Intravascular ultrasonography assisted carotid artery stenting for treatment of carotid stenosis: Two case reports

BACKGROUND Digital subtraction angiography(DSA),the gold standard of cerebrovascular disease diagnosis,is limited in its diagnostic ability to evaluate arterial diameter.Intravascular ultrasonography(IVUS)has advantages in assessing stenosis and plaque nature and improves the evaluation and effectiveness of carotid artery sten-ting(CAS).CASE SUMMARY Case 1:A 65-year-old man presented with a five-year history of bilateral lower limb weakness due to stroke.Physical examination showed decreased strength(5-/5)in both lower limbs.Carotid artery ultrasound,magnetic resonance angiography,and computed tomography angiography(CTA)showed a right proximal internal carotid artery(ICA)stenosis(70%-99%),acute cerebral infarction,and severe right ICA stenosis,respectively.We performed IVUS-assisted CAS to measure the stenosis and detected a low-risk plaque at the site of stenosis prior to stent implantation.Post-stent balloon dilatation was performed and postoperative IVUS demonstrated successful expansion and adherence.CTA six months postoperatively showed no significant increase in in-stent stenosis.Case 2:A 36-year-old man was admitted with a right common carotid artery(CCA)dissection detected by ultrasound.Physical examination showed no positive neurological signs.Carotid ultrasound and CTA showed lumen dilation in the proximal CCA with an intima-like structure and bulging in the proximal segment of the right CCA with strip-like low-density shadow(dissection or carotid web).IVUS-assisted DSA confirmed right CCA dissection.CAS was performed and intraoperative IVUS suggested a large residual false lumen.Post-stent balloon dilatation was performed reducing the false lumen.DSA three months postoperatively indicated good stent expansion with mild stenosis.CONCLUSION IVUS aids decision-making during CAS by accurately assessing carotid artery wall lesions and plaque nature preoperatively,dissection and stenosis morphology intraoperatively,and visualizing and confirming CAS postoperatively.

Monitoring cerebral ischemia during carotid endarterectomy and stenting

Current therapy for carotid stenosis mainly includes carotid endarterectomy and endovascular stenting,which may incur procedure-related cerebral ischemia.Several methods have been employed for monitoring cerebral ischemia during surgery,such as awake neurocognitive assessment,electroencephalography,evoked potentials,transcranial Doppler,carotid stump pressure,and near infrared spectroscopy.However,there is no consensus on the gold standard or the method that is superior to others at present.Keeping patient awake for real time neurocognitive assessment is effective and essential;however,not every surgeon adopts it.In patients under general anesthesia,cerebral ischemia monitoring has to rely on non-awake technologies.The advantageous and disadvantageous properties of each monitoring method are reviewed.

Evaluation of ischemic lesions after carotid artery stenting with diffusion-weighted imaging

BACKGROUND Almost 90%of cerebral thromboembolism cases are caused by atherosclerosis.Craniocervical atherosclerosis is often observed at the carotid bifurcation and is responsible for 20%-30%of all stroke cases.The course of atherosclerotic carotid artery stenosis varies depending on the grade of stenosis and characteristics of the plaque.Carotid artery stenting(CAS)can be used as a less invasive method in patients with symptomatic and asymptomatic high-grade carotid artery stenosis.Diffusion-weighted imaging(DWI)is an effective method for detection of silent or symptomatic acute ischemic lesions that may arise due to CAS or carotid endarterectomy.The number and volume of new ischemic lesions are determined using DWI.AIM To evaluate the number and volume of ischemic lesions and their cerebral parenchymal and vascular distribution after CAS using DWI.METHODS Forty-seven male(73.4%)and seventeen female(26.6%)patients(total,n=64)aged 42-84 years(mean 67.96±8.03 years)diagnosed with carotid stenosis between October 2006 and July 2012 were included in this retrospective study.Twelve of the cases(18.8%)were asymptomatic,while fifty-two(81.2%)were symptomatic.The area where the stenosis was highest was measured,and the stenosis rate was determined using the North American Symptomatic Carotid Endarterectomy Trial method.DWI of the cases was evaluated by two radiologists experienced in neuroradiology(B.A.with more than 15 years of experience,E.G.with more than 10 years of experience).Routine DWI examinations were carried out by a 1.5 T MR device 1 h before and after the operation.Since the ischemic lesions that developed in the first hour and in the follow-up period of 5-24 h were assumed to be due to CAS,all lesions within the first 24 h were considered as new ischemias.RESULTS In the present study,39 new ischemic lesions were detected in 20 cases.The average number of new lesions after all CAS operations was 0.62.They were mostly located in the occipital lobes,followed by the frontal and parietal lobes.These new ischemic lesions were most common in the middle cerebral artery territory,followed by the posterior cerebral artery territory and middle cerebral artery-posterior cerebral artery watershed areas.New lesions were found in 31.2%(20/64)of patients,including 17(26.5%)in ipsilateral and three(4.6%)in contralateral hemispheres.New bilateral lesions were detected in one case(1.5%).The average volume of the new ischemic lesions detected by the two observers was 1.10 cm³.The numbers of newly appearing ischemic lesions in DWI after CAS were significantly higher in cases where stenting was applied on the left side of the carotid artery and in cases where longer plaques(>1 cm)were responsible for the narrowing in symptomatic patients.The stenosis rate was low in the group with ulcerated plaques.CONCLUSION New ischemic lesions due to CAS appear mostly in the main arterial territory but they may also occur in watershed areas.

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient’s refusal for surgery, direct carotid access was his only option.

Carotid artery stenting in the elderly: the time has come

Introduction Affecting over half a million people per year, stroke is the third leading cause of death in the United States. Approximately 30% of strokes are caused by carotid occlusive disease.……

Ileal hemorrhagic infarction after carotid artery stenting:A case report and review of the literature

BACKGROUND Ileal hemorrhagic infarction after carotid artery stenting(CAS)is a fatal complication.The prognosis of ileal hemorrhagic infarction after CAS is very poor if not treated in a timely manner.We describe a rare case of ileal hemorrhagic infarction due to acute embolism of the mesenteric artery after CAS.CASE SUMMARY A 67-year-old man with acute ischemic stroke underwent CAS via the right femoral artery approach 21 d after intensive medical treatment.On the first day after surgery,the patient had abdominal distension and abdominal pain.Abdominal enhanced computed tomography revealed intestinal obstruction,severe stenosis of the superior mesenteric artery,and poor distal angiography.An exploratory laparotomy was performed,and pathological examination showed hemorrhagic ileal infarction.It was subsequently found that the patient had intestinal flatulence.With the guidance of an ultrasound scan,the patient underwent abdominal puncture,drainage,and catheterization.After 58 d of treatment,the patient was discharged from hospital with a National Institutes of Health Stroke Scale score of 2 points,and a Modified Rankin Scale score of 1 point.At the 6-mo follow-up,the patient had an excellent functional outcome without stroke or mesenteric ischemia.Furthermore,computed tomography angiography showed that the carotid stent was patent.CONCLUSION Ileal hemorrhagic infarction is a fatal complication after CAS,usually caused by mesenteric artery embolism.Thus,more attention should be paid to the complications of embolism in the vascular system as well as the nervous system after CAS,and the complications should be identified and treated as early as possible.

Transcervical access,reversal of flow and mesh-covered stents:New options in the armamentarium of carotid artery stenting

In the last 25 years, the very existence of carotid artery stenting(CAS) has been threatened on a number of occasions. The initial disappointing results that even lead to the discontinuation of an early randomized controlled trial have improved considerably with time. Novel devices, advanced stent and equipment technology, alternative types of access and several types of filters/emboli protecting devices have been reported to reduce stroke/death rates during/after CAS and improve CAS outcomes. The present review will provide a description of the various technology advances in the field that aim to reduce stroke and death rates associated with CAS. Transcervical access, reversal of flow and mesh-covered stents are currently the most promising tools in the armamentarium of CAS.

Efficacy of Different Types of Self-expandable Stents in Carotid Artery Stenting for Carotid Bifurcation Stenosis

Both open and closed loop self-expandable stents were used in carotid artery stenting（CAS） for carotid bifurcation stenosis. We sought to compare the efficacy of two types of stents in CAS. The data of 212 patients treated with CAS（42 and 170 cases implanted with closed and open loop stents, respectively） for carotid bifurcation stenosis and distal filtration protection devices were retrospectively analyzed. Between closed and open loop stents, there were no significant differences in hospitalization duration, NIHSS score before and after the treatment, stenosis at 12 th month, and cumulative incidence of primary endpoint events within 30 days or from the 31 st day to the 12 th month; while there were significant differences in hemodynamic changes and rate of difficulty in recycling distal filtration protection devices. Use of open vs. closed loop stents for carotid bifurcation stenosis seems to be associated with similar incidence of complications, except for greater rate of hemodynamic changes and lower rate of difficulty in recycling the distal filtration protection devices.

A Comprehensive Analysis of a Case of Internal Carotid Artery Stenting

With the development of science and technology and the continuous progress of interventional equipment,internal carotid artery stenting has become increasingly popular among patients in view of its advantages,which include high efficiency,minimally invasive,and fast postoperative recovery.It has grown importance as a surgical method for the treatment of severe internal carotid artery stenosis.This paper discusses a rare case of severe internal carotid artery stenosis and its management,where various types of pre-dilatation balloons were not able to be positioned in the stenting process.Relevant solutions have also been proposed in hope to provide a more theoretical and practical basis for clinical work.

Commentary on a case report and literature review of acute carotid stent thrombosis

In this commentary on the article entitled“Acute carotid stent thrombosis:A case report and literature review”,the key points of the article are discussed.Acute carotid stent thrombosis(ACST)in the setting of carotid artery stenting(CAS)represents a rare but potentially catastrophic event.There is a wide range of treatment options available,including carotid endarterectomy,which is generally recommended for cases of refractory ACST.While there is no standard treatment regimen,dual antiplatelet therapy is typically recommended both before and after CAS to reduce risk of ACST.

Recanalization of extracranial internal carotid artery occlusion A 12-year retrospective study

This study aimed to summarize therapy experience of carotid endarterectomy, carotid endarterec- tomy combined with Fogarty catheter embolectomy, and hybrid surgery for the treatment of extrac- ranial internal carotid artery occlusion. The study included 65 patients with extracranial internal ca- rotid artery occlusion who underwent carotid endarterectomy, carotid endarterectomy combined with Fogarty catheter embotectomy, or hybrid surgery in the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China between January 2006 and December 2012. Prior to surgery, all patients underwent perfusion CT or xenon CT to evaluate the occlusion. The procedure for each patient was chosen according to digital subtraction angiography data. The carotid artery was successfully recanalized in 46 of 51 patients who underwent carotid endarterectomy, 9 of 10 patients who underwent carotid endarterectomy combined with Fogarty catheter embolectomy, and 3 of 4 patients who underwent hybrid surgery. In patients with symptomatic carotid artery occlusion, the carotid artery can be recanalized by choosing a treatment procedure based on imaging ex- amination findings.

Acute carotid stent thrombosis:A case report and literature review

BACKGROUND Acute carotid stent thrombosis(ACST)is a rare but devastating complication in the carotid artery stenting(CAS)procedure.The aim of this article is to report a case and review cases of ACST reported in the literature,and investigate risk factors and management strategies for ACST.CASE SUMMARY We reviewed the treatment process of a patient with ACST after CAS.Then multiple databases were systematically searched to identify studies reporting ACST from 2005 to 2020.The demographic data,risk factors,treatment strategies,and prognosis were extracted and analyzed.CONCLUSION The reason for ACST is multifactorial.Proper patient selection,normative antiplatelet treatment,and perfect technical detail may decrease the incidence of ACST.Several treatment strategies such as thrombolysis,mechanical thrombectomy,and open surgery may be options for the treatment of ACST.Limited data have shown that carotid endarterectomy is effective with favorable results.

Evaluation of the Protégé^(TM) stent in the treatment of carotid artery stenosis with adjunctive use of a filter Embolic Protection Device (PROCAR)-one-month follow-up data on 77 patients

Objective The trial was designed to evaluate the safety and performance of the ev3 Protégé TM stent in the treatment of de novo or re-stenotic common and/or internal carotid artery stenoses with adjunctive use of a CE-marked filter embolic protection device.Methods This study was a prospective multi-center, single-arm trial. Between June and October 2003, 77 patients were enrolled in 8 investigational centers throughout Europe. The primary endpoint was the incidence of Major Neurological Events (MANE) through one month. Other endpoints were the ability to properly place the stent, and primary patency and MANE after six months. Eligible for the study were patients with a de novo or restenotic target lesion located in the common and/or internal carotid artery (>70% stenosis for asymptomatic and >50% stenosis for symptomatic patients). The ev3 Spider (Embolic Protection Filter was used in 75 of 77 cases. Results In 76 out of the 77 patients (99%), the stent could be successfully implanted with a residual stenosis ≤30% as criterion. Of the 74 patients that had a carotid ultrasound at one month follow-up, none had a re-stenosis of the target lesion. There were three MANEs during or immediately after the procedure (3.9%), two were major and one was a minor stroke. There were eight severe complications (9.1%); six of these happened during or immediately after the procedure and were related to the procedure, none was related to the device. They are resolved without sequelae. No deaths have occurred.Conclusions The Protégé stent is safe and performs well in the treatment of carotid artery stenosis. The technical success rate for placement of the Protégé stent as assessed by the residual stenosis post implant was very high and all stents were successfully deployed. The incidence of MANE was comparable with that in other recent carotid stent studies and still lower than standard CEA.

Plaque components affect wall stress in stented human carotid artery: A numerical study

Carotid artery stenting presents challenges of in-stent restenosis and late thrombosis, which are caused primarily by alterations in the mechanical environment of the artery after stent implantation. The present study constructed patient-specific carotid arterial bifurcation models with lipid pools and calcified components based on magnetic resonance imaging. We numerically analyzed the effects of multicomponent plaques on the distributions of von Mises stresses (VMSs) in the patient-specific models after stenting. The results showed that when a stent was deployed, the large soft lipid pool in atherosclerotic plaques cushioned the host artery and reduced the stress within the arterial wall; however, this resulted in a sharp increase of VMS in the fibrous cap. When compared with the lipid pool, the presence of the calcified components led to slightly increased stresses on the luminal surface. However, when a calcification was located close to the luminal surface of the host artery and the stenosis, the local VMS was elevated. Overall, compared with calcified components, large lipid pools severely damaged the host artery after stenting. Furthermore, damage due to the calcified component may depend on location.

Topical anaesthesia before transradial approach for supraoartic vessels angiography and stenting in the elderly： a feasible alternative

Over the years, the use of transradial approach （TRA） for carotid artery stenting （CAS） with distal embolic protection has been recognized as a valid alternative to the conventional femoral approach, improving the outcomes compared to carotid endoatherectomy.0-33 Indeed, despite the femoral artery remains the conventional access site for the endovascular treatment of supraoartic vessels, concomitant anatomical variations and/or peripheral vascular disease could complicate the cannulation of such arteries. Moreover, the TRA has been related with a lower incidence of bleeding complications and a shorter bed rest after the interventional procedure.

CAS and CEA in the Treatment of Severe Internal Carotid Artery Stenosis

Objective:To explore the clinical value of carotid artery stent implantation(CAS)and carotid endarterectomy(CEA)in the treatment of patients with severe internal carotid artery stenosis.Methods:88 patients with severe carotid artery stenosis who underwent CAS and CEA in the First People's Hospital of Changde City(hereafter referred as "our hospital")from January 2018 to December 2020 were selected as the research objects and divided into CAS group(n=43)and CEA group(n=45).To understand the clinical application value and feasibility of the two surgical schemes by comparing the general situation,cerebral blood flow,MMSE scale,MOCA scale score and serum miR-145,IGF1R levels of the two surgical schemes.Conclusions:CAS and CEA in the treatment of patients with severe internal carotid artery stenosis,have good curative effect,can effectively improve the patient's cerebral blood flow,regulate serum miR-145,IGF 1R levels,promote the recovery of cognitive function,but relatively speaking,the incidence of stroke and hypotension after CAS is higher,and the incidence of hypertension after CEA is higher.

Percutaneous transluminal stenting in patients with carotid artery stenosis

Objective To assess the efficacy and safety of percutaneous transluminal stenting for patients with carotid artery stenosis.Methods Selective percutaneous transluminal stenting was performed for patients with symptomatic carotid artery stenosis(luminal narrowing ≥ 70%).Success rates and complications associated with the procedures were observed.During six months of follow-up,both recurrent symptom and restenosis rates were recorded.Results There were 17 bifurcating lesions among 27 stenoses in 26 patients,of whom 18 had concomitant coronary artery diseases.The acute procedural success rate was 96.3%(26/27),and the degree of stenosis was reduced from 88.6% ± 8.9%(range 70 - 100)to 0.4% ± 2.0%(range 0 - 10).Six patients developed severe bradycardia and hypotension,and 3 experienced transient loss of consciousness during balloon dilatation.During hospitalization,2 patients experienced loss of consciousness and convulsion,respectively,due to hyperperfusion,and both recovered 12 hours later.There were 2 minor stroke cases (7.4%)but no cases of major stroke or death.At the 6-month follow-up,there were no cases of TIA or new onset of stroke.There was no restenosis detected in 16 cases using angiography and in 10 cases using MRI in 6 to 16 months of follow-up.Conclusions Percutaneous transluminal stenting for patients with carotid artery stenosis has a high procedural success rate with few and acceptable complications.Few patients suffered from recurrent symptoms or showed restenosis in long-term follow-up.

Efficacy of Acupuncture Combined with Local Anesthesia in Ischemic Stroke Patients with Carotid Artery Stenting:A Prospective Randomized Trial

Objective:To evaluate the efficacy of electro-acupuncture(EA)or transcutaneous electrical acupoint stimulation(TEAS)on perioperative cerebral blood flow(CBF)and neurological function in ischemic stroke(IS)patients undergoing carotid artery stenting(CAS).Methods:In total,124 consecutive IS patients were randomly allocated to the EA,TEAS,and sham groups(groups A,T,and S;41,42,and 41 cases,respectively)by softwarederived random-number sequence.Groups A and T received EA and TEAS,respectively,at the Shuigou(GV 26)and Baihui(GV 20),Hegu(LI4)and Waiguan(TE 5)acupoints.Group S received sham EA.The stimulation was started from 30 min before surgery until the end of the operation.The primary outcome was the CBF at 30 min after surgery,which was measured by transcranial Doppler sonography.The secondary outcomes included hyperperfusion incidence and neurological function.National Institutes of Health Stroke Scale(NIHSS)and General Evaluation Scale(GES)scores were recorded at 1 week,1 month,and 3 months postoperatively.Results:Mean CBF velocity at 30 min after surgery in groups A and T was much lower than that in Group S(P<0.05);the incidence of hyperperfusion in Groups A and T was also lower than that in group S(P<0.05).Acupuncture was an independent factor associated with reduced incidence of hyperperfusion(OR=0.042;95%CI:0.002–0.785;P=0.034).NIHSS and GES scores improved significantly at 1 week postoperatively in Groups A and T than in Group S(P<0.05).Relative to Group S,groups A and T exhibited significantly lower incidences of moderate pain,as well as higher incidences of satisfaction with anesthesia,at 1 day postoperatively(P<0.05).Conclusion:EA or TEAS administered in combination with local anesthesia during CAS can inhibit transient increases in CBF,reduce the incidence of postoperative hyperperfusion,and improve neurological function.

Thirty-day outcome of carotid artery stenting in Chinese patients： a single-center experience

Background Carotid artery stenting （CAS） as a competing treatment modality has had to adhere to limits to gain widespread acceptance in some studies. This study analyzed the clinical data of 1700 consecutive patients after CAS to retrospectively evaluate the 30-day outcome of CAS for internal carotid artery stenosis in a Chinese population. Methods Medical records of 1700 patients who underwent CAS at Xuanwu Hospital affiliated to Capital Medical University between January 2001 and August 2012 were reviewed. Postoperative 30-day complication rates were analyzed and compared with those of other studies. Univariate and multivariate Logistic regression analyses were used to identify factors associated with perioperation myocardial infarction （MI）, stroke, and death.

Fracture of a cerebral protection device wire in carotid artery stenting： an unexpected complication

There are very few reports concerning the failure of devices used in carotid artery stenting. Here we report a fracture of the distal part of the guiding wire of a cerebral protection device during carotid artery stenting for management of a restenotic lesion after carotid endarterectomy.