republic
| | - David Pakizer
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Tomáš Hrbáč
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic;
- Department of Neuroscience, Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
| | - Václav Procházka
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Tomáš Jonszta
- Department of Radiodiagnostics, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 703 00 Ostrava, Czech Republic; (V.P.); (T.J.)
| | - Roman Herzig
- Comprehensive Stroke Centre, Department of Neurology, Charles University Faculty of Medicine and University Hospital, 500 05 Hradec Králové, Czech Republic;
| | - David Školoudík
- Department of Neurology, University Hospital Ostrava, 708 00 Ostrava, Czech Republic; (D.V.); (M.R.)
- Centre for Health Research, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic;
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2
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Tiwari A, Bo R, Sivakumar K, Arcot KM, Ye P, Parrella DT, Farkas J. Safety and Efficacy of Flow Reversal in Acute and Elective Carotid Angioplasty and Stenting Using the Mo.Ma Device with Short-Term Follow-Up. INTERVENTIONAL NEUROLOGY 2019; 8:196-205. [PMID: 32508902 DOI: 10.1159/000499045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 02/20/2019] [Indexed: 11/19/2022]
Abstract
Objective To determine the safety and efficacy of flow reversal following proximal flow arrest as an embolic protection strategy for carotid angioplasty and stenting (CAS) with short-term follow-up. Method We performed a retrospective review of our CAS database for patients who underwent stent-supported carotid revascularization in the setting of acute/subacute stroke or TIA. We reviewed clinical and radiographic data during a 36-month period. Primary outcome was clinical evidence of ipsilateral stroke in the first 30 days. Secondary outcomes include clinical outcomes and sonographic and/or angiographic follow-up over 6 months, 6-month functional scale, and all-cause mortality. Results Fifty-five patients underwent CAS using flow reversal: 26 females and 29 males with a mean age of 69.7 years. Median time to treatment from index event was 3 days. 11% underwent stenting as part of hyperacute stroke therapy. Average luminal stenosis was 86%. The 9-Fr Mo.Ma device was used in combination with Penumbra aspiration in all cases. There were no ipsilateral strokes. Incidence of any ischemic event was 3.64%, but only 1 (1.82%) patient had a postoperative stroke. Clinical follow-up was available for 94.5%, while lesion follow-up was available for 73% of patients. Three patients had evidence of restenosis, but none were symptomatic. Luminal restenosis was ≤30% in all three. Median pre- and post-NIHSS were 1 and 1, respectively. Conclusion Flow reversal using the Mo.Ma device is a safe and effective strategy in preventing distal embolization during carotid artery revascularization.
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Affiliation(s)
- Ambooj Tiwari
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA.,Pacific Neuroscience Institute, Department of Vascular and Interventional Neurology, Providence St. Joseph Health, Santa Monica, California, USA
| | - Ryan Bo
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
| | - Keithan Sivakumar
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
| | - Karthikeyan M Arcot
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
| | - Philip Ye
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
| | - David T Parrella
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
| | - Jeffrey Farkas
- NYU School of Medicine, New York, New York, USA.,Departments of Neurology, Radiology & Neurosurgery, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA.,Interventional Neuro Associates, Bergenfield, New Jersey, USA
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4
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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Kohara K, Ishikawa T, Kobayashi T, Kawamata T. Retinal artery occlusion during carotid artery stenting with distal embolic protection device. Neuroradiol J 2018; 31:504-508. [PMID: 29862882 DOI: 10.1177/1971400918781990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Retinal artery occlusion associated with carotid artery stenosis is well known. Although it can also occur at the time of carotid artery stenting, retinal artery occlusion via the collateral circulation of the external carotid artery is rare. We encountered two cases of retinal artery occlusion that were thought to be caused by an embolus from the external carotid artery during carotid artery stenting with a distal embolic protection device for the internal carotid artery. A 71-year-old man presented with central retinal artery occlusion after carotid artery stenting using the Carotid Guardwire PS and a 77-year-old man presented with branch retinal artery occlusion after carotid artery stenting using the FilterWire EZ. Because additional new cerebral ischaemic lesions were not detected in either case by postoperative diffusion-weighted magnetic resonance imaging, it was highly likely that the debris that caused retinal artery occlusion passed through not the internal carotid artery but collaterals to retinal arteries from the external carotid artery, which was not protected by a distal embolic protection device. It is suggested that a distal protection device for the internal carotid artery alone cannot prevent retinal artery embolisation during carotid artery stenting and protection of the external carotid artery is important to avoid retinal artery occlusion.
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Affiliation(s)
- Kotaro Kohara
- 1 Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Tatsuya Ishikawa
- 1 Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | | | - Takakazu Kawamata
- 1 Department of Neurosurgery, Tokyo Women's Medical University, Japan
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6
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Szikra P, Boda K, Rarosi F, Thury A, Barzó P, Németh T, Vörös E. Aortic arch and common carotid artery plaques with soft components pose a substantial risk of cerebral embolization during carotid stenting. Interv Neuroradiol 2016; 22:438-44. [PMID: 26921167 DOI: 10.1177/1591019916633242] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES A higher rate of embolization is considered a disadvantage of carotid stenting (CAS), when compared with carotid endarterectomy. Plaques in the aortic arch (AA) and the common carotid artery (CCA) may be additional sources of embolization to stented internal carotid plaques during CAS. In this study, we aimed to investigate the relationship between these plaques and intracerebral embolization. METHODS We analyzed the occurrence and composition of plaques in the AA and CCA by computed tomography angiography (CTA) in 101 consecutive cases of CAS. Cases of peri-procedural embolization were detected on diffusion-weighted imaging as lesions demonstrating diffusion restriction. We applied the χ(2) and Fisher's exact tests, as well as logistic regression models. RESULTS The occurrence of plaques in the AA and CCA was significantly related to the appearance of new diffusion-weighted imaging lesions (p = 0.013 and p = 0.004, respectively). Patients with soft plaques in the AA or CCA had a significantly higher risk of embolization than those without plaques (p = 0.012 and p = 0.006, respectively). In contrast, homogeneously calcified plaques did not pose significantly higher risks. CONCLUSIONS Soft plaques in the AA and CCA result in a substantial risk of embolization during CAS. Use of a CTA examination of the AA and the CCA in patients with carotid stenosis may help to select lower-risk patients for CAS.
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Affiliation(s)
- Péter Szikra
- Department of Radiology, Medical University Center, University of Szeged, Szeged, Hungary
| | - Krisztina Boda
- Department of Medical Physics and Informatics, Medical University Center, University of Szeged, Szeged, Hungary
| | - Ferenc Rarosi
- Department of Medical Physics and Informatics, Medical University Center, University of Szeged, Szeged, Hungary
| | - Attila Thury
- Department of Cardiology, Medical University Center, University of Szeged, Szeged, Hungary
| | - Pál Barzó
- Department of Neurosurgery, University of Szeged, Medical University Center, Szeged, Hungary
| | - Tamás Németh
- Department of Neurosurgery, University of Szeged, Medical University Center, Szeged, Hungary
| | - Erika Vörös
- Department of Radiology, Medical University Center, University of Szeged, Szeged, Hungary
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7
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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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8
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Patel RAG. State of the art in carotid artery stenting: trial data, technical aspects, and limitations. J Cardiovasc Transl Res 2014; 7:446-57. [PMID: 24771314 DOI: 10.1007/s12265-014-9567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/13/2014] [Indexed: 10/25/2022]
Abstract
The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.
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Affiliation(s)
- Rajan A G Patel
- John Ochsner Heart & Vascular Institute, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA, 70121, USA,
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9
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Iko M, Aikawa H, Go Y, Nakai K, Tsutsumi M, Yu I, Mizokami T, Sakamoto K, Inoue R, Mitsutake T, Eto A, Hanada H, Kazekawa K. Treatment outcomes of carotid artery stenting with two types of distal protection filter device. SPRINGERPLUS 2014; 3:132. [PMID: 25674435 PMCID: PMC4320198 DOI: 10.1186/2193-1801-3-132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/21/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE Preventing cerebral embolism from debris produced during carotid artery stenting (CAS) is important. This study compared the treatment outcomes of CAS using two types of filter-based embolic protection devices currently in use in Japan. MATERIALS AND METHODS We assessed 121 consecutive cases of CAS performed with FilterWire EZ™ between July 2010 and November 2012 and 37 consecutive cases of CAS performed with the Spider FX™ between November 2012 and June 2013. A Carotid Wallstent™ was used in all cases. The incidence of positive lesions on diffusion-weighted magnetic resonance imaging (DWI) and stroke were compared between the groups. RESULTS Postoperative DWI-positive lesions were observed in 38 (31.4%) and 14 (37.8%) patients in the FilterWire and Spider groups, respectively. In the FilterWire group, complications were transient ischemic attacks in 3 (2.5%) patients, cerebral infarction in 2 (1.7%) patients (1 patient each with minor and major stroke), and cerebral hemorrhage due to hyperperfusion syndrome in 1 (0.8%) patient. In the Spider group, except for cerebral infarction (minor stroke) in 1 (2.7%) patient, no complications were observed. No significant differences were observed in the incidence of complications between the groups. CONCLUSION FilterWire EZ and Spider FX are comparable in terms of treatment outcome.
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Affiliation(s)
- Minoru Iko
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Hiroshi Aikawa
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Yoshinori Go
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kanji Nakai
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Masanori Tsutsumi
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Iwae Yu
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Taichiro Mizokami
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kimiya Sakamoto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Ritsuro Inoue
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Takafumi Mitsutake
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Ayumu Eto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Hayatsura Hanada
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kiyoshi Kazekawa
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
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10
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Heyer KS, Eskandari MK. Carotid stenting: risk factors for periprocedural stroke. Expert Rev Neurother 2014; 8:469-77. [DOI: 10.1586/14737175.8.3.469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Yi YJ, Yun JK, Kim DW, Kang SD. Ophthalmic artery occlusion after carotid revascularization. J Cerebrovasc Endovasc Neurosurg 2013; 15:326-9. [PMID: 24729961 PMCID: PMC3983535 DOI: 10.7461/jcen.2013.15.4.326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022] Open
Abstract
Distal embolization resulting from carotid angioplasty and stenting (CAS) occurs mainly in the cerebral hemisphere. We report a case of ophthalmic artery occlusion after carotid revascularization. A 75-year old man received emergency CAS for cervical internal carotid artery occlusion. Two months later, the patient was readmitted for decreased visual acuity. We found ophthalmic artery occlusion that was not noticed soon after CAS. Although ophthalmic artery occlusion after CAS is rare, endovascular neurosurgeons should be aware of this potential complication.
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Affiliation(s)
- Yeon Jin Yi
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Ji Kwang Yun
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Dae Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Sung Don Kang
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
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12
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White CJ, Ramee SR, Collins TJ, Jenkins JS, Reilly JP, Patel RAG. Carotid artery stenting: patient, lesion, and procedural characteristics that increase procedural complications. Catheter Cardiovasc Interv 2013; 82:715-26. [PMID: 23630062 DOI: 10.1002/ccd.24984] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/12/2013] [Accepted: 04/21/2013] [Indexed: 11/05/2022]
Abstract
From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra-indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.
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Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases, Ochsner Clinical School of the University of Queensland, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana, 70121
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Woodley-Cook J, Prabhudesai V, Moloney T. Use of embolic protective devices in treating acute arterial occlusions: an interventional radiology and vascular surgery collaborative learning experience. BMJ Case Rep 2013; 2013:bcr-2012-008132. [PMID: 23580669 DOI: 10.1136/bcr-2012-008132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 43-year-old man presented to the emergency department with left leg claudication. CT angiogram confirmed an acute left leg arterial occlusion from a left ventricular thrombus. During intra-arterial thrombolysis, he developed severe abdominal pain and a CT angiogram confirmed an acute occlusive thromboembolism to his left renal artery. Prior to left renal artery intra-arterial embolectomy, temporary intra-arterial occlusion balloons were inflated within his (1) right renal artery to protect this kidney from acute embolism and (2) left iliac artery to protect his left leg from further clot burden. Following the left renal embolectomy, an angiogram demonstrated patent renal arteries, acute occlusion of the right common iliac artery and persistent clot in his left iliac/lower limb. These occlusions were retrieved by surgical embolectomy. Final angiogram demonstrated patent bilateral iliac/lower limb arteries. The patient was discharged on lifelong anticoagulation and remains asymptomatic with bilateral palpable distal pulses and normal serum creatine.
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Affiliation(s)
- Joel Woodley-Cook
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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Seo HR, Jin SW, Rho SH. Relationship Between Nocturnal Dip, Carotid Artery Blood Flow, Brain Ischemic Change in Open Angle Glaucoma. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2013. [DOI: 10.3341/jkos.2013.54.9.1386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Hong Ryung Seo
- Department of Ophthalmology, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Sang Wook Jin
- Department of Ophthalmology, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Sae Heun Rho
- Department of Ophthalmology, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
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ITO Y, KATO N, MATSUMURA A, SONOBE M. Hemodynamic Instability Increases New Ischemic Brain Lesions on Diffusion-Weighted Imaging After Carotid Artery Stenting. Neurol Med Chir (Tokyo) 2013; 53:375-80. [DOI: 10.2176/nmc.53.375] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Yoshiro ITO
- Department of Neurosurgery, Mito Medical Center, National Health Organization
- Department of Neurosurgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba
| | - Noriyuki KATO
- Department of Neurosurgery, Mito Medical Center, National Health Organization
| | - Akira MATSUMURA
- Department of Neurosurgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba
| | - Makoto SONOBE
- Department of Neurosurgery, Mito Medical Center, National Health Organization
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Iko M, Tsutsumi M, Aikawa H, Matsumoto Y, Go Y, Nii K, Abe G, Ye I, Nomoto Y, Kazekawa K. Distal protection filter device efficacy with carotid artery stenting: comparison between a distal protection filter and a distal protection balloon. Jpn J Radiol 2012. [PMID: 23179785 DOI: 10.1007/s11604-012-0145-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This retrospective study aimed to compare the effectiveness of the embolization prevention mechanism of two types of embolic protection device (EPD)-a distal protection balloon (DPB) and a distal protection filter (DPF). METHODS Subjects were 164 patients scheduled to undergo carotid artery stenting: a DPB was used in 82 cases (DPB group) from April 2007 until June 2010, and a DPF was used in 82 cases (DPF group) from July 2010 to July 2011. Rates of positive findings on postoperative diffusion-weighted imaging (DWI) and stroke incidence were compared. RESULTS Positive postoperative DWI results were found in 34 cases in the DPB group (41.4 %), but in only 22 cases in the DPF group (26.8 %), and there was only a small significant difference within the DPF group. In the DPB group, there was one case of transient ischemic attack (TIA) (1.2 %) and four cases of brain infarction (2 minor strokes, 2 major strokes; 4.9 %), compared to the DFP group with one case of TIA (1.2 %) and no cases of minor or major strokes. CONCLUSIONS In this study, significantly lower rates of occurrence of DWI ischemic lesions and intraoperative embolization were associated with use of the DPF compared to the DPB.
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Affiliation(s)
- Minoru Iko
- Department of Neurosurgery, Fukuoka Kieikai Hospital, 5-11-5 Chihaya, Higashi-ku, Fukuoka, Fukuoka 813-0044, Japan.
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Kimiagar I, Gur AY, Auriel E, Peer A, Sacagiu T, Bass A. Long-term follow-up of patients after carotid stenting with or without distal protective device in a single tertiary medical center. Vasc Endovascular Surg 2012; 46:536-41. [PMID: 22903330 DOI: 10.1177/1538574412457471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the immediate and long-term clinical outcomes after carotid artery stenting (CAS) with and without protection devices (PDs), compared with carotid endarterectomy (CEA). METHODS A total of 116 patients with symptomatic carotid stenosis underwent CAS; 56 patients (48.3%) underwent CAS-PD; and 137 patients underwent CEA. RESULTS There were more ipsilateral transient ischemic attacks (TIAs) in the CEA group than in CAS-PD and CAS + PD (4 [3%] vs 1 [1.6%] and 0 respectively, P = 0.02). In the CAS-PD group there were more vertebrobasilar TIAs, ipsi- and contralateral strokes, myocardial infarctions, and death rates in the 30-day postprocedural period. After 8-year follow-up, there were 18 (30%) death cases in the CAS-PD group, 10 death cases (17%) in the CAS + PD patients, and 15 death cases (11%) in the CEA group of patients (P = .02). CONCLUSION Our data show that CAS + PD was associated with lower rate of vascular complications and mortality compared with CAS-PD and CEA.
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Affiliation(s)
- Itzhak Kimiagar
- Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Lee DH, Hwang SM, Lim OK, Kim JK. In vitro observation of air bubbles during delivery of various detachable aneurysm embolization coils. Korean J Radiol 2012; 13:412-6. [PMID: 22778562 PMCID: PMC3384822 DOI: 10.3348/kjr.2012.13.4.412] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 01/02/2012] [Indexed: 12/18/2022] Open
Abstract
Objective Device- or technique-related air embolism is a drawback of various neuro-endovascular procedures. Detachable aneurysm embolization coils can be sources of such air bubbles. We therefore assessed the formation of air bubbles during in vitro delivery of various detachable coils. Materials and Methods A closed circuit simulating a typical endovascular coiling procedure was primed with saline solution degassed by a sonification device. Thirty commercially available detachable coils (7 Axium, 4 GDCs, 5 MicroPlex, 7 Target, and 7 Trufill coils) were tested by using the standard coil flushing and delivery techniques suggested by each manufacturer. The emergence of any air bubbles was monitored with a digital microscope and the images were captured to measure total volumes of air bubbles during coil insertion and detachment and after coil pusher removal. Results Air bubbles were seen during insertion or removal of 23 of 30 coils (76.7%), with volumes ranging from 0 to 23.42 mm3 (median: 0.16 mm3). Air bubbles were observed most frequently after removal of the coil pusher. Significantly larger amounts of air bubbles were observed in Target coils. Conclusion Variable volumes of air bubbles are observed while delivering detachable embolization coils, particularly after removal of the coil pusher and especially with Target coils.
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Affiliation(s)
- Deok Hee Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
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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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Baik SK, Jeon U, Choo KS, Kim YW, Pil-Park K. What is the real risk of dislodging thrombi during endovascular revascularization of a proximal internal carotid artery occlusion? Neurosurgery 2011; 68:1084-90; discussion 1091. [PMID: 21792107 DOI: 10.1227/neu.0b013e31820a19fc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is a theoretical concern that a thrombus may be dislodged distally when crossing the occluded segment during recanalization of a complete occlusion. OBJECTIVE To assess the immediate postprocedural brain diffusion-weighted image (DWI) findings following endovascular recanalization using an embolic protection device for proximal internal carotid artery (ICA) occlusion. MATERIALS AND METHODS We retrospectively identified 12 patients who underwent stent implantation for sudden symptomatic occlusion of the proximal ICA. In 8 patients, no additional intracranial occlusions were identified. In 4 patients, an additional intracerebral thrombus was detected in the middle cerebral artery. Distal protection devices were used in all cases. We evaluated the presence and amount of retrieved embolic fragments in the distal protection devices. The incidence and location of postprocedural emboli were determined using DWI. RESULTS Recanalization of the proximal ICA was achieved in all patients. After complete occlusion of the proximal ICA was demonstrated, primary passage of the embolic protection device through the occluded ICA was gently navigated in 7 patients. However, this was not possible in 5 patients. Three patients developed new lesions on postprocedural DWI. Of the 12 patients in which distal protection devices were used, debris was detected in 7 patients. CONCLUSION In endovascular revascularization of proximal ICA occlusion, postprocedural emboli occur less frequently than reported in a systematic review of the DWI literature. The real risk of dislodging thrombi appears to be from plaque fragment mobilization by angioplasty, rather than from crossing an occluded segment.
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Affiliation(s)
- Seung Kug Baik
- Department of Diagnostic Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
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Grube E, Hauptmann KE, Müller R, Uriel N, Kaluski E. Coronary stenting with MGuard: extended follow-up of first human trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:138-146. [DOI: 10.1016/j.carrev.2010.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 06/18/2010] [Accepted: 06/24/2010] [Indexed: 10/18/2022]
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George JC, White CJ. Carotid artery stenting lessons From CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial). JACC Cardiovasc Interv 2011; 3:988-90. [PMID: 20850102 DOI: 10.1016/j.jcin.2010.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Initial experience of carotid artery stenting using the Carotid WALLSTENT and FilterWire EZ in Japan. Jpn J Radiol 2011; 29:51-8. [DOI: 10.1007/s11604-010-0518-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
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Abstract
In the past 3 years, there have been significant developments in the field of carotid revascularization, including: 1) the results of a large primary stroke prevention trial; 2) the emergence of novel platforms for emboli protection; 3) improved characterization of the high-risk carotid artery stent (CAS) patient; 4) completion of several very large post-market surveillance (PMS) trials of CAS in high-surgical-risk patients; and 5) the completion of 4 large randomized controlled trials comparing CAS with carotid endarterectomy in average-risk patients. The purpose of this review is to update the current status of revascularization therapies to reduce stroke in patients with extracranial carotid artery disease with a focus on the most recent developments regarding the role of CAS.
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Sakamoto M, Taoka T, Nakagawa H, Takayama K, Wada T, Myouchin K, Akashi T, Miyasaka T, Fukusumi A, Iwasaki S, Kichikawa K. Magnetic resonance plaque imaging to predict the occurrence of the slow-flow phenomenon in carotid artery stenting procedures. Neuroradiology 2010; 52:275-83. [PMID: 19936732 DOI: 10.1007/s00234-009-0623-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 10/28/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The purpose is to investigate the feasibility of magnetic resonance (MR) plaque imaging in predicting the arterial flow impairment (slow-flow phenomenon) during carotid artery stenting (CAS) using a filter-type protection device. METHODS Thirty-one carotid artery stenotic lesions in 30 patients (28 men and two women; mean age, 71.8 years) were evaluated by MR plaque imaging with black blood T1- and T2-weighted and time-of-flight sequences before CAS. Main plaque components were classified as vulnerable (intraplaque hemorrhage and lipid-rich/necrotic core) or stable (fibrous tissue and dense calcification) from the signal pattern. The plaque classification was statistically compared with the occurrence of slow-flow phenomenon. RESULTS The slow-flow phenomenon was observed in ten CAS procedures (five flow arrests and five flow reductions). Flow arrests consisted of four vulnerable and one stable plaque, and flow reductions consisted of four vulnerable and one stable plaque. The slow-flow phenomenon occurred significantly (P<0.01) more frequently in patients with vulnerable plaque. CONCLUSIONS Vulnerable carotid plaques have a significantly higher risk of slow-flow phenomenon than stable plaques. The occurrence of the slow-flow phenomenon can be predicted by MR plaque imaging before CAS.
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Affiliation(s)
- Masahiko Sakamoto
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
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White CJ. Proximal Embolic Protection. J Am Coll Cardiol 2010; 55:1668-70. [DOI: 10.1016/j.jacc.2009.12.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 12/18/2009] [Accepted: 12/22/2009] [Indexed: 11/28/2022]
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Henry M, Henry I, Polydorou A, Hugel M. How to avoid complications associated with carotid angioplasty and stenting. Future Cardiol 2009; 4:617-38. [PMID: 19804356 DOI: 10.2217/14796678.4.6.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery and is now performed more frequently and is well accepted, at least for high surgical risk patients. However, complications and particularly embolic strokes, even with a meticulous technique, can occur at any step of the procedure. Silent embolism is detected after CAS and may be a problem that needs to be discussed. To avoid and reduce these complications associated with CAS, it is important to have good indications dependent upon on good patient and lesions selection, as well as correct technique. New parameters have been proposed, particularly for asymptomatic lesions. The authors consider that embolic protection devices (EPDs) are mandatory for CAS, and new techniques will be presented. The choice of the EPD depends on the clinical status of the patient, the lesion morphology and characteristics, and the anatomy of the artery. All stents are not equivalent and so a good choice of the stent is necessary to avoid and reduce the complications associated with CAS, and experienced operators are also needed. With all these considerations, CAS can now be performed with acceptable outcomes and in certain population the results are comparable or superior to surgery. The results of ongoing randomized trials are awaited.
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Affiliation(s)
- M Henry
- Cabinet de Cardiologie, 80 Rue Raymond Poincaré, 54000 Nancy, France.
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Observation of the embolus protection filter for Carotid Artery Stenting. ACTA ACUST UNITED AC 2009; 72:532-7; discussion 537. [PMID: 19329161 DOI: 10.1016/j.surneu.2008.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Accepted: 12/16/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Carotid artery stenting in patients with high surgical risk is considered as an effective alternative to carotid endarterectomy. Because the occurrence of distal embolization with CAS is still a major concern, an embolus protection device is usually used during the procedure. We developed a technique for observation of embolus protection filter and evaluated the debris or thrombus microscopically, and the pathologic findings were compared with preoperative imaging studies. METHODS After completing CAS, the filter membrane was stained with HE solution and removed from filter strut. Mounting onto a glass slide, the filter was evaluated under a microscope. Plaque debris and appearance of filter membrane were evaluated, and the covered area was measured. The pathologic findings were compared with preoperative imaging studies. RESULTS Microscopic observation of the slide revealed atheromatous debris as well as thrombotic material to the filter membrane. Hematoxylin-eosin stain facilitates the characterization of the debris composition, namely, thrombotic debris, calcified debris, organized debris, fibrous debris, and lipid-rich debris. The subtypes of debris were consistent with preoperative imaging studies. Thus, in cases of intraprocedural flow impairment, more than 50% of the filter area was covered with debris or thrombotic material. CONCLUSION Carotid plaque debris captured during carotid stenting with protection filter can be visualized with HE stain on the glass side. This simple method allows us to better understand the plaque debris and appearance of embolus protection filter.
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Kaluski E, Tsai S, Klapholz M. Coronary stenting with MGuard: from conception to human trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:88-94. [DOI: 10.1016/j.carrev.2007.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 10/22/2022]
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