A Systematic Review of Procedural Outcomes in Patients With Proximal Common Carotid or Innominate Artery Disease With or Without Tandem Ipsilateral Internal Carotid Artery Disease

Management and Treatment of Tandem Carotid Lesions

BACKGROUND

Tandem lesions of the proximal aortic branch vessels and carotid bifurcation are uncommon. While management strategies vary, a hybrid approach of carotid endarterectomy with retrograde common carotid artery (CCA) or innominate artery (IA) stenting has become a mainstay of treatment. The purpose of this article was to provide a review of the literature, discuss alternative treatment modalities, and highlight technical considerations of the hybrid approach.

METHODS

We performed a systematic review of the literature by searching relevant key words in the Cochrane Library, PubMed/Medline, and Embase. The primary endpoints of this study were stroke and all-cause mortality at 30 days. Secondary outcomes included rate of technical success, re-stenosis and need for re-intervention, and stroke and all-cause mortality at 1 year.

RESULTS

We identified 15 retrospective cohort studies with a cumulative 242 patients who underwent hybrid repair. The average technical success rate of hybrid repair for the management of tandem carotid lesions was high (98.8%). Multiple studies reported zero events. The average 30-day mortality rate across all studies was 0.6% (pooled: 3/242, 1.2%) and average 30-day stroke rate across all studies was 0.9% (pooled: 7/242, 2.9%). Of the studies that reported rates of re-stenosis and need for re-intervention, the average re-stenosis rate was 9.6% (pooled 34/209; 16.3%). The most common area of re-stenosis was the proximal carotid CCA/IA (61.7%). The average reintervention rate across all studies was 4.5% (pooled 13/209; 6.2%).

CONCLUSIONS

A hybrid approach of carotid endarterectomy with retrograde CCA/IA stenting is a safe and effective treatment modality for tandem carotid disease. However, there remains a paucity of high-level data as single-center studies are subject to publication bias. This study highlights the critical need for a prospective registry to prognosticate the risk of stroke and mortality for patients with asymptomatic versus symptomatic tandem carotid lesions.

Safe Navigation of Guiding Catheters during Stenting for Common Carotid Artery Lesions: The "No-Touch" Technique

INTRODUCTION

During carotid artery stenting (CAS), safe navigation of the guiding catheter (GC) is essential for the success of procedures. However, in cases where stenosis or floating thrombi are located in the common carotid artery (CCA), especially for proximal lesions, advancing the GC without touching the lesions is often difficult. We describe a preliminary experience of the "no-touch" technique for navigating the GC to the CCA using an inner catheter with a specifically designed shape and stiffness optimized to overcome tortuous anatomy.

METHODS

We retrospectively reviewed CAS procedures involving the "no-touch" technique for treating stenotic lesions in the CCA. A 4-Fr Newton-shaped stiff catheter was positioned in the CCA. Given its high stiffness and dedicated shape, contact with the lesser curvature of the aortic arch absorbed kickback force. Then, a 6-Fr intermediate catheter and an 8- or 9-Fr balloon GC were coaxially advanced in sequence to the target position without guidewire support, ensuring "no-touch" with the plaques. Patient characteristics, aortic arch type, lesion location, and periprocedural complications were recorded.

RESULTS

The technique was applied to eight procedures (six left-sided lesions) in 7 patients (median age, 76 years; six men) among 53 CAS procedures performed on 49 patients. Lesions were located at the proximal CCA (four procedures) or the carotid bifurcation (four procedures). Three patients had floating thrombi, and four had type III aortic arches. GCs were successfully navigated without touching the lesions in all cases, with no periprocedural complications.

CONCLUSION

The "no-touch" technique with a Newton-shaped stiff catheter is useful and feasible for navigating the GC in treating stenotic lesions in the CCA, particularly with tortuous anatomy, proximal lesions, and vulnerable plaques.

[Treatment of tandem occlusions of the common and internal carotid arteries]

BACKGROUND

Proximal carotid tandem lesions are defined as multilevel lesions with significant (> 50%) atherosclerotic disease involving the internal carotid artery (ICA) in combination with the proximal ipsilateral common carotid artery (CCA) or innominate artery (IA). It is a relatively rare disease with an incidence of less than 5% in all patients with carotid stenosis at the level of the bifurcation.

METHODS

These patients are at high surgical risk and were, therefore, excluded from current randomized controlled trials. Although the effectiveness of carotid endarterectomy (CEA) and carotid stenting (CAS) in stroke prevention for patients is established, the optimal treatment approach for the subgroup of patients with a proximal tandem lesion is still controversial. Treatment of this condition is not well understood because it is difficult to determine the risk of each individual lesion becoming symptomatic. Therefore, concurrent treatment of severe (> 70% stenosis) proximal lesions is recommended when treating severe stenosis at the carotid bifurcation.

CONCLUSION

This disease can lead to embolic ischemic strokes or hemodynamic compromise. It is not possible to determine diagnostically which lesion led to the clinical symptoms, which is why both lesions should be corrected.

Hybrid repair of tandem high-grade innominate and carotid artery stenosis in an asymptomatic male

Tandem atherosclerotic lesions of the innominate artery (IA) and internal carotid artery (ICA) are challenging and represent an inherent risk of cerebrovascular accident. Treating asymptomatic patients is controversial; therefore, it is critical to minimize the risk of a cerebrovascular accident if repair is undertaken. An asymptomatic 78-year-old man with a chronically occluded left ICA and tandem stenoses of the IA and right ICA underwent a hybrid intervention with stenting of the IA lesion and right ICA endarterectomy. The intra- and postoperative course was successful, without any signs of neurological sequelae. Sixteen months later, the patient remained asymptomatic, with patent reconstructions.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Usefulness of stent placement for innominate artery stenosis via the right brachial artery under protection by balloon guide catheter: a technical case report

A method of cerebral protection during endovascular treatment for innominate artery stenosis (IAS) has not been established. Herein, we report a case of symptomatic IAS in a 76-year-old woman. A balloon guide catheter (BGC) was inserted through the right brachial artery (BA) and guided distally to the stenosis. The BGC balloon was inflated, and stenting was performed with balloon protection of both the anterior and posterior cerebral circulation, without any complications. Stenting of the IAS with the BGC using the BA approach is useful, as it is a simple technique that can prevent distal embolization.

Blunt Traumatic Innominate Artery Pseudoaneurysm Endografting without Heparin Due to Severe Brain Injury

Blunt traumatic innominate artery injuries occur in polytrauma victims who have suffered high-speed motor vehicle collisions. Their associated injuries may preclude the use of heparin and affect surgical management and perioperative neurological risk. The uniqueness of this case is combining the arterial injury repair with a severe progressive neurological injury that prohibited standard perioperative antiplatelet or anticoagulent use.

Addition of common carotid intervention increases the risk of stroke and death after carotid artery stenting for asymptomatic patients

BACKGROUND

A recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status.

METHODS

Vascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models.

RESULTS

There were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P < .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42).

CONCLUSIONS

The addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Hybrid and Total Endovascular Approaches to Tandem Carotid Artery Lesions Have Similar Short- and Long-Term Outcomes

BACKGROUND

Addition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study.

METHODS

VQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis>70%. Long-term outcomes were compared with Kaplan-Meier Analysis.

RESULTS

There were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P < 0.001), less likely to have diabetes (29.5% vs. 38.2%; P P< 0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P< 0.001), less likely to be symptomatic (34.6% vs. 52.8%; P < 0.001), and less likely to have >70% stenosis (77.3% vs. 95.6%%; P < 0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27).

CONCLUSION

Although simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach.  Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.

Simultaneous treatment of common carotid lesions increases the risk of stroke and death after carotid artery stenting

BACKGROUND

Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study.

METHODS

Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression.

RESULTS

There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006).

CONCLUSIONS

The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.

Adding Supra-Aortic Trunk Surgical Reconstruction to Carotid Endarterectomy: Implications on Risk of Stroke and Death

BACKGROUND

Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA.

STUDY DESIGN

Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed.

RESULTS

Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03-26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1-3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03).

CONCLUSIONS

CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.