Rare instances of concomitant acute myocardial infarction and stroke

Cardio-cerebral infarction (CCI) is a term coined to describe concomitant myocardial infarction and acute ischemic stroke. Acute myocardial infarction and stroke, as separate events, constitute some of the most important causes for disability and mortality in aging societies. Stroke can either occur simultaneously with myocardial infarction or become a serious complication of myocardial infarction and/or its treatment. The frequency of CCI has been reported at a 0.009% incidence rate in stroke patients and is associated with an extremely high mortality. Because of the rare occurrence of CCI, there are currently no guidelines for assessing its diagnosis and optimal treatment. Therefore, currently, the management of CCI cases needs to be individualized. Hopefully, in the future, the results of large clinical trials or prospective registries are expected to enhance our understanding of managing concomitant acute MI and stroke. In this review we have focused on the current literacy in the diagnosis and treatment of CCIs. The paper illustrates potential distinct scenarios of CCI through the analysis of three patient cases (Fig. 5, Ref. 65). Text in PDF www.elis.sk Keywords: myocardial infarction, stroke, cardio-cerebral infarction, carotid artery stenting, cardiac surgery.

Endovascular carotid revascularization under open-chest extracorporeal circulation combined with cardiac surgery in unstable patients at increased risk of carotid-related stroke: SIMultaneous urgent cardiac surgery and MicroNet-covered stent carotid revascularization in extreme-risk patients-SIMGUARD Study

BACKGROUND

In patients at urgent need for cardiac surgery coexisting with increased-stroke-risk carotid stenosis, any staged intervention increases the risk of complications from the primarily unaddressed pathology. In this challenging cohort, we assessed safety and feasibility of endovascular carotid revascularization under open-chest extracorporeal circulation (ECC) combined with cardiac surgery (hybrid-room true simultaneous treatment).

METHODS

Per-protocol (PP), after general anesthesia induction, chest-opening and ECC stand-by installation, carotid stenting (CAS) was performed (femoral/radial or direct carotid access) with ad-hoc/on-hand switch to ECC cardiac surgery.

RESULTS

Over 78 months, 60 patients (70.7±6.9years, 85% male, all American Society of Anesthesiology grade IV) were enrolled. All were at increased carotid-related stroke risk (ipsilateral recent stroke/transient ischemick attack, asymptomatic cerebral infarct, increased-risk lesion morphology, bilateral severe stenosis). Majority of study procedures involved CAS+coronary bypass surgery or CAS+valve replacement±coronary bypass. 45 (75%) patients were PP- and 15 (25%) not-PP (NPP-) managed (context therapy). CAS was 100% neuroprotected (transient flow reversal-64.4%, filters-35.6%) and employed micronet-covered plaque-sequestrating stents with routine post-dilatation optimization/embedding. 4 deaths (6.7%) and 7 strokes (11.7%) occurred by 30-days. Despite CAS+surgery performed on aspirin and unfractionated heparin-only (delayed clopidogrel-loading), no thrombosis occurred in the stented arteries, and 30-days stent patency was 100%. NPP-management significantly increased the risk of death/ipsilateral stroke (OR 38.5; P<0.001) and death/any stroke (OR 12.3; P=0.002) by 30-days.

CONCLUSIONS

In cardiac unstable patients at increased carotid-related stroke risk who require urgent cardiac surgery, simultaneous cardiac surgery and CAS with micronet-covered stent lesion sequestration is feasible and safe and shows efficacy in minimizing stroke risk. Larger-scale, multicentric evaluation is warranted. (SIMGUARD NCT04973579).

Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study

INTRODUCTION

Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated.

AIM

To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS.

MATERIALS AND METHODS

In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months.

RESULTS

Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22).

CONCLUSIONS

MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.

Cardiology cathlab-based management of thrombotic carotid stenoses in acute ischaemic stroke: tools, techniques, local stroke unit collaboration, challenges and patient outcomes

Background

Shortage of endovascular operators able to deliver thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis) in managing stroke mechanistic pathologies such as AFib (pharmacology/ablation) or PFO (diagnosis/closure).

Purpose

To present accumulating experience en route to a full interventional stroke service on the basis of a cardiac cathlab and local multi-specialty collaboration.

Methods

Withn the PARADIGM-EXTEND (symptomatic and increased-stroke-risk asymptomatic carotid stenosis) all-comer study we have treated, on an emergent basis, 21 patients (15 men, age 58–83 years, median 68 years) with AIS caused by severe carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service.

Results

All lesions (100%) were thrombotic (mobile thrombus - 29%; one was a thrombotic total occusion). Proximal neuroprotection (flow reversal using a CCA±ECA balloon) with thrombus aspiration was used in 19/21 patients (90.5%; in ICA total thrombotic occlusion TigerTrieverXL was used). In 2 patients proximal system use was unfeasible. All cases were done under ACT control and using, consistent with the PARADIGM-EXTEND protocol, the MicroNET-covered embolic prevention stent system (CGuard) that was routinely optimized with large balloons/high pressures.

There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases. Embolism-to-infarct territory was 0% and embolism-to-new territory was 0%. Vascular access closure device use was 76%. A 30-day good clinical outcome (mRS of 0–2) rate was 95.2%. One patient with thrombotic near-occlusion, in whom crescendo stroke episodes superimposing the baseline late presentation event necessitated treatment, had a haemorrhagic stroke transformation on day 2 that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred.

Conclusion

Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for AMI have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS. Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy. Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services, including thrombectomy, in the cardiology cathlab.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): John Paul II Hospital in Krakow and Jagiellonian University

Cardiology cathlab-based management of thrombotic carotid stenoses in acute ischaemic stroke en route to full interventional stroke service: tools, techniques, challenges and patient outcomes

Background

Shortage of endovascular operators able to deliver manual thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in many health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis and in absence of “territorial” issues) in managing stroke mechanistic pathologies such as atrial fibrillation (pharmacology/ablation) or PFO (diagnosis/closure).

Purpose

To establish a practical path towards a clinically and orranizationally effective cardiology cathlab-based acute ischaemic stroke service, including intracranial manual thrombectomy, in a large multi-specialty hospital with a high-volume stroke unit but absence of neuroradiology service.

Methods

Withn a symptomatic and increased-stroke-risk asymptomatic carotid stenosis all-comer endovascular revascularization study (NeuroVascular Team decision-making) we have treated, on an emergent basis, 17 patients (13 men, age 58–75 years, median 67 years) with AIS caused by severe thrombotic carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service.

Results

All lesions (100%) were thrombotic (mobile thrombus - 29%). Proximal neuroprotection (flow reversal using a common carotid artery±external carotid artery occlusive balloon/s) was used in 15/17 patients (88%). In 2 patients (12%) filter protection was applied as proximal system use was unfeasible for anatomic or clinical reasons. All cases were done under activated clotting time control and using a micronet-covered embolic prevention stent system that was routinely optimized -under an effective neuroprotection- with large balloons/high pressures. There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases.

Vascular access closure device use was 76%.

A 30-day good clinical outcome (mRS of 0–2) rate was 94%. One patient had a haemorrhagic stroke transformation that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred

Conclusions

Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for acute myocardial infarction have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS.

Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy.

Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services including thrombectomy.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College

Long-term outcomes and determinants of restenosis after renal artery angioplasty in hypertensive patients with renovascular disease

Introduction

Restenosis (RS) following percutaneous angioplasty (PTA) of renal artery stenosis (RAS) might have an unfavorable impact on renal function and blood pressure (BP) outcomes.

Aim

To evaluate prevalence and predictors of RS in patients treated with PTA for RAS, and relationship between BP and renal function (RF) changes with RS.

Material and methods

We analyzed freedom from RS in 210 patients (64.6±12.8; range:20–85y.o.), who underwent 248 successful stent-assisted PTAs in RAS. The change in levels of serum creatinine (SCC), eGFR, systolic/diastolic BPs (SBP/DBP) were analyzed prior to PTA, at 6-, 12-months and final follow-up visits, and whenever RS was diagnosed.

Results

RS was identified in 30 (14.3%) patients and 36 (14.5%) lesions. The Kaplan-Meier RS-free survival curves in fibromuscular dysplasia, atherosclerosis and vasculitis were: 100% and 100%; 95.6 and 83.9%, while 71.4 and 39.7% at 1 and 7-years, respectively. Patients with RS, as compared to RS-free patients, presented with lesser response in changes of: SBP (1.4±17.6 vs −15.8±25.8mmHg; p=0.01), DBP (2.64±10.1 vs. −6.5±14.1mmHg; p=0.002), SCC (22.4±55.2 vs −3.6±43.9μmol/L; p=0.002) and eGFR (−1.85±18 vs. −5.34±19.5mmHg; p=0.045).

In multivariate Cox regression analysis, independent predictors of RS occurred: lack of BP decrease (HR: 4.19, 95% CI: 1.67–10.3; p=0.002), lack of eGFR increase of less than ≤0.17 ml/min/1.73m2 (HR: 2.93, 95% CI: 1.08–7.91; p=0.033), stent diameter ≤5mm (HR: 2.76, 95% CI: 1.09–6.97; p=0.031) and vasculitis (HR: 5.61, 95% CI: 1.83–17.2; p=0.003). RS was treated in 24 patients with RS recurrence in 20%.

Conclusions

RS rate differs depending on RAS etiology. Lack of SBP/DBP and eGFR improvement, vasculitis, and stent diameter are associated with RS risk. Repeated PTA is effective, but recurrent RS occurs in 20% of cases.

Kaplan-Meier RS-free survival curves

Funding Acknowledgement

Type of funding source: None

Long-term outcomes of the micronet-covered stent system routine use for carotid revsacularization in stroke prevention: PARADIGM-Extend 5 year evidence

Background

Diffusion-weighted magnetic resonance imaging indicates that micronet-covered embolic prevention stent system effectively minimizes peri-procedural and prevents lesion-related post-procedural cerebral embolism in carotid artery stenting but long-term clinical evidence is missing.

Purpose

To provide long-term clinical and duplex ultrasound evaluation of safety and efficacy of the system use in consecutive carotid revascularization patients.

Methods

PARADIGM-EXTEND is in all-comer, all-referrals-tracked study with no exclusion criteria other than lack of NeuroVascular Team-determined indication. Clinically asymptomatic patients receive revascularization only in case of increased-stroke-risk characteristics. Adverse events are independently adjudicated.

Results

Currently 451 patients (48–87 years, 59% symptomatic, 127 women) with 490 arteries crossed the first follow-up window of 30 days. There has been 100% micronet-covered embolic prevention stent system use (ie, no other stent type/s used throughout study). Proximal/distal intra-procedural neuroprotection use was 38.3%/61.7%. Large balloon/high-pressure stent optimization was routine, leading to a single-digit (mean 6.9%) residual diameter stenosis. Independent neurologist and duplex evaluation are before and after revascularization (48h and 30 days, then yearly).

Peri-procedural death or major ischemic stroke rate was 0%. One event (prior infarct scar asymptomatic extension in prolonged hypotension course) was adjudicated as minor stroke (0.22%), and there was 1 periprocedural MI (type 2, in 2-vessel non-revascularizable CTO; 0.22%).

By 30 days there were no further ischaemic strokes (0%) but there was 1 haemorrhagic transformation that led to death (0.22%) and 1 bleeding-related death (0.22%). Thus total 30-day death/stroke was 0.66%, and total death/stroke/MI was 0.88%.

By 60 months there were 3 contralateral, 1 ipsilateral (device-unrelated), and 2 posterior circulation strokes. Baseline internal carotid artery velocities were 3.72±1.25 and 0.63±0.69 m/s (peak-systolic and end-diastolic). Post-procedural in-stent velocities were normal and remained normal throughout the 60-month follow-up period: 0.78±040 and 0.21±0.10 (1y); 0.75±0.36 0.19±0.09 (2y); 0.75±0,35 and 0.21±0.09 (3y); 0.72±0.27 and 0.20±0.07 (4y); 0.79±0.58 and 0.21±0.11m/s (5y).

There were 2 in-stent restenoses by 1y (including 1 that occurred with de novo neck radiotherapy) and 1 other by 2y (total 2y in-stent restenosis of 1.1%) but no further ones (0% in-stent restenosis at 2–5y).

Conclusions

PARADIGM-Extend long-term clinical and duplex ultrasound evidence is consistent with normal healing and sustained safety and stroke prevention efficacy of the micronet-covered embolic prevention stent system used routinely, on top of optimized medical therapy, for stroke prevention in symptomatic and increased-stroke-risk asymptomatic subjects with carotid stenosis recommended for revasularization by the NeuroVascular Team.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College

3048PARADIGM-Extend prospective academic trial: Accumulating long-term evidence for MicroNet-covered stent safety and stroke prevention efficacy

Aims

To provide long-term clinical (incl neurologic) and duplex ultrasound (DUS) evaluation of the CGuard MicroNet-covered embolic prevention stent system (EPS) routine use to perform CAS in all-comer (no exclusion criteria) patients with symptomatic or increased-stroke-risk asymptomatic carotid stenosis recommended for revascularization by the NeuroVascular Team.

Methods and results

PARADIGM-Extend is a non-industry-funded, prospective academic study in all-referrals-tracked symptomatic and asymptomatic carotid stenosis. In asymptomatic lesions, intervention is mandated only in case of increased-stroke-risk features. There is first-line consideration to use the study device, with EPD choice according to tailored-CAS algorithm. Independent neurologist evaluation and DUS are performed before CAS, at 48h, 30 days, and then every 12 months. There is external source data verification, external angiographic corelab, and external statistical analysis. Currently 325 patients (48–87 years, 54.2% symptomatic) crossed the 1st follow-up window. There has been 100% CGuardEPS use. Angiographic DS was reduced from 84±8% to only 6.9±5% (p<0.001, “CEA-like” effect of CAS).

Peri-procedural death or major stroke rate was 0%. One event was CEC-adjudicated as minor stroke (0.3%), and there was one (type2) MI (0.3%). By 30 days there was one haemorrhagic transformation leading to death (0.3%) and one bleeding-related death (0.3%). Thus total death/major stroke/minor stroke rate at 30 days was 0.9%, and total death/major stroke/minor stroke/MI rate at 30 days was 1.2%. At 1- 12 months were no strokes or stroke-related deaths (0%). At 12–24 months there was one cerebellar stroke in an AFib patient that was confirmed on MRI imaging but no carotid-territory stroke or stroke deaths (0%). By 24 and 36 months there was one posterior circulation (cerebellal) infarct but no cerebral infarctions. Post-procedural in-stent velocities were normal and remained normal throughout the 36-month follow-up period (peak-systolic/end-diastolic velocity 0.69±0.29/0.18±0.09 m/s at 30 days, 0.82±0.47/0.22±0.13m/s at 12 months, 0.73±0.31/0.19±0.09m/s at 24months and 0.80±0.31/0.21±0.11 at 24months), indicating normal device healing.

Conclusions

PARADIGM-Extend accumulating 36-month clinical and DUS evidence is consistent with unprecedented, sustained safety and cerebral embolism prevention efficacy of the CGuard™ MicroNET-covered embolic prevention stent system used routinely for stroke prevention in symptomatic and increased-stroke-risk asymptomatic subjects with carotid stenosis.

Acknowledgement/Funding

K/ZDS/007819 Jagiellonian University Medical College

One-day, sequential carotid artery stenting followed by cardiac surgery in patients with severe carotid and cardiac disease

Optimal management of patients with internal carotid artery (ICA) stenosis concurrent with severe cardiac disease remains undefined. The aim of this study is to evaluate the safety and feasibility of the one-day, sequential approach by carotid artery stenting (CAS) immediately followed by cardiac surgery. The study included 70 consecutive patients with symptomatic > 50% or ⩾ 80% asymptomatic ICA stenosis coexisting with severe coronary/valve disease, who underwent one-day, sequential CAS + cardiac surgery. The majority of patients (85.7%) had CSS class III or IV angina and 10% had non-ST elevation myocardial infarction. The EuroSCORE II risk was 2.4% (IQR 1.69-3.19%). All CAS procedures were performed according to the 'tailored' algorithm with a substantial use of proximal neuroprotection devices of 44.3%. Closed-cell (75.7%) and mesh-covered (18.6%) stents were implanted in most cases. The majority of patients underwent isolated coronary artery bypass grafting (88.6%) or isolated valve replacement (7.1%). No major adverse cardiac and cerebrovascular events (MACCE) occurred at the CAS stage. There were three (4.3%) perioperative MACCE: one myocardial infarction and two deaths. All MACCE were related to cardiac surgery and were due to the high surgical risk profile of the patients. Up to 30 days, no further MACCE were observed. No perioperative or 30-day neurological complications occurred. In this patient series, one-day, sequential CAS and cardiac surgery was relatively safe and did not result in neurological complications. Thus, a strategy of preoperative CAS could be considered for patients with severe or symptomatic ICA stenosis who require urgent cardiac surgery.

Highly-calcific carotid lesions endovascular management in symptomatic and increased-stroke-risk asymptomatic patients using the CGuard™ dual-layer carotid stent system: Analysis from the PARADIGM study

OBJECTIVES

To assess feasibility, safety, angiographic, and clinical outcome of highly-calcific carotid stenosis (HCCS) endovascular management using CGuard™ dual-layer carotid stents.

BACKGROUND

HCCS has been a challenge to carotid artery stenting (CAS) using conventional stents. CGuard combines a high-radial-force open-cell frame conformability with MicroNet sealing properties.

METHODS

The PARADIGM study is prospectively assessing routine CGuard use in all-comer carotid revascularization patients; the focus of the present analysis is HCCS versus non-HCCS lesions. Angiographic HCCS (core laboratory evaluation) required calcific segment length to lesion length ≥2/3, minimal calcification thickness ≥3 mm, circularity (≥3 quadrants), and calcification severity grade ≥3 (carotid calcification severity scoring system [CCSS]; G0-G4).

RESULTS

One hundred and one consecutive patients (51-86 years, 54.4% symptomatic; 106 lesions) received CAS (16 HCCS and 90 non-HCCS); eight others (two HCCS) were treated surgically. CCSS evaluation was reproducible, with weighted kappa (95% CI) of 0.73 (0.58-0.88) and 0.83 (0.71-0.94) for inter- and intra-observer reproducibility respectively. HCCS postdilatation pressures were higher than those in non-HCCS; 22 (20-24) versus 20 (18-24) atm, p = .028; median (Q1-Q3). Angiography-optimized HCCS-CAS was feasible and free of contrast extravasation or clinical complications. Overall residual diameter stenosis was single-digit but it was higher in HCCS; 9 (4-17) versus 3 (1-7) %, p = .002. At 30 days and 12 months HCCS in-stent velocities were normal and there were no adverse clinical events.

CONCLUSION

CGuard HCCS endovascular management was feasible and safe. A novel algorithm to grade carotid artery calcification severity was reproducible and applicable in clinical study setting. Larger HCCS series and longer-term follow-up are warranted.

A Prospective, Multicenter Study of a Novel Mesh-Covered Carotid Stent: The CGuard CARENET Trial (Carotid Embolic Protection Using MicroNet)

OBJECTIVES

This study sought to evaluate the feasibility of the CGuard Carotid Embolic Protective Stent system-a novel thin strut nitinol stent combined with a polyethylene terephthalate mesh covering designed to prevent embolic events from the target lesion in the treatment of carotid artery lesions in consecutive patients suitable for carotid artery stenting.

BACKGROUND

The risk of cerebral embolization persists throughout the carotid artery stenting procedure and remains during the stent healing period.

METHODS

A total of 30 consecutive patients (age 71.6 ± 7.6 years, 63% male) meeting the conventional carotid artery stenting inclusion criteria were enrolled in 4 centers in Germany and Poland.

RESULTS

The primary combined endpoint was the procedure success of the CGuard system and the number and volume of new lesions on the ipsilateral side assessed by diffusion-weighted magnetic resonance imaging at 48 h post-procedure and at 30 days. The secondary endpoint was 30-day major adverse cardiac or cerebrovascular events (death, stroke, or myocardial infarction). Protection devices were used in all procedures. Procedure success was 100%, with 0% procedural complications. The 30-day major adverse cardiac or cerebrovascular events rate was 0%. New ipsilateral ischemic lesions at 48 h occurred in 37.0% of patients and the average lesion volume was 0.039 ± 0.08 cm(3). The 30-day diffusion-weighted magnetic resonance imaging showed complete resolution of all but 1 periprocedural lesion and only 1 new minor (0.116 cm(3)) lesion in relation to the 48-h scan.

CONCLUSIONS

The use of the CGuard system in patients undergoing carotid artery stenting is feasible. In addition, the benefit of using CGuard may extend throughout the stent healing period.

Zotarolimus-eluting stent for the treatment of recurrent, severe carotid artery in-stent stenosis in the TARGET-CAS population

PURPOSE

To evaluate the safety and efficacy of a balloon-mounted drug-eluting stent (DES) for recurrent carotid in-stent stenosis (ISS).

METHODS

As part of our targeted carotid artery stenting (TARGET-CAS) protocol, neurological and ultrasound evaluations have been performed at 3, 6, and 12 months and then annually since 2001 in all carotid stent patients. For angiographically-confirmed >70% ISS, balloon angioplasty was performed as a first-line treatment. Recurrent ISS was treated with a 4.0-mm zotarolimus-eluting coronary stent (ZES) that was postdilated according to intravascular ultrasound imaging. Among the 1350 neuroprotected CAS procedures performed between January 2001 and March 2011, there were 7 (0.52%) patients (5 men; ages 51-72 years), all neurologically asymptomatic, with >70% recurrent ISS that occurred at 5 to 11 months after the initial balloon angioplasty treatment for ISS.

RESULTS

ZES implantation under distal embolic protection was technically successful and uncomplicated. Angiographic stenosis was reduced from 84.6%±7.5% to 10.7%±3.6% (p<0.01). In 5 patients with ZES implanted fully within the self-expanding carotid stent, duplex ultrasound follow-up (mean 17 months, range 6-36) revealed no evidence of restenosis or stent fracture/deformation. In the 2 other patients, the ZES had been implanted for distal edge ISS such that the ZES protruded beyond the original carotid stent. This protruding segment of the ZES demonstrated deformation/kinking in both; in one, this led to symptomatic stent occlusion.

CONCLUSION

The use of coronary ZES in the treatment of recurrent carotid ISS is feasible and appears effective provided the ZES is placed entirely within the original stent. Placement of a coronary ZES outside the carotid stent scaffold should be avoided.

Safety of embolic protection device-assisted and unprotected intravascular ultrasound in evaluating carotid artery atherosclerotic lesions

BACKGROUND

Significant atherosclerotic stenosis of internal carotid artery (ICA) origin is common (5-10% at ≥ 60 years). Intravascular ultrasound (IVUS) enables high-resolution (120 µm) plaque imaging, and IVUS-elucidated features of the coronary plaque were recently shown to be associated with its symptomatic rupture/thrombosis risk. Safety of the significant carotid plaque IVUS imaging in a large unselected population is unknown.

MATERIAL/METHODS

We prospectively evaluated the safety of embolic protection device (EPD)-assisted vs. unprotected ICA-IVUS in a series of consecutive subjects with ≥ 50% ICA stenosis referred for carotid artery stenting (CAS), including 104 asymptomatic (aS) and 187 symptomatic (S) subjects (age 47-83 y, 187 men). EPD use was optional for IVUS, but mandatory for CAS.

RESULTS

Evaluation was performed of 107 ICAs (36.8%) without EPD and 184 with EPD. Lesions imaged under EPD were overall more severe (peak-systolic velocity 2.97 ± 0.08 vs. 2.20 ± 0.08 m/s, end-diastolic velocity 1.0 ± 0.04 vs. 0.7 ± 0.03 m/s, stenosis severity of 85.7 ± 0.5% vs. 77.7 ± 0.6% by catheter angiography; mean ± SEM; p<0.01 for all comparisons) and more frequently S (50.0% vs. 34.6%, p=0.01). No ICA perforation or dissection, and no major stroke or death occurred. There was no IVUS-triggered cerebral embolization. In the procedures of (i) unprotected IVUS and no CAS, (ii) unprotected IVUS followed by CAS (filters - 39, flow reversal/blockade - 3), (iii) EPD-protected (filters - 135, flow reversal/blockade - 48) IVUS + CAS, TIA occurred in 1.5% vs. 4.8% vs. 2.7%, respectively, and minor stroke in 0% vs. 2.4% vs. 2.1%, respectively. EPD intolerance (on-filter ICA spasm or flow reversal/blockade intolerance) occurred in 9/225 (4.0%). IVUS increased the procedure duration by 7.27 ± 0.19 min.

CONCLUSIONS

Carotid IVUS is safe and, for the less severe lesions in particular, it may not require mandatory EPD use. High-risk lesions can be safely evaluated with IVUS under flow reversal/blockade.