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Endovascular repair of symptomatic external carotid artery stenosis
Endovascular repair of symptomatic external carotid artery stenosis Joshua A. Eisenberg, MD Paul J. Dimuzio, MD, Anthony Carabasi, MD, Robert Larson, MD, and Joseph V. Lombardi, MD, Philadelphia, Penn The treatment of external carotid artery stenosis has been described with a variety of operative interventions. We present a patient who presented with amaurosis fugax and a critical left external carotid artery stenosis with known left internal carotid artery occlusion. We treated this stenosis with angioplasty and stenting rather than endarterectomy. Our patient did well and had no complications from the procedure. Endovascular repair of symptomatic external carotid artery stenosis provides an alternative treatment method to conventional endarterectomy for patients with high surgical risk. ( J Vasc Surg 2005;42:1210 –2.)
Patients with occluded internal carotid arteries and symptomatic stenosis of the external carotid artery can prove to be a challenging dilemma. The external carotid artery provides an important source of collateral flow to both the brain and the eye when the internal carotid artery is occluded.1,2 Emboli may originate from either the internal carotid stump, common carotid artery, or the external carotid artery.3,4 These emboli most commonly cause ophthalmologic or neurologic symptoms. Treatment of these lesions has varied throughout the years and has included contralateral internal carotid endarterectomy, extracranialintracranial bypass, and carotid endarterectomy.4-8 We report a patient with a known occluded internal carotid artery and symptomatic stenosis of the external carotid artery treated with percutaneous transluminal angioplasty (PTA) and stenting. CASE REPORT A 70-year-old man with a known left internal carotid occlusion presented to his ophthalmologist with acute loss of vision in his left eye. The patient described his vision as “foggy” with central clearing. No other neurologic findings were found on examination. Funduscopic examination of the left eye revealed a mobile retinal plaque. The patient’s medical history was significant for hypertension, laryngeal cancer treated with surgery and radiation, and appendicitis. Upon presentation, a carotid ultrasound scan was performed that showed occlusion of the left internal carotid artery and antegrade flow through the vertebral artery. Velocities in the left external carotid artery were 202 cm/s and B mode imaging was consistent with high-grade stenosis. A computed tomography angiogram demonstrated mild diffuse narrowing of the left common carotid artery, occluded left internal carotid artery, and a plaque with high-grade stenosis of the left external carotid artery.
Because of the patient’s symptoms (which resolved spontaneously) and history of neck radiation, carotid angioplasty and stenting was planned. The patient was started on clopidogrel. The patient was taken to the operating room where he underwent cerebral arteriography. The finding of a high-grade stenosis of the external carotid artery was confirmed (Fig 1) as well as a communication between the external carotid artery and the ophthalmic artery. This was thought to be the cause of the patient’s visual symptoms. Arterial access was obtained through the patient’s left groin. The common carotid artery was accessed using Shuttle Select catheter (Cook Inc, Blomington, Ind). This maneuver was facilitated with our guidewire extending as far as the common carotid only. The patient received anticoagulation with heparin (100 U/kg). A 0.014-inch wire was guided through the external carotid lesion through a 4F angled multipurpose catheter (MPA). A cerebral protection device (CPD) was on hand with the intent of its use; however, the lesion was so stenotic, the MPA could not pass. To deliver the CPD, we would have needed to pre-dilatate the lesion. It was decided to forego cerebral protection, given pre-dilatation would have largely obviated its usefulness and excessive wire/catheter manipulation was not desired. A 4-mm ⫻ 2-mm balloon was used for pre-dilatation (Boston Scientific, Natick, Mass) followed by delivery of an 8 ⫻ 29 monorail Wallstent (Boston Scientific) placed across the lesion with preservation of the facial artery. A post-dilatation was performed with a 6-mm ⫻ 2-mm balloon. A completion angiogram (Fig 2) showed the stent to be in good position, with resolution of the stenosis. The patient tolerated the procedure well with no further symptoms and was discharged home on the first postoperative day. He was prescribed aspirin and clopidogrel. Our patient is now 6 months post-procedure and remains symptom free, with duplex surveillance negative for restenosis thus far.
DISCUSSION From Department of Surgery, Thomas Jefferson University Hospital. Competition of interest: none. Correspondence: Joshua A. Eisenberg, Thomas Jefferson University Hospital, Department of Surgery, 105 Walnut Street, Ste 605, Philadelphia, PA 19107 (e-mail: [email protected]). 0741-5214/$30.00 Copyright © 2005 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2005.06.034
1210
The extracranial carotid circulation has been studied extensively over the last 50 years as it relates to neurologic symptoms. Most of this literature has focused on the internal carotid and common carotid artery, with little focus on the external carotid artery. The benefit of treating internal carotid artery stenosis has been well described in both symptomatic and asymptomatic patients.9,10 The external
JOURNAL OF VASCULAR SURGERY Volume 42, Number 6
Eisenberg et al 1211
Fig 2. Post-angioplasty and stent of the left external carotid artery demonstrates the stent to be in good position and preservation of the facial artery. Fig 1. Arteriogram demonstrates occluded left internal carotid artery, with a high-grade stenosis of the external carotid artery.
carotid artery can provide significant collaterals to both the brain and to the eye in the face of ipsilateral internal carotid artery occlusion.1,6 Through these collateral vessels, the external carotid artery can also become a source of problems, causing both neurologic and ophthalmologic complications ranging from transient ischemic attacks, ischemic optic neuropathy, retinal artery occlusion, blurry vision, scotoma, and amaurosis fugax.3,4 Collateral pathways have been previously described between the external carotid artery and the ophthalmic artery.1,4 The source of these events is often embolic, and the emboli are thought to originate in either the common carotid, stump of the internal carotid, or in the external carotid artery.11 Therefore, it is believed that treatment of symptomatic patients with external carotid artery stenosis often provides improvement or resolution of these symptoms.3-5,7,8 Various treatments of external carotid artery stenosis have been documented in the literature. The most common repair of these lesions is with external carotid artery endarterectomy.2-4 External carotid-to-internal carotid artery bypass has been performed in this patient population, although this procedure has resulted in a high stroke rate (13.8%).4 Subclavian-to-external carotid artery bypass has
been successfully performed, with a stroke rate similar to that of carotid endarterectomy.4 However, it is our opinion that carotid endarterectomy is usually performed with less difficulty and thus would be the preferred operative approach. Patients who have undergone operative treatment of symptomatic external carotid artery stenosis associated with occluded internal carotid arteries, have demonstrated a low stroke rate and resolved or improved symptoms.3-5 Although symptomatic external carotid artery stenosis has been treated with a variety of open surgical approaches, endovascular approaches have only been described after extracranial to intracranial bypass or with carotid stump syndrome.11,12 This patient, with a history of neck surgery and radiation, made safe open endarterectomy a difficult treatment option. Carotid stenting of the internal carotid artery has become the preferred treatment of certain groups of high-risk patients.13 Risk factors that make open endarterectomy more difficult are patients with a history of previous neck surgery, radiation, tracheostomy, high bifurcation of the common carotid artery, and distal lesions. Various studies have shown that stenting of the internal carotid artery has a low complication rate and is associated acceptable rates of morbidity in these risk groups.13-16 We report successful endovascular treatment of a patient with symptomatic external carotid artery stenosis.
1212 Eisenberg et al
Although there is short follow up, this seems to be a reasonable alternative to conventional open repair in patients with significant comorbidities. REFERENCES 1. Jackson BB. The external carotid as a brain collateral. Am J Surg 1967;113:375-8. 2. Zarins CK. Revascularization of the external carotid artery. J Vasc Surg 1985;2:232-4. 3. Nicolosi A, Klinger D, Bandyk D, Towne J. External carotid endarterectomy in the treatment of symptomatic patients with internal artery occlusion. Ann Vasc Surg 1988;2:336-9. 4. Gertler JP, Cambria RP. The role of external carotid endarterectomy in the treatment of ipsilateral internal carotid occlusion: Collective review. J Vasc Surg 1987;6:158-67. 5. Street DL, Ricotta JJ, Green RM, DeWeese JA. The role of external carotid revascularization in the treatment of ocular ischemia. J Vasc Surg 1987;6:280-2. 6. Ascer E, Gennaro M, Pollina RM, Salles-Cunha S, Lorenson E, Yorkovich WR, et al. The natural history of the external carotid artery after carotid endarterectomy: Implications for management. J Vasc Surg 1996;23:582-6. 7. O’Hara PJ, Hertzer NR, Beven EG. External carotid revascularization: review of a ten-year experience. J Vasc Surg 1985;2:709-14. 8. Halstruk KS, Baker WH, Littooy FN. External carotid endarterectomy. J Vasc Surg 1984;1:398-402.
JOURNAL OF VASCULAR SURGERY December 2005
9. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-8. 10. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et.al. Protected carotid-artery stenting versus endarterectomy in highrisk patients. N Engl J Med 2004;351:1493-501. 11. Naylor AR, Bell PR, Bolia A. Endovascular treatment of carotid stump syndrome. J Vasc Surg 2003;38:593-5. 12. Weber JF, Kirsch E, Radu EW, Steck AJ, Kaiser HJ, Lyrer PA. Angioplasty in a patient with ocular ischemia due to occlusion of the internal and stenosis of the external carotid artery. Cerebrovasc Dis 2003; 16:436-9. 13. North American Symptomatic Carotid Endaterectomy Trial Collaborators. Beneficial effect of Carotid endarterectomy in symptomatic patients with high grade stenosis. N Engl J Med 1991;325:445-53. 14. Shawl F, Kadro W, Domanski MJ, Lapetina FL, Iqbal AA, Dougherty KG, et al. Safety and efficacy of elective carotid artery stenting in high-risk patients. J Am Coll Cardiol 2000;35:1721-8. 15. Chang DW, Schubart PJ, Veith FJ, Zarins CK. A new approach to carotid angioplasty and stenting with transcervical occlusion and protective shunting: Why it may be a better carotid intervention. J Vasc Surg 2004;39:994-1002. 16. Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, et al. Immediate and lat clinical outcomes of carotid stenting in patients with symptomatic and asymptomatic carotid artery stenosis. Circulation 2001;103:532-7. Submitted May 9, 2005; accepted Jun 30, 2005.
Patients with occluded internal carotid arteries and symptomatic stenosis of the external carotid artery can prove to be a challenging dilemma. The external carotid artery provides an important source of collateral flow to both the brain and the eye when the internal carotid artery is occluded.1,2 Emboli may originate from either the internal carotid stump, common carotid artery, or the external carotid artery.3,4 These emboli most commonly cause ophthalmologic or neurologic symptoms. Treatment of these lesions has varied throughout the years and has included contralateral internal carotid endarterectomy, extracranialintracranial bypass, and carotid endarterectomy.4-8 We report a patient with a known occluded internal carotid artery and symptomatic stenosis of the external carotid artery treated with percutaneous transluminal angioplasty (PTA) and stenting. CASE REPORT A 70-year-old man with a known left internal carotid occlusion presented to his ophthalmologist with acute loss of vision in his left eye. The patient described his vision as “foggy” with central clearing. No other neurologic findings were found on examination. Funduscopic examination of the left eye revealed a mobile retinal plaque. The patient’s medical history was significant for hypertension, laryngeal cancer treated with surgery and radiation, and appendicitis. Upon presentation, a carotid ultrasound scan was performed that showed occlusion of the left internal carotid artery and antegrade flow through the vertebral artery. Velocities in the left external carotid artery were 202 cm/s and B mode imaging was consistent with high-grade stenosis. A computed tomography angiogram demonstrated mild diffuse narrowing of the left common carotid artery, occluded left internal carotid artery, and a plaque with high-grade stenosis of the left external carotid artery.
Because of the patient’s symptoms (which resolved spontaneously) and history of neck radiation, carotid angioplasty and stenting was planned. The patient was started on clopidogrel. The patient was taken to the operating room where he underwent cerebral arteriography. The finding of a high-grade stenosis of the external carotid artery was confirmed (Fig 1) as well as a communication between the external carotid artery and the ophthalmic artery. This was thought to be the cause of the patient’s visual symptoms. Arterial access was obtained through the patient’s left groin. The common carotid artery was accessed using Shuttle Select catheter (Cook Inc, Blomington, Ind). This maneuver was facilitated with our guidewire extending as far as the common carotid only. The patient received anticoagulation with heparin (100 U/kg). A 0.014-inch wire was guided through the external carotid lesion through a 4F angled multipurpose catheter (MPA). A cerebral protection device (CPD) was on hand with the intent of its use; however, the lesion was so stenotic, the MPA could not pass. To deliver the CPD, we would have needed to pre-dilatate the lesion. It was decided to forego cerebral protection, given pre-dilatation would have largely obviated its usefulness and excessive wire/catheter manipulation was not desired. A 4-mm ⫻ 2-mm balloon was used for pre-dilatation (Boston Scientific, Natick, Mass) followed by delivery of an 8 ⫻ 29 monorail Wallstent (Boston Scientific) placed across the lesion with preservation of the facial artery. A post-dilatation was performed with a 6-mm ⫻ 2-mm balloon. A completion angiogram (Fig 2) showed the stent to be in good position, with resolution of the stenosis. The patient tolerated the procedure well with no further symptoms and was discharged home on the first postoperative day. He was prescribed aspirin and clopidogrel. Our patient is now 6 months post-procedure and remains symptom free, with duplex surveillance negative for restenosis thus far.
DISCUSSION From Department of Surgery, Thomas Jefferson University Hospital. Competition of interest: none. Correspondence: Joshua A. Eisenberg, Thomas Jefferson University Hospital, Department of Surgery, 105 Walnut Street, Ste 605, Philadelphia, PA 19107 (e-mail: [email protected]). 0741-5214/$30.00 Copyright © 2005 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2005.06.034
1210
The extracranial carotid circulation has been studied extensively over the last 50 years as it relates to neurologic symptoms. Most of this literature has focused on the internal carotid and common carotid artery, with little focus on the external carotid artery. The benefit of treating internal carotid artery stenosis has been well described in both symptomatic and asymptomatic patients.9,10 The external
JOURNAL OF VASCULAR SURGERY Volume 42, Number 6
Eisenberg et al 1211
Fig 2. Post-angioplasty and stent of the left external carotid artery demonstrates the stent to be in good position and preservation of the facial artery. Fig 1. Arteriogram demonstrates occluded left internal carotid artery, with a high-grade stenosis of the external carotid artery.
carotid artery can provide significant collaterals to both the brain and to the eye in the face of ipsilateral internal carotid artery occlusion.1,6 Through these collateral vessels, the external carotid artery can also become a source of problems, causing both neurologic and ophthalmologic complications ranging from transient ischemic attacks, ischemic optic neuropathy, retinal artery occlusion, blurry vision, scotoma, and amaurosis fugax.3,4 Collateral pathways have been previously described between the external carotid artery and the ophthalmic artery.1,4 The source of these events is often embolic, and the emboli are thought to originate in either the common carotid, stump of the internal carotid, or in the external carotid artery.11 Therefore, it is believed that treatment of symptomatic patients with external carotid artery stenosis often provides improvement or resolution of these symptoms.3-5,7,8 Various treatments of external carotid artery stenosis have been documented in the literature. The most common repair of these lesions is with external carotid artery endarterectomy.2-4 External carotid-to-internal carotid artery bypass has been performed in this patient population, although this procedure has resulted in a high stroke rate (13.8%).4 Subclavian-to-external carotid artery bypass has
been successfully performed, with a stroke rate similar to that of carotid endarterectomy.4 However, it is our opinion that carotid endarterectomy is usually performed with less difficulty and thus would be the preferred operative approach. Patients who have undergone operative treatment of symptomatic external carotid artery stenosis associated with occluded internal carotid arteries, have demonstrated a low stroke rate and resolved or improved symptoms.3-5 Although symptomatic external carotid artery stenosis has been treated with a variety of open surgical approaches, endovascular approaches have only been described after extracranial to intracranial bypass or with carotid stump syndrome.11,12 This patient, with a history of neck surgery and radiation, made safe open endarterectomy a difficult treatment option. Carotid stenting of the internal carotid artery has become the preferred treatment of certain groups of high-risk patients.13 Risk factors that make open endarterectomy more difficult are patients with a history of previous neck surgery, radiation, tracheostomy, high bifurcation of the common carotid artery, and distal lesions. Various studies have shown that stenting of the internal carotid artery has a low complication rate and is associated acceptable rates of morbidity in these risk groups.13-16 We report successful endovascular treatment of a patient with symptomatic external carotid artery stenosis.
1212 Eisenberg et al
Although there is short follow up, this seems to be a reasonable alternative to conventional open repair in patients with significant comorbidities. REFERENCES 1. Jackson BB. The external carotid as a brain collateral. Am J Surg 1967;113:375-8. 2. Zarins CK. Revascularization of the external carotid artery. J Vasc Surg 1985;2:232-4. 3. Nicolosi A, Klinger D, Bandyk D, Towne J. External carotid endarterectomy in the treatment of symptomatic patients with internal artery occlusion. Ann Vasc Surg 1988;2:336-9. 4. Gertler JP, Cambria RP. The role of external carotid endarterectomy in the treatment of ipsilateral internal carotid occlusion: Collective review. J Vasc Surg 1987;6:158-67. 5. Street DL, Ricotta JJ, Green RM, DeWeese JA. The role of external carotid revascularization in the treatment of ocular ischemia. J Vasc Surg 1987;6:280-2. 6. Ascer E, Gennaro M, Pollina RM, Salles-Cunha S, Lorenson E, Yorkovich WR, et al. The natural history of the external carotid artery after carotid endarterectomy: Implications for management. J Vasc Surg 1996;23:582-6. 7. O’Hara PJ, Hertzer NR, Beven EG. External carotid revascularization: review of a ten-year experience. J Vasc Surg 1985;2:709-14. 8. Halstruk KS, Baker WH, Littooy FN. External carotid endarterectomy. J Vasc Surg 1984;1:398-402.
JOURNAL OF VASCULAR SURGERY December 2005
9. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-8. 10. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et.al. Protected carotid-artery stenting versus endarterectomy in highrisk patients. N Engl J Med 2004;351:1493-501. 11. Naylor AR, Bell PR, Bolia A. Endovascular treatment of carotid stump syndrome. J Vasc Surg 2003;38:593-5. 12. Weber JF, Kirsch E, Radu EW, Steck AJ, Kaiser HJ, Lyrer PA. Angioplasty in a patient with ocular ischemia due to occlusion of the internal and stenosis of the external carotid artery. Cerebrovasc Dis 2003; 16:436-9. 13. North American Symptomatic Carotid Endaterectomy Trial Collaborators. Beneficial effect of Carotid endarterectomy in symptomatic patients with high grade stenosis. N Engl J Med 1991;325:445-53. 14. Shawl F, Kadro W, Domanski MJ, Lapetina FL, Iqbal AA, Dougherty KG, et al. Safety and efficacy of elective carotid artery stenting in high-risk patients. J Am Coll Cardiol 2000;35:1721-8. 15. Chang DW, Schubart PJ, Veith FJ, Zarins CK. A new approach to carotid angioplasty and stenting with transcervical occlusion and protective shunting: Why it may be a better carotid intervention. J Vasc Surg 2004;39:994-1002. 16. Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, et al. Immediate and lat clinical outcomes of carotid stenting in patients with symptomatic and asymptomatic carotid artery stenosis. Circulation 2001;103:532-7. Submitted May 9, 2005; accepted Jun 30, 2005.