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Zhou Y, Ma Y, Qian D, Zhou Z, Li B, Chai E. The Atherogenic Index of Plasma Predicts Carotid in-Stent Restenosis: Development and Validation of a Nomogram. Int J Gen Med 2024; 17:263-274. [PMID: 38292824 PMCID: PMC10824612 DOI: 10.2147/ijgm.s447008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose To explore the predictive value of atherogenic index of plasma(AIP) for carotid in-stent restenosis(ISR). Methods Patients who underwent carotid artery stenting (CAS) in hospital from January 2016 to January 2021 were retrospectively enrolled. They were randomly divided into training and validation sets. Based on the results of carotid digital subtraction angiography (DSA) during the follow-up period, the patients were divided into ISR group and non-ISR group. The differences of AIP and lipid levels between the two groups were compared. The independent risk factors of ISR and the predictive value of AIP for ISR were analyzed. A nomogram was developed based on the independent risk factors, and the receiver operating characteristic (ROC) curve, the calibration curve and the decision curve analysis were conducted to assess the predictive ability and clinical practicability of the nomogram in both the training set and validation sets. Results A total of 361 patients were enrolled, including 98 in the ISR group and 263 in the non-ISR group. In the training set, AIP was significantly higher in the ISR group than in the non-ISR group (P < 0.05) and was independently associated with ISR (OR= 10.912, 95% CI: 2.520-47.248). When AIP was 0.10, it had the highest predictive value for ISR, with a sensitivity of 72. 1% and a specificity of 75.0%. Additionally, hypertension, residual stenosis, symptomatic stenosis and Hcy were also independent risk factors for ISR. The nomogram showed good discrimination performance and clinical practicability in both the training set (AUC = 0.827) and the validation set (AUC = 0.880). Conclusion AIP was an independent risk factor for ISR and was closely related to ISR. The nomogram developed by AIP and other variables had good predictive ability and clinical practicability for ISR.
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Affiliation(s)
- Yu Zhou
- First Clinical Medical College, Lanzhou University, Lanzhou, People’s Republic of China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Yong Ma
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
- Clinical Medicine College, Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Dongliang Qian
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Zhou Zhou
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, People’s Republic of China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, People’s Republic of China
| | - Bin Li
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
| | - Erqing Chai
- First Clinical Medical College, Lanzhou University, Lanzhou, People’s Republic of China
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, People’s Republic of China
- Key Laboratory of Cerebrovascular Diseases, Lanzhou, People’s Republic of China
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Ginanni Corradini L, Maresca L, Lucatelli P, Balocco S, D'Onofrio A, Stefanini M. The role of post-dilatation in carotid MicroNet-covered stent implantation, evaluated using 3D cone-beam CT angiography. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:608-614. [PMID: 38015552 DOI: 10.23736/s0021-9509.23.12756-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND This study aims to assess the role and safety of post-dilatation in protected carotid artery stenting (PCAS) using the new MicroNet-covered 2nd-generation stent assessed by cone beam CT scans. METHODS From March 2020 to March 2022, patients were enrolled in the study according to CT angiography results based on the following criteria: Evidence of 70% to 99% carotid stenosis in asymptomatic patients and 50% to 99% in symptomatic patients, per the NASCET index. Using a FilterWire EZ™ (Boston Scientific, Natick, MA, USA) embolic protection system (EPS), MicroNet-covered stent PCAS was performed by two interventional radiologists with at least 8 years of experience in endovascular intervention. Each patient underwent post-dilatation following stent placement. Finally, a third radiologist (not participating in the interventional procedures) evaluated the cone beam CT scans and calculated residual stenosis. Major and minor complications were recorded in the 30 days following the procedure. RESULTS A total of 192 patients (121 male, mean age 73±10 years) were included in the study, and all patients received post-dilatation following stent implantation. Technical successes were achieved in all procedures. Adverse events noted in this study were limited to periprocedural transient ischemic attacks that occurred in three out of 192 patients (1.6%) and showed a swift complete recovery. The post-dilatation balloon diameters used in the study were: 5.0 mm (30.3%), 5.5 mm (39.3%) and 6 mm (30.3%). Optimized postdilatation resulted in a significant increase in the final luminal area. Similar improvements were observed in all subtypes of plaque. CONCLUSIONS Post-dilatation in protected CAS is safe and induces a significant improvement in the cross-sectional area regardless of the stenotic plaque.
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Affiliation(s)
| | - Luciano Maresca
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | | | - Simone Balocco
- Department of Mathematics and Informatics, University of Barcelona, Barcelona, Spain
- Computer Vision Center, Bellaterra, Spain
| | - Adolfo D'Onofrio
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
| | - Matteo Stefanini
- Department of Radiology and Interventional Radiology, Casilino Hospital, Rome, Italy
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Jia L, Hua Y, Jiao L, Ma Y, Xing Y, Wang L, Hui P, Pan X, Fang Y, Peng T, Meng X, Zhu H, Wu C, Yan Y, Han B, Yang J, Zhang N, Zhang K, Xu D. Effects of plaque characteristics and artery hemodynamics on the residual stenosis after carotid artery stenting. J Vasc Surg 2023; 78:430-437.e4. [PMID: 37076105 DOI: 10.1016/j.jvs.2023.03.500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Carotid artery stenting (CAS) has become an alternative strategy to carotid endarterectomy for carotid artery stenosis. Residual stenosis was an independent risk factor for restenosis, with the latter affecting the long-term outcomes of CAS. This multicenter study aimed to evaluate the echogenicity of plaques and hemodynamic alteration by color duplex ultrasound (CDU) examination and investigate their effects on the residual stenosis after CAS. METHODS From June 2018 to June 2020, 454 patients (386 males and 68 females) with a mean age of 67.2 ± 7.9 years, who underwent CAS from 11 advanced stroke centers in China were enrolled. One week before recanalization, CDU was used to evaluate the responsible plaques, including the morphology (regular or irregular), echogenicity of the plaques (iso-, hypo-, or hyperechoic) and calcification characteristics (without calcification, superficial calcification, inner calcification, and basal calcification). One week after CAS, the alteration of diameter and hemodynamic parameters were evaluated by CDU, and the occurrence and degree of residual stenosis were determined. In addition, magnetic resonance imaging was performed before and during the 30-day postprocedural period to identify new ischemic cerebral lesions. RESULTS The rate of composite complications, including cerebral hemorrhage, symptomatic new ischemic cerebral lesions, and death after CAS, was 1.54% (7/454 cases). The rate of residual stenosis after CAS was 16.3% (74/454 cases). After CAS, both the diameter and peak systolic velocity (PSV) improved in the preprocedural 50% to 69% and 70% to 99% stenosis groups (P < .05). Compared with the groups without residual stenosis and with <50% residual stenosis, the PSV of all three segments of stent in the 50% to 69% residual stenosis group were the highest, and the difference in the midsegment of stent PSV was the largest (P < .05). Logistic regression analysis showed that preprocedural severe (70% to 99%) stenosis (odds ratio [OR], 9.421; P = .032), hyperechoic plaques (OR, 3.060; P = .006) and plaques with basal calcification (OR, 1.885; P = .049) were independent risk factors for residual stenosis after CAS. CONCLUSIONS Patients with hyperechoic and calcified plaques of the carotid stenosis are at a high risk of residual stenosis after CAS. CDU is an optimal, simple and noninvasive imaging method to evaluate plaque echogenicity and hemodynamic alterations during the perioperative period of CAS, which can help surgeons to select the optimal strategies and prevent the occurrence of residual stenosis.
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Affiliation(s)
- Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Lijuan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Pinjing Hui
- Department of Carotid and Cerebrovascular Ultrasonography, The First Affiliated Hospital of Soochow University, Soochow, China
| | - Xiaofang Pan
- Department of Ultrasonography, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, China
| | - Yalan Fang
- Department of Ultrasonography, The First Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Tao Peng
- Department of Ultrasonography, The Second People's Hospital of Liaocheng, Liaocheng, China
| | - Xuan Meng
- Neurovascular Function Department, Lanzhou University Second Hospital, Lanzhou, China
| | - Haohui Zhu
- Department of Ultrasonography, Henan Provincial Hospital, Zhengzhou, China
| | - Chunxia Wu
- Department of Ultrasonography, Liaocheng Brain Hospital, Liaocheng, China
| | - Yuanyuan Yan
- Department of Ultrasonography, Zhengzhou Central Hospital, Zhengzhou, China
| | - Bing Han
- Department of Ultrasonography, Weihai Municipal Hospital, Weihai, China
| | - Jie Yang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Nan Zhang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Ke Zhang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
| | - Duo Xu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China
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Ryu JC, Bae JH, Ha SH, Kwon B, Song Y, Lee DH, Chang JY, Kang DW, Kwon SU, Kim JS, Kim BJ. In-stent restenosis and stented-territory infarction after carotid and vertebrobasilar artery stenting. BMC Neurol 2023; 23:79. [PMID: 36803229 PMCID: PMC9942307 DOI: 10.1186/s12883-023-03110-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS. METHODS We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared. RESULTS Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS. CONCLUSIONS Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.
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Affiliation(s)
- Jae-Chan Ryu
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Han Bae
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hee Ha
- grid.256155.00000 0004 0647 2973Department of Neurology, Gil Medical Center, Gachon University, Incheon, Korea
| | - Boseong Kwon
- grid.267370.70000 0004 0533 4667Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yunsun Song
- grid.267370.70000 0004 0533 4667Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- grid.267370.70000 0004 0533 4667Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Young Chang
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U. Kwon
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S. Kim
- grid.267370.70000 0004 0533 4667Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Achim A, Lackó D, Hüttl A, Csobay-Novák C, Csavajda Á, Sótonyi P, Merkely B, Nemes B, Ruzsa Z. Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting. J Diabetes Res 2022; 2022:4196195. [PMID: 35860343 PMCID: PMC9293551 DOI: 10.1155/2022/4196195] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/28/2022] [Accepted: 06/09/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS. METHODS A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up. RESULTS There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04). CONCLUSION The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.
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Affiliation(s)
- Alexandru Achim
- Department of Internal Medicine, Division of Invasive Cardiology, University of Szeged, Szeged, Hungary
- Department of Invasive Cardiology, Medicala 1 Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Dávid Lackó
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Artúr Hüttl
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | | | - Ádám Csavajda
- Bács-Kiskun County Hospital, Teaching Hospital of the Szent-Györgyi Albert Medical University, Kecskemét, Hungary
| | - Péter Sótonyi
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Béla Merkely
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Balázs Nemes
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
| | - Zoltán Ruzsa
- Department of Invasive Cardiology, Medicala 1 Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Semmelweis University, Cardiac and Vascular Center, Budapest, Hungary
- Bács-Kiskun County Hospital, Teaching Hospital of the Szent-Györgyi Albert Medical University, Kecskemét, Hungary
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Tao Y, Hua Y, Jia L, Jiao L, Liu B. Risk Factors for Residual Stenosis After Carotid Artery Stenting. Front Neurol 2021; 11:606924. [PMID: 33584505 PMCID: PMC7876267 DOI: 10.3389/fneur.2020.606924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Stent residual stenosis is an independent risk factor for restenosis after stenting. This study aimed to analyze the factors influencing residual stenosis after carotid artery stenting (CAS). Methods: A total of 570 patients who underwent CAS with 159 closed-loop stents (CLS) and 411 open-loop stents (OLS) from January 2013 to January 2016 were retrospectively enrolled in this study. Carotid stenosis location in the common carotid artery or in internal carotid artery, plaque size, and features (regular or irregular morphology; with or without calcification), degree of carotid artery stenosis, and stent expansion rate were detected by carotid duplex ultrasonography. Residual stenosis was defined as a stenosis rate ≥30% after CAS, as detected by digital subtraction angiography. A logistic regression analysis was used to analyze residual stenosis risk factors. Results: The overall incidence of residual stenosis was 22.8% (130/570 stents). The incidence of residual stenosis in the CLS group was higher than that in the OLS group (29.5 vs. 20.2%, χ2 = 5.71, P = 0.017). The logistic regression analysis showed that CLS [odds ratio (OR), 1.933; 95% confidence interval (CI), 1.009-3.702], irregular plaques (OR, 4.237; 95% CI, 2.391-7.742), and plaques with calcification (OR, 2.370; 95% CI, 1.337-4.199) were independent risk factors for residual stenosis after CAS. In addition, a high radial expansion rate of stent was a protective factor for residual stenosis (OR, 0.171; 95% CI, 0.123-0.238). The stenosis location and stent length did not impact the occurrence of residual stenosis. After 1-year follow-up, the incidence of restenosis in the residual stenosis group was higher than that in the group without residual stenosis (13.1 vs. 2.0%, χ2 = 28.05, P < 0.001). Conclusions: The findings of this study suggest that plaque morphology, echo characteristics (with calcification), and stents type influence residual stenosis.
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Affiliation(s)
- Yunlu Tao
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
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AbuRahma AF, AbuRahma ZT, Scott G, Adams E, Mata A, Beasley M, Dean LS, Davis E. The incidence of carotid in-stent stenosis is underestimated ≥50% or ≥80% and its clinical implications. J Vasc Surg 2018; 69:1807-1814. [PMID: 30552039 DOI: 10.1016/j.jvs.2018.08.185] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/08/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The incidence of carotid in-stent stenosis has been reported to vary between 1% and 30%. Most published studies have short follow-up, which may lead to underestimation of the incidence of in-stent stenosis. This study analyzed the incidence of ≥50% and ≥80% in-stent stenosis using validated duplex ultrasound criteria and its clinical implications. METHODS This is a retrospective analysis of prospectively collected data of 450 carotid artery stenting (CAS) procedures (February 6, 2001-December 19, 2016). All patients had postoperative carotid duplex ultrasound examination, which was repeated at 1 month, 6 months, and every 6 to 12 months thereafter. A Kaplan-Meier analysis was used to estimate rates of freedom from ≥50% in-stent stenosis (internal carotid artery peak systolic velocity of ≥224 cm/s) and ≥80% in-stent stenosis (internal carotid artery peak systolic velocity of ≥325 cm/s), freedom from reintervention, and survival. RESULTS The mean age was 68.3 years, with a mean follow-up of 40.3 months. A total of 201 patients (45% [201/450]) had CAS for symptomatic disease. Primary CAS was done in 291 patients (65%); in the remaining 35%, CAS was done for postcarotid endarterectomy (CEA) stenosis. A total of 101 patients (23%) had ≥50% late carotid in-stent stenosis, and of these, 33 (7.4%) had ≥80% in-stent stenosis. Nineteen patients (4.3%) developed late transient ischemic attack and three (0.7%) late stroke. Twenty-three (5.2%) patients had late reintervention. Rates of freedom from ≥50% in-stent stenosis in the whole series were 85%, 79%, 75%, 72%, and 70% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥50% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were not statistically significant (P = .540). The rates of freedom from ≥80% in-stent stenosis for the whole series were 96%, 95%, 93%, 90%, and 89% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥80% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were also not statistically significant (P = .516). Rates of freedom from reintervention were 98%, 96%, 93%, 93%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, and there were no significant differences between primary CAS and CAS for post-CEA stenosis (P = .939). The overall late survival rates were 99%, 97%, 96%, 94%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years. CONCLUSIONS The incidence of ≥50% in-stent stenosis is relatively high; however, the rates of ≥80% stenosis and late neurologic events are low. Longer follow-up of patients with ≥50% carotid in-stent stenosis may yield higher incidence of ≥80% stenosis.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, WVa.
| | | | - Grant Scott
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Elliot Adams
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Abe Mata
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Matthew Beasley
- Department of Surgery, West Virginia University, Charleston, WVa
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WVa
| | - Elaine Davis
- CAMC Health Education and Research Institute, Charleston, WVa
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Katano H, Nishikawa Y, Yamada H, Mase M. Calcification in original plaque and restenosis following carotid artery stenting. Surg Neurol Int 2017; 8:279. [PMID: 29279796 PMCID: PMC5705928 DOI: 10.4103/sni.sni_263_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/13/2017] [Indexed: 12/30/2022] Open
Abstract
Background: The relationship between calcification in primary plaque and recurrent stenosis after carotid artery stenting (CAS) is not established, but an inverse association with restenosis following carotid endarterectomy (CEA) has been suggested. Methods: We retrospectively analyzed 75 plaques of 109 consecutive CAS with regard to calcification, using the calcium score and shape, location, and other characteristics of original plaques together with stenting-related factors. CAS was performed in a standard fashion with an embolic protection device. Greater-than-moderate restenosis (≥50%) was assessed by peak systolic velocity (PSV) with duplex ultrasonography (≥130 cm/s, internal/common carotid or distal/proximal PSV ratio ≥2.0). Results: Univariate analysis revealed percentages of dyslipidemia treated with statins (P = 0.03), calcification in distal ICA (P = 0.02), and immediate residual stenosis (P = 0.02) were significantly higher in patients with greater-than-moderate restenosis, whereas calcification in carotid bulb and usage of open-cell stent were rather less frequent (P < 0.001 and P = 0.02, respectively). Multivariate logistic regression analysis showed that rarity of calcification in carotid bulb was a sole independent predictor for greater-than-moderate recurrent carotid stenosis 1 year after CAS (OR = 0.21, CI = 0.06–0.77, P = 0.02). Conclusions: Calcium score was not significantly related to restenosis at 1 year after CAS, as was previously found following CEA, though scarcity of calcification in carotid bulb was suggested as a predictor of in-stent restenosis. Compared to post-CEA restenosis, carotid plaque calcification may be inversely but tenuously associated with recurrent stenosis 1 year post-CAS. No other stenting factors (e.g., stent design, pre-/post-dilation, or protection devices) showed a significant association with recurrent stenosis post-CAS.
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Affiliation(s)
- Hiroyuki Katano
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan.,Department of Medical informatics and Integrative Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Yusuke Nishikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Hiroshi Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
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9
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Sorkin GC, Dumont TM, Eller JL, Mokin M, Hopkins LN, Snyder KV, Siddiqui AH, Levy EI. Instent restenosis after carotid stenting: treatment using an off-label cardiac scoring balloon. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2014; 7:29-34. [PMID: 24920986 PMCID: PMC4051902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Treatment of instent restenosis after carotid artery stenting because of circumferential or calcified lesions can be difficult and refractory to conventional balloon angioplasty. We describe the off-label use of a cardiac scoring balloon that was used for lesions refractory to angioplasty with other balloons. CASE DESCRIPTIONS Two patients with a history of carotid artery stenting 6 and 8 years ago, presented with symptomatic carotid instent restenosis caused by circumferential and calcified lesions, respectively. Angioplasty with conventional compliant and noncompliant balloons was unsuccessful. An AngioSculpt percutaneous transluminal coronary angioplasty (PTCA) scoring balloon catheter (AngioScore, Fremont CA, USA) was successful in achieving vessel recanalization despite the refractory nature of these lesions. No further conventional balloons or use of cutting balloons was required. CONCLUSION The AngioSculpt PTCA scoring balloon catheter can be a useful option for treatment of refractory calcified or circumferential carotid instent restenosis.
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Affiliation(s)
- Grant C. Sorkin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Travis M. Dumont
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Jorge L. Eller
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Maxim Mokin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - L. Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Kenneth V. Snyder
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Adnan H. Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Elad I. Levy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
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10
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Khan M, Qureshi AI. Factors Associated with Increased Rates of Post-procedural Stroke or Death following Carotid Artery Stent Placement: A Systematic Review. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2014; 7:11-20. [PMID: 24920983 PMCID: PMC4051899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND PURPOSE We provide an assessment of clinical, angiographic, and procedure related risk factors associated with stroke and/or death in patients undergoing carotid artery stent placement which will assist in patient stratification and identification of high-stent risk patients. METHODS A comprehensive search of Medline from January 1st 1996 to December 31st 2011 was performed with key words "carotid artery stenosis", " carotid artery stenting", "carotid artery stent placement", "death" , " mortality", "stroke", "outcome", "clinical predictors", "angiographic predictors", was performed in various combinations. We independently abstracted data and assessed the quality of the studies. This analysis led to the selection of 71 articles for review. RESULTS Clinical factors including age≥80 years, symptomatic status, procedure within 2 weeks of symptoms, chronic renal failure, diabetes mellitus, and hemispheric TIA were associated with stroke (ischemic or hemorrhagic) and death within 1 month after carotid artery stent placement. Angiographic factors including left carotid artery intervention, stenosis > 90%, ulcerated and calcified plaques, lesion length > 10mm, thrombus at the site, ostial involvement, predilation without EPD, ICA-CCA angulation > 60%, aortic arch type III, and aortic arch calcification were also associated with 1 month stroke and/or death. Intra-procedural platelet GP IIb/IIIa inhibitors, protamine use, multiple stents, predilatation prior to stent placement were associated with stroke (ischemic or hemorrhagic) and death after carotid artery stent placement. Intraprocedural use of embolic protection devices and stent design (open versus closed cell design) did not demonstrate a consistent relationship with 1 month stroke and/or death. Procedural statin use, and operator and center experience of more than 50 procedures per year were protective for 1 month stroke and/or death. CONCLUSIONS Our review identified risk factors for stroke, death, and MI within 1 month in patients undergoing carotid artery stent placement. Such information will result in better patient selection for carotid artery stent placement particularly in those who are also candidates for carotid endarterectomy.
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Affiliation(s)
- Muhib Khan
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI
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11
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Computer methods for follow-up study of hemodynamic and disease progression in the stented coronary artery by fusing IVUS and X-ray angiography. Med Biol Eng Comput 2014; 52:539-56. [DOI: 10.1007/s11517-014-1155-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
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12
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Crosstalk between TGF-β/Smad3 and BMP/BMPR2 signaling pathways via miR-17-92 cluster in carotid artery restenosis. Mol Cell Biochem 2013; 389:169-76. [PMID: 24378993 DOI: 10.1007/s11010-013-1938-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/18/2013] [Indexed: 10/25/2022]
Abstract
In the recent decades, carotid angioplasty and stenting (CAS) has been developed into a credible option for the patients with carotid stenosis. However, restenosis remains a severe and unsolved issue after CAS treatment. Restenosis is characterized by neointimal hyperplasia, which is partially caused by vascular smooth muscle cells (VSMC) proliferation. However, the molecular mechanism involved in the restenosis is still unclear. In this study, we demonstrated a functional crosstalk between two TGF-β superfamily signaling pathway members, Smad3 and BMPR2, in VSMC proliferation. Smad3 plays an important role in the TGF-β/Smad3 signaling pathway, and is significantly upregulated in the carotid artery with restenosis to promote VSMC proliferation. In contrast, BMP receptor II (BMPR2), an inhibitor of VSMC proliferation is downregulated in carotid restenosis. We further found that BMPR2 downregulation is mediated by miR-17-92 cluster, which is transcriptionally regulated by Smad3. Thus, Smad3 upregulation and Smad3/miR-17-92 cluster-dependent BMPR2 downregulation are likely to promote VSMC proliferation and restenosis. Taken together, our results may provide novel clues for early diagnosis of carotid restenosis and developing new therapeutic strategy.
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13
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De Santis G, Conti M, Trachet B, De Schryver T, De Beule M, Degroote J, Vierendeels J, Auricchio F, Segers P, Verdonck P, Verhegghe B. Haemodynamic impact of stent–vessel (mal)apposition following carotid artery stenting: mind the gaps! Comput Methods Biomech Biomed Engin 2013; 16:648-59. [DOI: 10.1080/10255842.2011.629997] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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14
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Society for Vascular Nursing clinical practice guideline (CPG) for carotid artery stenting. JOURNAL OF VASCULAR NURSING 2013; 31:32-55. [PMID: 23481879 DOI: 10.1016/j.jvn.2012.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 11/30/2012] [Accepted: 12/03/2012] [Indexed: 02/07/2023]
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15
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Computer Simulations in Stroke Prevention: Design Tools and Virtual Strategies Towards Procedure Planning. Cardiovasc Eng Technol 2013. [DOI: 10.1007/s13239-013-0134-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Pizzolato R, Hirsch JA, Romero JM. Imaging challenges of carotid artery in-stent restenosis. J Neurointerv Surg 2013; 6:32-41. [DOI: 10.1136/neurintsurg-2012-010618] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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17
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18
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Clinical impact and predictors of carotid artery in-stent restenosis. J Neurol 2012; 259:1896-902. [PMID: 22318354 PMCID: PMC3432778 DOI: 10.1007/s00415-012-6436-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 01/16/2012] [Accepted: 01/20/2012] [Indexed: 10/29/2022]
Abstract
To assess the incidence and clinical significance as well as predictors of in-stent restenosis (ISR) after carotid artery stenting (CAS) diagnosed with serial duplex sonography investigations. We analyzed 215 CAS procedures that had clinical and serial carotid duplex ultrasound investigations. The incidence of in-stent restenosis (ISR) and periprocedural as well as long-term clinical complications were recorded. The influence of an ISR on clinical complication was analyzed using Kaplan-Meier curves and clinical risk factors for the development of an ISR with multivariate logistic regression. During a median follow-up time of 33.4 months (interquartile range 15.3-53.7) an ISR of ≥70% was detected in 12 (6.1%) of 215 arteries (mean age of 68.1 ± 9.8 years, 71.6% male). The combined stroke and death rate during long-term follow-up was significantly higher in the group with an ISR [odds ratio (OR): 3.59, 95% confidence interval (CI): 1.50-8.59, p = 0.004]. After applying multivariate logistic regression analysis contralateral carotid occlusion (OR 10.11, 95% CI 2.06-49.63, p = 0.004), carotid endarterectomy (CEA) restenosis (OR 8.87, 95% CI 1.68-46.84, p = 0.010) and postprocedural carotid duplex ultrasound with a PSV ≥120 cm/s (OR 6.33, 95% CI 1.27-31.44, p = 0.024) were independent predictors of ISR. ISR after CAS during long-term follow-up is associated with a higher proportion of clinical complications. A close follow-up is suggested especially in those patients with the aforementioned independent predictors of an ISR. Against the background of a lacking established treatment of ISR, these findings should be taken into account when offering CAS as a treatment alternative to CEA.
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Zhang L, Huang Q, Zhang Y, Liu J, Hong B, Xu Y, Zhao W. Wingspan stents for the treatment of symptomatic atherosclerotic stenosis in small intracranial vessels: safety and efficacy evaluation. AJNR Am J Neuroradiol 2012; 33:343-7. [PMID: 22173759 DOI: 10.3174/ajnr.a2772] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Until now, endovascular treatment of symptomatic atherosclerotic stenosis in small intracranial arteries (≤2.5 mm) was limited. We evaluated the safety and efficacy of the treatment by using Wingspan stents in arteries of this caliber. MATERIALS AND METHODS From March 2007 to July 2010, 53 symptomatic intracranial stenoses with narrowing of at least 50% in 53 patients were treated by using Wingspan stents. Clinical manifestations and imaging features were recorded. RESULTS The technical success rate was 98.1%. There were no serious complications, with the exception of 1 patient who experienced a small cerebral hemorrhage caused by perforation of microwire. Thirty-nine patients (74%) were available for follow-up imaging with DSA. ISR was documented in 13 of these patients, including 2 patients with symptomatic ISR. The median length of the vascular lesions was 5.39 mm, and patients whose vascular lesions were longer than 5.39 mm had a much higher incidence of ISR than patients whose vascular lesions were shorter than 5.39 mm (53% versus 15%, respectively). The median ratio of the reference artery diameter to the stent diameter was 0.78, and patients whose ratio was smaller than 0.78 had a much higher incidence of ISR than patients whose ratio was larger than 0.78 (53% versus 15%, respectively). CONCLUSIONS In our series, percutaneous transluminal angioplasty and stent placement of small intracranial arteries by using Wingspan stents was safe. The ISR rate was relatively high; most patients having ISR were asymptomatic. Further follow-up is needed to assess the long-term efficacy of this procedure.
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Affiliation(s)
- L Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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20
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Diabetes is not a predictor of outcome for carotid revascularization with stenting as it may be for carotid endarterectomy. J Vasc Surg 2012; 55:79-89; discussion 88-9. [DOI: 10.1016/j.jvs.2011.07.080] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 07/19/2011] [Accepted: 07/20/2011] [Indexed: 11/19/2022]
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21
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Broussalis E, Kunz AB, Luthringshausen G, Klein S, McCoy MR, Trinka E, Killer-Oberpfalzer M. Treatment of vertebral artery origin stenosis with a Pharos stent device: a single center experience. Interv Neuroradiol 2011; 17:316-22. [PMID: 22005693 DOI: 10.1177/159101991101700306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 04/24/2011] [Indexed: 11/15/2022] Open
Abstract
Atherosclerotic stenosis of vertebral artery (VA) origin exceeding 70% severity accounts for one third of all vertebrobasilar strokes. For a period of one year the results of endovascular treatment of VA stenosis with the new Pharos stent device were assessed.Twenty-two patients with symptomatic VA stenosis were treated with the Pharos stent. Clinical status and stenosis grade were documented before treatment and 24 hours, one, three and twelve months after treatment via ultrasound and magnetic resonance tomography.All procedures proved to be technically successful without the occurrence of intra-procedural complications. During the observation period of more than one year, 55% of patients were documented with a mean stenosis degree of 60%: two (10%) of these patients showed a residual stenosis after angioplasty and nine patients (45%) an in-stent restenosis, whereas only two patients were documented with a hemodynamically relevant in-stent restenosis of 80%. These two patients were retreated with balloon dilatation. None of the patients showed neurological deterioration or new abnormalities at magnetic resonance tomography examination. Neither VA occlusion nor restenosis of the contralateral VA negatively affected the clinical outcome. An in-stent restenosis was developed by more female than male patients.VA origin stenting with the Pharos stent device is an effective treatment of stenosis. The good clinical results compared to the high restenosis rates have to be examined in further studies. Pin particular, it has to be determined whether the Pharos stent allows the vessel time for collateralization, whether double antiplatelet treatment prevents recurrent cerebrovascular events or whether merely the low restenosis degree is causative for the clinical outcome.
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Affiliation(s)
- E Broussalis
- Department of Neurology, Paracelsus Medical University, Christian Doppler Klinik, Salzburg, Austria.
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