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.

Diagnosis and treatment for advanced hilar cholangiocarcinoma:experience of 24 cases

The aim of this paper is to evaluate the effi-cacy of the surgical treatment for advanced hilar cholan-giocarcinoma(CCA)in order to improve the resection rate and curative effect.A retrospective analysis was performed on the data of 24 patients who had under-gone surgical treatment for advanced hilar CCA.According to the Bismuth classification,there were four cases of type IIIa,six cases of type IIIb,and 14 cases of type IV.Based on the treatment approaches,these patients were divided into three groups:①Radical resection group:There were five cases(one type IIIa,three type IIIb,and one type IV).The tumor visible to the naked eyes was resected thoroughly and the cut mar-gin was free of tumor by microscopic examination.Then,Roux-en-Y hepatico-jejunal anastomosis was per-formed to restore the bile flow.②Palliative resection group:There were 11 cases.The bile flow was restored by Roux-en-Y hepatico-jejunal anastomosis directly in five cases(two type IIIa,three type IIIb)and by internal drainage through a hepatico-jejunal bridge in the other six cases(one type IIIa,five type IV).③Simple internal biliary drainage group:There were eight cases of type IV,including three cases with the internal drainage through hepatico-jejunal bridge by laparotomy,three cases with endoscopic retrograde biliary drainage(ERBD),two cases with percutaneous transhepatic biliary drainage(PTBD).The rate of radical resection was 20.8%and the overall resection rate was 66.7%.All of the 24 patients were fol-lowed-up.The cumulative surviving rates were significantly different among these three groups(Log-rank x2=17.56,P=0.0002).For advanced hilar CCA,the best choice of treatment is radical resection.If radical resection is impractical,palliative resection combined with partial hepatectomy can significantly prolong the survival time.Internal drainage through a hepatico-jejunal bridge can enhance the surgical resection rate and decrease the occur-rence rate of postoperative biliary leakage.