Use of an embolic protection system during endovascular recanalization of a totally occluded cervical internal carotid artery at the chronic stage. Case report

Delayed revascularization in acute ischemic stroke patients

Stroke shares a significant burden of global mortality and disability. A significant decline in the quality of life is attributed to the so-called post-stroke cognitive impairment including mild to severe cognitive alterations, dementia, and functional disability. Currently, only two clinical interventions including pharmacological and mechanical thrombolysis are advised for successful revascularization of the occluded vessel. However, their therapeutic effect is limited to the acute phase of stroke onset only. This often results in the exclusion of a significant number of patients who are unable to reach within the therapeutic window. Advances in neuroimaging technologies have allowed better assessment of salvageable penumbra and occluded vessel status. Improvement in diagnostic tools and the advent of intravascular interventional devices such as stent retrievers have expanded the potential revascularization window. Clinical studies have demonstrated positive outcomes of delayed revascularization beyond the recommended therapeutic window. This review will discuss the current understanding of ischemic stroke, the latest revascularization doctrine, and evidence from clinical studies regarding effective delayed revascularization in ischemic stroke.

Low-dose intravenous tirofiban infusion after endovascular recanalization for non-acute middle cerebral artery occlusion

Background and purpose

Endovascular recanalization for patients with symptomatic non-acute middle cerebral artery occlusion still remines challenging. Postoperative treatment is still controversial. This study aims to investigate the safety and effectiveness of tirofiban after elective angioplasty in patients with non-acute middle cerebral artery occlusion related ischemic stroke.

Methods

Our study is a retrospective case series study of 48 stroke patients who received elective endovascular recanalization for middle cerebral artery occlusion. Patients who received EVT without hemorrhage were divided into 2 groups: those who did not receive intravenous tirofiban treatment (control group, n = 25); those who received continuous intravenous infusion of 0.2-0.3 mg/h tirofiban for 48 h after endovascular recanalization (intravenous tirofiban group, n = 23). Early reocclusion of treated arteries, symptomatic hemorrhage, and 90-day functional outcome of the 2 groups were compared.

Results

The 90-day mRS score and NIHSS score after endovascular recanalization showed no significantly different between the two groups. However, the rate of mRS score reverse (≥1) was significantly higher in the intravenous tirofiban group than the control (73.9% versus 24.0%, P = 0.001), and the rate of NIHSS score reverse (≥3) in the intravenous tirofiban group was also higher (43.5% verse 16.0%, P = 0.037). The rate of early reocclusion, symptomatic hemorrhage (4.3% versw 4%, P = 0.734), showed no difference between the two groups.

Conclusions

Low-dose intravenous tirofiban infusion (0.2-0.3 mg/h for 48 h) after endovascular treatment seems to be safe and potentially effective for non-acute middle cerebral artery occlusion patients.

Spotlight on clinical strategies of Chronic Internal Carotid Artery Occlusion: Endovascular interventions and external-intracarotid bypasses compared to conservative treatment

Chronic internal carotid artery occlusion (CICAO) has high prevalence and incidence rates, and patients with CICAO can be completely asymptomatic, experience a devastating stroke or die. It is important to note that CICAO causes cerebrovascular accidents. Currently, the external carotid-internal carotid (EC-IC) bypass technique is used to treat CICAO. However, many clinical studies showed that EC-IC bypass was not beneficial for many patients with CICAO. Meanwhile, endovascular intervention treatment options for CICAO are evolving, and an increasing number of patients are undergoing endovascular intervention therapy. Accordingly, a review comparing both techniques is warranted. For this review, we searched PubMed and collected relevant case study reports comparing endovascular interventional therapy and internal and external cervical bypass surgeries to provide strategies for clinical treatment.

Carotid artery stenting in patients with chronic internal carotid artery occlusion

BACKGROUND

The risk of ischemic stroke in patients with chronic total occlusion (CTO) of the internal carotid artery (ICA) on best medical treatment has been estimated to be 5.5% per year. The purpose of this study was to assess early and mid-term outcome of patients who underwent an attempt at transfemoral carotid artery stenting (CAS) for CTO of the ICA.

METHODS

Clinical data of symptomatic patients who underwent attempt at CAS for CTO of the ICA between January 1, 2010 and July 1, 2020 were retrospectively reviewed. Clinical success, perioperative and mid-term stroke and death rates were recorded. Descriptive statistics were used.

RESULTS

There were 27 patients, 14 females, 13 males, with a mean age of 66.8 years, range: 57 to 79. All patients had symptoms within 6 months prior to the procedure. 16 had ipsilateral stroke at a mean of 2.8 months, ranges: 1.5-4 months, two had transient ischemic attack (TIA), at 1 week and at 6 months, one had amaurosis fugax at one week, two had chronic ocular ischemia and six had chronic cerebral hypoperfusion. Technical success was 52% (14/27). One patient developed a minor reversible stroke (1/27, 3.7%) there was no early death, for an overall 30-day stroke and death rate of 3.7% (1/27). Two patients had perioperative TIAs. Among 14 patients with successful CAS (group A) one had minor, reversible ipsilateral stroke during a follow-up of 29 months (range: 4-112), two had contralateral stroke. There was no death. One patient developed asymptomatic stent occlusion, three had asymptomatic in-stent restenosis >50%, two had reinterventions. Among patients with unsuccessful attempt at CAS (group B), 31% (4/13) had stroke at 4, 10, 14 and 22 months, respectively. One stroke patient died at 10 months.

CONCLUSIONS

Transfemoral CAS of symptomatic patients with CTO of the ICA was feasible in half of the patients, with no mortality or major stroke, for an overall early stroke/death rate of 3.7%. Since one third of the patients with unsuccessful stenting developed stroke during follow-up, further studies to investigate the safety, efficacy and durability of CAS for CTO of the ICA are needed.

A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery

The management of patients with symptomatic chronic total occlusion (CTO) of the internal carotid artery (ICA) is controversial. The aim of this systematic review was to investigate patient selection, technical success, early and late outcome of endovascular treatment for CTO of the ICA. PubMed/Medline and EMBASE databases were searched until January 2, 2020 for studies on endovascular treatment for CTO of the ICA. A descriptive analysis of demographic, clinical and anatomic data, endovascular technique, perioperative and late outcomes was performed. A total of 1,222 articles were screened, 8 retrospective or prospective cohort studies were reviewed; 276 patients, 18.9% females, mean age: 64.3 years, underwent attempt at endovascular treatment of 278 lesions. Two hundred and thirteen patients (77.2%) had neurological symptoms; the others had evidence of ipsilateral cerebral hypoperfusion. Two hundred and thirty-eight lesions (91.2%) were treated >30 days after diagnosis of occlusion. Technical success was 66.9%. Perioperative mortality was 1.64% (4/243), early stroke rate was 3.3%. Follow-up averaged 23.4 months (range, 0.25–84 months), late mortality was 1.89% (5/265), stroke rate was 3.4% (9/265). Stroke rate was similar after successful stenting (3.57%, 4/112) vs. failed stenting (3.61%, 2/61; P=1.00), stroke/death rates were also similar after successful stenting (5.36%, 6/112) than after failed stenting (3.28%, 2/61; P=0.71). Endovascular treatment of CTO of the ICA in eight cohort studies was safe and feasible with a technical success of 67% and a low rate of early and late neurological complications. Pooled data in this review failed to confirm the benefit of successful stenting on stroke and mortality, but some of the included studies suggest benefit and some also supported improvement in neurocognitive function after successful stenting. Prospective randomized trials to investigate the benefit of endovascular treatment in addition to best medical therapy for symptomatic CTO of the ICA are urgently needed.

Mid-/Long-Term Outcome of Neuroendovascular Treatment for Chronic Carotid Artery Total Occlusion

Objective

The natural course of chronic carotid artery total occlusion (CTO) is poor. Previous reports suggested that carotid artery stenting (CAS) improves the clinical outcome of CTO. However, its long-term efficacy has not been established. This study assessed the mid- and long-term clinical outcome of CAS for CTO.

Methods

We evaluated the clinical outcome of 15 patients who underwent CAS for CTO between September 2010 and October 2019.

Results

The technical success rate of recanalization was 93.3% (14 of 15 patients). Eight patients were treated using self-expanding stents, and six were treated using self-expanding coronary stents. Symptomatic procedure-related complications developed in two patients (13.3%). During the follow-up period (mean 34.9 months), symptomatic ipsilateral stroke was not noted. One patient (7.1%) developed asymptomatic re-occlusion, but stent patency was preserved in 13 patients (92.9%).

Conclusion

CAS for CTO may be safe and feasible based on the mid- and long-term outcome.

Delayed Recanalization-How Late Is Not Too Late?

Stroke has become the second most prevalent cause of mortality in the world. Currently, the treatment of ischemic stroke is based on thrombolytic and thrombectomy therapy shortly after the ischemic event (≤ 4.5 h for thrombolytic strategies; ≤ 6 h for thrombectomy strategies). However, the majority of patients are unable to receive prompt treatment, particularly in undeveloped countries. Alternative solutions are lacking for those patients that miss the optimal window of opportunity for treatment. Recently, new developments in imaging techniques and intravascular interventional devices enable the expansion of the window of opportunity for treating stroke patients. Clinical studies have reported that delayed recanalization at 24 h, or even more than 1 month, was beneficial for some patients. However, the mechanisms of neuroprotection that underly the delayed recanalization in these ischemic stroke patients remain unclear. In this review, we will summarize the clinical studies of delayed recanalization, and organize them according to the duration of occlusion. Additionally, we will discuss the changing guidelines and possible mechanisms based on animal research, and attempt to draw conclusions and future perspectives.

Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion

Introduction

Symptomatic internal carotid artery occlusion (ICAO) can lead to neurologic decline, recurrent stroke, and mortality.

Objective

We sought to evaluate the safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO).

Design, setting, and participants

This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO.

Main outcome(s) and measure(s)

Study endpoints included discharge neurologic examination, post-procedural infarct burden, 3-month functional outcomes, and treatment durability.

Results

A total of 107 patients with symptomatic angiographically-confirmed cervical ICAO without tandem LVO were identified. Median admission NIH Stroke Scale (NIHSS) score was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical imaging mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable/improved NIHSS score, while at 3 months 65% achieved independence (modified Rankin Scale score ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1 year.

Conclusions

Stenting in selected patients at risk of neurologic deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.

Delayed Recanalization Promotes Functional Recovery in Rats Following Permanent Middle Cerebral Artery Occlusion

Most large vessel stroke patients have permanent occlusion, for which there are no current treatment options. Recent case studies have indicated delayed recanalization, that is recanalization outside of the 6-h treatment window, may lead to improved outcome. We hypothesized that delayed recanalization will restore cerebral blood flow, leading to improved function in rats. Male SD rats were subjected to pMCAO or sham surgery. Delayed recanalization was performed on either day 3, 7, or 14 after pMCAO in a subset of animals. Cerebral blood flow was monitored during suture insertion, during recanalization, and then at sacrifice. Neurological function was evaluated for 1 week after delayed recanalization and at 4 weeks post-ictus. After sacrifice, cerebral morphology was measured. Compared to no treatment, delayed recanalization restored cerebral blood flow, leading to sensorimotor recovery, improved learning and memory, reduced infarct volume, and increased neural stem/progenitor cells within the infarction. The data indicate that earlier delayed recanalization leads to better functional and histological recovery. Yet, even restoring cerebral blood flow 14 days after pMCAO allows for rats to regain sensorimotor function. This exploratory study suggests that delayed recanalization may be a viable option for treatment of permanent large vessel stroke.

Current understanding of chronic total occlusion of the internal carotid artery

At present, there is limited understanding of chronic total occlusion (CTO) of the internal carotid artery (ICA). Therefore, the present report collected related cases from PubMed and reviewed the literature. Cerebral vessels may form collateral circulation immediately or gradually following CTO of the ICA. The natural history of CTO of the ICA includes a variety of outcomes, all of which are biased toward a non-benign progressive process and are characterized by insufficient cerebral perfusion, embolus detachment and cognitive dysfunction. The majority of cases of CTO of the ICA require treatment. In early studies, the results of external-ICA bypass were unsatisfactory, while recanalization is now considered the only viable option. The current treatment indications mainly depend on the degree of injury to the cerebrovascular reserve and the extent to which the oxygen extraction fraction is increased. The length, height and duration of ICA occlusion are also relevant, though more frequently, the condition depends on multiple factors. Endovascular interventional recanalization, carotid endarterectomy (CEA) and hybrid surgery may be conducted in a select group of patients. As novel materials are developed, the success rate of simple recanalization may gradually increase; however, hybrid surgery may be more representative of the current trend, as advanced CEA can remove carotid atherosclerosis plaques, thus reducing the technological demands of the subsequent interventional recanalization. There are many complications that may result from recanalization following CTO of the ICA, including hyperperfusion and technical errors; therefore, the operation must be conducted carefully. If the recanalization is successful, it typically results in a stable improvement of patient condition in the long term. However, despite these conclusions, more studies are required in the future to further improve current understanding of CTO of the ICA.

Precision Stroke Animal Models: the Permanent MCAO Model Should Be the Primary Model, Not Transient MCAO

An argument for preclinical stroke research to make more use of the permanent middle cerebral artery occlusion (MCAO) model, rather than transient MCAO, is presented. Despite STAIR recommending permanent MCAO as the primary model, preclinical stroke research has not been listened. In 2012, Hossmann reported that 64% of the treatment studies for MCAO used prompt transient MCAO models and only 36% of the studies used permanent MCAO or gradual transient MCAO (i.e., embolic stroke model). Then, in 2014 and 2015, 88% of published basic science studies on large vessel occlusion used the transient MCAO model. However, this model only represents 2.5-11.3% of large vessel stroke patients. Therefore, the transient MCAO model, which mimics stroke with reperfusion, does not accurately reflect the majority of clinical stroke cases. Thus, once again, the argument for studying permanent MCAO as a primary model is made and supported.

Endovascular Revascularization of a Symptomatic Common Carotid Artery Occlusion

Although the common carotid artery is the second most common site for extracranial carotid artery stenosis, complete symptomatic occlusion in the absence of devastating stroke is rare. We present a case of complete common carotid artery occlusion failing medical management and requiring endovascular intervention. The clinical presentation, diagnostic investigations, and management of complete carotid artery occlusions are discussed.

Management of Bilateral Carotid Occlusive Disease

BACKGROUND

Symptomatic bilateral internal carotid occlusive disease is a rare but potentially devastating entity. Medical therapy alone is associated with high rates of mortality and recurrent stroke. The optimal management of this disease remains poorly understood.

METHODS

A retrospective review of a prospectively maintained database was conducted for patients who presented with an acute stroke in the setting of bilateral carotid occlusive disease between May and October 2013.

RESULTS

We identified 3 patients. The admission National Institutes of Health Stroke Scale score ranged from 4 to 7. All patients had small- to moderate-sized infarcts in the anterior circulation on presentation. Angiography confirmed bilateral internal carotid occlusions with collateral filling via the posterior communicating artery and retrograde filling via external carotid artery supply to the ophthalmic artery. All patients were initially managed with permissive hypertension and anticoagulation followed by carotid angioplasty and stenting. At 1-year follow-up, all patients demonstrated a modified Rankin scale score of 0-1.

CONCLUSIONS

Carotid stenting may be a safe and effective therapy for patients presenting with symptomatic bilateral carotid occlusions.

Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion: a prospective, controlled, single-center study

Symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment remains a dismal disease when untreated. In this prospective, single-center, controlled study, we investigated the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic ICA occlusion. Forty patients with symptomatic chronically occluded ICA were assigned to receive endovascular recanalization (group A, n = 18) or conservative management (group B, n = 22). The primary end point was 100% complete recanalization of the primary occlusion at 60 minutes, and secondary end points were improvement in neurologic function and cognitive function. Patients in the 2 groups were comparable in demographic and baseline characteristics. Successful recanalization was achieved in 88.9% (16 of 18) of patients with the restoration of Thrombolysis in Myocardial Ischemia/Thrombolysis in Cerebral Ischemia 2 or 3 flow. There was no procedural or new cerebral ischemic event. Improvement in brain perfusion was observed in 12 (12 of 18, 75%) patients on single-photon emission computed tomography. Improvement in neurologic function defined as a reduction of ≥4 points on the National Institutes of Health Stroke Scale (NIHSS) at 6 months was observed in group A (baseline, 6.83 ± 3.01 vs 6 months, 2.61 ± 1.20; P < .01) and group B (baseline, 6.05 ± 2.75 vs 6 months, 4.77 ± 1.69; P < .05). A significant difference in NIHSS scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Improvement in cognitive function defined as an increase of ≥8 on the Montreal Cognitive Assessment (MoCA) was observed in group A at 3 and 6 months (baseline, 14.67 ± 3.56 vs 3 months, 24.17 ± 3.55 and 6 months, 24.72 ± 2.85; P < .01). Significant improvement in MoCA was also observed in group B (P < .01). Furthermore, a significant difference in MoCA scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Endovascular recanalization is feasible and safe for patients with symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization.

Analysis of reserve capacity and subsequent stenting in a case of subacute occlusion of the internal carotid artery

Introduction

While acute internal carotid artery (ICA) occlusions are increasingly being treated with carotid angioplasty and stenting (CAS), the utility of CAS in subacute stages is unclear.

Case Report

A 65-year-old patient with an acute left ICA occlusion and pre-existing occlusion on the right side presented with dysarthria and central right-sided facial palsy. Carbon dioxide (CO₂) reactivity within the left hemisphere was markedly reduced. Due to acute deterioration despite maximal conservative therapy CAS was performed 8 days after the initial event with an excellent result and symptoms subsided.

Conclusion

CAS in subacute ICA occlusion is possible. Patients should be selected carefully. Assessment of cerebrovascular CO₂ reactivity might provide valuable information.

Wire-probing technique to revascularize subacute or chronic internal carotid artery occlusion

During endovascular revascularization of subacute and chronic occlusion of the cervical internal carotid artery (ICA) it may be difficult to penetrate the lesion. Selecting the appropriate "true lumen", a remnant of what had been the arterial lumen, at the initial step may facilitate the procedure. Because plaque at the carotid bifurcation is known to propagate from the posterior wall, a gateway to this "true lumen" should exist in the anterior side of the occluded stump. This hypothesis was studied retrospectively in our series of revascularizing ICA subacute and chronic occlusion. Eleven patients underwent endovascular revascularization for symptomatic cervical ICA occlusion. Procedures were performed by initially penetrating the occluded stump with a guidewire, followed by supporting catheter advancement through the occluded segment to secure the distal normal arterial lumen. Cases were analyzed with regard to the location of initial guidewire penetration. Eight patients underwent successful revascularization. In five cases, the entry point to the occluded stump was located at the anterior side, and in three, at the posterior side. Two posterior stump penetration cases were met with resistance in guidewire advancement, whereas penetration was smooth in the anterior cases. In addition, two posterior stump penetration cases resulted in contrast stasis in the posterior ICA wall. In our series of revascularizing cervical ICA subacute and chronic occlusion, initially targeting the anterior side of the occluded stump resulted in favorable results. This may be the result of selecting the "true lumen" at the beginning of the procedure.

Delayed Endovascular Revascularization in a Patient With Progressive Neurological Deterioration From Bilateral Intracranial Vertebral Artery Occlusions: Case Report

BACKGROUND AND IMPORTANCE:

This article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranial occlusive lesions.

CLINICAL PRESENTATION:

A 48-year-old man presented with a 6-week history of progressive headache, nausea, and ataxia. Bilateral intracranial vertebral artery occlusions and a left posterior inferior cerebellar artery stroke were diagnosed, and the patient began warfarin therapy. Despite these measures, the patient developed dense lower cranial neuropathies, including severe dysarthria, decreased left-sided hearing acuity, and left facial droop. He presented at this point for endovascular evaluation. The patient underwent successful revascularization with intravascular Wingspan stents (Boston Scientific, Natick, Massachusetts) in a delayed fashion (approximately 6 weeks after his initial stroke presentation). His neurological syndrome stabilized and began to improve slowly.

CONCLUSION:

Patients with arterial occlusion should be evaluated acutely for potential revascularization. In the posterior circulation, clinical progression may supplant physiological imaging in the assessment of hemodynamic collapse. A subpopulation of patients will present with progressive deficits distinct from extracranial manifestations of vertebrobasilar insufficiency; these patients should be considered for delayed revascularization.

Direct endovascular recanalization of chronic carotid occlusion: should we do it? Case report

BACKGROUND AND IMPORTANCE

Patients with chronic carotid artery occlusion face a significant risk of stroke. It is believed that treatment is indicated if medical therapy fails or even as prophylaxis in high-risk patients. Direct surgical repair with carotid endarterectomy has a considerable failure rate and significant associated risks. Indirect repair with an extracranial-to-intracranial bypass has become the mainstay of surgical treatment. In this case study, the authors assess the feasibility of direct endovascular recanalization in the setting of chronic carotid occlusion, and discuss technical nuances and indications in comparison with the world literature and alternative options.

CLINICAL PRESENTATION

Two patients presented with symptomatic, chronic, complete occlusion of the proximal carotid artery. The duration of documented occlusion exceeded 3 years in one patient and 6 months in the other.

METHODS

Endovascular recanalization was attempted using extracranial and intracranial stenting with proximal protection (flow arrest/reversal). Both patients had an excellent radiographic result, improving from Thrombolysis in Cerebral Infarction (TICI) grade 0 (no perfusion) to grade 3 (complete perfusion). The first patient's clinical symptoms resolved. The second patient remained unchanged with a mild facial droop.

CONCLUSION

These preliminary results show potential for the endovascular management of this complicated disease. Long-term results and more data will determine the ultimate place of endovascular recanalization for symptomatic chronic carotid occlusion among other therapies.

Endovascular revascularization of chronic symptomatic vertebrobasilar occlusion

BACKGROUND AND PURPOSE

Acute basilar artery occlusion is associated with a high risk of stroke, mortality, and poor outcome in survivors. Timely vessel revascularization is critical to improve the clinical outcome in this condition. A subset of patients survives acute occlusion with mild or no disability and some of these individuals develop recurrent ischemic events despite optimal medical therapy. The strategy for management of these patients is unknown.

CASE SUMMARY

We described 3 patients with chronic intracranial vertebrobasilar occlusions who presented with recurrent ischemic symptoms and progressive disability. All 3 patients were treated successfully with angioplasty and stenting. One patient experienced headache postprocedure and was found to have subarachnoid hemorrhage, which was self-limiting without need for intervention or result in permanent neurological sequela. All 3 patients have been free of recurrent symptoms for up to 30 months.

CONCLUSIONS

Revascularization of chronic vertebrobasilar occlusions is technically feasible. Due to the high-risk nature, it should be reserved as an option only for selected group of patients with recurrent ischemic symptoms and progressive disability despite maximal medical therapy. Further prospective study is helpful to clarify the role of this intervention.

External Carotid Artery Stenting to Treat Patients With Symptomatic Ipsilateral Internal Carotid Artery Occlusion

BACKGROUND

The external carotid artery (ECA) anastomoses in many distal territories supplied by the internal carotid artery (ICA) and is an important source of collateral circulation to the brain. Stenosis of the ECA in ipsilateral ICA occlusion can produce ischemic sequelae.

OBJECTIVE

To examine the effectiveness of ECA stenting in treating symptomatic ipsilateral ICA occlusion.

METHODS

We retrospectively reviewed patient databases from 5 academic medical centers to identify all individuals who underwent ECA stenting after 1998. For all discovered cases, coinvestigators used a common submission form to harvest relevant demographic information, clinical data, procedural details, and follow-up results for further analysis.

RESULTS

Twelve patients (median age, 66 years; range, 45–79 years) were identified for our cohort. Vessel disease involvement included severe ECA stenosis ≥ 70% in 11 patients and ipsilateral ICA occlusion in all patients. Presenting symptoms included signs of transient ischemic attack, stroke, and amaurosis fugax. ECA stenting was associated with preservation of neurological status in 11 patients and resolution of symptoms in 5 patients at a median follow-up time of 26 months (range, 1–87 months; mean, 29 months). Symptomatic in-stent restenosis did not occur within any patient during the follow-up course.

CONCLUSION

We found ECA stenting in symptomatic ipsilateral ICA disease to be a potentially effective strategy to preserve neurological function and to relieve ischemic symptoms. Further investigation with larger studies and longer follow-up periods is warranted to elucidate the true indications of this management strategy.

Successful carotid stenting for chronic total occlusion of the internal carotid artery

A 64-year-old man complaining of pulsatile headache was admitted. Imaging studies revealed a near-total occlusion of the right proximal internal carotid artery (ICA) with slow antegrade flow into the distal ICA. Right cerebral flow was supplied by collateral flow through the posterior communicating and ophthalmic arteries. He was successfully treated by carotid artery stenting. No new neurological deficit or transient ischemic attack occurred after treatment.

Endovascular recanalization of the completely occluded internal carotid artery using a flow reversal system at the subacute to chronic stage

OBJECT

The efficacy and pitfalls of endovascular recanalization were evaluated in cases of internal carotid artery (ICA) occlusion in the subacute to chronic stage.

METHODS

Fourteen cases (15 lesions) of symptomatic ICA occlusion with hemodynamic compromise or recurrent symptoms were treated at the subacute to chronic stage using an endovascular technique. The Parodi embolic protection system was used during the recanalization procedure to prevent embolic stroke by reversing the flow from the distal ICA to the common carotid artery.

RESULTS

Recanalization of the occluded ICA was possible in 14 of 15 lesions. The occlusion points were 10 cervical ICAs and 4 petrous/cavernous ICAs in successfully recanalized cases. Ischemic symptoms disappeared completely after the treatment, and new ischemic symptoms did not appear related to the treated lesion. Single photon emission computed tomography findings demonstrated the improvement of hemodynamic compromise in all cases. One case showed right middle cerebral artery branch occlusion during the procedure, but this patient's neurological symptoms were stable due to preexisting hemiparesis. Endovascular recanalization was possible and effective in improving hemodynamic compromise. However, there are still several problems with this technique, such as hyperperfusion syndrome after recanalization, cerebral embolism during treatment, durability after treatment, and identification of the occlusion point before treatment.

CONCLUSIONS

Endovascular recanalization using an embolic protection device can be considered as an alternative treatment for symptomatic ICA occlusion with hemodynamic compromise or refractoriness to antiplatelet therapy, even in the subacute to chronic stage of the illness.

Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery

BACKGROUND AND PURPOSE

The natural course of symptomatic carotid artery occlusion with hemodynamic impairment is poor. Surgical revascularization may improve the outcome; however, its efficacy has not been established yet. The goal of this study was to characterize the technical and clinical outcomes following endovascular recanalization of the ICA under cerebral circulatory protection.

MATERIALS AND METHODS

Endovascular recanalization was attempted in 8 patients with symptomatic ICA occlusions. The duration of the occlusion ranged from 7 days to 7 months (mean, 2.5 months), and the mean length of the occlusion was 95 mm. Cerebral hemodynamics ipsilateral to the side of the occlusion were severely impaired in all patients. The endovascular procedure was performed under total cerebral circulatory protection, beginning with proximal protection with a subsequent switch to distal protection after successful guidewire passage.

RESULTS

The occlusion was recanalized successfully in 7 of 8 patients (88%), resulting in improvement of ipsilateral cerebral hemodynamics without symptomatic stroke. Small asymptomatic ischemic lesions were detected in 6 of 8 patients (75%) on DWI, and 1 patient developed a mild groin hematoma. Ischemic episodes did not recur during the mean follow-up period of 19 months. However, 1 patient experienced asymptomatic reocclusion, which was re-treated successfully without complications, while another patient developed mild retinal hemorrhage at 3 months after the procedure due to the combination of antiplatelet and anticoagulant therapy.

CONCLUSIONS

Endovascular revascularization of an ICA occlusion is feasible and well-tolerated in patients with subacute or chronic total occlusion of the ICA.

External carotid artery angioplasty and stenting to augment cerebral perfusion in the setting of subacute symptomatic ipsilateral internal carotid artery occlusion

✓The authors performed external carotid artery (ECA) angioplasty and stenting in a 45-year-old man who had presented with right hemispheric crescendo ischemic symptoms stemming from acute right internal carotid artery occlusion (ICAO). This unique application of ECA angioplasty and stenting augmented cerebral perfusion and improved clinical symptoms. In certain situations, ECA stenting can increase cerebral perfusion in the setting of ICAO and ECA stenosis. The authors are the first to describe this approach in this context.

Endovascular recanalization of basilar artery occlusion 80 days after symptom onset

BACKGROUND AND PURPOSE

Acute basilar artery occlusion portends high risk of stroke and death. Thrombolysis or endovascular therapy has been limited to patients who present within hours of symptom onset. Without recanalization, acute basilar artery occlusion almost always results in death or severe disability.

SUMMARY OF CASE

We report a case of basilar artery occlusion and successful endovascular recanalization 80 days after symptom onset.

CONCLUSIONS

Endovascular therapy can be feasible and safe for symptomatic basilar artery occlusion at chronic stage.

Percutaneous transluminal angioplasty and stenting for chronic total occlusion of intracranial carotid artery: a case report

SUMMARY

Chronic total occlusion of cerebrovascular lesions is regarded as a contraindication to revascularization. We describe a case of chronic total occlusion of intracranial internal carotid artery that iwass successfully recanalized by endovascular treatment. A 72-year-old man who presented with slight right hemiparesis was proved to have chronic total occlusion of the left intracranial internal carotid artery. Percutaneous transluminal angioplasty/stenting was achieved using reversal of flow with the Parodi Anti-Embolic System. The present case indicates that percutaneous transluminal angioplasty/stenting can be an effective therapeutic option in selected patients with chronic total occlusion of cerebrovascular lesions.

Carotid angioplasty with stenting for chronic internal carotid artery occlusion: technical note

INTRODUCTION

Carotid angioplasty with stenting (CAS) is becoming accepted as an effective and reliable treatment option for severe carotid artery stenosis. However, it is rarely applied for carotid occlusion, especially in its chronic stage. We report our experience of CAS for chronic internal carotid artery occlusion representing compromised cerebral blood flow using various protection methods.

METHODS

A 77-year-old woman, who was already diagnosed with severe left internal carotid artery stenosis, suddenly had right hemiparesis and aphasia. At that time, she was treated conservatively because her neurological status was quite good, in spite of left carotid artery occlusion. Her symptoms improved in the short term, except slight aphasia, but deteriorated again 18 days from the onset, and magnetic resonance imaging (MRI) showed new ischemic lesions. CAS was then performed for the occluded carotid artery on the 23rd day from the first onset.

RESULTS

Using the proximal protection technique, the occluded lesion was crossed carefully with a microguidewire. Stents were also placed successfully with the distal protection technique. The occluded carotid artery was completely recanalized without any unfavorable events or neurological deterioration.

CONCLUSION

In this patient, CAS was successfully to treat chronic carotid artery occlusion. These procedures and techniques are reviewed and discussed.

Percutaneous angioplasty of a chronic total occlusion of the intracranial internal carotid artery. Case report

BACKGROUND

A CTO of the intracranial ICA is usually managed medically and rarely by EC-IC bypass in selected patients. Percutaneous transluminal angioplasty has not been used.

CASE DESCRIPTION

A 73-year-old man presented with frequent temporary blindness of the left eye and dizziness due to thrombotic occlusion of the left intracranial ICA, causing hemodynamic compromise. This patient was successfully treated by percutaneous angioplasty (balloon angioplasty and stent placement) under proximal balloon protection at 7 weeks from the ictus. Ischemic symptoms had not recurred during the 6-month follow-up period.

CONCLUSION

Percutaneous angioplasty for a CTO of the intracranial ICA is technically feasible and can be an alternative to EC-IC bypass in a selected group of patients with symptomatic hemodynamic compromise, which is refractory to the best medical treatment.