Posterior transverse plication of the internal carotid artery to correct for kinking

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

INTRODUCTION

Tortuous vascular anatomy is one of the greatest challenges in mechanical thrombectomy. This study examines the impact of vascular tortuosity on the performance of stent retrievers and evaluates the efficacy of the newer generation stent retrievers with segmented design.

MATERIALS AND METHODS

Models with mild, moderate, and severe tortuosity with an internal carotid artery (ICA) and a middle cerebral artery (MCA) were created. An elastic and cohesive clot was placed in the MCA lying from distal M1 and proximal M2. We assessed the revascularization rates of two commonly used stent retrievers (Trevo XP and Solitaire FR) and two newer stent retrievers with segmented design (Embotrap and Versi) in each vascular model.

RESULTS

Both the type of stent retriever and the severity of vessel tortuosity significantly affected the successful recanalization rate. Post-hoc tests showed that the rate of revascularization was significantly less in severe tortuosity than in mild or moderate tortuosity (P<0.001). The Versi resulted in higher success rates than the Solitaire (P<0.01) and the Trevo (P<0.05). The success rates of the Embotrap were higher than the Solitaire and Trevo stent retrievers, although the difference was not statistically significant.

CONCLUSIONS

Severe tortuosity reduces the performance of mechanical thrombectomy. The segmented design in stent retrievers could improve the efficacy of mechanical thrombectomy in tortuous vessels.

TRIAL REGISTRATION

ESCAPE NCT01778335;SWIFT PRIME >NCT01657461; REVASCAT >NCT01692379; All post-results.

Current Understanding of Dolichoarteriopathies of the Internal Carotid Artery: A Review

Dolichoarteriopathies of the internal carotid artery (DICAs) are not uncommon, and although several studies have investigated DICAs, several questions regarding the etiology and best management course for DICAs remain unanswered. It is also difficult to correlate the occurrence of DICAs with the onset of clinical symptoms. Therefore, we surveyed the literature in PubMed and performed a review of DICAs to offer a comprehensive picture of our understanding of DICAs. We found that DICAs can be classified into three types, specifically tortuous, coiling and kinking, and are not associated with atherosclerotic risk factors. Cerebral hemodynamic changes are mainly associated with the degree of bending of DICAs. DICAs can result in symptoms of the brain and eyes due to insufficient blood supply and can co-occur with a pulsatile cervical mass, a pharyngeal bulge and pulsation. The diagnostic tools for the assessment of DICAs include Doppler ultrasonography, computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), and although DSA remains the gold standard, Doppler ultrasonography is a convenient method that provides useful data for the morphological evaluation of DICAs. CTA and MRA are efficient methods for detecting the morphology of the cervical segment of DICAs. Some DICAs should be treated surgically based on certain indications, and several methods, including correcting the bending or shortening of DICAs, have been developed for the treatment of DICAs. The appropriate treatment of DICAs results in good outcomes and is associated with low morbidity and mortality rates. However, despite the success of surgical reconstruction, an appropriate therapeutic treatment remains a subject of numerous debates due to the lack of multicentric, randomized, prospective studies.

Surgical Revascularization of Symptomatic Kinking of the Internal Carotid Artery

Objective:

To evaluate the safety and outcomes of surgical revascularization for patients with symptomatic kinking of the internal carotid artery (ICA).

Methods:

Twenty-five consecutive patients presented with symptomatic kinking of the ICA and a history of transient ischemic attack (TIA) or stroke were prospectively enrolled in this study. All patients were treated with ICA transection and end-to-side reimplantation at the level of the carotid bulb. Patients were followed up for a median of 32 months.

Results:

There were no deaths or strokes within the 30 days of the treatment. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. One (4%) patient had temporary recurrent nerve palsy, which was completely recovered at 4-week follow-up. One (4%) patient had a myocardial ischemic event. At the end of the 32-month follow-up, 1 (4%) patient developed ipsilateral minor stroke. No recurrent stenosis was detected by Doppler ultrasound.

Conclusion:

Surgical treatment for isolated, symptomatic kinking of the ICA and a history of TIA or stroke is safe, and the outcomes are acceptable.