Carotid stenting and endarterectomy

International Journal of Cardiology 214 (2016) 166–174

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Review

Carotid stenting and endarterectomy Hon-Kan Yip a,b,c,d,e,⁎, Pei-Hsun Sung f, Chiung-Jen Wu f, Cheuk-Man Yu g,h,⁎⁎ a

Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC c Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC d Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC e Department of Nursing, Asia University, Taichung, 41354, Taiwan, ROC f Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC g Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong h Institute of Vascular Medicine, LCW Institute of Innovative Medicine, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong b

a r t i c l e

i n f o

Article history: Received 11 March 2016 Accepted 20 March 2016 Available online 29 March 2016 Keywords: Carotid artery stenosis Endarterectomy Carotid stenting Transradial or transbrachial artery approach

a b s t r a c t Stroke, either ischemic or hemorrhagic, remains the second commonest cause of death worldwide in the last decade. Etiologies for ischemic stroke (IS) vary widely. Atherothrombotic occlusion is an essential cause to which carotid artery stenosis (CAS) is a major contributor. Administration of anti-platelet agent to patients with CAS has been shown to reduce incidence of long-term IS. In additional, in patients with symptomatic CAS, clinical trials have demonstrated that carotid endarterectomy (CEA) is superior to medical therapy for prevention of future CAS-related IS. However, CEA is not suitable for CAS post-radiotherapy or those located at higher level of the internal carotid artery; and major complications of this procedure including cranial nerve injuries have stimulated the interest of using percutaneous transfemoral carotid stenting as an alternative approach. Although transfemoral arterial approach of carotid stenting is not inferior to CEA in improving clinical outcomes, it has been reported to be associated with vascular complication and has its limitations in patients with atheroocclusive disease of abdominal aorta or bilateral iliac arteries, level II or III aortic arch, or bovine type carotid arterial anatomy. Therefore, transradial/transbrachial arterial approach has emerged as a novel method for carotid stenting. This article provides a critical review on interventional approaches for the treatment of CAS. © 2016 Elsevier Ireland Ltd. All rights reserved.

Stroke shatters a lot of patients' hopes and takes more than ten million of lives every year worldwide [1–5]. Despite state-of-the-art therapy which includes thrombolytic therapy by tissue plasminogen activator [6–8], more aggressive treatment with endovascular therapy [9–11] for acute ischemic stroke (IS), surgical intervention for acute hemorrhagic stroke [12–14] as well as regular update of guidelines [15,16], stroke is still the second commonest cause of death and the third commonest cause of disability-adjusted life-years worldwide [3] in the last decade [5,17,18]. There are two main types of stroke, namely IS due to lack of intracerebral blood flow and hemorrhagic stroke due to intracranial bleeding [18]. The etiologies of IS vary widely [9–12] which include atherothrombotic stroke, embolic stroke, cerebral hypoperfusion and venous thrombosis. However, atherothrombotic occlusion is the principal cause of IS [19–21] and carotid artery stenosis (CAS) is a major ⁎ Correspondence to: H.K. Yip, Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123, Dapi Road, Niaosung Dist., Kaohsiung City 83301, Taiwan, ROC. ⁎⁎ Correspondence to: C.M. Yu, Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong. E-mail addresses: [email protected] (H.-K. Yip), [email protected] (P.-H. Sung), [email protected] (C.-J. Wu), [email protected] (C.-M. Yu).

http://dx.doi.org/10.1016/j.ijcard.2016.03.172 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.

contributor to atherothrombotic IS or transient ischemic attack (TIA) [22–24]. Clinical studies have shown previously that anti-platelet therapy [6, 25–27] has effectively reduced the incidence of CAS-induced IS. On the other hand, further investigations have demonstrated that surgical carotid endarterectomy (CEA) is more effective than anti-platelet therapy in reducing the incidence of IS or death in patients with symptomatic (defined as IS, TIA or retinal TIA) severe (defined as ≥70% to 99% of stenosis) CAS [28–31]. Accordingly, CEA is the first established gold standard treatment of symptomatic CAS [28–34]. However, CEA is not without limitations. Firstly, it is not suitable for patients who had received radiotherapy which usually causes fibrosis and deformity over the skin and muscle layers of the neck area. Secondly, patients with the CAS located at higher level of internal carotid artery are not amenable to CEA due to limited surgical field accessibility. Thirdly, the result of CEA is much less favorable in the high-risk subset with severe coronary artery disease, pulmonary disease or renal dysfunction [35]. Fourthly, CEA may cause cranial nerve injuries and associated with the risk of ipsilateral ischemic events following the procedure [36–40]. These limitations of CEA raise the need of an alternative option for the treatment of CAS. Growing data have shown that carotid stenting (CS) by transfemoral arterial approach is not inferior to CEA for improving the

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short- and long-term prognosis in patients with symptomatic CAS [41– 43]. Accordingly, CS is currently being adopted as a complementary treatment to CEA for patients with CAS [41–45]. However, CS by transfemoral arterial approach is associated with vascular puncture site complications and is not feasible for patients with atherosclerotic occlusion of abdominal aorta or bilateral iliac arteries, level II–III aortic arch and carotid arterial anatomy of bovine arch [46–48]. Therefore, transradial/transbrachial arterial approach has emerged as a novel method for CS [49–51]. This review will describe, and compare the clinical values between CEA and CS of different vascular approaches for patients with CAS. 1. Carotid endarterectomy—a milestone for the treatment of CAS Previously clinical observational studies have clearly shown that the annual incidence of major IS was up to 5–6% in patients with symptomatic CAS [52–55]. Further analysis has shown that the 2-year cumulative neurologic event rate was estimated to be up to 20% in this group of patients [52]. The results of these clinical observational studies illustrated the need for aggressive and strategic management for symptomatic CAS by CEA [28–34]. As a matter of fact, the CEA was initially introduced in the 1950s as a therapeutic modality for treatment of sporadic patients with recurrent IS [56,57]. Later, with the improvement and refinement of surgical technique and accumulating clinical experience [58–62], the number of the patients with symptomatic CAS who underwent CEA treatment in the United States raised rapidly from 15,000 cases in 1970 to 107,000 cases in 1985 [63,64]. However, in the mid- and late-1980s, the use of CEA as prophylactic treatment against stroke declined dramatically [64] due to a number of reasons [28,64–69]. These included inappropriate categorization of CAS, inappropriate criteria and indication for CEA, uncertainties of whether the pre-operative risk is high enough to justify medical treatment alone, high rates of complications, and continuous uncertainty about marked geographic variation of the efficacy of CEA. On the other hand, with the improvement of risk factor modifications, recognition and education for preventing stroke, and the prompt utilization of antiplatelet agents in preventing the CAS-related stroke [70– 74] had reduced the need of CEA in CAS. Furthermore, despite CEA has been accepted widely as an important stroke-prevention strategy since 1950s, up to the mid 1980s, there has not been any strong evidence of its efficacy based on randomized, controlled clinical trials in symptomatic patients. Subsequently, two randomized clinical trials showed negative results of CEA [75,76], and the indication and benefits of CEA in symptomatic patients were being questioned [66,69,77,78]. These raised the opportunity to re-evaluate the efficacy and safety of CEA in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) (phase I) [28]. The results from this study demonstrated that CEA is highly beneficial to patients with symptomatic and ipsilateral high-grade stenosis (70 to 99%) of the internal carotid artery [28]. Three further randomized trial in the 1990s [28,30,31] have also

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showed that as compared with medical treatment, the CEA can effectively reduce the risk of subsequent death or cerebral IS with sustained benefit at long-term follow-up (Table 1). Taking together the results of these large randomized clinical trials [28,30,31] and the NASCET (phase II) trial [29], the following clinical questions were being addressed: Whether CEA offers real benefit for those asymptomatic CAS patients? How large is the benefit of CEA when compared to medical treatment alone? What kind of patients should receive CEA? What is the acceptable complication rate of CEA? How sustainable are the benefits of CEA? In NASCET (phase II) trial [29], the investigators focused on the examination of the benefit of CEA in patients with asymptomatic moderate stenosis (defined as b70%). They found that among patients with CAS of 50% to 69%, the five-year rate of any ipsilateral stroke (i.e., defined as failure rate) was 15.7% among patients treated surgically and 22.2% among those of patients treated medically (P = 0.045) [29]. Moreover, they further identified that patients with CAS of b50% did benefit from CEA [29]. The results have provided important information to guide the currently practice in the treatment of CAS patients. Clinical evidence to support the use of CEA in asymptomatic patients with severe CAS (i.e., N 70%, b 99%) is also compelling [79–82]. All except one randomized trial [79] have clearly demonstrated that CEA reduced the incidence of long-term stroke or death when compared with patients who received medical therapy alone [80–82]. Based on the results of the randomized clinical trials, CEA became the gold standard therapy for patients with severe CAS, irrespective of whether they are symptomatic [28,30,31] or asymptomatic [79–82] (Table 1). 2. Complications and contraindications of CEA While the benefit of CEA on improving the clinical outcome of patients with severe CAS has been well-established, the complications of the procedure reported by randomized clinical trials and observational studies should not be undermined [28–31,64–69,77,78,80–82]. Cranial nerve injury has been reported to be one of the commonest complications with an estimated incidence from 4.0% to 16.0% [40,83–85]. In another large study that enrolled 3061 patients received CEA over a 10year period, the prevalence of the composite end point (i.e., stroke, myocardial infarction or death) has been reported to be up to 7.4% in the high-risk subgroup (defined as patients who had severe coronary artery disease or renal insufficiency) [35]. In addition, another randomized trial observed that the frequency of a major stroke or death at 3year follow-up is up to 14.9% [31]. Of these complications, the highrisk patient group has been identified as the major contributors. Therefore, initial clinical evaluation for the suitability of CEA should be carefully undertaken in such high-risk population (Table 2). The CEA procedure also has major contraindications. Accumulated experiences have identified that the following patient groups are not suitable for the procedure. These include post-radiotherapy for head and neck cancers, obstructions at higher level of internal carotid artery or lower level of common carotid artery (i.e., below the clavicle level),

Table 1 Benefit of Carotid Endarterectomy (CEA) versus Medical Treatment in improving future clinical outcome in patients with symptomatic and asymptomatic severe carotid artery stenosis based on randomized clinical trials. Name of clinical trials

CEA

Medical treatment

Follow-up duration

Absolute RR (%)

p-Value

Symptomatic CAS NASCET [28] trial: end point (major or fatal ipsilateral stroke) VA [30] trial: end point (stroke or TIA) ECST [31] trial: end point (major stroke or death)

2.5% 7.7% 14.9%

13.1% 19.7% 26.5%

2 years 1 year 3 years

10.6% 11.7% 11.6%

b0.001 0.011 b0.001

5.1% 8.0% 4.1%

11.0% 20.6% 10.0%

5 years 4 years 5 years

53.0% 38.0% 59.0%

b0.001 b0.001 b0.001

Asymptomatic CAS ACAS [80] trial: accumulative end point (5-years for ipsilateral stroke & any perioperative stroke or death) VA [81] trial: end point (combined incidence of ipsilateral neurologic events) ACST [82] trial (stroke)

RR = relative risk; TIA = transient ischemic stroke; NASCET = North American Symptomatic Carotid Endarterectomy Trial; VA = Veterans Affairs; ECST = European Carotid Surgery Trial; ACAS = Asymptomatic Carotid Atherosclerosis Study; ACST = Asymptomatic Carotid Surgery Trial.

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severe bilateral carotid artery obstruction, severe congestive heart failure, severe coronary artery disease with advanced left ventricular dysfunction, and recent myocardial infarction with left ventricular dysfunction (Table 2). The high complication rate and contraindications of CEA as well as its invasive nature warranted the need of alternative methods for the treatment of severe CAS. 3. Transfemoral arterial approach for carotid arterial intervention — an alternative to CEA for CAS Based on the already well-developed techniques of percutaneous coronary intervention with appropriate modifications, it is intuitive to perform carotid artery intervention by percutaneous approach. In fact, transfemoral arterial approach (TFA) of carotid angioplasty for CAS has been documented as far as early 1980s [86,87]. Since the beginning of 1990s, TFA for carotid angioplasty became more acceptable to physicians [88–90]. However, TFA of carotid intervention was rapidly increased only just after significant advancement of the instruments for carotid intervention, i.e., the development of different kinds of carotid stents and distal protective device (in particular Filter wires) for prevention of embolic IS. In fact, carotid stenting was introduced as an alternative option to prevent stroke in 1994. The key issues to be addressed in stenting for CAS are the safety, efficiency, and short- and long-term clinical outcomes, when compared with CEA treatment. In fact, several large, randomized clinical trials had been conducted to address this important clinical question [43– 45,91–93]. Majority of these clinical trials had demonstrated that the rates of composite outcome (disability stroke, myocardial infarction or death) were not significantly different between carotid stenting and CEA during short-, intermediate- and long-term follow-up [43–45,91– 96]. These findings [43–45,93–96] underscored that the carotid stenting in combination with the use of distal protective device is non-inferior to CEA for patients with symptomatic severe CAS. Therefore, carotid stenting remains the treatment of choice for patients suitable for surgery [94]. 4. Transradial arterial approach for carotid intervention—safety and efficacy Despite the clinical outcomes of TFA for carotid stenting has been established to be non-inferior to that of CEA for patients with CAS, this procedure has also been identified to be problematic or even contraindicated in patients with the following conditions: elongated aortic arch and brachiocephalic trunk, distal abdominal aortic disease, morbid obesity, severe peripheral vascular disease, previous iliofemoral bypass graft placement and aortoiliac occlusion, the presence of bovine arches Table 2 High risk factors and unfavorable anatomies for carotid endarterectomy. High risk for CEA

Unfavorable anatomies for CEA

Unstable angina

Critical stenosis (≥90%) or total occlusion of contralateral internal carotid artery Restenosis of previous CEA

Multi-vessel coronary artery disease Recent myocardial Previous radiation or surgery over the neck area infarction (b6 weeks) Advanced CHF (NYHA class Neck immobility due to any reason III/IV) Poor LVEF (≤30%) Inaccessible lesions at or above C2 or below clavicle level Chronic renal failure (stage Tracheostomy due to any reason IV/V) Chronic obstructive lung Laryngeal nerve palsy caused by any reason disease Old age (≥80 years old) Bilateral critical stenosis with the requirement of treatment CEA = carotid endarterectomy; CHF = congestive heart failure; NYHA = New York Heart Association; LVEF = Left ventricular ejection fraction.

Table 3 Baseline clinical characteristics and outcome of the 450 patients who received transradial or transbrachial carotid stenting. Variables

% (n) or mean ± SD

Age (years) Male gender Hypertension Diabetes mellitus Hypercholesterolemia Old stroke Angiographic finding of CAD Right CAS Left CAS Procedural success Procedure-related IS In-hospital mortalitya

70.0 ± 9.3 81.6% (367/450) 78.4% (353/450) (164/450) (189/450) (165/450) 77.1% (347/450) (226/450) (224/450) 99.1% (446/450) 4.7% (21/450) 0.7% (3/450)

CAD = coronary artery disease; CAS = carotid artery disease; IS = ischemic stroke. a All deaths were due to intra-cranial hemorrhage.

(i.e. left and right common carotid artery stems from a main trunk), aortic arch anomaly (Kommerell's diverticulum), tortuous and redundant common carotid arteries (CCAs), as well as patients with a deep-set takeoff of the innominate or left CCA, classified as a level II to III aortic arch [97–105]. Many of these anatomical features are most apparent in the elderly, especially the octogenarians. With the combined need for excessive catheter manipulation due to technical and anatomical challenges, it will lead to a high stroke rate or mortality at 30 days of up to 11.3% [106,107]. Furthermore, TFA is also associated with Table 4 Stepwise illustration of CLARET for carotid and cerebral angiographic studies and carotid intervention for Extra-Cranial Carotid Artery (ECCA) stenosis. Variables

RCCA/RICA

LCCA/LICA

Arterial access

(1) high-TRA;a or (2) brachial arteryb (1) CLARET; or (2) directly engage to RCCAc

(1) high-TRAa; or (2) brachial arteryb CLARET

(1) J-tip Teflon guide wired, or (2) Terumo wire

(1) J-tip Teflon guide wired; or (2) Terumo wire associated with PCI wire for identifying the LCCA 6-Fr Kimny guiding catheter

Method for carotid & cerebral angiographic studies Wire selection for guiding catheter engagement Guiding catheter for carotid & cerebral angiographic studies Guiding catheter for carotid intervention Instrument for supporting the guiding-catheter engage into CCA

6-Fr Kimny guiding catheter

(1) 7-Fr Kimny guiding catheter, or (2) 7-Fr JR4 guiding catheter (directly engage to RCCA) (1) double-wire technique (two J-tip Teflon guide wires), or (2) J-tip Teflon guide wire set-into VTK catheter, or (3) PCI wire in ECA with balloon inflation for anchoring or (4) a PercuSurge GuardWire in ECA for anchoring

7-Fr Kimny guiding catheter

(1) double-wire technique (two J-tip Teflon guide wires), or (2) J-tip Teflon guide wire set-into VTK catheter, or (3) PCI wire in ECCA with balloon inflation or for anchoring (4) a PercuSurge GuardWire in ECA for anchoring

CLARET = catheter looping and retrograde engagement technique; RCCA = right common carotid artery; RICA = right internal carotid artery; LICA = left internal carotid artery; LCCA = left common carotid artery; TRA = transradial arterial approach; Fr = French; PCI = percutaneous coronary intervention; ECA = external carotid artery. a Defined as a puncture site 10 cm above styloid process. b The high-TRA should be utilized in following situations: (1) patients taller than 175 cm; (2) The diameter of both radial arteries at high-radial arterial level is too small; (3) The pulsations at high-radial arterial level are weak or loss on both sides; or (4) Allen's test in both hands is positive, TBA was utilized. c The guiding catheter along with the guide wire directly engages into the RCCA from right innominate artery. d Indicates a 0.035-inch (length: 260 cm) J-tip Teflon guide wire (Argon Medical Devices, Inc.).

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hemostatic and groin complications [108] which may prolong hospitalization. Accordingly, a safer and equally efficacious method is required to resolve the limitations of TFA [103]. The transradial arterial approach (TRA) is currently a safe and widelyused method for both diagnostic cardiac catheterization and percutaneous coronary intervention, in particular in Asia [108,109]. Based on the transradial technique, cardiologists evolved CAS treatment by applying the TRA to carotid stenting and examined its feasibility and efficacy [50,51,103,104,110–112]. Of these clinical studies, only one was a

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randomized clinical trial [51]. The results demonstrated that although the TRA for carotid stenting was safe and efficacious, the crossover rate was 10% in the TRA group and 1.5% in the TFA group (p b 0.05) [51]. This means only 90% of cases were successfully performed in TRA. Furthermore, the procedure success rate was reported to be less than 90% in other studies [50,51,110–112]. The majority of procedure failure occurred in left carotid artery intervention [50,110–112]. Therefore the early techniques of carotid artery intervention by TRA remain suboptimal which stimulated interventionists to develop better techniques of TRA.

Fig. 1. Transradial/transbrachial artery approach and direct engagement for carotid stenting. A) 7 French arterial sheath (black arrow) was inserted into the radial arterial, illustrating the technical approach of high transradial arterial approach (H-TRA) for extra-cranial carotid (ECC) and intracranial angiographic studies and carotid intervention. B) A 7 French arterial sheath (black arrow) was inserted via transbrachial arterial approach (TBA) for purpose of ECC and intracranial angiographic studies and carotid intervention. Red arrow indicated the usually TRA puncture site. C) From C-1 to C-11 illustrating the step by step procedure for the technique of direct engagement of guiding catheter into right common carotid artery (CCA) for carotid stenting. C-1) Carotid angiographic study showing the critical stenosis of right internal carotid artery (RICA) (white arrows). C-2 to C-5) The 7-Fr guiding catheter (white arrows) was advanced along the J-tip Teflon guide wire (white arrow heads) into the right CCA. C-6 to C-8) Showing the guiding catheter provided the good support for stent (black arrows) advancement into RICA. C-9) Balloon (white arrow heads) dilatation after stent (black arrow heads) deployed into RICA. C-10) Carotid angiographic study showing a good result of carotid stenting. C-11) The intracranial vessels were clearly identified by cerebral angiographic study after carotid stenting. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

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5. Catheter looping and retrograde engagement technique (CLARET) — a novel method for carotid stenting The use of CLARET for cerebral angiographic study is a novel technique which was first introduced by the authors in 2005 [102], and technical refinement for carotid stenting was reported in 2006 [103] and in 2010 [104]. The procedural success rate by CLARET for carotid stenting was reported to be greater than 98.5% [103,104] and the risk of procedure-related IS rate was less than 3.0%, which was comparable with other studies [43–45,93,94]. Between January 2004 and June 2015, CAS by either TRA or TBA was performed in 450 cases at our hospital (Table 3). Among them, the first 98 patients did not receive the Filter wire for distal protection due to unavailability in the hospital. The mean age was 70 ± 9.3 years and 81.6% were male gender. The procedural success was 99.1% (446 / 450). In four patients the TRA was unsuccessful due to severe aortic regurgitation in one case, and very tortuosity aortic root and aortic arch in the other three cases. The procedurerelated IS rate was 4.7% (21 / 450). Of these 21 patients, 4 patients who experienced acute IS within 7 days prior to the procedure, and in

8 patients the Filter wire for distal protection was not used due to unavailability (i.e., they were the first 98 cases). Of these patients, two patients were dead due to sepsis and multiple organ failure during hospitalization. The other patients were finally discharged from hospital and being regularly followed-up at the outpatient department. To date, CLARET is routinely used in our hospital that mastered mature transradial intervention techniques. To ensure a successful CLARET technique of carotid stenting, the following essential steps are essential [102–104](Table 4): (I) Select the appropriate puncture site (Fig. 1). After carefully examining the radial pulse, either left or right high radial artery puncture should be considered the first choice, i.e., a puncture site 10 cm or higher above the styloid process. Alternatively, transbrachial arterial approach (TBA) should be considered for the following conditions: (1) patients who are taller than 175 cm; (2) The diameter of both radial arteries at high radial level is too small, or the pulsations are weak or absent on both sides; or (3) Allen's test in both hands is positive. A 7-French

Fig. 2. “Catheter looping and retrograde engagement technique” (CLARET) for left side carotid artery stenting. A) Step 1: The 6-Fr Kimny guiding catheter was first looped (i.e., catheter looping technique) (white arrows) in aortic root with the tip of guiding catheter pointed to left common carotid artery (LCCA) (white arrow head). The J-tip Teflon wire (260 cm in length) (small white arrows) was guided by looping Kimny guiding catheter towards to the direction of LCCA. If the J-tip Teflon wire could not enter the LCCA, a buddy wire [i.e., a percutaneous coronary intervention wire (0.014″) (small white arrow heads)] should be utilized as a guide wire for easier identification of LCCA. B to D) Step-2: the J-tip Teflon wire was then easily advanced into the LCCA (B). At this moment, if the J-tip Teflon wire could not offer a good support, the 5 Fr VTK guiding catheter should be utilized [i.e., J-tip Teflon guide wire (white arrow heads) set-into VTK catheter (white small arrows)] for providing further strengthening support (C). Finally, the 6 Fr Kimny guiding catheter (black arrows) was easily advanced into LCCA (D). E) The angiographic results of LCCA showed subtotal occlusion of let internal carotid artery (LICA) (small white arrow heads). F and G) Step 3: After carotid and intracranial angiographic studies, the J-tip Teflon guide wire was advanced into the LCCA, the 6 Fr Kimny guiding catheter was removed and replaced by 7 Fr Kimny guiding catheter. For offering a good support, another J-tip Teflon guide wire was used and advanced into LCCA (F), i.e., this is the “double-wire technique” (small black arrows). Based on the double-wire support, the 7 Fr Kimny guiding catheter (G) could be easily advanced into the LCCA at a right position (black arrow heads). H) After the stent (small black arrows) was deployed into the LICA, a balloon was utilized for post dilatation (small white arrow heads). I to K) Finally, good and clearly angiographic results of LCCA and LICA (I) and intracranial vessels in frontal (J) and lateral (K) views were observed.

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(Fr) arterial sheath (i.e., for carotid stenting) is inserted into the artery following successful puncture.

(II) Selection of guiding catheter for carotid angiography and carotid intervention (Fig. 2). A 6-Fr Kimny Miniradial guiding catheter (Boston Scientific, Scimed, Inc. Maple Grove, MN) should be utilized for extracranial carotid artery angiographic study. To avoid repeated engagement for diagnostic and interventional procedures on the same side, angiographic examination of the nonculprit side should be performed first followed by the culprit side using the same guiding catheter. After carotid angiography, the 6-Fr Kimny guiding catheter is then replaced by a 7-Fr Kimny guiding catheter for carotid intervention.

(III) Using CLARET for Carotid Intervention (Figs. 2 and 3). A 6-Fr Kimny guiding catheter along with a 0.035-inch J-tipped Teflon long (length: 260 cm) guide wire (Argon Medical Devices, Inc.) is passed through the arterial sheath and into the ascending aorta. The guiding catheter is then curved at the aortic cusp level. The tip of the guiding catheter is manipulated towards the left side for the engagement of the left CCA, and vice versa to engage the right CCA for the purpose of allowing the Teflon guide wire to advance into the CCA. The guiding catheter is then being pushed forward along the guide wire

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to engage into the CCA. This is the so called CLARET. The guiding catheter provides an anatomical triangle by hinging at three points, namely subclavian or innominate artery, right aortic cusp and CCA. This triangle provides a good support for carotid stenting.

(IV) Successful exchange of 6 French to 7 French guiding catheter is a crucial step for successful carotid stenting (Figs. 2 and 3). After carotid angiographic studies, the 6-Fr Kimny guiding catheter must be replaced with a 7-Fr Kimny guiding catheter for carotid stenting. In order to achieve this, a J-tip Teflon guide wire is first advanced into the CCA or external carotid artery to provide support for exchanging the 7-Fr Kimny guiding catheter. If a single Teflon guide wire does not offer an adequate support, one of the following methods should be utilized. Using the “doublewire” technique, two J-tip Teflon guide wires are advanced into the CCA or alternatively one in the CCA and the other into the external carotid artery). Alternatively, the 7-Fr Kimny guiding catheter can be preloaded with a VTK catheter before inserted into the CCA so as to provide a stronger support to advancing the guiding catheter into CCA. The third method is the “anchoring” technique in which a 0.014″ guide wire with a balloon inflation or the PercuSurge GuardWire (GuardWire Plus™, temporary occlusion system, Medtronic AVE) is advanced into external carotid artery. This is followed by inflating the balloon for anchorage at

Fig. 3. “Catheter looping and retrograde engagement technique” (CLARET) for right side carotid artery stenting. A to C) Step 1: The guiding catheter was first looped and pointed to the right CCA (RCCA) (white arrows) (A). The J-tip Teflon guide wire was then advanced into the RCCA (black arrows) (A, B). The J-tip Teflon guide wire (B, C) (small white arrows) situated in RCCA provided the good support for the 6 Fr Kimny guiding catheter (B, C) (small black arrows) advancing into the RCCA (C). D and E) Angiographic results showed a critical stenosis at the proximal portion of the right internal carotid artery (RICA) (white arrow) (D). However, there was no stenosis at the intracranial large vessels (E). F and G) Step 2: After carotid and intracranial angiographic studies, the J-tip Teflon guide wire (white arrows) was advanced into the RCCA (F), the 6 Fr Kimny guiding catheter was removed and replaced by 7 Fr Kimny guiding catheter (small white arrows) (F, G). H and J) Step 3: Based on the good support from the 7 Fr guiding catheter, the stent was easily advanced into the RICA (small black arrows) and deployment. J) After the stent (small black arrows) was deployed into the RICA, a balloon was utilized for post-dilatation (small white arrow heads). K and L) Finally, angiographic examination shows good results of RICA stenting (small white arrows) (K) and no flow limitation over intracranial vessels (L).

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the external carotid artery so as to provide the necessary tracking force to advance the guiding catheter into the CCA.

[6]

[7]

(V) Direct technique to engage the right CCA (Fig. 1). This technique is only suitable for the right CCA. A 6-Fr Kimny guiding catheter together with a 0.035-inch Terumo guide wire was inserted directly into the right innominate artery near the ostium of right CCA. The Terumo guide wire is then directly advanced into the right CCA. The 6-Fr Kimny guiding catheter is gently advanced into the right CCA using clockwise and moving-forward technique. This is followed by exchanging the Terumo wire with a J-tip Teflon guide wire which is then advanced into the right CCA or external carotid artery. The 7-Fr Kimny guiding catheter is finally advanced gently into the right CCA using the J-tip Teflon guide wire to provide tracking support.

[8]

[9]

[10]

[11]

[12]

[13]

The CLARET approach of transradial carotid stenting also has some limitations [102–104]. Although the incidence of simultaneous occlusion/obstruction of both innominate and left subclavian arteries is very rare, this situation excludes the application of TRA or TBA. Also, the support for retrograde engagement of CCA would not be enough in patients with severe aortic regurgitation, or in a situation of extremely tortuous aorta and horizontal heart position. Furthermore, in situation of extremely tortuous aortic arch, the J-tip Teflon guide wire would be more difficult to be advanced into the left CCA. In conclusion, CEA remains the gold-standard method for the treatment of patients with severe CAS. However, careful and comprehensive evaluation prior to CEA is essential in order to minimize the morbidity and mortality in those high-risk patients with symptomatic high grade CAS. TFA of carotid stenting is an alternative percutaneous treatment option which is widely accepted and proven to be non-inferior to surgical approach. It is particularly useful for those who are identified to be high-risk or unsuitable candidates for CEA. Finally, TRA or TBA currently emerges as an alternative to TFA for carotid intervention, in particular in those without femoral vascular access or having anatomical limitations of the aorta. The complementary role of CEA, TFA and TRA or TBA of carotid intervention has now provided a total solution for patient with severe CAS. Conflict of interest

[14] [15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

The authors report no relationships that could be construed as a conflict of interest.

[23]

Acknowledgment

[24]

We appreciated Yen-Nan Fang, Po-Jei Wu, and Hsin-Ju Chiang for helping data collection of carotid artery stenting in Kaohsiung ChangGung Memorial Hospital.

[25]

[26]

References [1] V.L. Feigin, C.M. Lawes, D.A. Bennett, S.L. Barker-Collo, V. Parag, Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review, Lancet Neurol. 8 (2009) 355–369. [2] R. Lozano, M. Naghavi, K. Foreman, S. Lim, K. Shibuya, V. Aboyans, et al., Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010, Lancet (London, England) 380 (2012) 2095–2128. [3] C.J. Murray, T. Vos, R. Lozano, M. Naghavi, A.D. Flaxman, C. Michaud, et al., Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010, Lancet (London, England) 380 (2012) 2197–2223. [4] C.J. Murray, M. Ezzati, A.D. Flaxman, S. Lim, R. Lozano, C. Michaud, et al., GBD 2010: design, definitions, and metrics, Lancet (London, England) 380 (2012) 2063–2066. [5] V.L. Feigin, M.H. Forouzanfar, R. Krishnamurthi, G.A. Mensah, M. Connor, D.A. Bennett, et al., Global and regional burden of stroke during 1990–2010: findings

[27] [28] [29]

[30]

[31]

from the Global Burden of Disease Study 2010, Lancet (London, England) 383 (2014) 245–254. S.M. Zinkstok, Y.B. Roos, Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial, Lancet (London, England) 380 (2012) 731–737. J.M. Wardlaw, V. Murray, E. Berge, G.J. del Zoppo, Thrombolysis for acute ischaemic stroke, Cochrane Database Syst. Rev. 7 (2014), CD000213. X. Huang, B.K. Cheripelli, S.M. Lloyd, D. Kalladka, F.C. Moreton, A. Siddiqui, et al., Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study, Lancet Neurol. 14 (2015) 368–376. B. Singh, A.K. Parsaik, L.J. Prokop, M.K. Mittal, Endovascular therapy for acute ischemic stroke: a systematic review and meta-analysis, Mayo Clin. Proc. 88 (2013) 1056–1065. C.J. Chen, D. Ding, R.M. Starke, P. Mehndiratta, R.W. Crowley, K.C. Liu, et al., Endovascular vs medical management of acute ischemic stroke, Neurology 85 (2015) 1980–1990. J.H. Badhiwala, F. Nassiri, W. Alhazzani, M.H. Selim, F. Farrokhyar, J. Spears, et al., Endovascular thrombectomy for acute ischemic stroke: a meta-analysis, JAMA 314 (2015) 1832–1843. J.C. Takahashi, T. Funaki, K. Houkin, T. Inoue, K. Ogasawara, J. Nakagawara, et al., Significance of the hemorrhagic site for recurrent bleeding: prespecified analysis in the Japan Adult Moyamoya Trial, Stroke 47 (2016) 37–43. J.J. Wei, H.F. Liu, S. Chai, X.M. Kang, A fast cranial drilling technique in treating severe intracranial hemorrhage, Surg. Neurol. Int. 6 (2015) 159. H.T. Zhang, A.J. Shang, B.J. He, R.X. Xu, Transsylvian–transinsular approach to large lateral thalamus hemorrhages, J. Craniofac. Surg. 26 (2015) e98–102. R.A. McTaggart, S.A. Ansari, M. Goyal, T.A. Abruzzo, B. Albani, A.J. Arthur, et al., Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery, J. Neurointerventional Surg. (2015). M.J. Mulder, R.J. van Oostenbrugge, D.W. Dippel, Letter by Mulder et al regarding article, “2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association”, Stroke 46 (2015) e235. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, Lancet (London, England) 385 (2015) 117–171. R.V. Krishnamurthi, A.E. Moran, V.L. Feigin, S. Barker-Collo, B. Norrving, G.A. Mensah, et al., Stroke prevalence, mortality and disability-adjusted life years in adults aged 20–64 years in 1990–2013: data from the Global Burden of Disease 2013 Study, Neuroepidemiology 45 (2015) 190–202. H.P. Adams Jr., B.H. Bendixen, L.J. Kappelle, J. Biller, B.B. Love, D.L. Gordon, et al., Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment, Stroke 24 (1993) 35–41. L.B. Goldstein, M.R. Jones, D.B. Matchar, L.J. Edwards, J. Hoff, V. Chilukuri, et al., Improving the reliability of stroke subgroup classification using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, Stroke 32 (2001) 1091–1098. J.W. Chung, S.H. Park, N. Kim, W.J. Kim, J.H. Park, Y. Ko, et al., Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging, J. Am. Heart Assoc. 3 (2014). F. Purroy, J. Montaner, C.A. Molina, P. Delgado, M. Ribo, J. Alvarez-Sabin, Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes, Stroke 38 (2007) 3225–3229. O.C. Sheehan, L. Kyne, L.A. Kelly, N. Hannon, M. Marnane, A. Merwick, et al., Population-based study of ABCD2 score, carotid stenosis, and atrial fibrillation for early stroke prediction after transient ischemic attack: the North Dublin TIA study, Stroke 41 (2010) 844–850. T. Kiyohara, M. Kamouchi, Y. Kumai, T. Ninomiya, J. Hata, S. Yoshimura, et al., ABCD3 and ABCD3-I scores are superior to ABCD2 score in the prediction of short- and long-term risks of stroke after transient ischemic attack, Stroke 45 (2014) 418–425. H.C. Diener, L. Cunha, C. Forbes, J. Sivenius, P. Smets, A. Lowenthal, European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke, J. Neurol. Sci. 143 (1996) 1–13. CAPRIE Steering Committee, A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE), Lancet (London, England) 348 (1996) 1329–1339. P.A. Sandercock, C. Counsell, M.C. Tseng, E. Cecconi, Oral antiplatelet therapy for acute ischaemic stroke, Cochrane Database Syst. Rev. 3 (2014), CD000029. Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade carotid stenosis, N. Engl. J. Med. 325 (1991) 445–453. H.J. Barnett, D.W. Taylor, M. Eliasziw, A.J. Fox, G.G. Ferguson, R.B. Haynes, et al., Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators, N. Engl. J. Med. 339 (1998) 1415–1425. M.R. Mayberg, S.E. Wilson, F. Yatsu, D.G. Weiss, L. Messina, L.A. Hershey, et al., Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group, JAMA 266 (1991) 3289–3294. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST), Lancet (London, England) 351 (1998) 1379–1387.

H.-K. Yip et al. / International Journal of Cardiology 214 (2016) 166–174 [32] G.G. Ferguson, M. Eliasziw, H.W. Barr, G.P. Clagett, R.W. Barnes, M.C. Wallace, et al., The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients, Stroke 30 (1999) 1751–1758. [33] B. Young, W.S. Moore, J.T. Robertson, J.F. Toole, C.B. Ernst, S.N. Cohen, et al., An analysis of perioperative surgical mortality and morbidity in the asymptomatic carotid atherosclerosis study. ACAS Investigators. Asymptomatic Carotid Atherosclerosis Study, Stroke 27 (1996) 2216–2224. [34] A.P. Gasecki, M. Eliasziw, G.G. Ferguson, V. Hachinski, H.J. Barnett, Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, J. Neurosurg. 83 (1995) 778–782. [35] K. Ouriel, N.R. Hertzer, E.G. Beven, P.J. O'Hara, L.P. Krajewski, D.G. Clair, et al., Preprocedural risk stratification: identifying an appropriate population for carotid stenting, J. Vasc. Surg. 33 (2001) 728–732. [36] A.J. Maniglia, D.P. Han, Cranial nerve injuries following carotid endarterectomy: an analysis of 336 procedures, Head Neck 13 (1991) 121–124. [37] E. Ballotta, G. Da Giau, L. Renon, S. Narne, M. Saladini, E. Abbruzzese, et al., Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study, Surgery 125 (1999) 85–91. [38] A.F. AbuRahma, M.A. Choueiri, Cranial and cervical nerve injuries after repeat carotid endarterectomy, J. Vasc. Surg. 32 (2000) 649–654. [39] A. Assadian, C. Senekowitsch, N. Pfaffelmeyer, O. Assadian, H. Ptakovsky, G.W. Hagmuller, Incidence of cranial nerve injuries after carotid eversion endarterectomy with a transverse skin incision under regional anaesthesia, Eur. J. Vasc. Endovasc. Surg. 28 (2004) 421–424. [40] E.J. Cunningham, R. Bond, M.R. Mayberg, C.P. Warlow, P.M. Rothwell, Risk of persistent cranial nerve injury after carotid endarterectomy, J. Neurosurg. 101 (2004) 445–448. [41] G.S. Roubin, G. New, S.S. Iyer, J.J. Vitek, N. Al-Mubarak, M.W. Liu, et al., Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis, Circulation 103 (2001) 532–537. [42] Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial, Lancet (London, England) 357 (2001) 1729–1737. [43] J.S. Yadav, M.H. Wholey, R.E. Kuntz, P. Fayad, B.T. Katzen, G.J. Mishkel, et al., Protected carotid-artery stenting versus endarterectomy in high-risk patients, N. Engl. J. Med. 351 (2004) 1493–1501. [44] T.G. Brott, R.W. Hobson 2nd, G. Howard, G.S. Roubin, W.M. Clark, W. Brooks, et al., Stenting versus endarterectomy for treatment of carotid-artery stenosis, N. Engl. J. Med. 363 (2010) 11–23. [45] L.H. Bonati, J. Dobson, R.L. Featherstone, J. Ederle, H.B. van der Worp, G.J. de Borst, et al., Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial, Lancet (London, England) 385 (2015) 529–538. [46] Maciejewski D, Pieniazek P, Tekieli L, Paluszek P, Dzierwa K, Trystula M, et al. Transradial approach for carotid artery stenting in a patient with severe peripheral arterial disease. Postepy w kardiologii interwencyjnej = Adv. Interv. Cardiol. 2014; 10:47–9. [47] F. Burzotta, R. Nerla, G. Pirozzolo, C. Aurigemma, G. Niccoli, A.M. Leone, et al., Clinical and procedural impact of aortic arch anatomic variants in carotid stenting procedures, Catheter. Cardiovasc. Interv. 86 (2015) 480–489. [48] G. Ventoruzzo, G. Biondi-Zoccai, F. Maioli, F. Liistro, L. Bolognese, G. Bellandi, A tailored approach to overcoming challenges of a bovine aortic arch during left internal carotid artery stenting, J. Endovasc. Ther. 19 (2012) 329–338. [49] C. Bakoyiannis, K.P. Economopoulos, S. Georgopoulos, E. Psathas, M. Kazefa, C. Tsigris, et al., Transradial access for carotid artery stenting: a single-center experience, Int. Angiol. 29 (2010) 41–46. [50] T. Patel, S. Shah, A. Ranjan, H. Malhotra, S. Pancholy, J. Coppola, Contralateral transradial approach for carotid artery stenting: a feasibility study, Catheter. Cardiovasc. Interv. 75 (2010) 268–275. [51] Z. Ruzsa, B. Nemes, L. Pinter, B. Berta, K. Toth, B. Teleki, et al., A randomised comparison of transradial and transfemoral approach for carotid artery stenting: RADCAR (RADial access for CARotid artery stenting) study, EuroIntervention 10 (2014) 381–391. [52] M.A. Mansour, M.A. Mattos, W.E. Faught, K.J. Hodgson, L.D. Barkmeier, D.E. Ramsey, et al., The natural history of moderate (50% to 79%) internal carotid artery stenosis in symptomatic, nonhemispheric, and asymptomatic patients, J. Vasc. Surg. 21 (1995) 346–356 (discussion 56-7). [53] Y. Tong, J. Royle, Outcome of patients with symptomless carotid bruits: a prospective study, Cardiovasc. Surg. (London, England) 4 (1996) 174–180. [54] C.J. Klijn, P.A. van Buren, L.J. Kappelle, C.A. Tulleken, B.C. Eikelboom, A. Algra, et al., Outcome in patients with symptomatic occlusion of the internal carotid artery, Eur. J. Vasc. Endovasc. Surg. 19 (2000) 579–586. [55] S. Persoon, M.J. Luitse, G.J. de Borst, A. van der Zwan, A. Algra, L.J. Kappelle, et al., Symptomatic internal carotid artery occlusion: a long-term follow-up study, J. Neurol. Neurosurg. Psychiatry 82 (2011) 521–526. [56] H.H. Eastcott, G.W. Pickering, C.G. Rob, Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia, Lancet (London, England) 267 (1954) 994–996. [57] K. Welch, B. Eiseman, Arterial graft and endarterectomy in reconstitution of the common carotid artery two years following ligation, J. Neurosurg. 14 (1957) 575–579. [58] T.R. Freeman, W.H. Lippitt, Carotid artery syndrome. Results of endarterectomy in twenty-six cases, Ann. Surg. 150 (1959) 1041–1045.

173

[59] J.C. Coles, S.E. Carroll, N. Gergely, A method of providing adequate cerebral blood flow during carotid artery thromboendarterectomy, Can. Med. Assoc. J. 86 (1962) 835–837. [60] E.S. Gurdjian, W.G. Hardy, D.W. Lindner, L.M. Thomas, Results of endarterectomy in the treatment of cerebrovascular disease, Angiology 15 (1964) 88–102. [61] F. Murphey, D.A. Maccubbin, Carotid endarterectomy: a long-term follow-up study, Clin. Neurosurg. 13 (1965) 291–312. [62] A. Heyman, W.G. Young Jr., I.W. Brown Jr., K.S. Grimson, Long-term results of endarterectomy of the internal carotid artery for cerebral ischemia and infarction, Circulation 36 (1967) 212–221. [63] National Center for Health Statistics, Eighth revision, international classification of diseases, Adapted for Use in the United States, Vols 1 and 2, Public Health Service Publication Publication No. 1693US Government Printing Office, Washington DC, 1980. [64] R. Pokras, M.L. Dyken, Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head, Stroke 19 (1988) 1289–1290. [65] M.L. Dyken, R. Pokras, The performance of endarterectomy for disease of the extracranial arteries of the head, Stroke 15 (1984) 948–950. [66] C. Warlow, Carotid endarterectomy: does it work? Stroke 15 (1984) 1068–1076. [67] T. Brott, K. Thalinger, The practice of carotid endarterectomy in a large metropolitan area, Stroke 15 (1984) 950–955. [68] A. Muuronen, Outcome of surgical treatment of 110 patients with transient ischemic attack, Stroke 15 (1984) 959–964. [69] C.M. Winslow, D.H. Solomon, M.R. Chassin, J. Kosecoff, N.J. Merrick, R.H. Brook, The appropriateness of carotid endarterectomy, N. Engl. J. Med. 318 (1988) 721–727. [70] R. Shinton, G. Beevers, Meta-analysis of relation between cigarette smoking and stroke, BMJ (Clin. Res. Ed) 298 (1989) 789–794. [71] M.J. Klag, P.K. Whelton, A.J. Seidler, Decline in US stroke mortality. Demographic trends and antihypertensive treatment, Stroke 20 (1989) 14–21. [72] W.M. Garraway, J.P. Whisnant, The changing pattern of hypertension and the declining incidence of stroke, JAMA 258 (1987) 214–217. [73] Antiplatelet Trialists' Collaboration, Secondary prevention of vascular disease by prolonged antiplatelet treatment, Br. Med. J. (Clin. Res. Ed.) 296 (1988) 320–331. [74] The ESPS Group, The European Stroke Prevention Study (ESPS). Principal endpoints, Lancet (London, England) 2 (1987) 1351–1354. [75] D.A. Shaw, G.S. Venables, N.E. Cartlidge, D. Bates, P.H. Dickinson, Carotid endarterectomy in patients with transient cerebral ischaemia, J. Neurol. Sci. 64 (1984) 45–53. [76] The EC/IC Bypass Study Group, Failure of extracranial–intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial, N. Engl. J. Med. 313 (1985) 1191–1200. [77] S.M. Davis, P.C. Gates, Carotid endarterectomy: why question it now? Med. J. Aust. 150 (1989) 28–30. [78] H.J. Barnett, F. Plum, J.N. Walton, Carotid endarterectomy—an expression of concern, Stroke 15 (1984) 941–943. [79] The CASANOVA Study Group, Carotid surgery versus medical therapy in asymptomatic carotid stenosis, Stroke 22 (1991) 1229–1235. [80] Executive Committee for the Asymptomatic Carotid Atherosclerosis Study, Endarterectomy for asymptomatic carotid artery stenosis, JAMA 273 (1995) 1421–1428. [81] R.W. Hobson 2nd, D.G. Weiss, W.S. Fields, J. Goldstone, W.S. Moore, J.B. Towne, et al., Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group, N. Engl. J. Med. 328 (1993) 221–227. [82] A. Halliday, M. Harrison, E. Hayter, X. Kong, A. Mansfield, J. Marro, et al., 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial, Lancet (London, England) 376 (2010) 1074–1084. [83] W.E. Evans, D.S. Mendelowitz, C. Liapis, V. Wolfe, C.L. Florence, Motor speech deficit following carotid endarterectomy, Ann. Surg. 196 (1982) 461–464. [84] M.S. Sajid, B. Vijaynagar, P. Singh, G. Hamilton, Literature review of cranial nerve injuries during carotid endarterectomy, Acta Chir. Belg. 107 (2007) 25–28. [85] R.J. Hye, A. Mackey, M.D. Hill, J.H. Voeks, D.J. Cohen, K. Wang, et al., Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial, J. Vasc. Surg. 61 (2015) 1208–1214. [86] S.A. Bockenheimer, K. Mathias, Percutaneous transluminal angioplasty in arteriosclerotic internal carotid artery stenosis, AJNR Am. J. Neuroradiol. 4 (1983) 791–792. [87] A.L. Tievsky, E.M. Druy, J.G. Mardiat, Transluminal angioplasty in postsurgical stenosis of the extracranial carotid artery, AJNR Am. J. Neuroradiol. 4 (1983) 800–802. [88] M.M. Brown, P. Butler, J. Gibbs, M. Swash, J. Waterston, Feasibility of percutaneous transluminal angioplasty for carotid artery stenosis, J. Neurol. Neurosurg. Psychiatry 53 (1990) 238–243. [89] L.M. Munari, G. Belloni, A. Perretti, H.F. Ghia, L. Moschini, M. Porta, Carotid percutaneous angioplasty, Neurol. Res. 14 (1992) 156–158. [90] W.M. Clark, S.L. Barnwell, G. Nesbit, O.R. O'Neill, M.L. Wynn, B.M. Coull, Safety and efficacy of percutaneous transluminal angioplasty for intracranial atherosclerotic stenosis, Stroke 26 (1995) 1200–1204. [91] H.H. Eckstein, P. Ringleb, J.R. Allenberg, J. Berger, G. Fraedrich, W. Hacke, et al., Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial, Lancet Neurol. 7 (2008) 893–902. [92] J. Ederle, L.H. Bonati, J. Dobson, R.L. Featherstone, P.A. Gaines, J.D. Beard, et al., Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial, Lancet Neurol. 8 (2009) 898–907.

174

H.-K. Yip et al. / International Journal of Cardiology 214 (2016) 166–174

[93] V.A. Mantese, C.H. Timaran, D. Chiu, R.J. Begg, T.G. Brott, The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease, Stroke 41 (2010) S31–S34. [94] J. Ederle, J. Dobson, R.L. Featherstone, L.H. Bonati, H.B. van der Worp, G.J. de Borst, et al., Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial, Lancet (London, England) 375 (2010) 985–997. [95] F. Siddiq, M.M. Adil, A.A. Malik, M.H. Qureshi, A.I. Qureshi, Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial results on the performance of carotid artery stent placement and carotid endarterectomy in the United States, Neurosurgery 77 (2015) 726–732 (discussion 32). [96] J.C. Grimm, I. Arhuidese, R.J. Beaulieu, U. Qazi, B.A. Perler, J.A. Freischlag, et al., Surgeon's 30-day outcomes supporting the carotid revascularization endarterectomy versus stenting trial, JAMA Surg. 149 (2014) 1314–1318. [97] T.R. Wells, B.H. Landing, W.R. Shankle, Syndromal associations of common origin of the carotid arteries, Pediatr. Pathol. 13 (1993) 203–212. [98] C. Spaulding, T. Lefevre, F. Funck, B. Thebault, M. Chauveau, K. Ben Hamda, et al., Left radial approach for coronary angiography: results of a prospective study, Catheter. Cardiovasc. Diagn. 39 (1996) 365–370. [99] H. Sievert, R. Ensslen, A. Fach, H. Merle, C. Rubel, H. Spies, et al., Brachial artery approach for transluminal angioplasty of the internal carotid artery, Catheter. Cardiovasc. Diagn. 39 (1996) 421–423. [100] M.H. Wholey, M. Wholey, P. Bergeron, E.B. Diethrich, M. Henry, J.C. Laborde, et al., Current global status of carotid artery stent placement, Catheter. Cardiovasc. Diagn. 44 (1998) 1–6. [101] F. Castriota, A. Cremonesi, R. Manetti, M. Lamarra, G. Noera, Carotid stenting using radial artery access, J. Endovasc. Surg. 6 (1999) 385–386. [102] C.J. Wu, W.C. Hung, S.M. Chen, C.H. Yang, C.J. Chen, C.I. Cheng, et al., Feasibility and safety of transradial artery approach for selective cerebral angiography, Catheter. Cardiovasc. Interv. 66 (2005) 21–26. [103] C.J. Wu, C.I. Cheng, W.C. Hung, C.Y. Fang, C.H. Yang, C.J. Chen, et al., Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting, Catheter. Cardiovasc. Interv. 67 (2006) 967–971.

[104] H.Y. Fang, S.Y. Chung, C.K. Sun, A.A. Youssef, A. Bhasin, T.H. Tsai, et al., Transradial and transbrachial arterial approach for simultaneous carotid angiographic examination and stenting using catheter looping and retrograde engagement technique, Ann. Vasc. Surg. 24 (2010) 670–679. [105] H.S. Gurm, J.S. Yadav, P. Fayad, B.T. Katzen, G.J. Mishkel, T.K. Bajwa, et al., Long-term results of carotid stenting versus endarterectomy in high-risk patients, N. Engl. J. Med. 358 (2008) 1572–1579. [106] R.W. Hobson 2nd, V.J. Howard, G.S. Roubin, T.G. Brott, R.D. Ferguson, J.J. Popma, et al., Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase, J. Vasc. Surg. 40 (2004) 1106–1111. [107] M. Schluter, B. Reimers, F. Castriota, T. Tubler, C. Cernetti, A. Cremonesi, et al., Impact of diabetes, patient age, and gender on the 30-day incidence of stroke and death in patients undergoing carotid artery stenting with embolus protection: a post-hoc subanalysis of a prospective multicenter registry, J. Endovasc. Ther. 14 (2007) 271–278. [108] H.K. Yip, S.Y. Chung, H.T. Chai, A.A. Youssef, A. Bhasin, C.H. Yang, et al., Safety and efficacy of transradial vs transfemoral arterial primary coronary angioplasty for acute myocardial infarction: single-center experience, Circ. J. 73 (2009) 2050–2055. [109] H.K. Yip, C.J. Wu, H.W. Chang, C.Y. Fang, C.H. Yang, S.M. Chen, et al., Effect of the PercuSurge GuardWire device on the integrity of microvasculature and clinical outcomes during primary transradial coronary intervention in acute myocardial infarction, Am. J. Cardiol. 92 (2003) 1331–1335. [110] E.I. Levy, S.H. Kim, B.R. Bendok, A.I. Qureshi, L.R. Guterman, L.N. Hopkins, Transradial stenting of the cervical internal carotid artery: technical case report, Neurosurgery 53 (2003) 448–451 (discussion 51-2). [111] L. Pinter, C. Cagiannos, Z. Ruzsa, C. Bakoyiannis, R. Kolvenbach, Report on initial experience with transradial access for carotid artery stenting, J. Vasc. Surg. 45 (2007) 1136–1141. [112] N. Etxegoien, D. Rhyne, S. Kedev, R. Sachar, T. Mann, The transradial approach for carotid artery stenting, Catheter. Cardiovasc. Interv. 80 (2012) 1081–1087.