Long-Term Outcome of Symptomatic Patients Undergoing Hybrid Revascularisation for Extracranial Carotid Artery Tandem Stenosis

Abstract

WHAT THIS PAPER ADDS This study shows that hybrid revascularisation is feasible and safe in symptomatic patients with an extracranial carotid artery tandem stenosis. This study provides data on purely symptomatic patients including a long-term clinical and imaging follow up period of more than six years. In the future, these surgical outcomes need to be offset against the natural course in patients with a symptomatic carotid tandem lesion. Objectives: Carotid tandem lesions are a multilevel significant (>50%) atherosclerotic disease involving both the internal carotid artery (ICA) and either the ipsilateral common carotid artery (CCA) or the innominate artery (IA). These lesions may be challenging to treat. Current guidelines offer no definitive recommendation on the optimal treatment algorithm. The aim of this analysis was to assess the long-term outcome of patients undergoing surgical revascularisation for tandem lesions. Methods: In two centres, consecutive patients who underwent carotid endarterectomy (CEA) for a symptomatic carotid artery stenosis between 2003 and 2017 were screened retrospectively for the presence of a carotid artery tandem lesion. All eligible patients were treated by a hybrid approach, consisting of retrograde stenting of the proximal CCA or IA followed by CEA. All patients had a yearly clinical check up including duplex ultrasound. The primary outcome was occurrence of any stroke, death, myocardial infarction (MI), or transient ischaemic attack (TIA) within 30 days. Secondary outcomes were any stroke, death, MI, or TIA and occurrence of restenosis 50% during follow up. Results: Sixteen of 2368 symptomatic patients were included. Besides a high grade ICA stenosis, patients had a significant ipsilateral stenosis of the CCA (n ¼ 13) or IA (n ¼ 3). Within 30 days there were no deaths, strokes, or TIAs. Two patients had a clinical MI. During a median follow up of 73 (interquartile range 22e85) months, three patients died. One patient developed a symptomatic restenosis of the ICA (ipsilateral TIA). Two patients (without restenosis) developed an ipsilateral stroke and a MI. Conclusions: In this small case series, hybrid revascularisation of carotid tandem lesions in symptomatic patients seems feasible and safe. Long-term data show a relatively high number of any adverse events. These surgical outcomes need to be offset against the natural course in patients with a symptomatic carotid tandem lesion.

Comparison of 30 Day Stroke and Death in Hybrid Intervention and Open Surgical Reconstruction for the Treatment of Tandem Carotid Bifurcation and Supra-aortic Trunk Disease

“…Others have also more recently appreciated the technical simplification, but agreed that the procedure carried more risk than CEA alone. 14,15 Herein, the CEA þ IPE cohort showed a similar overall stroke and death risk of 3.8% as these previous reports. Full open surgical management of tandem lesions has been done for decades.…”

Usefulness of Hybrid Surgery Combining CEA and CAS for Carotid Artery Stenosis with a Large Amount of Vulnerable Plaque

“…On the other hand, several studies reported retrograde stenting (ipsilateral proximal endovascular intervention [IPE]) for stenotic lesions of the proximal CCA or brachiocephalic artery, [10][11][12][13][14][15][16][17] as demonstrated in our series. Many studies applied this procedure for patients with plaque continuing from the internal-external carotid bifurcation to the CCA side or in those with tandem lesions in which stenosis was separately present at the internal-external carotid bifurcation and in the proximal CCA brachiocephalic artery.…”

“…Many studies reported a combination of direct surgery and endovascular treatment for carotid artery stenosis using a hybrid operating room. [9][10][11][12][13][14][15][16][17] There are some variations among these studies. Initially, there is a method to directly puncture the CCA in patients in whom accessing for CAS is difficult.…”

“…On those with tandem lesions involving a lesion at the bifurcation, CEA was initially performed, followed by stenting through the site of arteriotomy. [11][12][13][14][15][16] As an advantage of this method, vulnerable plaque or a markedly calcified lesion, which may induce embolic complications, can be accurately removed using CEA, and an atherosclerotic lesion at a site that is difficult to reach during CEA can be simultaneously treated. As three carotid branches are exposed, blood flow can be accurately blocked with a clip; therefore, debris that deviated to the arterial lumen at the was unable to be fully treated by CEA, was performed.…”

“…They emphasized that the course was not always favorable, although the detailed outcome of a spontaneous history of symptomatic tandem lesions was unclear. 14) Furthermore, several studies involving a relatively large number of patients treated by CEA+IPE reported perioperative cerebral infarction and death, suggesting that whether this treatment is indicated should be carefully evaluated. 15,16) Clouse et al investigated the results of CEA+IPE for stenotic lesions of the proximal CCA or brachiocephalic artery in 62 patients at multiple institutions, and reported that perioperative ipsilateral cerebral infarction, hyperperfusion syndrome, and perioperative death (cerebral infarction in one patient and myocardial infarction in two patients) were noted in four (6.5%), two, and three (4.8%) patients, respectively.…”