- Email: [email protected]
Endovascular Treatment of Tandem Lesions of the Carotid Arteries.
Case Report Endovascular Treatment of Tandem Lesions of the Carotid Arteries. Fotis A. Markatis,1 George S. Sfyroeras,1 Konstantinos G. Moulakakis,1 John Kakisis,1 Elias N. Brountzos,2 and Christos D. Liapis,1 Athens, Greece
Background: High-grade stenoses of both common (CCA) and the internal (ICA) carotid arteries are rare and represent a therapeutic dilemma for the treating physician. The aim of this article is to present our experience with fully endovascular repair of those lesions. Methods: Between January 2011 and December 2012, 5 patients (all male, age 73.6 years) with concomitant CCA and ICA stenoses were treated endovascularly. All patients were asymptomatic. The lesions involved the left carotid in 3 and the right carotid in 2 cases. Common carotid artery stenosis was located at the ostium (1 patient), the middle (3 patients) and the distal segment (1 patient) of the CCA. In 3 cases, CCA stenting was initially performed followed by ICA treatment, whereas in the remaining 2, ICA stenting preceded CCA stenting. A filter embolic protection device was used in 2 cases. Results: All procedures were successfully completed. Technical success rate was 100%. Mortality rate was 0%. One patient experienced transient neurologic complication. An 82-year-old who underwent left mid-CCA and ICA stenosis without embolic protection device suffered a transient ischemic attack with dysarthria lasting for a few minutes. A 73-year-old patient with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection experienced symptoms consistent with cerebral hyperperfusion. Patients were followed up for a mean of 6 months. No neurologic complications or stent restenosis were detected. Conclusions: Angioplasty and stenting is a technically feasible method for the treatment of concomitant CCA and ICA stenosis with acceptable short- and mid-term results.
INTRODUCTION Carotid endarterectomy is an established procedure for the treatment of high-grade carotid stenoses mainly for symptomatic patients. In the past, the detection of carotid stenosis was performed using invasive procedures that included views of the carotid vasculature as well as intracranial views. Today
1 Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens Greece. 2 Second Department of Radiology, Athens University Medical School, Attikon University Hospital, Athens, Greece.
Correspondence to: Fotis A. Markatis, MD, 1 Rimini St, 124 62, Athens, Greece; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2013.09.021 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: July 30, 2013; manuscript accepted: September 12, 2013; published online: ---.
the detection and evaluation of carotid bifurcation lesions is performed by magnetic resonance angiography or computed tomography (CT) angiography of the supra-aortic vessels together with projections of the aortic arch. Incidental lesions in other parts of the carotid vasculature are not an infrequent finding during imaging evaluation. These lesions are referred to as tandem or serial carotid lesions. Tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA) are present in approximately 4.3% of cases.1 Patients with such lesions have to be treated for both stenoses of the extracranial vasculature to avoid either carotid thrombosis following carotid endarterectomy or cerebral embolization from remnant untreated lesions. The planning and treatment of these threatening lesions is challenging. Endovascular techniques can be helpful in their management, either in addition to surgical endarterectomy (hybrid procedures) or 1
2 Case Report
Annals of Vascular Surgery
Table I. Patient comorbidities and risk factors
Diabetes mellitus Smoking Hypertension Hyperlipidemia Coronary artery disease Chronic obstructive pulmonary disease Malignancy Inflammatory bowel disease
n
%
3 4 4 4 1 1 1 1
60 80 80 80 20 20 20 20
as independent endovascular procedures. Hybrid repair is well described,2e5 but to our knowledge there is only 1 case report6 for total endovascular management of tandem extracranial carotid lesions; the technique was reviewed by Moore and Schneider in 2011.7 Our aim with this article is to describe our experience of a fully endovascular planning and treatment of diffuse carotid lesions, offering some periprocedural hints for successful results.
METHODS Between January 2011 and December 2012, 5 patients with CCA and ICA stenosis were treated endovascularly (Table I). All patients were men with mean age 73.6 years (range 62e82). In 3 patients, the lesions were located in the left CCA and ICA, and in the remaining 2, they were located in the right arteries. All patients were asymptomatic from the ipsilateral carotid territory. One of our patients, a 65-year-old man, presented with symptoms of critical limb ischemia of his right lower limb. Carotid stenoses were incidental findings when he was found to have a cervical bruit on physical examination. A brain CT, and carotid ultrasound were routinely performed in all cases before the operation. According to the preoperative imaging, all the carotid plaques appeared stable on ultrasound examination (type IV carotid plaques) with a reduction diameter of 85% to 90%. The preoperative scan of an 82-year-old male patient revealed the presence of an ischemic lesion to the ipsilateral frontal lobe; however, he had not had any neurologic symptoms. In all cases, the ipsilateral ICA stenosis was >70%. CCA stenosis was hemodynamically significant and located to the ostium (1 patient), middle (3 patients), and distal (1 patient) segments of the CCA. Contralateral ICA was occluded in 3 patients, whereas the remaining 2 had a 50% and a 70% stenosis. All patients received a dual-antiplatelet regimen (acetylsalicylic acid 100 mg/day and clopidogrel 75 mg/day) at least 7 days before surgery.
All procedures were performed in the angiographic suite under local anaesthesia. The common femoral artery was punctured, and 5000 IU of heparin was administered intravenously. Using a selective catheter (Simmons 2, Terumo International Systems), the common carotid artery was cannulated and a selective angiogram was performed to locate the lesions. In 3 patients (2 with mid and a patient with ostial CCA stenosis), the CCA angioplasty was initially performed (Fig. 1). In the remaining 2 cases, the ICA angioplasty was performed first. In all cases, primary stenting without predilation of the stenosis was performed. Tapered 9e7 40 mm Xact self-expandable stents (Abbott Vascular, Illinois USA) were used for the ICA stenosis (Fig. 2). In CCA stenosis tapered 9e7 40 stents were used in two cases and non-tapered self-expandable stents in 3 cases. A filter embolization protection device (Emboshield Nav6, Abbott Vascular, Abbott Park, IL) was used in 2 procedures (Table II). After stenting of an ostial CCA stenosis in a 62-year-old patient, a filter embolic protection device (EPD) was deployed to the ICA distally to the lesion, and ICA stenting was performed thereafter. In another case, a 62-year-old patient with ICA and mid-CCA stenosis, a filter EPD was initially deployed, and then 2 self-expandable tapered 9e7 40-mm stents were deployed covering both lesions. In a third case, the EPD could not be advanced because of severe angulation of the ICA. All stents were postdilated using the appropriate balloon catheters. Intravenous atropine 0.5 to 1 mg was administered in all cases to prevent bradycardia when dilation of the carotid sinus was performed. After completion angiography and removal of all material, hemostasis was achieved using a closure device. For the patient presenting with critical limb ischemia, we should mention that the right common iliac lesion was treated before the carotid treatment with the use of 9 4 selfexpandable stent and concomitant balloon angioplasty (Fig. 3). All patients were restricted to bed rest for 12 hours. Dual antiplatelet therapy was continued after the procedures, and the patients were ambulatory on the first postoperative day.
RESULTS All procedures were completed with successful stent deployment to the intended location. There was no residual stenosis >30%. Technical success was 100%. Mortality was 0%. During the postoperative period, 1 patient suffered transient neurologic complications. An 82-year-old patient who underwent left mid-CCA and ICA stenting without EPD suffered
Vol.
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2014
Case Report 3
Fig. 1. Pre- and Postdilation and stenting of a left common carotid artery stenosis, with a 9 4-mm self-expandable stent.
Fig. 2. Internal carotid artery stenosis showing a near occlusive lesion. (Right) The final result following deployment of a 9e7 4-mm self-expandable stent in the same patient.
Table II. Patient age, anatomic data, operative data, and outcome Patient no
Age
Side
CCA stenosis
Contralateral ICA
CCA stent first
EPD
CCA stent
1 2 3 4 5
68 83 62 73 82
R R L L L
Middle Distal Ostial Middle Middle
Occluded Occluded 50% Occluded 70%
+
e
+
+ +
7 9e7 10 9e7 8
+
40 40 30 40 60
ICA stent
9e7 9e7 9e7 9e7 9e7
40 40 40 40 40
Outcome
d d d Headache, dizziness Transient ischemic attack
CCA, common carotid artery; EPD, embolic protection device; ICA, internal carotid artery.
a transient ischemic attack (TIA) with dysarthria lasting for a few minutes. His neurologic status improved the day after, and patient was discharged 5 days after the procedure without any neurologic deficit. A second patient, aged 73 years, with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection, experienced severe headache and disorientation that lasted for 12 hours after the procedure.
He did not present any focal neurologic symptoms according to the neurologic consultation. He underwent a brain CT, which did not demonstrate any new lesions. The patient’s symptomatology was consistent with cerebral hyperperfusion. There was no permanent neurologic deficit or any new lesions in the brain CT scan. Mean hospital stay was 5 days. Patients were followed up for a mean period of 6 months (range
4 Case Report
Annals of Vascular Surgery
Fig. 3. The patient presented in Figure 2 with a repair of a tight common iliac artery stenosis in the same session.
1e12 months). No neurologic complications occurred during follow-up. No in-stent restenosis was detected.
DISCUSSION Degenerative pathologies of the supra-aortic arteries are diagnosed because of the increasing number of CT angiograms of the aortic arch and cervical arteries. Multiple lesions at different levels of the CCA and ICA (tandem lesions) are rarely seen, with an incidence of 4.3%.1 As with isolated ICA stenosis, the potential risk of distal embolization becomes more prominent when dealing with multiple lesions of the CCA and ICA, especially if those of the CCA were not previously diagnosed. The anatomic localization of these lesions vary throughout the length of the supra-aortic vessels and between the extracranial and intracranial vessels, as noted by Malik et al.8 The most frequent are lesions at the origin of the aortic arch and carotid bifurcation. They pose serious risks during CAS procedures because of manipulations of the catheters across the arch. In cases of unknown ostial stenosis of the CCA, clumsy efforts for carotid catheterization can result in particle dislocation from the atheromatous plaque with poor results. Tandem carotid lesions can be approached with different methods, which have been described in detail. Because of the rarity of this condition, there are only a few case series and a meta-analysis describing possible treatment options. One possibility is the open surgical procedure combining a median sternotomy with endarterectomy of the ostial, anonymous, or arch lesion with concomitant endarterectomy of the carotid bifurcation. This option poses serious peri-interventional risks to the patient
due to the surgical trauma caused by sternotomy.10e12 Since the introduction of endovascular techniques, especially for the supra-aortic arteries, the risk of treatment at the level of the aortic arch origin have diminished. For tandem carotid lesions, many references report the use of ‘‘hybrid’’ surgical and endovascular procedures. This approach comprises carotid endarterectomy of the carotid bifurcation followed by retrograde endovascular repair of the CCA stenosis before the closure of the carotid arteriotomy.13 A recent meta-analysis9 describes the procedure and the feasibility and applicability of such an approach. The authors concluded that for combined stroke and death rate, the results are equal or even better than for endarterectomy alone because it is a less invasive procedure. A key step during the procedure is the discontinuation of the cerebral circulation during the endovascular part of the technique, which is imperative to minimize the risk of cerebral embolization during balloon angioplasty of the CCA. Extending the treatment options for tandem stenoses, we describe a total endovascular approach. For stable asymptomatic carotid plaques, as in our patients, endovascular treatment can be as safe and efficient as carotid endarterectomy.14e18 To our knowledge, there is only 1 case report described in the literature6 using this technique; here we describe the results of 5 cases of antegrade endovascular treatment. In the case described by Alexandrescu et al,6 the authors performed a retrograde and an antegrade approach through a small cervical cut-down and dissection of the CCA before the carotid bifurcation. In our series, we use the transfemoral route for all the procedures, as described in the Methods section. From a technical point of view it is important to differentiate between the localization of the
Vol.
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No.
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2014
atheromatous plaque on the CCA. The lesions may be found at the ostium of the artery, its mid-portion, at the distal segment of the CCA, or in any combination of these. The endovascular approach varies among these 3 conditions. For ostial and mid-carotid lesions, the catheterization of the orifice of the CCA is performed in the usual manner with our catheter followed by the passage of the .035-inch Terrumo guidewire, directed toward the external carotid artery. In this case, the angioplasty and stenting of the CCA is performed first over the .035-inch wire without the use of an EPD. Because this is an unprotected step of the procedure, balloon angioplasty precedes stent deployment to minimize the embolization risk. After this step, the .035-inch guidewire is exchanged for the .014-inch, and the procedure is performed in the usual manner with the use of EPDs. For lesions of the distal portion of the CCA near the carotid bifurcation, the technique is done with catheterization of the ICA and deployment of the EPD first. The ICA stent is deployed, followed by a second stent below that, which covers the stenosis extending into the CCA. The stents are deployed from top to bottom in a continuous manner. It is important for the vascular surgeon to differentiate these lesions; the manipulation of the catheter at the aortic arch should be delicate for ostial lesions because there is no protection during this step. During the procedures, we had 1 neurologic event, a TIA, in a patient with a mid-CCA lesion. The TIA was attributed to either the passage of the .035-inch guidewire or the subsequent stent deployment. Another patient with a contralateral ICA occlusion suffered from dizziness, headache, and temporary disorientation, with a temporary increase in arterial blood pressure, which was expected because of the history of his lesions and the patient’s age (73 years). He had an uneventful recovery with excellent pressure control, corticoid treatment, and analgesics on the second postoperative day. All the patients were on dual-antiplatelet treatment for 3 months; during follow-up, they presented no signs of ischemic event for the first 6 months. All stents are patent with no in-stent stenosis.
CONCLUSION According to the results of our small series we find that total endovascular treatment of tandem carotid lesions is an efficient and feasible option with good mid- term results, which in the same time extend the treatment options at the armamentarium of the vascular surgeon.
Case Report 5
REFERENCES 1. Rouleau PA, Huston J 3rd, Gilbertson J, et al. Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy. AJNR Am J Neuroradiol 1999;20:621e5. 2. Allie DE, Hebert CJ, Lirtzman MD, et al. Intraoperative innominate and common carotid intervention combined with carotid endarterectomy: a ‘‘true’’ endovascular surgical approach. J Endovasc Ther 2004;11:258e62. 3. Arko FR, Buckley CJ, Lee SD, et al. Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels. J Cardiovasc Surg (Torino) 2000;41:737e42. 4. Levien LJ, Benn CA, Veller MG, et al. Retrograde balloon angioplasty of brachiocephalic or common carotid artery stenoses at the time of carotid endarterectomy. Eur J Vasc Endovasc Surg 1998;15:521e7. 5. Vermeulen T, Hendriks JM, Baeten M, et al. Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery. Acta Chir Belg 2011;111:312e4. 6. Alexandrescu V, Bergeron P, Ngongang CH, et al. Synchronous endovascular treatment for serial tandem proximal common carotid artery and internal carotid lesions. Acta Chir Belg 2006;106:230e2. 7. Moore JD, Schneider PA. Management of simultaneous common and internal carotid artery occlusive disease in the endovascular era. Semin Vasc Surg 2011;24:2e9. 8. Malik AM, Vora NA, Lin R. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 2011;42: 1653e7. 9. Sfyroeras GS, Karathanos C, Giannoukas AD. A metaanalysis of combined endarterectomy and proximal balloon angioplasty, for tandem disease of the arch vessels and carotid bifurcation. J Vasc Surg 2011;54:534e40. 10. Azakie A, McElhinney DB, Higashima R. Innominate artery reconstruction: over 3 decades of experience. Ann Surg 1998;228:402e10. 11. Azakie A, McElhinney DB, Messina LM. Common brachiocephalic trunk: strategies for revascularization. Ann Thorac Surg 1999;67:657e60. 12. Ligush J Jr, Criado E, Keagy BA. Innominate artery occlusive disease: management with central reconstructive techniques. Surgery 1997;121:556e62. 13. Karathanos C, Sfyroeras GS, Stamoulis K. Hybrid procedures for the treatment of multi-focal ipsilateral internal carotid and proximal common carotid or innominate artery lesions. Vasa 2011;40:241e5. 14. de Donato G, Setacci C, Deloose K. Long-term results of carotid artery stenting. J Vasc Surg 2008;48:1431e40. 15. Knur R. Carotid artery stenting: a systematic review of randomized clinical trials. Vasa 2009;38:281e91. 16. Ielasi A, Latib A, Godino C. Clinical outcomes following protected carotid artery stenting in symptomatic and asymptomatic patients. J Endovasc Ther 2010;17:298e307. 17. Giacovelli JK, Egorova N, Dayal R. Outcomes of carotid stenting compared with endarterectomy are equivalent in asymptomatic patients and inferior in symptomatic patients. J Vasc Surg 2010;52:906e913.. 18. Kakisis JD, Avgerinos ED, Antonopoulos K. The European Society for Vascular Surgery guidelines for carotid intervention: an updated independent assessment and literature review. Eur J Vasc Endovasc Surg 2012;44: 238e43.
Background: High-grade stenoses of both common (CCA) and the internal (ICA) carotid arteries are rare and represent a therapeutic dilemma for the treating physician. The aim of this article is to present our experience with fully endovascular repair of those lesions. Methods: Between January 2011 and December 2012, 5 patients (all male, age 73.6 years) with concomitant CCA and ICA stenoses were treated endovascularly. All patients were asymptomatic. The lesions involved the left carotid in 3 and the right carotid in 2 cases. Common carotid artery stenosis was located at the ostium (1 patient), the middle (3 patients) and the distal segment (1 patient) of the CCA. In 3 cases, CCA stenting was initially performed followed by ICA treatment, whereas in the remaining 2, ICA stenting preceded CCA stenting. A filter embolic protection device was used in 2 cases. Results: All procedures were successfully completed. Technical success rate was 100%. Mortality rate was 0%. One patient experienced transient neurologic complication. An 82-year-old who underwent left mid-CCA and ICA stenosis without embolic protection device suffered a transient ischemic attack with dysarthria lasting for a few minutes. A 73-year-old patient with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection experienced symptoms consistent with cerebral hyperperfusion. Patients were followed up for a mean of 6 months. No neurologic complications or stent restenosis were detected. Conclusions: Angioplasty and stenting is a technically feasible method for the treatment of concomitant CCA and ICA stenosis with acceptable short- and mid-term results.
INTRODUCTION Carotid endarterectomy is an established procedure for the treatment of high-grade carotid stenoses mainly for symptomatic patients. In the past, the detection of carotid stenosis was performed using invasive procedures that included views of the carotid vasculature as well as intracranial views. Today
1 Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens Greece. 2 Second Department of Radiology, Athens University Medical School, Attikon University Hospital, Athens, Greece.
Correspondence to: Fotis A. Markatis, MD, 1 Rimini St, 124 62, Athens, Greece; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2013.09.021 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: July 30, 2013; manuscript accepted: September 12, 2013; published online: ---.
the detection and evaluation of carotid bifurcation lesions is performed by magnetic resonance angiography or computed tomography (CT) angiography of the supra-aortic vessels together with projections of the aortic arch. Incidental lesions in other parts of the carotid vasculature are not an infrequent finding during imaging evaluation. These lesions are referred to as tandem or serial carotid lesions. Tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA) are present in approximately 4.3% of cases.1 Patients with such lesions have to be treated for both stenoses of the extracranial vasculature to avoid either carotid thrombosis following carotid endarterectomy or cerebral embolization from remnant untreated lesions. The planning and treatment of these threatening lesions is challenging. Endovascular techniques can be helpful in their management, either in addition to surgical endarterectomy (hybrid procedures) or 1
2 Case Report
Annals of Vascular Surgery
Table I. Patient comorbidities and risk factors
Diabetes mellitus Smoking Hypertension Hyperlipidemia Coronary artery disease Chronic obstructive pulmonary disease Malignancy Inflammatory bowel disease
n
%
3 4 4 4 1 1 1 1
60 80 80 80 20 20 20 20
as independent endovascular procedures. Hybrid repair is well described,2e5 but to our knowledge there is only 1 case report6 for total endovascular management of tandem extracranial carotid lesions; the technique was reviewed by Moore and Schneider in 2011.7 Our aim with this article is to describe our experience of a fully endovascular planning and treatment of diffuse carotid lesions, offering some periprocedural hints for successful results.
METHODS Between January 2011 and December 2012, 5 patients with CCA and ICA stenosis were treated endovascularly (Table I). All patients were men with mean age 73.6 years (range 62e82). In 3 patients, the lesions were located in the left CCA and ICA, and in the remaining 2, they were located in the right arteries. All patients were asymptomatic from the ipsilateral carotid territory. One of our patients, a 65-year-old man, presented with symptoms of critical limb ischemia of his right lower limb. Carotid stenoses were incidental findings when he was found to have a cervical bruit on physical examination. A brain CT, and carotid ultrasound were routinely performed in all cases before the operation. According to the preoperative imaging, all the carotid plaques appeared stable on ultrasound examination (type IV carotid plaques) with a reduction diameter of 85% to 90%. The preoperative scan of an 82-year-old male patient revealed the presence of an ischemic lesion to the ipsilateral frontal lobe; however, he had not had any neurologic symptoms. In all cases, the ipsilateral ICA stenosis was >70%. CCA stenosis was hemodynamically significant and located to the ostium (1 patient), middle (3 patients), and distal (1 patient) segments of the CCA. Contralateral ICA was occluded in 3 patients, whereas the remaining 2 had a 50% and a 70% stenosis. All patients received a dual-antiplatelet regimen (acetylsalicylic acid 100 mg/day and clopidogrel 75 mg/day) at least 7 days before surgery.
All procedures were performed in the angiographic suite under local anaesthesia. The common femoral artery was punctured, and 5000 IU of heparin was administered intravenously. Using a selective catheter (Simmons 2, Terumo International Systems), the common carotid artery was cannulated and a selective angiogram was performed to locate the lesions. In 3 patients (2 with mid and a patient with ostial CCA stenosis), the CCA angioplasty was initially performed (Fig. 1). In the remaining 2 cases, the ICA angioplasty was performed first. In all cases, primary stenting without predilation of the stenosis was performed. Tapered 9e7 40 mm Xact self-expandable stents (Abbott Vascular, Illinois USA) were used for the ICA stenosis (Fig. 2). In CCA stenosis tapered 9e7 40 stents were used in two cases and non-tapered self-expandable stents in 3 cases. A filter embolization protection device (Emboshield Nav6, Abbott Vascular, Abbott Park, IL) was used in 2 procedures (Table II). After stenting of an ostial CCA stenosis in a 62-year-old patient, a filter embolic protection device (EPD) was deployed to the ICA distally to the lesion, and ICA stenting was performed thereafter. In another case, a 62-year-old patient with ICA and mid-CCA stenosis, a filter EPD was initially deployed, and then 2 self-expandable tapered 9e7 40-mm stents were deployed covering both lesions. In a third case, the EPD could not be advanced because of severe angulation of the ICA. All stents were postdilated using the appropriate balloon catheters. Intravenous atropine 0.5 to 1 mg was administered in all cases to prevent bradycardia when dilation of the carotid sinus was performed. After completion angiography and removal of all material, hemostasis was achieved using a closure device. For the patient presenting with critical limb ischemia, we should mention that the right common iliac lesion was treated before the carotid treatment with the use of 9 4 selfexpandable stent and concomitant balloon angioplasty (Fig. 3). All patients were restricted to bed rest for 12 hours. Dual antiplatelet therapy was continued after the procedures, and the patients were ambulatory on the first postoperative day.
RESULTS All procedures were completed with successful stent deployment to the intended location. There was no residual stenosis >30%. Technical success was 100%. Mortality was 0%. During the postoperative period, 1 patient suffered transient neurologic complications. An 82-year-old patient who underwent left mid-CCA and ICA stenting without EPD suffered
Vol.
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No.
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2014
Case Report 3
Fig. 1. Pre- and Postdilation and stenting of a left common carotid artery stenosis, with a 9 4-mm self-expandable stent.
Fig. 2. Internal carotid artery stenosis showing a near occlusive lesion. (Right) The final result following deployment of a 9e7 4-mm self-expandable stent in the same patient.
Table II. Patient age, anatomic data, operative data, and outcome Patient no
Age
Side
CCA stenosis
Contralateral ICA
CCA stent first
EPD
CCA stent
1 2 3 4 5
68 83 62 73 82
R R L L L
Middle Distal Ostial Middle Middle
Occluded Occluded 50% Occluded 70%
+
e
+
+ +
7 9e7 10 9e7 8
+
40 40 30 40 60
ICA stent
9e7 9e7 9e7 9e7 9e7
40 40 40 40 40
Outcome
d d d Headache, dizziness Transient ischemic attack
CCA, common carotid artery; EPD, embolic protection device; ICA, internal carotid artery.
a transient ischemic attack (TIA) with dysarthria lasting for a few minutes. His neurologic status improved the day after, and patient was discharged 5 days after the procedure without any neurologic deficit. A second patient, aged 73 years, with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection, experienced severe headache and disorientation that lasted for 12 hours after the procedure.
He did not present any focal neurologic symptoms according to the neurologic consultation. He underwent a brain CT, which did not demonstrate any new lesions. The patient’s symptomatology was consistent with cerebral hyperperfusion. There was no permanent neurologic deficit or any new lesions in the brain CT scan. Mean hospital stay was 5 days. Patients were followed up for a mean period of 6 months (range
4 Case Report
Annals of Vascular Surgery
Fig. 3. The patient presented in Figure 2 with a repair of a tight common iliac artery stenosis in the same session.
1e12 months). No neurologic complications occurred during follow-up. No in-stent restenosis was detected.
DISCUSSION Degenerative pathologies of the supra-aortic arteries are diagnosed because of the increasing number of CT angiograms of the aortic arch and cervical arteries. Multiple lesions at different levels of the CCA and ICA (tandem lesions) are rarely seen, with an incidence of 4.3%.1 As with isolated ICA stenosis, the potential risk of distal embolization becomes more prominent when dealing with multiple lesions of the CCA and ICA, especially if those of the CCA were not previously diagnosed. The anatomic localization of these lesions vary throughout the length of the supra-aortic vessels and between the extracranial and intracranial vessels, as noted by Malik et al.8 The most frequent are lesions at the origin of the aortic arch and carotid bifurcation. They pose serious risks during CAS procedures because of manipulations of the catheters across the arch. In cases of unknown ostial stenosis of the CCA, clumsy efforts for carotid catheterization can result in particle dislocation from the atheromatous plaque with poor results. Tandem carotid lesions can be approached with different methods, which have been described in detail. Because of the rarity of this condition, there are only a few case series and a meta-analysis describing possible treatment options. One possibility is the open surgical procedure combining a median sternotomy with endarterectomy of the ostial, anonymous, or arch lesion with concomitant endarterectomy of the carotid bifurcation. This option poses serious peri-interventional risks to the patient
due to the surgical trauma caused by sternotomy.10e12 Since the introduction of endovascular techniques, especially for the supra-aortic arteries, the risk of treatment at the level of the aortic arch origin have diminished. For tandem carotid lesions, many references report the use of ‘‘hybrid’’ surgical and endovascular procedures. This approach comprises carotid endarterectomy of the carotid bifurcation followed by retrograde endovascular repair of the CCA stenosis before the closure of the carotid arteriotomy.13 A recent meta-analysis9 describes the procedure and the feasibility and applicability of such an approach. The authors concluded that for combined stroke and death rate, the results are equal or even better than for endarterectomy alone because it is a less invasive procedure. A key step during the procedure is the discontinuation of the cerebral circulation during the endovascular part of the technique, which is imperative to minimize the risk of cerebral embolization during balloon angioplasty of the CCA. Extending the treatment options for tandem stenoses, we describe a total endovascular approach. For stable asymptomatic carotid plaques, as in our patients, endovascular treatment can be as safe and efficient as carotid endarterectomy.14e18 To our knowledge, there is only 1 case report described in the literature6 using this technique; here we describe the results of 5 cases of antegrade endovascular treatment. In the case described by Alexandrescu et al,6 the authors performed a retrograde and an antegrade approach through a small cervical cut-down and dissection of the CCA before the carotid bifurcation. In our series, we use the transfemoral route for all the procedures, as described in the Methods section. From a technical point of view it is important to differentiate between the localization of the
Vol.
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No.
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2014
atheromatous plaque on the CCA. The lesions may be found at the ostium of the artery, its mid-portion, at the distal segment of the CCA, or in any combination of these. The endovascular approach varies among these 3 conditions. For ostial and mid-carotid lesions, the catheterization of the orifice of the CCA is performed in the usual manner with our catheter followed by the passage of the .035-inch Terrumo guidewire, directed toward the external carotid artery. In this case, the angioplasty and stenting of the CCA is performed first over the .035-inch wire without the use of an EPD. Because this is an unprotected step of the procedure, balloon angioplasty precedes stent deployment to minimize the embolization risk. After this step, the .035-inch guidewire is exchanged for the .014-inch, and the procedure is performed in the usual manner with the use of EPDs. For lesions of the distal portion of the CCA near the carotid bifurcation, the technique is done with catheterization of the ICA and deployment of the EPD first. The ICA stent is deployed, followed by a second stent below that, which covers the stenosis extending into the CCA. The stents are deployed from top to bottom in a continuous manner. It is important for the vascular surgeon to differentiate these lesions; the manipulation of the catheter at the aortic arch should be delicate for ostial lesions because there is no protection during this step. During the procedures, we had 1 neurologic event, a TIA, in a patient with a mid-CCA lesion. The TIA was attributed to either the passage of the .035-inch guidewire or the subsequent stent deployment. Another patient with a contralateral ICA occlusion suffered from dizziness, headache, and temporary disorientation, with a temporary increase in arterial blood pressure, which was expected because of the history of his lesions and the patient’s age (73 years). He had an uneventful recovery with excellent pressure control, corticoid treatment, and analgesics on the second postoperative day. All the patients were on dual-antiplatelet treatment for 3 months; during follow-up, they presented no signs of ischemic event for the first 6 months. All stents are patent with no in-stent stenosis.
CONCLUSION According to the results of our small series we find that total endovascular treatment of tandem carotid lesions is an efficient and feasible option with good mid- term results, which in the same time extend the treatment options at the armamentarium of the vascular surgeon.
Case Report 5
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