1
|
Che WQ, Dong H, Jiang XJ, Peng M, Zou YB, Xiong HL, Yang YJ, Gao RL. Clinical outcomes and influencing factors of in-stent restenosis after stenting for symptomatic stenosis of the vertebral V1 segment. J Vasc Surg 2018; 68:1406-1413. [PMID: 29789215 DOI: 10.1016/j.jvs.2018.02.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 02/24/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate 30-day and long-term clinical outcomes and influencing factors of in-stent restenosis (ISR) after stenting for symptomatic stenosis of the vertebral V1 segment. METHODS The clinical and follow-up data of 301 consecutive patients (mean age, 64 ± 8 years; 252 men) with symptomatic V1 stenosis who underwent stenting at the Fuwai Hospital between January 2010 and June 2016 were collected retrospectively. The 30-day and long-term follow-up of stroke and death after stenting and the recurrence of symptoms, ISR, and repeated revascularization were assessed. RESULTS Technical success was 100%. The mean stenosis of lesions was reduced from 82.8% ± 7.6% to 4.4% ± 4.0% immediately after 312 stents (165 bare-metal stents [BMSs] and 147 drug-eluting stents) were implanted. The overall risk of combined any stroke and death was 1.0% (3/301) within 30 days after stenting. The rates of freedom from any stroke and death were 98.2%, 96.8%, and 91.4% at 1 year, 3 years, and 5 years, respectively. After a mean follow-up of 2.9 ± 1.5 years, 46 (15.8%) patients developed ISR, of whom 19 (6.5%) were symptomatic. Twenty-two (7.6%) patients with ISR underwent repeated revascularization. The primary and assisted patency rates were 90.0% and 95.4%, 82.6% and 90.3%, and 80.3% and 87.9% at 1 year, 3 years, and 5 years, respectively. BMS (hazard ratio, 2.02; 95% confidence interval, 1.01-4.06; P < .05) and diabetes (hazard ratio, 1.87; 95% confidence interval, 1.04-3.37; P = .04) were independently associated with an increased risk of ISR. CONCLUSIONS Percutaneous stent placement for symptomatic V1 stenosis is safe and associated with a good long-term patency rate. BMS and diabetes are independent predictive factors of ISR.
Collapse
Affiliation(s)
- Wu-Qiang Che
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Dong
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiong-Jing Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Meng Peng
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu-Bao Zou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Liang Xiong
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
2
|
Alexander MD, Rebhun JM, Hetts SW, Amans MR, Settecase F, Darflinger RJ, Dowd CF, Halbach VV, Higashida RT, Cooke DL. Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions. Surg Neurol Int 2017; 8:284. [PMID: 29279801 PMCID: PMC5705933 DOI: 10.4103/sni.sni_255_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/22/2017] [Indexed: 11/04/2022] Open
Abstract
Background Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis. Methods Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals. Results One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P < 0.001) and mRS >2 at last contact (OR 12.83, P < 0.001). Stenting treatment with conjunctive angioplasty had lower rates of death (OR 0.303, P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent. Conclusion Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.
Collapse
Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Imaging Sciences, Division of Neurointerventional Radiology, Salt Lake City, Utah, USA
| | - Jeffrey M Rebhun
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Fabio Settecase
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Robert J Darflinger
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Wang J, Zhong C, Zhang Y, Wei Y, Liu H, Wu C, Yan Y. Seven years' follow-up of comparative study between stenting and medication for treatment of symptomatic vertebrobasilar artery stenosis. Interv Neuroradiol 2017; 24:43-50. [PMID: 29058985 DOI: 10.1177/1591019917736032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Endovascular stent-assistant angioplasty (ESAA) is a valid treatment for symptomatic vertebrobasilar artery stenosis (SVAS), but the long-term effect and the improvement of condition compared with medication treatment are unknown. This study investigated the long-term efficacy of ESAA in patients with moderate and severe SVAS, and compared the efficacy with medication treatment. Materials and methods We conducted a retrospective analysis of clinical data of 43 patients with moderate and severe SVAS hospitalized in our department. According to different treatment methods they were divided into 29 cases in an ESAA group and 14 cases in a medication treatment group. During the follow-up period, the degree of vascular stenosis, vascular blood flow velocity, restenosis rate, recovery of neurological function and the incidence of cerebral ischemic events in the two groups were analyzed. Results The average clinical follow-up period was 89.4 ± 10.2 months. Before treatment, the stenosis rate and average blood flow velocity of the two groups were not statistically significant ( p > 0.05). During the follow-up period, both were significantly lower than the medication treatment group ( p < 0.01). In the ESAA group, three cases of stent stenosis, and three cases in the medication treatment group were completely occluded. The total ischemic events in ESAA group were three cases, compared with nine cases in the medication treatment group; the difference was statistically significant ( p < 0.05). Conclusion ESAA has a long-term effect in the treatment of symptomatic moderate and severe vertebrobasilar artery stenosis. It is superior to medication therapy in preventing posterior circulation ischemia (PCI), but a larger sample size is still needed to confirm the study.
Collapse
Affiliation(s)
- Jun Wang
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Changyang Zhong
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Yan Zhang
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Yingnan Wei
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Huili Liu
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Chunli Wu
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| | - Yongxing Yan
- Department of Neurology, Hangzhou Clinical College of Medical University of Anhui; Hangzhou Third Hospital, Hangzhou, P.R. China
| |
Collapse
|
4
|
Georgeto SM, Zicarelli CAM, Gariba MA, Aguiar LR. T1-weighted gradient-echo imaging, with and without inversion recovery, in the identification of anatomical structures on the lateral surface of the brain. Radiol Bras 2017; 49:382-388. [PMID: 28057964 PMCID: PMC5210034 DOI: 10.1590/0100-3984.2015.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To compare brain structures using volumetric magnetic resonance imaging with
isotropic resolution, in T1-weighted gradient-echo (GRE) acquisition, with
and without inversion recovery (IR). Materials and methods From 30 individuals, we evaluated 120 blocks of images of the left and right
cerebral hemispheres being acquired by T1 GRE and by T1 IR GRE. On the basis
of the Naidich et al. method for localization of anatomical landmarks, 27
anatomical structures were divided into two categories: identifiable and
inconclusive. Those two categories were used in the analyses of
repeatability (intraobserver agreement) and reproducibility (interobserver
agreement). McNemar's test was used in order to compare the T1 GRE and T1 IR
GRE techniques. Results There was good agreement in the intraobserver and interobserver analyses
(mean kappa > 0.60). McNemar's test showed that the frequency of
identifiable anatomical landmarks was slightly higher when the T1 IR GRE
technique was employed than when the T1 GRE technique was employed. The
difference between the two techniques was statistically significant. Conclusion In the identification of anatomical landmarks, the T1 IR GRE technique
appears to perform slightly better than does the T1 GRE technique.
Collapse
Affiliation(s)
- Sergio Murilo Georgeto
- Neurosurgeon at the Irmandade da Santa Casa de Londrina and in the Department of Neurosurgery at the Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil
| | - Carlos Alexandre Martins Zicarelli
- Neurosurgeon at the Irmandade da Santa Casa de Londrina and in the Department of Neurosurgery at the Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil
| | - Munir Antônio Gariba
- Professor in the Graduate Program in Health Technology at the Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil
| | - Luiz Roberto Aguiar
- Professor in the Graduate Program in Health Technology at the Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil
| |
Collapse
|
5
|
Guimaraens L, Vivas E, Sola T, Izquierdo J, Nasis N, Soler L, Benitez, Leon M, Miquel L. Stent-Assisted Angioplasty of Intracranial Vertebrobasilar Atherosclerosis: The Best Therapeutic Option in Recurrent Transient Ischemic Events Unresponsive to Anticoagulant Treatments. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140090501800507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Atherosclerotic stenosis of the posterior circulation refractory to medical treatment generally has a poor prognosis resulting in a high morbidity-mortality rate and the recurrence of ischemic events. Extracranial bypass in the vertebrobasilar system is possible but is also associated with high morbidity (3–21%) and mortality (13–55%)1,2, and has not been demonstrated to reduce the risk of stroke. Percutaneous angioplasty alone has also not shown favorable results, and further, has been associated with a remarkable number of complications. The improvement resulting from endovascular therapy has taken the treatment of this pathology to a new dimension. We describe eight patients with severe symptomatic basilar artery stenosis who, in addition to medical therapy, were treated by our service with angioplasty and stent placement. Three of them received urgent treatment. All patients suffering from severe stenosis of the basilar artery were treated by the insertion of balloon expandable stents. The degree of pre-stent stenosis was approximately 80% in all cases, and was reduced to 5–10% after the stent implant. There were no complications during treatment. There has not been a recurrence of symptoms or a new ischemic lesion during the one-year follow-up period. Endovascular therapy with a balloon expandable stent or angioplasty plus stent are presented as improved choices for treatment of patients with severe basilar artery stenosis refractory to medical treatment.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - L. Miquel
- Department of Anesthesia, General Hospital of Catalonia; Sant Cugat del Vallés, Catalonia, Spain
| |
Collapse
|
6
|
Stenting Versus Aggressive Medical Management for Symptomatic Vertebral Artery Stenosis. World Neurosurg 2015; 84:613-5. [DOI: 10.1016/j.wneu.2015.07.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
7
|
Alexander MD, Rebhun JM, Hetts SW, Kim AS, Nelson J, Kim H, Amans MR, Settecase F, Dowd CF, Halbach VV, Higashida RT, Cooke DL. Lesion location, stability, and pretreatment management: factors affecting outcomes of endovascular treatment for vertebrobasilar atherosclerosis. J Neurointerv Surg 2015; 8:466-70. [PMID: 25795438 DOI: 10.1136/neurintsurg-2014-011633] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/02/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The proper role of endovascular treatment of cervicocerebral atherosclerosis is unclear. Posterior circulation disease has not been investigated as extensively as disease in the anterior circulation. In this study, we characterized the rates of technical success, transient ischemic attack, stroke, and death or disability, for both acute and elective endovascular treatment of atherosclerosis in the vertebrobasilar system. METHODS We identified patients with atherosclerosis of the vertebrobasilar circulation who underwent endovascular intervention at our hospital through retrospective medical record review, and evaluated the association between lesion and treatment features and subsequent stroke, death, or disability at 30 days and 1 year. RESULTS We identified 136 lesions in 122 patients, including 13 interventions for acute strokes. Technical success was achieved in 123 of 136 cases (90.4%). Elective procedures had higher rates of technical success (6.5% vs 15.4%, p=0.21) and better clinical outcomes. In multivariate analysis, intracranial lesions were associated with more disability (modified Rankin Scale score >2) at 30 days (OR 7.1, p=0.01) and 1 year (OR 10, p=0.03). Patients with non-hypoperfusion related symptoms had fewer strokes at follow-up at 1 year when treated after an asymptomatic interval of >10 days compared with those treated within 10 days of the presenting symptoms (OR 0.2, p=0.03). Statin treatment prior to intervention was associated with favorable outcomes across several examined endpoints. Preoperative antiplatelet treatment was associated with lower rates of disability at 30 days and 1 year (OR 0.1, p<0.01 and OR 0.07, p=0.01, respectively), and preoperative anticoagulation treatment was associated with higher rates of death at 30 days, particularly when prescribed for reasons other than atrial fibrillation (OR 6.4, p=0.01). CONCLUSIONS Endovascular treatment of symptomatic vertebrobasilar atherosclerosis can be performed safely and with good outcomes. Technical results were better for those with extracranial disease while clinical outcomes were more favorable in those patients with non-progressive symptoms in the subacute period and those receiving statin therapy.
Collapse
Affiliation(s)
| | | | - Steven W Hetts
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Anthony S Kim
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Fabio Settecase
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
8
|
Lee YJ, Lim YS, Lim HW, Yoo WJ, Choi BG, Kim BS. Diagnostic accuracy of 64-slice multidetector CT angiography for detection of in-stent restenosis of vertebral artery ostium stents: comparison with conventional angiography. Acta Radiol 2014; 55:1000-7. [PMID: 24107930 DOI: 10.1177/0284185113507922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are very few reports assessing in-stent restenosis (ISR) after vertebral artery ostium (VAO) stents using multidetector computed tomography (MDCT). PURPOSE To compare the diagnostic accuracy of computed tomography angiography (CTA) using 64-slice MDCT with digital subtraction angiography (DSA) for detection of significant ISR after VAO stenting. MATERIAL AND METHODS The study evaluated 57 VAO stents in 57 patients (39 men, 18 women; mean age 64 years [range, 48-90 years]). All stents were scanned with a 64-slice MDCT scanner. Three sets of images were reconstructed with three different convolution kernels. Two observers who were blinded to the results of DSA assessed the diagnostic accuracy of CTA for detecting significant ISR (≥50% diameter narrowing) of VAO stents in comparison with DSA as the reference standard. The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. RESULTS Of the 57 stents, 46 (81%) were assessable using CTA, while 11 (19%) were not. No stents with diameters ≤2.75 mm were assessable. DSA revealed 13 cases of significant ISR in all stents. The respective sensitivity, specificity, positive and negative predictive values, and accuracy were 92%, 82%, 60%, 97%, and 84% for all stents. On excluding the 11 non-assessable stents, the respective values were 88%, 95%, 78%, 97%, and 93%. Of the 46 CTA assessable stents, eight significant ISRs were diagnosed on DSA. Seven of eight patients with significant ISR by DSA were diagnosed correctly with CTA. The area under the receiver-operating characteristic curve (AUC) was 0.87 for all stents and 0.91 for assessable stents, indicating good to excellent agreement between CTA and DSA for detecting significant ISR after VAO stenting. CONCLUSION Sixty-four-slice MDCT is a promising non-invasive method of assessing stent patency and can exclude significant ISR with high diagnostic values after VAO stenting.
Collapse
Affiliation(s)
- Youn Joo Lee
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Yeon Soo Lim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Hyun Wook Lim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Won Jong Yoo
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Byung Gil Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
9
|
Management of atherosclerotic supraaortic lesions. Eur Surg 2014. [DOI: 10.1007/s10353-014-0268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
10
|
Kikuchi T, Ishii A, Nakahara I, Miyamoto S, Sakai N. Japanese Registry of Neuroendovascular Therapy: extracranial steno-occlusive diseases except for internal carotid artery stenosis. Neurol Med Chir (Tokyo) 2013. [PMID: 24257542 PMCID: PMC4508694 DOI: 10.2176/nmc.st2013-0194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although utilization of endovascular treatment of extracranial steno-occlusive lesions except for internal carotid artery stenosis continues to increase, there is no consensus regarding the natural course and standard treatment of these lesions. The aim of this study was to characterize the utility of endovascular treatment for extracranial steno-occlusive lesions except for internal carotid artery stenosis. A total of 1249 procedures for extracranial steno-occlusive lesions were identified from the Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET2. Excluding the cases of carotid lesions (290 cases), endovascular procedures were performed for 471 (37.7%) subclavian artery stenoses, 404 (32.3%) extracranial vertebral artery stenoses, and 38 (3.0%) innominate artery stenoses with a technical success rate of 97.2%. A stent was placed for 783 lesions and percutaneous transluminal angioplasty was performed for 183 lesions. Forty complications were reported in this cohort. Among these, ischemic complications were the most frequent (12 cases). Comparison between JR-NET1 and JR-NET2 demonstrated a marked increase in the number of procedures, a change in the utilization of antiplatelet therapy, and an increased rate of favorable outcome. We conclude that the endovascular treatment for extracranial steno-occlusive lesions is relatively safe. Continuous efforts should be made to reduce the complication rate, and further trials are needed to validate the beneficial effect of this procedure.
Collapse
Affiliation(s)
- Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | | | | | | | | |
Collapse
|
11
|
Shutze W, Gierman J, McQuade K, Pearl G, Smith B. Treatment of proximal vertebral artery disease. Vascular 2013; 22:85-92. [DOI: 10.1177/1708538112473966] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.
Collapse
|
12
|
Alcocer F, David M, Goodman R, Jain SKA, David S. A forgotten vascular disease with important clinical implications. Subclavian steal syndrome. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:58-62. [PMID: 23569564 PMCID: PMC3614262 DOI: 10.12659/ajcr.883808] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 12/19/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Subclavian Steal Syndrome (SSS) is a fascinating vascular phenomenon in which a steno-occlusive lesion of the proximal subclavian artery causes retrograde flow in the vertebral artery away from the brain stem subsequently causing vertebrobasilar insufficiency. SSS can present with a myriad of neurological and vascular signs and symptoms, but most commonly this phenomenon presents as an incidental finding in an asymptomatic patient. CASE REPORT Our patient is a 73-year-old female sent to the cardiology clinic for surgical clearance in preparation for an elective cholecystectomy. Shortness of breath was her only complaint. Review of systems was remarkable for left arm pain and blurry vision with repetitive movement. Physical examination noticeable for absence of left radial pulse. Percutaneous angiography demonstrated a totally occulted left subclavian artery with collateral circulation form the vertebrobasilar apparatus. CONCLUSIONS Atypical presentation of this unique entity represents a challenge for physicians who require a high index of suspicion to make the diagnosis. We present an atypical case with radiographical evidence of the steal syndrome, followed by an extensive literature review of the most current diagnostic methods as well as latest recommendations for treatment options and secondary prevention.
Collapse
Affiliation(s)
- Fernando Alcocer
- Providence Heart Institute, Providence Hospital and Medical Center, Wayne State University School of Medicine, Southfield, MI, U.S.A
| | | | | | | | | |
Collapse
|
13
|
Kocak B, Korkmazer B, Islak C, Kocer N, Kizilkilic O. Endovascular treatment of extracranial vertebral artery stenosis. World J Radiol 2012; 4:391-400. [PMID: 23024840 PMCID: PMC3460226 DOI: 10.4329/wjr.v4.i9.391] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 09/03/2012] [Accepted: 09/10/2012] [Indexed: 02/06/2023] Open
Abstract
Percutaneous angioplasty and stenting for the treatment of extracranial vertebral artery (VA) stenosis seems a safe, effective and useful technique for resolving symptoms and improving blood flow to the posterior circulation, with a low complication rate and good long-term results. In patients with severe tortuosity of the vessel, stent placement is a real challenge. The new coronary balloon-expandable stents may be preferred. A large variability of restenosis rates has been reported. Drug-eluting stents may be the solution. After a comprehensive review of the literature, it can be concluded that percutaneous angioplasty and stenting of extracranial VA stenosis is technically feasible, but there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.
Collapse
|
14
|
Samaniego EA, Linfante I, Dabus G. Techniques for the diagnosis of vertebral artery origin stenosis and considerations for determining treatment and timing. Interv Cardiol 2012. [DOI: 10.2217/ica.12.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
15
|
Schneider JI, Olshaker JS. Vertigo, Vertebrobasilar Disease, and Posterior Circulation Ischemic Stroke. Emerg Med Clin North Am 2012; 30:681-93. [DOI: 10.1016/j.emc.2012.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
16
|
Yan Y, Liang L, Chen T, Zhong C, Li P. Treatment of symptomatic vertebrobasilar artery stenosis with stent-assistant angioplasty in the elderly. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1590/s0104-42302012000400011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
17
|
Treatment of symptomatic vertebrobasilar artery stenosis with stent-assistant angioplasty in the elderly. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70223-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
18
|
Siddiq F, Chaudhry SA, Khatri R, Rodriguez GJ, Tummala R, Suri MFK, Qureshi AI. Rate of Postprocedural Stroke and Death in SAMMPRIS Trial–Eligible Patients Treated With Intracranial Angioplasty and/or Stent Placement in Practice. Neurosurgery 2012; 71:68-73. [DOI: 10.1227/neu.0b013e3182518575] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The SAMMPRIS (Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) trial, comparing aggressive medical vs stent treatment in patients with symptomatic intracranial stenosis, was halted after a 14% stroke and death rate was observed in the stent-treated group.
OBJECTIVE:
To study the 30-day stroke and death rate in intracranial angioplasty- and stent-treated patients meeting SAMMPRIS trial eligibility criteria.
METHODS:
A retrospective analysis of 96 patients treated with intracranial angioplasty and stent placement at 3 university-affiliated institutions was performed. Patients were divided into SAMMPRIS trial eligible and ineligible groups based on inclusion and exclusion criteria for the SAMMPRIS trial.
RESULTS:
Sixty-nine patients were determined to be SAMMPRIS eligible and 27 patients were ineligible. The SAMMPRIS-eligible group was divided into angioplasty- and stent-treated subgroups (30 and 39 patients, respectively). The overall 30-day postprocedure stroke and death rate was 7.2% in the SAMMPRIS-eligible group and 7.4% in the SAMMPRIS-ineligible group (P = .97). The 30-day postprocedure stroke and death rate was 3.3% in the SAMMPRIS-eligible, angioplasty-treated subgroup and 10.2% in the SAMMPRIS-eligible, stent-treated subgroup (P = .27).
CONCLUSION:
The overall 30-day postprocedure stroke and death rate in our study was lower in both SAMMPRIS-eligible and -ineligible groups than the reported 14% stroke and death rate in the SAMMPRIS trial. We hypothesize that a more judicious use of primary angioplasty may be responsible for better postprocedure outcomes and should be considered an acceptable treatment in future trials.
Collapse
Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | | | | |
Collapse
|
19
|
Antoniou GA, Murray D, Georgiadis GS, Antoniou SA, Schiro A, Serracino-Inglott F, Smyth JV. Percutaneous transluminal angioplasty and stenting in patients with proximal vertebral artery stenosis. J Vasc Surg 2011; 55:1167-77. [PMID: 22206680 DOI: 10.1016/j.jvs.2011.09.084] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 09/06/2011] [Accepted: 09/24/2011] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atherosclerotic occlusive disease of the proximal vertebral artery is an important cause of cerebrovascular ischemic events with a significant associated morbidity and mortality. Endovascular treatment has emerged as a promising tool of the therapeutic armamentarium, along with medical therapy and surgical reconstruction. Our objective was to systemically review the pertinent evidence on the endovascular management of proximal vertebral artery disease and perform an analysis of the published outcomes. METHODS A systematic review of the literature identified all studies reporting percutaneous transluminal angioplasty or stenting, or both, for proximal vertebral artery stenosis. Web-based search engines were searched using the Medical Subject Headings terms "vertebral artery," "angioplasty," and "stents" in all possible combinations. Studies comprising a series of at least five patients were considered for analysis. Periprocedural transient ischemic attack and stroke and death from any cause ≤30 days of treatment were defined as the primary outcome end points. RESULTS One randomized controlled trial comparing angioplasty and stenting of the proximal vertebral artery and medical therapy was identified. No comparative studies of endovascular treatment and open surgical repair were found. Forty-two selected studies reported endovascular treatment (angioplasty or stenting, or both) of 1117 vertebral arteries in 1099 patients. The weighted mean technical success rate was 97% (range, 36%-100%). Periprocedural transient ischemic attack occurred in 17 patients (1.5%). The combined stroke and death rate was 1.1%. Recurrent symptoms of vertebrobasilar insufficiency developed in 65 of 967 patients (8%) within a reported follow-up of 6 to 54 months. Restenosis developed in 183 of 789 patients (23%) who underwent follow-up imaging (range, 0%-58%). Reintervention for recurrent disease during follow-up occurred in 86 patients (9%; range, 0%-35%). CONCLUSIONS There is limited comparative evidence on the efficacy of medical, surgical, and endovascular treatment of proximal vertebral artery disease. Percutaneous transluminal angioplasty and stenting has low periprocedural neurologic adverse events and mortality.
Collapse
Affiliation(s)
- George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
| | | | | | | | | | | | | |
Collapse
|
20
|
Mohammadian R, Najaran A, Sohrabi B, Mansourizadeh R, Mohammadian F, Nasiri B, Farhoudi M. Vertebral artery orifice stenosis: a report of 43 cases from northwest iran treated with angioplasty and stenting. Neuroradiol J 2011; 24:749-57. [PMID: 24059771 DOI: 10.1177/197140091102400513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 02/27/2011] [Indexed: 11/16/2022] Open
Abstract
More than one quarter of all transient ischemic attacks (TIA's) and ischemic strokes involve tissue supplied by the vertebrobasilar (VB) circulation. Vertebral artery stenotic lesion, particularly at the origin of the vertebral artery, is not uncommon but it is a less studied area. Here we present our endovascular treatment experience in a group of patients with vertebral artery orifice stenosis. We enrolled a group of patients with vertebral artery orifice stenosis who presented with confirmed posterior circulation stroke. Vertebrobasilar insufficiency syndrome was confirmed by imaging studies and clinical findings. Vertebral artery stenosis diagnosed by CT or MR Angiography and confirmed by Conventional and digital subtraction angiography (DSA). Angiography was performed by using of femoral or radial artery approach. From October 2008 to January 2010, forty-three consecutive patients (69.8% men) underwent stent placement for symptomatic vertebral artery orifice stenosis. Mean degree of stenosis was 70.45 +/- 7.455 percent and mean age was 71.65 +/- 7.743 years . In the 22 patients (22/43, 51.16%) stenosis were in left side. In the thirty patients (30/43, 69.6%) there was evidence of atherosclerotic disease in the internal carotid artery and in the 23% contra lateral vertebral artery was involved. There were five different cases with left renal artery stenosis especially in the men with left vertebral artery stenosis. Initial technical success rate was 100%. No cerebrovascular complications or embolic events occurred. Six months control angiography follow-up revealed one patient with stent occlusion and moderate (40%) restenosis in the another patient. According to our finding angioplasty and stenting for vertebral artery orifice stenosis is safe and effective. Patients with vertebral artery orifice disease frequently have coexistent atherosclerotic stenosis in the other major extracranial arteries including carotid and renal arteries.
Collapse
Affiliation(s)
- R Mohammadian
- Neuroscience Research Center (NSRC); Tabriz University of Medical Sciences; Tabriz, Iran - ,
| | | | | | | | | | | | | |
Collapse
|
21
|
Vertebral Artery Origin Stenosis and its Treatment. J Stroke Cerebrovasc Dis 2011; 20:369-76. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/25/2011] [Accepted: 05/04/2011] [Indexed: 01/28/2023] Open
|
22
|
Yurdakul M, Tola M. Doppler criteria for identifying proximal vertebral artery stenosis of 50% or more. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:163-168. [PMID: 21266553 DOI: 10.7863/jum.2011.30.2.163] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The proximal segment of the vertebral artery is a frequent site of obstructive atherosclerosis. The purpose of this study was to determine Doppler criteria for identifying proximal vertebral artery stenosis of 50% or more by comparison with digital subtraction angiography. METHODS Forty-eight patients with vertebral artery stenosis were examined prospectively with color Doppler sonography and digital subtraction angiography. The peak systolic velocity (PSV), end-diastolic velocity (EDV), peak systolic velocity ratio (PSVr), and end-diastolic velocity ratio (EDVr) were evaluated by receiver operating characteristic curve analysis for their ability to detect vertebral artery stenosis of 50% or more. The optimal criteria for identifying proximal vertebral artery stenosis of 50% or more were determined. RESULTS For identifying vertebral artery stenosis, the parameter with the highest accuracy was the PSVr (area under the receiver operating characteristic curve, 0.967 [95% confidence interval, 0.899-0.994]). A PSVr of greater than 2.2 was found to be the optimal criterion for identifying proximal vertebral artery stenosis of 50% or more, with sensitivity and specificity of 96% and 89%, respectively. The optimal thresholds for the other Doppler parameters in identifying proximal vertebral artery stenosis of 50% or more were as follows: PSV, greater than 108 cm/s; EDV, greater than 36 cm/s; and EDVr, greater than 1.7. CONCLUSIONS Color Doppler sonography is an accurate method for identifying proximal vertebral artery stenosis. The PSVr is superior to other Doppler parameters for detecting vertebral artery stenosis.
Collapse
Affiliation(s)
- Mehmet Yurdakul
- Department of Radiology, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey.
| | | |
Collapse
|
23
|
Park MS, Fiorella D, Stiefel MF, Dashti SR, Gonzalez LF, McDougall CG, Albuquerque FC. Vertebral Artery Origin Stents Revisited. Neurosurgery 2010; 67:41-8; discussion 48. [PMID: 20568666 DOI: 10.1227/01.neu.0000370010.09419.23] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Vertebral origin angioplasty and stenting (VOAS) with bare metal stents is associated with a high rate of in-stent restenosis (ISR).
OBJECTIVE
We evaluated the rate of ISR after VOAS with drug-eluting stents.
METHODS
Twenty patients (15 men, 5 women; age range, 36–88 years; mean, 63.7 years) were treated for VOAS with a paclitaxel-eluting stent (Taxus Express2, Boston Scientific, Natick, Massachusetts). Stenosis at follow-up was quantified as insignificant (0%–24%), mild (25%–49%), moderate (50%–74%), and severe (75%–100%). ISR was defined using a binary criteria of > 50% stenosis at follow-up angiography.
RESULTS
All procedures were technically successful with no periprocedural complications. Follow-up angiography (range, 4–48 months; mean, 14.7 months) showed insignificant stenosis in 9 patients, mild in 6, moderate in 4, and severe in 1. In 1 patient with “moderate” stenosis, the stent migrated distally; therefore, the lesion restenosis was not within the stent. Thus, 4 of 19 patients (21%) exhibited binary moderate or severe ISR, and 5 of 20 showed restenosis at the lesion (25%). The patient with severe stenosis developed stent thrombosis > 3 years after VOAS.
CONCLUSION
VOAS with drug-eluting stents was associated with a low incidence of periprocedural complications. Although the rate of restenosis was half that seen with the use of bare metallic stents, 21% of patients still developed moderate or severe ISR. These patients may require ≥ 1 revascularization procedures. The risk of delayed stent thrombosis may necessitate lifelong dual antiplatelet medications.
Collapse
Affiliation(s)
- Min S. Park
- Division of Neurosurgery, University of California, San Diego, San Diego, California
| | - David Fiorella
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael F. Stiefel
- Department of Neurosurgery and Division of Interventional Neuroradiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shervin R. Dashti
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - L. Fernando Gonzalez
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cameron G. McDougall
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C. Albuquerque
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
24
|
Jenkins JS, Patel SN, White CJ, Collins TJ, Reilly JP, McMullan PW, Grise MA, Grant AG, Ramee SR. Endovascular stenting for vertebral artery stenosis. J Am Coll Cardiol 2010; 55:538-42. [PMID: 20152558 DOI: 10.1016/j.jacc.2009.08.069] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Revised: 08/07/2009] [Accepted: 08/10/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to demonstrate the safety and long-term durability of catheter-based therapy for symptomatic vertebral artery stenosis (VAS). BACKGROUND Symptomatic VAS carries with it a 5-year 30% to 35% risk of stroke. The 2-year mortality approaches 30% for medically managed strokes involving the posterior circulation. Surgical bypass is rarely performed, due to high morbidity and mortality. Endovascular revascularization with primary stenting offers an attractive treatment option for these patients. METHODS One-hundred five consecutive symptomatic patients (112 arteries, 71% male) underwent stent placement for extracranial (91%) and intracranial (9%) VAS from 1995 to 2006. Fifty-seven patients (54%) had bilateral VAS, 71 patients (68%) had concomitant carotid disease, and 43 patients (41%) had a prior stroke. RESULTS Procedural and clinical success was achieved in 105 (100%) and 95 (90.5%) patients, respectively. One-year follow-up was obtained in 87 (82.9%) patients, of which 69 patients (79.3%) remained symptom-free. At 1 year, 6 patients (5.7%) had died and 5 patients (5%) had a posterior circulation stroke. Target vessel revascularization occurred in 7.4% at 1 year. At a median follow-up of 29.1 months (interquartile range 12.8 to 50.9 months), 13.1% underwent target vessel revascularization, 71.4% were alive, and 70.5% remained symptom-free. CONCLUSIONS In experienced hands, stenting for symptomatic VAS can be accomplished with a very high success rate (100%), with few periprocedural complications, and is associated with durable symptom resolution in the majority (approximately 80%) of patients. We conclude that endovascular stenting of vertebral artery atherosclerotic disease is safe and effective compared with surgical controls and should be considered first-line therapy for this disease.
Collapse
Affiliation(s)
- J Stephen Jenkins
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Allaqaband S, Kirvaitis R, Jan F, Bajwa T. Endovascular treatment of peripheral vascular disease. Curr Probl Cardiol 2009; 34:359-476. [PMID: 19664498 DOI: 10.1016/j.cpcardiol.2009.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.
Collapse
|
26
|
Siddiq F, Memon MZ, Vazquez G, Safdar A, Qureshi AI. COMPARISON BETWEEN PRIMARY ANGIOPLASTY AND STENT PLACEMENT FOR SYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC DISEASE. Neurosurgery 2009; 65:1024-33; discussion 1033-4. [PMID: 19934961 DOI: 10.1227/01.neu.0000360138.54474.52] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction.
METHODS
We identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression.
RESULTS
After applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone–treated group (8.9%; 95% confidence interval [CI], 7.1%–10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent–treated group (8.1%; 95% CI, 6.6%–9.5%) during a 1-month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%–23.5%), compared with 14.2% (95% CI, 11.9%–16.9%) in the angioplasty-with-stent–treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%–84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%–96.6%) in the angioplasty-with-stent–treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8–16.6%) in the angioplasty-alone group, as compared with 11.1% (95% CI, 9.2%–13.0%) in the angioplasty-with-stent–treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death.
CONCLUSION
Risk of 1-year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone.
Collapse
Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
| | | | - Gabriela Vazquez
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan Safdar
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan I. Qureshi
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
| |
Collapse
|
27
|
Schumacher HC, Meyers PM, Higashida RT, Derdeyn CP, Lavine SD, Nesbit GM, Sacks D, Rasmussen P, Wechsler LR. Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis. J Vasc Interv Radiol 2009; 20:S451-73. [PMID: 19560032 DOI: 10.1016/j.jvir.2009.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Revised: 10/27/2008] [Accepted: 11/04/2008] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSION In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.
Collapse
Affiliation(s)
- H Christian Schumacher
- Saul R. Korey Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Intracranial Angioplasty and Stenting for Cerebral Atherosclerosis: A Position Statement of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, and the American Society of Neuroradiology. J Vasc Interv Radiol 2009; 20:S312-6. [DOI: 10.1016/j.jvir.2009.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
29
|
Reporting Standards for Carotid Artery Angioplasty and Stent Placement. J Vasc Interv Radiol 2009; 20:S349-73. [DOI: 10.1016/j.jvir.2009.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Accepted: 01/14/2004] [Indexed: 11/24/2022] Open
|
30
|
Calabrò RS, Laganà A, Savica R, La Spina P, Mento G, Longo M, Musolino R. Brainstem ischemia, steno-occlusive pathology of the vertebral arteries, and alterations in the circadian blood pressure pattern: a case report. J Stroke Cerebrovasc Dis 2009; 18:309-12. [PMID: 19560687 DOI: 10.1016/j.jstrokecerebrovasdis.2008.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 10/30/2008] [Accepted: 11/03/2008] [Indexed: 10/20/2022] Open
Abstract
We report the case of a patient with vertebrobasilar steno-occlusive pathology associated with ischemic brainstem symptomatic lesions related to abnormal decrease in blood pressure (BP). A 63-year-old man presented vertigo and persistent gait impairment as a result of a posterior cerebellar infarction and, during hospitalization, experienced a new episode of cerebral ischemia in the territory of the anterior cerebellar artery. Cerebral angiography showed occlusion of the left vertebral artery and two severe stenoses of the right vertebral artery, and 24-hour dynamic BP monitoring evidenced severe postprandial hypotension. Medical treatment was not effective so he underwent an endovascular procedure. This report documents the importance of BP monitoring for a better understanding of the pathophysiology of posterior ischemic strokes and, above all, for a more reliable prognosis and therapy.
Collapse
Affiliation(s)
- Rocco Salvatore Calabrò
- Istituto di Ricoveroe Cura a Carattere Scientifico, Centro Neurolesi Bonino-Pulejo, Policlinico Universitario, Messina, Italy.
| | | | | | | | | | | | | |
Collapse
|
31
|
Taylor RA, Siddiq F, Memon MZ, Qureshi AI, Vazquez G, Hayakawa M, Chaloupka JC. Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results. Neuroradiology 2009; 51:531-9. [PMID: 19437002 DOI: 10.1007/s00234-009-0531-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/15/2009] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The study's purpose is to report the technical and clinical outcomes of a patient cohort that underwent vertebral artery ostium stent placement for atherosclerotic stenosis. METHODS We retrospectively analyzed a prospectively collected database of neurointerventional procedures performed at a single center from 1999 to 2005. Outcome measures included recurrent transient neurological deficits (TNDs), stroke, and death. Kaplan-Meier analysis was used to estimate stroke- and/or death-free survival at 12 months. Cox proportional hazard was used to identify risk factors for recurrent vertebrobasilar ischemic events. RESULTS Seventy-two patients with 77 treated vertebral ostial lesions were included. The 30-day stroke and/or death rate was 5.2% (n = 4), although no event was directly related to the vertebral ostium stent placement. Three procedure-related strokes were secondary to attempted stent placement at other sites (one carotid artery and two basilar arteries), and the one death was secondary to the presenting stroke severity. The mean clinical follow-up time available for 66 patients was 9 months. There were 14 TNDs (21%), two strokes (3%), and two deaths (3%) recorded in the follow-up. Recurrent vertebrobasilar ischemic events occurred in nine patients (seven TNDs and two strokes). No recurrent stroke and/or deaths were related to the treated vertebral ostium. Stroke- and/or death-free survival rate (including periprocedural stroke and/or death) was 89 +/- 5% at 12 months. No vascular risk factor was significantly associated with recurrent vertebrobasilar ischemic events. CONCLUSIONS Vertebral artery ostium stent placement can be safely and effectively performed with a low rate of recurrent stroke in the territory of the treated vessel. Patients who also underwent attempted treatment of a tandem intracranial stenosis appeared to be at highest risk for periprocedure stroke.
Collapse
Affiliation(s)
- Robert A Taylor
- Zeenat Qureshi Stroke Research Center, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Kakino S, Ogasawara K, Kubo Y, Kashimura H, Konno H, Sugawara A, Kobayashi M, Sasaki M, Ogawa A. Clinical and angiographic long-term outcomes of vertebral artery–subclavian artery transposition to treat symptomatic stenosis of vertebral artery origin. J Neurosurg 2009; 110:943-7. [DOI: 10.3171/2008.10.jns08687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although angioplasty and stent placement for vertebral artery (VA)–origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA–subclavian artery (SA) transposition.
Methods
Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46–76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin.
Results
Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to ≤ 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them.
Conclusions
The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Makoto Sasaki
- 2Radiology, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | | |
Collapse
|
33
|
Abstract
Atherosclerotic vascular disease is the leading cause of ischemic stroke, resulting in occlusive or severely stenotic lesions of major intracranial or extracranial arteries and narrowing of small penetrating arteries of the brain. Atherosclerosis of the coronary arteries (ie, coronary artery disease) is an indirect cause of cardioembolic stroke secondary to myocardial infarction. Ischemic heart disease may also be complicated by atrial fibrillation and cardioembolic stroke. Prevention of recurrent stroke and other ischemic events, including myocardial infarction, is a key component of treatment for patients with symptomatic ischemic cerebrovascular disease. Prevention of recurrent stroke involves controlling those factors that promote the course of atherosclerosis, including hypertension, hyperlipidemia, diabetes mellitus, and smoking, as well as such local interventions as carotid endarterectomy and endovascular treatment. Nevertheless, administration of antiplatelet agents remains the core of management for preventing recurrent stroke and other cardiovascular events in at-risk patients.
Collapse
Affiliation(s)
- Harold P Adams
- Department of Neurology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| |
Collapse
|
34
|
Abstract
Atherosclerotic vascular disease is the leading cause of ischemic stroke, resulting in occlusive or severely stenotic lesions of major intracranial or extracranial arteries and narrowing of small penetrating arteries of the brain. Atherosclerosis of the coronary arteries (ie, coronary artery disease) is an indirect cause of cardioembolic stroke secondary to myocardial infarction. Ischemic heart disease may also be complicated by atrial fibrillation and cardioembolic stroke. Prevention of recurrent stroke and other ischemic events, including myocardial infarction, is a key component of treatment for patients with symptomatic ischemic cerebrovascular disease. Prevention of recurrent stroke involves controlling those factors that promote the course of atherosclerosis, including hypertension, hyperlipidemia, diabetes mellitus, and smoking, as well as such local interventions as carotid endarterectomy and endovascular treatment. Nevertheless, administration of antiplatelet agents remains the core of management for preventing recurrent stroke and other cardiovascular events in at-risk patients.
Collapse
Affiliation(s)
- Harold P Adams
- Department of Neurology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| |
Collapse
|
35
|
Seifert T, Augustin M, Klein GE, Horner S, Niederkorn K, Fazekas F. Symptomatic stenosis of the vertebrobasilar arteries: results of extra- and intracranial stent-PTA. Eur J Neurol 2009; 16:31-6. [DOI: 10.1111/j.1468-1331.2008.02297.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
36
|
Carotid endarterectomy, stenting, and other prophylactic interventions. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18793902 DOI: 10.1016/s0072-9752(08)94065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
|
37
|
Proximal STA to proximal PCA bypass using a radial artery graft by posterior oblique transzygomatic subtemporal approach. Neurosurg Rev 2008; 32:95-9; discussion 99. [DOI: 10.1007/s10143-008-0157-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 06/10/2008] [Accepted: 07/26/2008] [Indexed: 11/26/2022]
|
38
|
Zavala-Alarcon E, Emmans L, Little R, Bant A. Percutaneous intervention for posterior fossa ischemia. A single center experience and review of the literature. Int J Cardiol 2008; 127:70-7. [PMID: 17651834 DOI: 10.1016/j.ijcard.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 05/03/2007] [Accepted: 05/11/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of our study was to evaluate the results of endovascular treatment of symptomatic vertebro-basilar insufficiency (VBI) unresponsive to medical therapy. METHODS Cardiac patients regularly followed in our cardiology clinic with symptoms suggestive of posterior fossa ischemia diagnosed by the attending cardiologist, had diagnostic or suspicious findings of vertebral artery stenosis on ultrasound evaluation, with reversed vertebral flow on Doppler examination. These patients were referred for selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age of 64 years, range 54-87) had critical lesions (> 70% stenosis) in the vertebral or pre-vertebral subclavian arteries or both. After confirmation of the severity of the lesions and feasibility for revascularization, all these patients underwent percutaneous intervention and stent placement. All patients were followed-up through clinic visits for a mean of 14.2 months, (range 3.5-24.3). RESULTS In our 28 patients that were treated, 25 vertebral and 10 subclavian stents were placed. Success (< 20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient undergoing intervention for an ostial subtotal occlusion of the left subclavian artery, developed a minor posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive and 22 (88%) of those had no further neurologic complaints. Three (11%) patients that had vertebral artery stents, died during follow-up from cardiac complications, unrelated to the neurovascular intervention. One patient (3.5%) had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. The two other patients with persistent symptoms (only dizziness) had no evidence of restenosis and underwent further work-up that has not clarified the etiology. CONCLUSIONS Posterior fossa ischemia is an under-diagnosed condition that occurs with relative frequency in cardiac patients. Awareness of this condition and adequate non-invasive testing permits identification of these patients. Endovascular treatment using coronary wires and stents including drug eluting stents, seems to be the treatment of choice for vertebral artery revascularization due to the high technical success rate, low complication rate, and long-term durability.
Collapse
|
39
|
Assessment of vertebral artery stents using 16-slice multi-detector row CT angiography in vivo evaluation: comparison of a medium-smooth kernel and a sharp kernel. Eur J Radiol 2008; 70:362-8. [PMID: 18359179 DOI: 10.1016/j.ejrad.2008.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 01/23/2008] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To assess the lumen visibility of extracranial vertebral artery stents examined with 16-slice multi-detector row computed tomography (MDCT) angiography in vivo using a medium-smooth kernel (B30s) and a sharp kernel (B60s), and to compare these with digital subtraction angiography (DSA) after stent placement. METHODS Twenty stents from 20 patients (14 men, 6 women; mean age, 62.7+/-10.1 years) who underwent CT angiography (CTA) with 16-slice MDCT were retrospectively analyzed. In CT angiograms using a B30s and a B60s, the lumen diameters and CT attenuations of the stented vessels were measured three times by three observers, and artificial luminal narrowing (ALN) was calculated. To assess measurement reliability on CT angiograms, the intraclass correlation coefficient (ICC) was used. DSA served as the reference standard for the in-stent luminal measurements on CT angiography. The median interval between CT angiography and DSA was 1 day (range 1-10). RESULTS For interobserver reliability, intraclass correlation coefficients for the lumen diameters on CT angiograms with a B30s and a B60s were 0.90 and 0.96, respectively. The lumen diameters on CT angiograms using a B30s were consistently smaller than that on CT angiograms using a B60s (p<0.01). The mean ALN was 37+/-7% on CT angiograms using a B30s and 25+/-9% on CT angiograms using a B60s. The mean CT attenuation in in-stent lumen was 347+/-55HU on CT angiograms using a B30s and 295+/-46HU on CT angiograms using a B60s. The ALN and CT attenuation within the stented vessels between CT angiograms using a B30s and a B60s was significant (p<0.01). CONCLUSIONS 16-slice MDCT using a sharp kernel allows good visualization of the stented vessels and is useful in the assessment of vertebral artery stent patency after stent placement.
Collapse
|
40
|
Brisman JL. Wingspan stenting of symptomatic extracranial vertebral artery stenosis and perioperative evaluation using quantitative magnetic resonance angiography: report of two cases. Neurosurg Focus 2008; 24:E14. [DOI: 10.3171/foc/2008/24/2/e14] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓The best management strategy for symptomatic vertebrobasilar ischemia is currently not well-defined. Noninvasive Optimal Vessel Analysis (NOVA, VasSol, Inc.) is computer software that, using quantitative magnetic resonance (MR) angiography technology, represents the only commercially available means of noninvasively measuring blood flow within the human vasculature.
The author used quantitative MR angiography to study cerebral blood flow in 2 patients who underwent angioplasty and stenting for medically refractory extracranial cervical vertebral artery (VA) stenosis using the recently Food and Drug Administration–approved WingSpan stent (Boston Scientific, Target). WingSpan stents were successfully placed after balloon angioplasty in both patients without complications. At the 5-month clinical follow-up examination, 1 patient was symptom free and the other had had a possible transient ischemic attack without sequelae. The WingSpan stent may represent an alternative management scheme for symptomatic vertebrobasilar ischemia from extracranial VA stenosis. Quantitative MR angiography can readily measure blood flow in the vertebrobasilar system, and these values correlated with the angiographic outcomes in the 2 patients treated in the present study.
Collapse
|
41
|
Dabus G, Moran CJ, Derdeyn CP, Cross DT. Endovascular treatment of vertebral artery-origin and innominate/subclavian disease: indications and technique. Neuroimaging Clin N Am 2007; 17:381-92, ix. [PMID: 17826639 DOI: 10.1016/j.nic.2007.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Approximately 20% to 40% of patients who have cerebral vascular disease have a vertebral artery-origin stenosis. Atherosclerotic lesions of vertebral arety origin are a potential cause of posterior circulation ischemia, which can be disabling or deadly. Endovascular treatment of vertebral artery-origin and innominate/subclavian artery stenosis has changed in the last 15 years. Surgery usually is successful technically; however, it is also associated with high rates of procedural and periprocedural complications. New techniques and technologies that can be used in the treatment of such lesions are being developed. In this article, the authors discuss the indications, technical aspects, and long-term results of angioplasty and stenting of these vessels.
Collapse
Affiliation(s)
- Guilherme Dabus
- Division of Interventional Neuroradiology, Gray 241, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | | | | | | |
Collapse
|
42
|
MUKHERJEE DEBABRATA, PINEDA GUILLERMO. Extracranial Vertebral Artery Intervention. J Interv Cardiol 2007; 20:409-16. [DOI: 10.1111/j.1540-8183.2007.00289.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
43
|
García-Lara J, Valdesuso R, Hurtado J, Valdés M. Arteriopatía periférica en el contexto de la angiografía coronaria: abriendo camino. Rev Esp Cardiol 2007. [DOI: 10.1157/13111795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
44
|
Zavala-Alarcon E, Emmans L, Cecena F, Little R, Bant A. Percutaneous vertebral artery intervention: a necessary tool in every interventional cardiologist armamentarium. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:107-13. [PMID: 17574170 DOI: 10.1016/j.carrev.2006.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Accepted: 11/17/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the results of endovascular treatment of symptomatic vertebrobasilar insufficiency unresponsive to medical therapy. METHODS Twenty-eight patients who were regularly followed up in our cardiology clinic with symptoms suggestive of posterior fossa ischemia and with diagnostic or suspicious findings on ultrasound evaluation were evaluated with selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age, 64 years; range, 54-87) had critical lesions (>70% stenosis) in the vertebral or subclavian arteries or both. Those lesions that were considered severe enough to explain the reported symptomatology underwent percutaneous intervention and stent placement. All patients were followed up through clinic visits for a mean of 14.2 months (range, 3.5-24.3). RESULTS In the 28 patients treated, 25 vertebral and 10 subclavian stents were placed. Success (<20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient who had been undergoing intervention for a subtotal occlusion of the left subclavian artery developed a posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive, and 22 (88%) of those had no further neurological complaints. Three (11%) patients died during follow-up from cardiac complications. One (3.5%) patient had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. CONCLUSIONS Posterior fossa ischemia is an underdiagnosed condition that occurs with relative frequency in the usual patient population that interventional cardiologists attend to. Endovascular treatment using coronary wires and stents including drug-eluting stents is the treatment of choice for vertebral artery revascularization due to its high technical success rate, low complication rate, and long-term durability.
Collapse
|
45
|
Posters. Interv Neuroradiol 2007. [DOI: 10.1177/15910199070130s210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
46
|
Kim SR, Baik MW, Yoo SH, Park IS, Kim SD, Kim MC. Stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery origin and treatment with the stent-in-stent technique. J Neurosurg 2007; 106:907-11. [PMID: 17542539 DOI: 10.3171/jns.2007.106.5.907] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The authors report two cases of stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery (VA) origin, and describe management of restenosis with the stent-in-stent technique. Two women, one 62 and the other 67 years of age, underwent stent placement in the VA origin to treat symptomatic and angiographically significant stenosis in this vessel. Sirolimus-eluting coronary stents (Cypher) were used in both cases. Four months after placement of the devices, the symptoms recurred. Follow-up angiography performed 5 months after insertion of the devices revealed a transverse stent fracture with separation of the fragments and severe in-stent restenosis in both cases. The restenoses were treated with reinsertion of coronary stents (Cypher and Jostent FlexMaster) by using the stent-in-stent technique. After stent reinsertion, the patients exhibited relief of symptoms.
This paper is the first report of fracture in a drug-eluting stent and restenosis after stent placement in the VA origin. Restenosis caused by such a fracture can be managed successfully by performing the stent-in-stent maneuver. The physical properties of metallic devices, stent strut geometry, and anatomical peculiarities of the subclavian artery may be associated with stent fractures. Earlier follow-up angiography studies (within 6 months) are warranted.
Collapse
Affiliation(s)
- Seong-Rim Kim
- Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Bucheon, Kyeonggi-do, Republic of Korea.
| | | | | | | | | | | |
Collapse
|
47
|
Canyigit M, Arat A, Cil BE, Turkbey B, Saatci I, Cekirge S, Balkanci F. Distal Embolization After Stenting of the Vertebral Artery: Diffusion-Weighted Magnetic Resonance Imaging Findings. Cardiovasc Intervent Radiol 2007; 30:189-95. [PMID: 17200903 DOI: 10.1007/s00270-005-0384-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE We retrospectively evaluated our experience with stenting of the vertebral artery in an effort to determine the risk of distal embolization associated with the procedure. METHODS Between June 2000 and May 2005, 35 patients with 38 stenting procedures for atherosclerotic disease of the vertebral origin in our institution were identified. The average age of the patients was 60.3 years (range 32-76 years). Sixteen of these patients (with 18 stents) had MR imaging of the brain with diffusion-weighted imaging and an apparent diffusion coefficient map within 2 days before and after procedure. RESULTS On seven of the 16 postprocedural diffusion-weighted MR images, a total of 57 new hyperintensities were visible. All these lesions were focal in nature. One patient demonstrated a new diffusion-weighted imaging abnormality in the anterior circulation without MR evidence of posterior circulation ischemia. Six of 16 patients had a total of 25 new lesions in the vertebrobasilar circulation in postprocedural diffusion-weighted MR images. One patient in this group was excluded from the final analysis because the procedure was complicated by basilar rupture during tandem stent deployment in the basilar artery. Hence, new diffusion-weighted imaging abnormalities were noted in the vertebrobasilar territory in 5 of 15 patients after 17 stenting procedures, giving a 29% rate of diffusion-weighted imaging abnormalities per procedure. No patient with bilateral stenting had new diffusion-weighted imaging abnormalities. CONCLUSION Stenting of stenoses of the vertebral artery origin may be associated with a significant risk of asymptomatic distal embolization. Angiography, placement of the guiding catheter, inflation of the stent balloon, and crossing the lesion with guidewires or balloon catheters may potentially cause distal embolization. Further studies to evaluate measures to increase the safety of vertebral artery stenting, such as the use of distal protection devices or short-term postprocedural anticoagulation, should be considered for patients with clear indications for this procedure.
Collapse
Affiliation(s)
- Murat Canyigit
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100 Ankara, Turkey
| | | | | | | | | | | | | |
Collapse
|
48
|
Mazighi M, Abou-Chebl A. Management of symptomatic intracranial arterial stenosis: endovascular therapy. Curr Atheroscler Rep 2006; 8:298-303. [PMID: 16822395 DOI: 10.1007/s11883-006-0007-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with symptomatic intracranial stenosis are at high risk of subsequent stroke despite the use of antithrombotic agents or surgical management. Although endovascular therapy appears to promise therapeutic solutions, the reported high peri-procedural adverse event rate limits the widespread use of this technique. In the past few years, the morbidity and mortality associated with intracranial angioplasty and stenting have decreased with the development of new intracranial specific devices. The most recent prospective studies on intracranial stenting have been nothing more than registries of patients with symptomatic intracranial stenosis of 50% or greater who have failed medical therapy. However, no randomized controlled data exist on the comparison between endovascular therapy and medical treatment. There are new data identifying factors associated with a higher risk of stroke in medically treated patients. These findings will help to define a high-risk patient population on whom the initial controlled trials will be conducted.
Collapse
Affiliation(s)
- Mikael Mazighi
- Department of Neurology, S 90, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | | |
Collapse
|
49
|
Dabus G, Gerstle RJ, Derdeyn CP, Cross DT, Moran CJ. Endovascular treatment of the vertebral artery origin in patients with symptoms of vertebrobasilar ischemia. Neuroradiology 2006; 48:917-23. [PMID: 17086409 DOI: 10.1007/s00234-006-0151-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Accepted: 08/04/2006] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We report our experience with the endovascular treatment of the vertebral artery origin in patients presenting with symptomatic vertebrobasilar ischemia and compare our results with those reported in the literature. METHODS In 25 patients, 28 procedures were performed. Patients presented with posterior circulation ischemic symptoms despite optimal medical therapy with antiplatelet drugs and had a digital subtraction angiogram demonstrating stenosis of the origin of the vertebral artery greater than 50%. Retrospective review of the medical records, clinical notes and radiologic-procedural reports was performed. RESULTS Of the 25 patients, 18 were male and 7 female. Their ages ranged from 50 to 84 years. In 23 of the 25 patients the contralateral vertebral artery was occluded, hypoplastic, absent, or had greater than 50% stenosis. In 13 of the 25 patients angiographic evidence of significant anterior circulation disease was demonstrated. In 18 of the 25 patients the left vertebral artery was affected. The mean stenosis was 82.6%. Follow-up records were available in 19 patients. The mean follow-up was 24 months. Five of the 19 patients had recurrent symptoms of vertebrobasilar ischemia and three patients were retreated. Of the 28 procedures performed, 23 were angioplasty/stenting and 5 were angioplasties alone. Overall technical success was achieved in 26 of the 28 procedures (92.8%). No procedure-related transient ischemic attack, stroke or death was noted. CONCLUSION Endovascular treatment of the vertebral artery origin in this patient population is feasible, safe, and effective. There are some questions regarding the long-term follow-up and rate of restenosis and clinical recurrences that are yet to be answered.
Collapse
Affiliation(s)
- Guilherme Dabus
- Division of Interventional Neuroradiology, Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital, Washington University School of Medicine, P.O. Box 8131, 510 S. Kingshighway Boulevard, St. Louis, MO 63110, USA.
| | | | | | | | | |
Collapse
|
50
|
Abstract
An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.
Collapse
Affiliation(s)
- Suhail Allaqaband
- School of Medicine and Public Health-Milwaukee Clinical Campus, University of Wisconsin, Milwaukee, WI, USA
| | | | | | | |
Collapse
|