Angioplasty of the Internal Carotid Artery: Results, Complications and FoIlow-Up in 61 Cases

Eckert, Bernd; Zanella, Friedhelm E.; Thie, Andreas; Steinmetz, Jacob; Zeumer, H.

doi:10.1159/000108004

Cited by 39 publications

(9 citation statements)

References 19 publications

(32 reference statements)

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“…[11][12][13][14] In contrast, case series of carotid endovascular treatment have shown that although restenosis may occasionally cause recurrent symptoms, most patients with moderate or severe stenosis after treatment remain asymptomatic at least in the first few years after treatment. [3][4][5][15][16][17] Our results support these findings, but we have also shown that the proportion of patients experiencing recurrent ischemic symptoms is significantly increased in patients with Ն70% stenosis at 1 year after endovascular treatment. However, most symptoms that occurred in association with Ն70% stenosis in the endovascular group were TIAs; no patient in this stenosis category had a disabling or fatal stroke during follow-up.…”

Section: Discussionsupporting

confidence: 87%

Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)

McCabe

Pereira

Clifton

et al. 2005

Stroke

137

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on behalf of the CAVATAS InvestigatorsBackground and Purpose-Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) patients with carotid stenosis were randomized between endovascular treatment and endarterectomy. The rates of residual severe stenosis and restenosis and their contribution to recurrent symptoms was unclear. Methods-Endovascular patients were treated by balloon angioplasty alone (88%) or stenting (22%). Patches were used in 63% of endarterectomy patients. Carotid stenosis was categorized as mild (0% to 49%), moderate (50% to 69%), severe (70% to 99%), or occluded, using standardized Doppler ultrasound criteria at the examination closest to 1 month (nϭ283) and 1 year (nϭ347) after treatment. Recurrent cerebrovascular symptoms during follow-up were analyzed. Results-More patients had Ն70% stenosis of the ipsilateral carotid artery 1 year after endovascular treatment than after endarterectomy (18.5% versus 5.2%, Pϭ0.0001). Residual severe stenosis was present in 6.5% of patients at 1 month after endovascular treatment. Between 1 month and 1 year, restenosis to Ն70% stenosis occurred in 10.5% of the endovascular group. After endarterectomy, 1.7% had residual severe stenosis at 1 month, and 2.5% developed severe restenosis. The results were significantly better after stenting compared with angioplasty alone at 1 month (PϽ0.001) but not at 1 year. Recurrent ipsilateral symptoms were more common in endovascular patients with severe stenosis (5/32 [15.6%]) compared with lesser degrees of stenosis at 1 year (11/141 [7.8%], Pϭ0.02), but most were transient ischemic attacks and none were disabling or fatal strokes. There were no recurrent symptoms in the 9 endarterectomy patients with Ն70% stenosis at 1 year. Conclusions-Carotid stenosis 1 year after endovascular treatment is partly explained by poor initial anatomical results and partly by restenosis. The majority of patients were treated by angioplasty without stenting. Further randomized studies are required to determine whether newer carotid stenting techniques are associated with a lower risk of restenosis. The low rate of recurrent stroke in both endovascular and endarterectomy patients suggests that treatment of restenosis should be limited to patients with recurrent symptoms, but long term follow up data are required.

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Section: Discussionsupporting

confidence: 87%

Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)

McCabe

Pereira

Clifton

et al. 2005

Stroke

137

View full text Add to dashboard Cite

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“…However, these authors noted that the blood pressure was elevated in the majority of patients at the time of presentation with the hyperperfusion syndrome. Percutaneous transluminal angioplasty (PTA) and angioplasty with stenting are increasingly being used as an alternative to carotid surgery in patients with carotid stenosis, [3][4][5][6][7] but as experience with this novel technique accrues the true complication rate has not yet been established.…”

mentioning

confidence: 99%

Fatal Cerebral Reperfusion Hemorrhage After Carotid Stenting

McCabe

Brown

Clifton

1999

Stroke

123

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Background-The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery (ICA) angioplasty are few, and this complication has never been reported following internal carotid stenting. Case Description-A 68-year-old normotensive man was referred to our hospital for assessment 5 months after experiencing a left hemispheric ischemic stroke. Angiography confirmed 95% stenosis of the left ICA. Left carotid percutaneous transluminal stenting was performed without any initial complications. Color Doppler ultrasound of the ICA immediately after stenting revealed an elevated peak systolic velocity of 2.3 m/s, in the absence of significant vessel stenosis or spasm on angiography. Seven hours after the procedure, the patient suddenly deteriorated. CT of the brain revealed extensive intracerebral hemorrhage (ICH), and he subsequently died 18 days later. There was no history of headache or seizure activity, and his blood pressure was only mildly elevated at the time of the deterioration. This is the first report of ICH after internal carotid stenting. Key Words: hypertension Ⅲ intracerebral hemorrhage Ⅲ stents Ⅲ ultrasonography, Doppler I n 1981, Sundt et al 1 used the term "hyperperfusion syndrome" to describe a triad of complications that included atypical migrainous phenomena, transient focal seizure activity, and intracerebral hemorrhage (ICH) after carotid endarterectomy. Symptoms usually developed 5 to 7 days postoperatively and were often preceded by unilateral headaches; the triad was not complete in all patients. The features were attributed to elevated ipsilateral cerebral blood flow without a significant change in systemic blood pressure. Breen et al 2 reported that the frequency of the hyperperfusion syndrome was 2.7% in their series, and in a recent review of the literature the frequency of ICH after carotid endarterectomy ranged from 0.3% to 1.2%. However, these authors noted that the blood pressure was elevated in the majority of patients at the time of presentation with the hyperperfusion syndrome. Percutaneous transluminal angioplasty (PTA) and angioplasty with stenting are increasingly being used as an alternative to carotid surgery in patients with carotid stenosis, 3-7 but as experience with this novel technique accrues the true complication rate has not yet been established. Conclusions-ICH Case ReportA 68-year-old right-handed man was referred for treatment of carotid stenosis after an ischemic stroke in which he developed a sudden onset of expressive dysphasia and right-sided facial and limb weakness. In the distant past, he had smoked heavily and had a history of excess alcohol intake, but had stopped both 24 years previously. There was no history of hypertension or other vascular risk factors. He had been initially treated with 75 mg aspirin daily and 20 mg paroxetine daily for depression. When assessed in our hospital 5 months later, his blood pressure was 142/85 mm Hg and he had mild dyscalculia, dysgra...

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“…Diese Art der Therapie führte allerdings zu einem unakzeptablen Anstieg embolischer Schlaganfallkomplikationen [45]. Der Grund für das erhöhte Embolierisiko waren thrombotische, beim Einbringen des Stents nach der Karotis-PTA mobilisierte Auflagerungen an reicht [25]. Die Kombinationstherapie mit ASS und Thienopyridin-Derivaten hemmt die Thrombozytenaggregation synergistisch und ist der Behandlung mit ASS und UFH bzw.…”

Section: Wissenschaftliche Basis Für Die Endovaskuläre Karotisrekanalunclassified

Stent-PTA der Karotis: Behandlungstechnik und medikament�se Begleitbehandlung

Koch

2004

Klinische Neuroradiologie

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ZusammenfassungEs wird die Entwicklung der Behandlungstechnik und der medikamentösen Begleitbehandlung zur endovaskulären Behandlung von Karotisstenosen beschrieben. Seit 1987 wurde bei 361 Patienten eine endovaskuläre Behandlung einer hochgradigen Karotisstenose durchgeführt. 101 der insgesamt 372 behandelten Stenosen wurden durch perkutane transluminale Angioplastie ohne oder mit nachfolgender Stentimplantation behandelt, 271 Stenosen wurden durch direkte Stentangioplastie therapiert. Alle endovaskulären Behandlungen wurden ohne zerebrale Protektion durchgeführt. Mit Einführung der direkten Stentangioplastie wurde die periinterventionelle Blutgerinnungshemmung von einer Zweifachkombination mit Acetylsalicylsäure (ASS) und unfraktioniertem Heparin (UFH) auf eine Dreifachkombination mit ASS, Clopidogrel und niedermolekularem Heparin (NMH) umgestellt. Durch die technischen und medikamentösen Veränderungen wurde die Häu-figkeit von periinterventionellen Komplikationen um mehr als 50% auf 1,5% reduziert. Durch die geänderte Behandlungstechnik mit direkter Stentangioplastie und verbesserter Blutgerinnungshemmung wurden die Voraussetzungen für einen direkten Vergleich der endovaskulären Behandlung von Karotisstenosen mit der chirurgischen Therapie im Rahmen der SPACE-Studie geschaffen, deren erste Ergebnisse in Kürze erwartet werden. Weitere Verbesserungen der Behandlungstechnik und der medikamentösen Begleitbehandlung sind abzusehen. Schlüsselwörter: Stent-Implantation · Ballondilatation · Minimal-invasive Chirurgie · Endovaskuläre Therapie · Stenose der Karotisarterie · Endarterektomie · Blutgerinnung AbstractThe technical and medical developments of endovascular treatment of carotid stenosis are described. Since 1987, endovascular treatment of high-grade carotid stenosis has been performed in 361 patients. 101 of 372 stenoses were treated by percutaneous transluminal angioplasty without and with stenting, respectively, while 271 stenoses were treated by direct stenting. All procedures were performed without cerebral protection. With implementation of direct stenting, the periprocedural anticoagulation was changed from acetylsalcylic acid (ASA) and unfractionated heparin (UFH) to a combination of ASA, clopidogrel and low molecular weight heparin (LMWH). By changing the technical and medical procedure, the relative risk reduction for morbidity and mortality was more than 50% to an absolute 1.5%. The combination of direct stenting and improved medical treatment enabled a direct comparison of endovascular treatment with surgical therapy within the SPACE trial with first results to be expected shortly. Further improvements of technical and medical treatment are conceivable.

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Angioplasty of the Internal Carotid Artery: Results, Complications and FoIlow-Up in 61 Cases

Cited by 39 publications

References 19 publications

Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)

Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)

Fatal Cerebral Reperfusion Hemorrhage After Carotid Stenting

Stent-PTA der Karotis: Behandlungstechnik und medikament�se Begleitbehandlung

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