Transcarotid vascular access for transcatheter aortic valve implantation: is choosing the left side always right?

BACKGROUND

The transcarotid (TC) vascular access for transcatheter aortic valve implantation (TAVI) has emerged as the first-choice alternative to the transfemoral access, in patients unsuitable for the latter. The use of both the left and right common carotid arteries (CCAs) for TC-TAVI has been described, but the optimal side is subject to debate. We conducted this pilot study to compare the level of vessel tortuosity and plaque burden from either the left CCA to the aortic annulus, or the right CCA to the aortic annulus, considering them as surrogates for technical and procedural complexity.

METHODS

Consecutive patients who underwent TC-TAVI between 2018 and 2021 in our institution were included. Using three-dimensional reconstruction, pre-TAVI neck and chest computed tomography angiography exams were reviewed to assess the tortuosity index (TI), sum of angles metric, as well as plaque burden, between each CCA and the aortic annulus.

RESULTS

We included 46 patients who underwent TC-TAVI. No significant difference regarding the mean TIs between the left and right sides (respectively 1.20 and 1.19, p = 0.82), the mean sum of angles (left side: 396°, right side: 384°, p = 0.27), and arterial plaque burden (arterial plaque found in 30% of left CCAs and 45% of right CCAs, p = 0.19) was found.

CONCLUSIONS

We found no convincing data favoring the use of one particular access side over the other one. The choice of the CCA side in TC-TAVI should to be made on a case-by-case basis, in a multidisciplinary fashion, and may also depend on the operators' experience.

Open surgery for the infected pseudoaneurysm of common carotid artery: A case report

OBJECTIVE

To report a patient of pseudoaneurysm of carotid artery caused by brucellosis infection and improve the recognition, diagnosis and treatment of this disease.

METHODS

The etiology, clinical data and treatment of false aneurysm were reviewed A 75-year-old man with a high probability of pseudoaneurysm of the left common carotid artery was found by enhanced CT. Open surgery was performed. Bacterial culture return was Brucella. After regular oral drug treatment, the patient recovered well.

RESULTS

The patient recovered well after surgery and took oral medication regularly for 3 months without recurrence.

CONCLUSION

Pseudoaneurysms of the carotid artery caused by brucella infection are very rare, and correct diagnosis and open surgery combined with drug therapy are the best choices.

[Internal carotid artery pseudoaneurysm caused by parapharyngeal abscess: A case report]

Pseudoaneurysms of the neck are seldom, and those caused by neck infections especially parapharyngeal abscess are even rarer. However, it is life-threatening and may bring sudden death due to the obstruction of airway and the pseudoaneurysms rupture. We analyzed the clinical features, diagnosis and treatment of the disease through a case summary and literature review in order to guide clinical diagnosis and treatment of pseudoaneurysms. The patient, whom we presented was an 87-year-old male and admitted in emergency of our hospital with the chief complaint of neck swelling for 7 days and shortness of breath for 2 days. Cervical ultrasound examination showed that there was an liquid dark area next to the left common carotid artery which was approximately 8.0 cm × 5.0 cm, consideration of formation of left carotid artery pseudoaneurysm, and the liquid dark area which was visible on the right considered of pseudoaneurysm or infection. Angiography of neck showed a clustered high-density shadow around the bifurcation of the left carotid artery, with an overall range of approximately 65 mm × 52 mm × 72 mm, the pseudoaneurysms for sure, while on the right side of the lesion, mixed low density shadows with air could be seen, the parapharyngeal abscess for sure.Then he was diagnosed as the pseudoaneurysm of left internal carotid artery which was caused by parapharyngeal abscess. After tracheal intubation and anti-infection treatment, the patient died due to hemorrhagic shock of the ruptured of the pseudoaneurysm. Morever we performed literature search on PubMed, Wanfang database and CNKI with keywords of "neck pseudoaneurysm, neck infection, parapharyngeal abscess" and enrolled 10 cases. Then we summarized the clinical characteristics and treatment. We analyzed and summarized the 10 case reports, in which the number of male was 7. Among them, there were 4 pediatric, and 6 adults were enrolled overall. Most of the symptoms were neck swelling, and the diseased blood vessel was mainly the right internal carotid artery which accounted for half overall. All the patients underwent surgical intervention, and recovered well. So we draw the conclusion that the clinical incidence of cervical pseudoaneurysms is low and can be caused by a variety of factors, especially caused by infectious factors. When a patient has a progressive pulsating mass in the neck, the preliminary diagnosis should be made by ultrasound as soon as possible, and the aortic enhancement CT should be used to further confirm.For a patient with cervical pseudo-aneurysms caused by parapharyngeal infections, he should take operation timely combined with antibiotic treatment in time.

Effect of 40 Hz light flicker on cognitive impairment and transcriptome of hippocampus in right unilateral common carotid artery occlusion mice

Vascular cognitive impairment caused by chronic cerebral hypoperfusion (CCH) seriously affects the quality of life of elderly patients. However, there is no effective treatment to control this disease. This study investigated the potential neuroprotective effect of the 40 Hz light flicker in a mouse model of CCH. CCH was induced in male C57 mice by right unilateral common carotid artery occlusion (rUCCAO), leading to chronic brain injury. The mice underwent 40 Hz light flicker stimulation for 30 days after surgery. The results showed that 40 Hz light flicker treatment ameliorated memory deficits after rUCCAO and alleviated the damage to neurons in the frontal lobe and hippocampus. Light flicker administration at 40 Hz decreased IL-1β and TNF-α levels in the frontal lobe and hippocampus, but immunohistochemistry showed that it did not induce angiogenesis in mice with rUCCAO. Gene expression profiling revealed that the induction of genes was mainly enriched in inflammatory-related pathways. Our findings demonstrate that 40 Hz light flicker can suppress cognitive impairment caused by rUCCAO and that this effect may be involved in the attenuation of neuroinflammation.

Surgical experience in repairing the right common carotid artery and the right internal jugular vein after ECMO in neonates: early clinical results

BACKGROUND

The purpose of this study was to summarize the early clinical results and surgical experience of repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates.

METHODS

We retrospectively collected the clinical data of 16 neonates with circulatory and respiratory failure who were treated with ECMO via the right common carotid artery and the right internal jugular vein in our hospital from June 2021 to December 2022. The effects of repairing the common carotid artery and internal jugular vein were evaluated.

RESULTS

All 16 patients successfully underwent right cervical vascular cannulation, and the ECMO cycle was successfully established. Twelve patients were successfully removed from ECMO. The right common carotid artery and the right internal jugular vein were successfully repaired in these 12 patients. There was unobstructed arterial blood flow in 9 patients, mild stenosis in 1 patient, moderate stenosis in 1 patient and obstruction in 1 patient. There was unobstructed venous blood flow in 10 patients, mild stenosis in 1 patient, and moderate stenosis in 1 patient. No thrombosis was found in the right internal jugular vein. Thrombosis was found in the right common carotid artery of one patient.

CONCLUSION

Repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates was feasible, and careful surgical anastomosis techniques and standardized postoperative anticoagulation management can ensure early vascular patency. However, long-term vascular patency is still being assessed in follow-up.

A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children

INTRODUCTION

In pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO).

METHODS

PubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed.

RESULTS

Eighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes.

CONCLUSIONS

Studies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.

A modified method of elastase-induced saccular aneurysm creation in rabbits: Schematic representation of the method

BACKGROUND

The purpose of our study was to investigate the safety and effectiveness of a modified technique using a short guiding catheter for instillation of elastase in comparison with the previously described method of creating elastase-induced aneurysm in rabbits.

METHODS

Following right common carotid artery (RCCA) access using an arterial sheath and inflating the Fogarty balloon in the subclavian artery, a short guiding catheter was used for the instillation of the elastase in the experimental group (n = 5) while it was performed with a microcatheter in the control group (n = 5). The procedure duration was recorded from the RCCA puncture to the sheath removal. The histological changes were characterized using H&E and Masson's trichrome (MT) staining.

RESULTS

The procedure time was 23 ± 2 min in the experimental group and 29 ± 2 min in the control group. All the rabbits (100%) in the experimental group survived without neurologic deficits, but two rabbits (40%) survived in the control group. All aneurysms were created in the saccular shape (100%) with a neck size of 2.3 ± 0.29 mm, a width of 2.75 ± 0.36 mm, and height of 6.37 ± 0.46 mm, and a dome to neck ratio of 1.21 ± 0.23. The aneurysm walls were partly thickened due to the degradation of the media tunica and adventitia proliferation with loss of the internal elastic lamina.

CONCLUSION

By using a short guiding catheter, we could instill the elastase in a more effective and safe manner in the creation of the elastase-induced aneurysm model in rabbits.

Society for Vascular Surgery duplex ultrasound surveillance guidelines are safe and cost effective for transcarotid artery revascularization

BACKGROUND

Carotid duplex ultrasound (CDUS) examination is used in the long-term surveillance after transcarotid artery revascularization (TCAR). The objective of this study was to evaluate the usefulness and cost effectiveness of post-TCAR CDUS surveillance regimens in monitoring for in-stent restenosis (ISR) and associated stroke risk at a single-center community institution.

METHODS

CDUS data were collected retrospectively from patients who had undergone TCAR between January 2017 and January 2023. ISR >50% was defined as a peak systolic velocity (PSV) of >220 cm/s and an internal carotid artery (ICA) to common carotid velocity ratio of >2.7. ISR >80% was defined as a PSV of >340 cm/s and an ICA/common carotid artery ratio of >4.15. Study outcomes included incidences of ISR, reintervention, transient ischemic attacks (TIAs), strokes, and mortality. A Kaplan-Meier survival analysis was done to calculate the rates of freedom from ISR.

RESULTS

During the study period, 108 TCAR stents were deployed in 104 patients. Eight patients were excluded in analysis or lost to follow-up. Preoperatively, 62% of patients had >80% stenosis, and 39% were symptomatic. No intraprocedural complications were noted. One patient suffered an immediate postoperative dissection. Eight stents (8%) experienced ISR progression from <50% to >50%. Three of the eight had further ISR progression to >80%. One patient had high-grade ISR and a contralateral ICA occlusion that warranted reintervention. There were no occurrences of postoperative TIAs, strokes, or TCAR-related deaths. Rates of freedom from ISR progression from <50% to >50% were 97.4%, 95.9%, 90.9%, 88.2%, and 88.2% at 6, 12, 24, 36, and 42 months, respectively. Rates of freedom from ISR >80% were 100%, 100%, 98.5%, 95.5%, and 95.5% at the same time points. Patients with >50% ISR tended to be females with hyperlipidemia. In addition, they had higher average lesion lengths and lower rates of postdilation balloon angioplasty. The 5-year estimated surveillance cost in this cohort using the Society for Vascular Surgery 2022, and 2018 guidelines, as well as our current protocol would be $113,853, $221,382, and $193,207, respectively.

CONCLUSIONS

This study revealed a low incidence of ISR progression, as well as no TIA, stroke, or TCAR-related deaths, highlighting the safety and efficacy of TCAR. Post-TCAR CDUS examination using the updated Society for Vascular Surgery guidelines are safe and cost effective. Patients with contralateral occlusion or stenosis, or who have significant risk factors, should have more frequent surveillance regimens.

Penetrating carotid artery injury by air rifle: a case report

BACKGROUND

Air rifle injuries can cause significant vascular injuries. This air rifle injury has resulted in a penetrating neck trauma traversing the common carotid artery. There is debate around the need for radiological investigation, the most appropriate investigational modality, and the need for surgical exploration versus a conservative approach. This case report aims to exemplify a successful approach to managing Penetrating Carotid Injuries (PCI) while shedding light on the rationale behind the management decisions.

PRESENTATION

An 18-year-old Caucasian man arrived at the hospital following an air rifle injury to the right side of the neck, with active bleeding and a moderate haematoma displacing the trachea. He was haemodynamically stable, with a Glasgow Coma Scale (GCS) of 15 and no evidence of bruit. Computed Tomography Angiography (CTA) showed Right common carotid (CCA) artery injury with associated post-traumatic pseudoaneurysm. The pellet trajectory traverses the right superior thyroid gland. A duplex ultrasound scan (USS) confirmed two areas of arterial blush at the right CCA. Management involved neck exploration under General Anaesthesia (G.A.), repair of right CCA, bullet extraction, and wound washout. He received antibiotics for ten days and a single agent of antiplatelets for three months and was discharged two days postoperatively with no complications. He was followed up for eight months with no evidence of any trauma sequelae.

CONCLUSION

Penetrating carotid artery injuries are a serious concern. The small-sized pellets carry the risk of embolization. Therefore, neck exploration remains the gold standard treatment for PCI. Appropriate operative planning is crucial and can be optimised using radiological diagnostic modalities in haemodynamically stable patients. CTA is a non-invasive, swift, and adequate alternative to arteriography, providing valuable diagnostic information on vascular and aerodigestive injuries and bullet trajectory. This enables appropriate preparedness to achieve excellent outcomes in such critical cases.

Optimal guiding catheter position during advancement of the guiding catheter into the carotid artery from the aortic arch via transfemoral approach

BACKGROUND

Guiding catheter (GC) advancement into the target carotid artery is a crucial step in neuroendovascular therapy. In difficult anatomies, alternative methods have been reported to overcome difficult carotid access for swift GC advancement. However, studies focusing on the positional relationship between the GC and inner catheter (IC) at the aortic arch are lacking.

METHODS

We evaluated the impact of the positional relationship between the GC and IC on whether the GC position affects catheter support or system straightening. We retrospectively reviewed 89 patients who underwent neuroendovascular therapy. We assessed the time to carotid access across difficult arch anatomies. The GC position was divided into Position 1, descending aorta level; Position 2, aortic arch level; and Position 3, origin of the left common carotid artery or innominate artery. We also evaluated the GC support and straightening effects in an in vitro vascular model study.

RESULTS

The coaxial catheter flexion angle at the aortic arch was significantly larger when the GC was set to Position 3 (p < 0.0001). A significantly shorter time to carotid access was observed with Positions 2 and 3 than with Position 1 in the difficult arch anatomy group. In the in vitro vascular model evaluation, the catheter support effect significantly increased as the GC position became closer to the IC tip (p < 0.0001) and straightening effect significantly increased as the GC moved to Position 2 from Position 1 (p < 0.0001).

CONCLUSION

During GC advancement, the GC positional relationship changed the support of the coaxial system with system straightening. The optimal GC position, Position 3, facilitated swift GC advancement.

Combined Endovascular Antegrade and Direct Retrograde Carotid Artery Stenting for Chronic and Long Segment Common Carotid Artery Occlusion: Technical Note and Review of Literature

Common carotid artery (CCA) occlusion (CCAO) is a rare cause of ischemic stroke and bypass surgery is the common treatment approach. However, safer alternatives should be developed to treat CCAO. A 68-year-old male was diagnosed with left-sided CCAO with decreased left visual acuity due to neck radiation therapy for laryngeal cancer. Recanalization therapy using a pull-through technique was initiated because cerebral blood flow progressively decreased during the follow-up period. First, after a short sheath was inserted into the CCA, the occluded CCA was retrogradely penetrated through the sheath. Second, a micro-guidewire was guided to the aorta from the femoral sheath where it was caught using a snare wire guided from the cervical sheath. Subsequently, the micro-guidewire was gently pulled out from the cervical sheath, penetrated the occluded lesion, and was secured to the femoral and cervical sheaths. Finally, the occluded lesion was dilated using a balloon, and the stent was placed. Five days postprocedure, the patient was discharged uneventfully and exhibited improved left visual acuity. In terms of reliable penetration of obstructive lesions and reduction of embolic and hemorrhagic complications, combined endovascular antegrade and direct retrograde carotid artery stenting is a versatile and minimally invasive treatment option for CCAO.

[Total replacement of both carotid arteries combined with ascending aorta and aortic arch replacement for acute DeBakey type I aortic dissection]

Involvement of supra-aortic vessels into acute DeBakey type I aortic dissection is a significant predictor of adverse postoperative neurological outcomes and mortality. The choice of surgical tactics remains open in such patients. We present total replacement of both common carotid arteries and proximal part of the right subclavian artery with reconstruction of ascending aorta and aortic arch for acute DeBakey type I dissection.

Segmented carotid endarterectomy for treatment of Riles type 1A common carotid artery occlusion

OBJECTIVE

Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. Symptomatic lesions are resistant to medical treatment and revascularization is often required, but there is no consensus on the treatment of CCAO at present. Riles type 1A CCAO is most likely to benefit from revascularization because it has patent outflow tract (internal carotid artery) which was supplied by patent external carotid artery (ECA) from collateral circulation. We described a novel surgical technique improved on the basis of the carotid endarterectomy (CEA) for treatment of Riles type 1A CCAO.

METHODS

We rigorously screened ten patients with symptomatic Riles type1A CCAO for surgery from January 2017 to May 2019 and performed a full preoperative assessment of the inadequate collateral circulation compensation. Moreover, we retrospectively reviewed our experience of the segmented CEA in the treatment of them in our single center.

RESULTS

Segmented CEA was performed on the left side in four cases and on the right side in six cases. The technical success rate of the procedure was 100%. Primary suture was used in nine cases. Only one patient (right CCAO) who had a history of neck radiotherapy was treated by the patch CEA. The mean temporary blocking time during surgery was 52.8 ± 9.15 min. The mean temporary blocking time for treating the upper segment of the common carotid artery (CCA) was 11.1 ± 2.64 min. In the postoperative period, cerebral perfusion on the ipsilateral site improved in all patients, myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another. No ischemic events or re-occlusion or restenosis (> 50%) of the treated CCA occurred during the mean follow-up of 32.6 ± 9.3 months. The preoperative mean modified Rankin Scale (mRS) score was 1.9 (range, 1-3; median, 2). At last follow-up for all patients, the mRS score was 1 (range, 0-3; median, 1).

CONCLUSION

Segmented CEA, which utilizes the compensatory effect of collateral circulation, is an effective and safe technique to treat patients suffering from Riles type 1A CCAO with hemodynamic cerebrovascular compromise.

[Hybrid Treatment of the Intrathoracic Right Subclavian Artery Aneurysm:Report of a Case]

A 78-years-old woman was referred to our institution for the treatment of right subclavian artery (SCA) aneurysm. She previously underwent total arch replacement via median sternotomy approach. Preoperative computed tomography revealed a 55 mm sized SCA aneurysm. Stent graft was inserted from brachiocephalic artery to right common carotid artery via the graft anastomosed. The orifice of the right SCA was covered with stent graft inserted into the right common carotid artery-brachiocephalic artery and the right SCA was occluded with coils distal to the aneurysm, carotid-SCA bypass was performed with 8 mm ePTFE graft. Postoperative examination confirmed complete exclusion of the aneurysm and patency of the bypass graft. We thought that hybrid treatment for this patient was a less invasive alternative to conventional surgical procedure.

Mizagliflozin, a selective SGLT1 inhibitor, improves vascular cognitive impairment in a mouse model of small vessel disease

Previously, we showed that sodium/glucose cotransporter 1 (SGLT1) participates in vascular cognitive impairment in small vessel disease. We hypothesized that SGLT1 inhibitors can improve the small vessel disease induced-vascular cognitive impairment. We examined the effects of mizagliflozin, a selective SGLT1 inhibitor, and phlorizin, a non-selective SGLT inhibitor, on vascular cognitive impairment in a mouse model of small vessel disease. Small vessel disease was created using a mouse model of asymmetric common carotid artery surgery (ACAS). Two and/or 4 weeks after ACAS, all experiments were performed. Cerebral blood flow (CBF) was decreased in ACAS compared with sham-operated mice. Phlorizin but not mizagliflozin reversed the decreased CBF of ACAS mice. Both mizagliflozin and phlorizin reversed the ACAS-induced decrease in the latency to fall in a wire hang test of ACAS mice. Moreover, they reversed the ACAS-induced longer escape latencies in the Morris water maze test of ACAS mice. ACAS increased SGLT1 and proinflammatory cytokine gene expressions in mouse brains and phlorizin but not mizagliflozin normalized all gene expressions in ACAS mice. Hematoxylin/eosin staining demonstrated that they inhibited pyknotic cell death in the ACAS mouse hippocampus. In PC12HS cells, IL-1β increased SGLT1 expression and decreased survival rates of cells. Both mizagliflozin and phlorizin increased the survival rates of IL-1β-treated PC12HS cells. These results suggest that mizagliflozin and phlorizin can improve vascular cognitive impairment through the inhibition of neural SGLT1 and phlorizin also does so through the improvement of CBF in a mouse model of small vessel disease.

A multi-registry analysis of military and civilian penetrating cervical carotid artery injury

INTRODUCTION

Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management.

METHODS

Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality.

RESULTS

There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005).

CONCLUSION

The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke.

LEVEL OF EVIDENCE

Retrospective cohort analysis, level III.

[Revascularization of the Right Common Carotid Artery Prior to Central Repair for Stanford Type A Acute Aortic Dissection with Brain Malperfusion:Report of a Case]

A 67-year-old woman had sudden loss of consciousness and chest and back pain. She was transported by ambulance about two hours later. Computed tomography (CT) showed dissection of the aorta, the brachiocephalic artery and the right common carotid artery (RCCA). RCCA was completely obstructed. Emergency surgery was conducted one hour later. RCCA's blood flow was reestablished prior to hemi-arch replacement. Postoperative CT revealed diminishment of the false lumen and recovery of the blood flow of RCCA, and she was discharged on foot without any complications.

Ozagrel a thromboxane A2 synthase inhibitor extenuates endothelial dysfunction, oxidative stress and neuroinflammation in rat model of bilateral common carotid artery occlusion induced vascular dementia

The present study investigates the potential of ozagrel, a thromboxane A2 (TXA2) synthase inhibitor, in bilateral common carotid artery occlusion (BCCAo) induced vascular dementia (VaD). Wistar rats were subjected to BCCAo procedure under anesthesia to induce VaD. Morris water maze (MWM) test was employed on 7th day post-surgery to determine learning and memory. Endothelial dysfunction was assessed in isolated aorta by observing endothelial dependent vasorelaxation and levels of serum nitrite. A battery of biochemical and histopathological estimations was performed. Expression analysis of inflammatory cytokines TNF-α and IL-6 was carried out by RT-PCR. BCCAo produced significant impairment in endothelium dependent vasorelaxation and decrease in serum nitrite levels indicating endothelial dysfunction along with poor performance on MWM represents impairment of learning and memory. There was a significant rise in brain oxidative stress level (indicated by increase in brain thiobarbituric acid reactive species and decrease in reduced glutathione levels); increase in brain acetylcholinesterase activity; brain myeloperoxidase activity; brain TNF-α & IL-6 levels, brain TNF-α & IL-6 mRNA expression and brain neutrophil infiltration (as marker of inflammation) were also observed. Treatment of ozagrel (10 & 20 mg/kg, p. o.)/donepezil (0. 5 mg/kg, i.p., serving as standard) ameliorated BCCAo induced endothelial dysfunction; memory deficits; biochemical and histopathological changes in a significant manner. It may be concluded that ozagrel markedly improved endothelial dysfunction; learning and memory; biochemical and histopathological alteration associated with BCCAo induced VaD and that TXA2 can be considered as an important therapeutic target for the treatment of VaD.

Long-term feasibility of the new sutureless excimer laser-assisted non-occlusive anastomosis clip in a pig model

BACKGROUND

High flow bypass surgery can be a last resort procedure for patients suffering from complex neurovascular pathology. Temporary occlusion of a recipient artery in these patients could result in debilitating neurological deficits. We developed a sutureless, mechanical anastomotic connection device, the SELANA clip (Sutureless Excimer Laser-Assisted Non-occlusive Anastomosis clip: SEcl). In the present study, we aim to determine the long-term non-inferiority of the SEcl technique compared with historical data of the conventional ELANA anastomosis technique.

METHODS

A total of 18 SEcl bypasses were created on the carotid artery in a porcine model in 6 different survival groups. Mean application times, flap retrieval rates, hemostasis, patency, flow, endothelialization, and remodeling were assessed.

RESULTS

The mean application time of the SEcl anastomoses was 15.2 ± 9.6 min, which was faster compared with the conventional ELANA anastomoses. The flap retrieval rate of the SEcl anastomoses was 86% (32/37). Direct hemostasis was achieved in 89% (33/37) SEcl anastomoses. Patency in all surviving animals was 94% (17/18). Bypass flow after six months was 156.5 ± 24.7 mL/min. Full endothelialization of the SEcl pins was observed after 3 weeks.

CONCLUSION

The SEcl technique is not inferior to the ELANA technique regarding patency, flap retrieval rate, flow, and endothelialization. On the basis of a significantly shorter application time and superior hemostasis, the SEcl technique could be preferable over the ELANA technique. A pilot study in patients is a logical next step based on our current results.

Robot-Assisted Carotid Artery Stenting: A Safety and Feasibility Study

PURPOSE

Endovascular robotics is an emerging technology within the developing field of medical robotics. This was a prospective evaluation to assess safety and feasibility of robotic-assisted carotid artery stenting.

MATERIALS AND METHODS

Consecutive cases of carotid artery stenting cases performed over period of 24 months, from May 2015 to October 2016, using the Magellan Robotic System (Hansen, Mountain View, CA) were included. All cases utilised the robotic system to navigate the arch, obtain a stable position in the common carotid artery, followed by manual manipulation of Embolic Protection Devices and self-expandable stents through the robotic catheter. Patients demographics, clinical indications, anatomical features, technical and clinical success, complication rate and hospital stay were prospectively recorded.

RESULTS

Thirteen patients, 10 males (78.5%), with an average age of 68.7 years were treated. Mean follow up time was 30 months. Ten patients (91%) were symptomatic at presentation. Anatomical indications for endovascular stent insertion were previous open surgery to the neck ± radiotherapy (87.5%) and hostile anatomy for open surgery (12.5%). Technical success was 100% and the robotic system demonstrates enhanced stability during arch and lesion crossing. There were no neurological complications post-operatively. Average hospital stay was 3 days (range 2-6 days) and a change in serum creatinine of -7.8 μmol/L. There was no documented case of in stent restenosis, new or worsening neurology during follow-up.

CONCLUSION

These results illustrate safety and feasibility of robotic endovascular revascularisation for carotid disease and demonstrates potential to enhance peri-procedural safety through improved control and stability.

Comparison of the Effectiveness of Ring-Stripping Retrograde Endarterectomy and Carotid Artery Crossover Bypass in the Treatment of Patients with Symptomatic Riles Type 1A Common Carotid Artery Occlusion

OBJECTIVE

The surgical procedure most appropriate for treating symptomatic Riles type 1A common carotid artery occlusion (CCAO) is unclear. This study compares the effects of ring-stripping retrograde endarterectomy (RSRE) and carotid artery crossover bypass (CACB) on cerebral perfusion improvement in patients with symptomatic Riles type 1A CCAO.

METHODS

We conducted a retrospective analysis of symptomatic Riles type 1A CCAO patients treated at our centre. Postoperative improvements in the ipsilateral internal carotid artery (ICA) flow rate, ipsilateral cerebral blood perfusion (CBP) and the stroke recurrence rate were compared between patients who underwent RSRE and those who underwent CACB.

RESULTS

A total of 20 CCAO patients were surgically treated at our centre from 2011 to 2018. Nine of these patients underwent RSRE, and eleven underwent CACB. No significant differences were identified between the groups in the ipsilateral blood flow rate of the ICA immediately after surgery and the ipsilateral-to-contralateral mean transit time ratios 1 day after surgery. However, the flow rate in the ICA was significantly higher in the RSRE group than in the CACB group 1 year after surgery (135.44 ± 19.22 ml/min vs. 116.36 ± 17.70 ml/min, p = 0.033). For CBP, the ipsilateral-to-contralateral mean transit time ratios were significantly lower in RSRE patients than in CACB patients 1 year after surgery (1.005 ± 0.052 vs. 1.064 ± 0.066, p = 0.044). In addition, the postoperative modified Rankin scale (mRS) score at the latest follow-up point (p = 0.884) and the stroke recurrence rate during the follow-up (88.9% vs. 90.9%, p > 0.999) were not significantly different between the two groups.

CONCLUSIONS

Although the postoperative mRS score and the stroke recurrence rate were not significantly different between RSRE and CACB patients, compared to CACB, RSRE was better for improving the ipsilateral ICA flow rate and cerebral perfusion in symptomatic Riles type 1A CCAO patients.

An updated systematic review and meta-analysis of results of transcervical carotid artery stenting with flow reversal

OBJECTIVE

Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal.

METHODS

An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates.

RESULTS

A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures.

CONCLUSIONS

This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.

Repair of Type Ia Endoleaks Involving the Distal Arch Using Left Subclavian Artery-Left Common Carotid Artery Transposition with a Stented Elephant Trunk

BACKGROUND

Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk.

METHODS

Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient.

RESULTS

There were no in-hospital deaths. Fourteen patients required mechanical ventilation for <24 h and one for <48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up.

CONCLUSIONS

The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

Carotid Artery Stenosis after Radiation Therapy in a Patient with Lung Cancer: A Case Report and Literature Review

We reported a case of carotid artery stenosis with stroke symptoms detected in a patient with lung cancer after radiotherapy. The patient was a 58-year-old male with a complaint of \"a single episode of temporary amaurosis in the right eye for 10 minutes". The clinical diagnosis at admission, after consideration of the patient's age, medical history, and auxiliary examination results, was as follows: lung cancer; right common carotid artery stenosis; left common carotid artery stenosis; left vertebral artery stenosis; and right subclavian artery occlusion with right subclavian steal syndrome (Grade 3). Carotid angioplasty and stenting (CAS) were subsequently performed. During the 6-month follow-up, we observed no episode of temporary vision loss or other signs of stroke. Clinicians should pay great attention to delayed radiation-induced carotid stenosis. It is recommended that patients with a history of radiotherapy should undergo regular color Doppler ultrasound examination of the cervical region to diagnose, prevent, and treat RICS in an expedient fashion. This approach should improve survival rate and quality of life.

Bypass strategies for common carotid artery occlusion

BACKGROUND

Common carotid artery occlusion (CCA-occlusion) is a rare condition where standard revascularization is not feasible. Here, we analyzed our experience with surgical revascularization of CCA-occlusion to develop an algorithm for selection of the most suitable bypass strategy according to the Riles classification.

METHODS

During a 10-year period, 16 out of 288 patients with cerebrovascular disease and compromised hemodynamic reserve underwent revascularization for unilateral CCA-occlusion. The utilized bypass strategies included (1) a saphenous vein graft from the subclavian artery (SA) to the internal carotid artery (ICA), (2) a radial artery graft from the V3 segment of the vertebral artery (VA) to a superficial branch of the middle cerebral artery (MCA), or (3) a saphenous vein graft from the SA to a deep branch of the MCA.

RESULTS

In CCA-occlusion with maintained external carotid artery (ECA)/ICA patency (Riles type 1A), an SA-ICA bypass was performed (25%). In cases without ECA/ICA patency (Riles type 1B or 2) but suitable VA, a VA-MCA bypass was grafted (31%). In cases with unsuitable VA, a long SA-MCA interposition bypass was performed (38%). Transient postoperative neurological deficits occurred in 5 patients (31%) with 1 patient (6%) suffering permanent neurological worsening and 1 mortality (6%). Overall, no difference was found between the median preoperative mRS (2; range, 1-4) and the mRS at the time point of the last follow-up (2; range, 1-6; p = 0.75). The long-term graft patency was 94%.

CONCLUSIONS

Although surgical revascularization for CCA-occlusion is feasible, it is associated with a higher risk than standard bypass grafting. Considering the poor natural history of CCA-occlusion, however, this risk may be justified in carefully selected patients.

Common carotid artery puncture in anterior circulation thrombectomy in patients with unfavorable vascular anatomy: A case-control study

The objective of this study was to compare clinical outcomes in patients who with unfavorable vascular anatomy underwent mechanical thrombectomy (MT) by common carotid artery access versus transfemoral approach.A retrospective review was performed in our hospital database to identify patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion (LVO) between August 2015 and November 2018. Transcarotid and transfemoral cohorts were compared. Patient characteristics, procedural techniques, clinical outcomes were recorded.A total of 52 patients were included, 16 (31%) underwent MT via transcarotid access. There were no significant differences in patient characteristics, intravenously recombinant tissue plasminogen activator therapy, clot location, or carotid tortuosity and presence of aortic arch type. There were significant differences in clinical outcomes between the 2 cohorts, including mean access-to-reperfusion time (84 vs 44 minutes; P = .000), poor clinical outcome (modified Rankin scale >2) at 90 days follow-up (37.5% vs 63.9%; P = .034). But there were no significant differences in successful revascularization rates (thrombolysis in cerebral infarction score ≥2b 87.5% vs 80.6%; P = .541), post-thrombectomy symptomatic intracranial hemorrhage (12.5% vs 13.9%; P = .892), and mortality (12.5% vs 22.2%; P = .412) were similar between transcarotid and transfemoral cohorts.Our results demonstrate that transcarotid access for MT of anterior circulation LVO in patients with unfavorable vascular anatomy may be considerable. Transcarotid access may be better than transfemoral access in well-selected unfavorable vascular anatomy patients undergoing MT.

Penetrating neck trauma with common carotid artery injury caused by a percussive drill: A case report

RATIONALE

Penetrating neck traumas are dangerous and have a high mortality rate, particularly in patients with common carotid artery injuries. Advances in diagnostic imaging technology have shifted management of penetrating neck injuries from mandatory exploration to selective management. The question is now regarding optimal selection of auxiliary examinations to assess "stability" rapidly and guide clinics in managing such patients.

PATIENT CONCERNS

A 56-year-old man suffered neck trauma with the right common carotid artery caused by a percussive drill. The carotid artery could not be clearly displayed in computed tomography (CT) angiography imaging.

DIAGNOSES

Penetrating neck trauma due to percussive drill bit with common carotid artery injury.

INTERVENTIONS

X-ray and bedside duplex ultrasound with color Doppler flow imaging were used to assess the state of trauma and the foreign body was removed under general anesthesia.

OUTCOMES

The patient was discharged at postoperative day 10 with no complication. The patient had no sequelae from this injury at 6-month follow up.

LESSONS

X-ray provides a comprehensive assessment of damage, and can efficiently detect foreign bodies in the skull and cervical vertebrae. Duplex ultrasound to be a viable method to exclude macrovascular injury in unstable patients who are not eligible for computed tomography angiography (CTA) or catheter angiography imaging. Widely available duplex ultrasound and x-ray should be considered in emergency situations.

Femoral artery pseudoaneurysm after carotid artery stenting: Two case reports

RATIONALE

Pseudoaneurysm, the most common complication of femoral artery catheterization, involves the formation of a space between the lumen and the surrounding fibrous tissue through the damaged arterial wall. In patients treated with antiplatelet and anticoagulant agents, the incidence of vascular complications increases with the increasing use of minimally invasive procedures.

PATIENT CONCERNS

We experienced 2 cases of procedure-induced pseudoaneurysms. A 79-year-old man with right hemiparesis visited our hospital. Brain magnetic resonance imaging showed acute left middle cerebral artery territory infarction and severe stenosis of the left proximal carotid artery. The patient was prescribed apixaban and underwent carotid stenting through the right femoral artery. Hematoma and tenderness were observed in the right inguinal region after the procedure. The hemoglobin level decreased from 16.9 g/dL to 9.4 g/dL. Another 78-year-old man with left common carotid artery stenosis was admitted. We performed stent implantation through the right femoral artery and administered aspirin and clopidogrel. After the procedure, hematoma and tenderness of the puncture site were observed. The hemoglobin level decreased from 14.5 g/dL to 10.9 g/dL.

DIAGNOSIS

Emergency computed tomography confirmed a pseudoaneurysm with a massive hematoma in the right inguinal area. The patients were diagnosed with infection-associated right pseudoaneurysm for which an emergency puncture site repair was performed.

INTERVENTIONS

We performed resection of pseudoaneurysm and repaired puncture site.

OUTCOMES

The hemoglobin level was stabilized postoperatively and vital sign remained stable.

LESSONS

Pseudoaneurysm is an important complication of femoral artery puncture. The use of a hemostatic device was not superior to manual compression, and the incidence of this complication was significantly higher in patients who received anticoagulant or antiplatelet agents. A pseudoaneurysm may cause a bad prognosis. Therefore, the early detection of pseudoaneurysm and immediate treatment after femoral arterial puncture are needed.

Middle Cerebral Artery Occlusion Allowing Reperfusion via Common Carotid Artery Repair in Mice

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue plasminogen activator (tPA) as an approved drug treatment to target ischemic strokes. Current research in the field of ischemic stroke focuses on better understanding the pathophysiology of stroke, to develop and investigate novel pharmaceutical targets. Reliable experimental stroke models are crucial for the progression of potential treatments. The middle cerebral artery occlusion (MCAO) model is clinically relevant and the most frequently used surgical model of ischemic stroke in rodents. However, the outcomes of this model, such as lesion volume, are associated with high levels of variability, particularly in mice. The alternative MCAO model described here allows the reperfusion of the common carotid artery (CCA) and the increased perfusion of the middle cerebral artery (MCA) territory, using a tissue pad with fibrinogen-based sealant to repair the vessel, and the improved welfare of the mice by avoiding external carotid artery (ECA) ligation. This reduces the reliance on the Circle of Willis, which is known to be highly anatomically variable in mice. Representative data show that using this alternative surgical approach decreases the variability in lesion volumes between the traditional MCAO approach and the alternative approach described here.

[Hybrid Treatment for Aortic Arch Aneurysm Concomitant with Right Subclavian Artery Aneurysm]

A 78-year-old man was hospitalized for aortic arch aneurysm concomitant with right subclavian artery aneurysm. Maximum diameter of each aneurysm was 65 mm and 40 mm, respectively. Both aneurysms clearly needed to be treated. However, simultaneous surgery of total arch replacement (TAR) and right subclavian artery grafting carries both technical difficulty of surgical exposure and considerable risk of bilateral recurrent nerve palsy. Thus, to avoid these serious problems, we chose hybrid treatment. TAR was performed as the 1st procedure, followed by stent graft placement to right subclavian artery aneurysm. At the 1st procedure, an 8 mm graft was anastomosed to right common carotid artery in end to side fashion. This was used for cerebral perfusion, and after that, another end of this graft was anastomosed to a branch of quadrant graft which was anastomosed to brachiocephalic artery. Then, right common carotid artery was ligated at proximal portion to create a proximal landing zone. As the 2nd procedure, excluder leg was deployed via right axillary artery without difficulty. He was discharged with uneventful postoperative course.

The degradation and transport mechanism of a Mg-Nd-Zn-Zr stent in rabbit common carotid artery: A 20-month study

Mg-based stent is a promising candidate of the next generation fully degradable vascular stents. The latest progress includes the CE approval of the Magmaris ® WE43 based drug eluting stent. However, so far, the long term (more than 1 year implantation) in vivo degradation and the physiological effects caused by the degradation products were still unclear. In this study, a 20 month observation was carried out after the bare Mg-Nd-Zn-Zr (abbr. JDBM) stent prototype was implanted into the common carotid artery of New Zealand white rabbit in order to evaluate its safety, efficacy and especially degradation behavior. The degradation of the main second phase Mg₁₂Nd was also studied. Results showed that the bare JDBM stent had good safety and efficacy with a complete re-endothelialization within 28 days. The JDBM stent struts were mostly replaced in situ by degradation products in 4 month. The important finding was that the volume and Ca concentration of the degradation products decreased in the long term, eliminating the clinicians' concern of possible vessel calcification. In addition, the alloying elements Mg and Zn in the stent could be safely metabolized as continuous enrichment in any of the main organs were not detected although Nd and Zr showed an abrupt increase in spleen and liver after 1 month implantation. Collectively, the long term in vivo results showed the rapid re-endothelialization of JDBM stent and the long term safety of the degradation products, indicating its great potential as the backbone of the fully degradable vascular stent.

STATEMENT OF SIGNIFICANCE

Mg-based stent is a promising candidate of the next generation fully degradable stents, especially after the recent market launch of one of its kind (Magmaris). However the fundamental question about the long term degradation and metabolic mechanism of Mg-based stent and its degradation products remain unanswered. We implanted our patented Mg-Nd-Zn-Zr bare stent into the common carotid artery of rabbits and conducted a 20 months observation. We found that the Ca containing degradation products could be further degraded in vivo. All the alloying elements showed no continuous enrichment in the main organs of rabbits. These findings eliminate the clinicians' concern of possible vessel calcification and element enrichment after the implantation of Mg alloy based stents to some extent.

Transcarotid Transcatheter Aortic Valve Replacement as Preferred Alternative Access in a Patient With Bilateral Carotid Artery Disease

A 78-year-old man presented with severe symptomatic aortic stenosis and a heavily calcified, stenotic aortic valve. Given multiple comorbidities, the heart team agreed on a transcatheter approach via the left common carotid artery.

Neuroprotective effects of erythropoietin on rat retinas subjected to oligemia

OBJECTIVES

Erythropoietin may have neuroprotective potential after ischemia of the central nervous system. Here, we conducted a study to characterize the protective effects of erythropoietin on retinal ganglion cells and gliotic reactions in an experimentally induced oligemia model.

METHODS

Rats were subjected to global oligemia by bilateral common carotid artery occlusion and then received either vehicle or erythropoietin via intravitreal injection after 48 h; they were euthanized one week after the injection. The densities of retinal ganglion cells and contents of glial fibrillary acidic protein (astrocytes/Müller cells) and cluster of differentiation 68 clone ED1 (microglia/macrophages), assessed by fluorescence intensity, were evaluated in frozen retinal sections by immunofluorescence and epifluorescence microscopy.

RESULTS

Retinal ganglion cells were nearly undetectable one week after oligemia compared with the sham controls; however, these cells were partially preserved in erythropoietin-treated retinas. The contents of glial fibrillary acidic protein and cluster of differentiation 68 clone ED1, markers for reactive gliosis, were significantly higher in retinas after bilateral common carotid artery occlusion than those in both sham and erythropoietin-treated retinas.

CONCLUSIONS

The number of partially preserved retinal ganglion cells in the erythropoietin-treated group suggests that erythropoietin exerts a neuroprotective effect on oligemic/ischemic retinas. This effect could be related to the down-modulation of glial reactivity, usually observed in hypoxic conditions, clinically observed during glaucoma or retinal artery occlusion conditions. Therefore, glial reactivity may enhance neurodegeneration in hypoxic conditions, like normal-tension glaucoma and retinal ischemia, and erythropoietin is thus a candidate to be clinically applied after the detection of decreased retinal blood flow.

Horner Syndrome in 2 Pigs (Sus scrofa) after Vascular Grafting of the Carotid Artery and Jugular Vein

The term Horner syndrome refers to the clinical presentation of oculosympathoparesis, comprising miosis, ptosis, and facial anhydrosis. To date, there are 2 reports of postoperative Horner syndrome in pigs. In this species the cervical sympathetic chain and cranial cervical sympathetic ganglion are consistently within the carotid artery sheath. This case study describes the sudden onset of Horner syndrome in 2 pigs, from a study cohort of 8, after the placement of a vascular graft between the carotid artery and external jugular vein. Anesthesia and surgery was uneventful in all the pigs in the study, but 2 pigs demonstrated clinical signs including ptosis, enophthalmos and prolapse of the nictitating membrane immediately after recovery from anesthesia. Horner syndrome was diagnosed in light of the clinical signs. These clinical signs persisted throughout the 2-mo study period and did not appear to improve or deteriorate in that time. Gross examination of the surgery site at the end of the study did not reveal an obvious lesion in the carotid artery sheath. The risk of Horner syndrome after surgery involving the carotid artery in pigs had not been reported prior to this study. Without specific measures to protect the cervical sympathetic ganglion during surgery, the incidence of postoperative Horner syndrome was 25% in our population of pigs. Although the welfare implications of this syndrome are minimal, concerted effort to avoid intraoperative damage to the cervical ganglion is essential for future work.

Spot Stenting of Supra-aortic Branch Vessels for Residual Type A Dissection

The purpose of this report was to describe the exclusion of the false lumen in a residual type A aortic dissection (TAAD) by the deployment of 2 covered stents: one in the right common carotid artery (RCCA) and one in the left subclavian artery (LSA). A 77-year-old female, already treated with ascending aorta replacement for acute TAAD, was referred to our center for a 97-mm post-dissection arch aneurysm. A computed tomography angiography (CTA) showed false lumen patency by reperfusion from secondary tears located at the level of RCCA and LSA. No primary aortic tear was noted. Under local anesthesia and by transfemoral percutaneous approach, the tears at the level of RCCA and LSA were covered by a 9-mm Viabahn stent graft (Gore, Flagstaff, AZ), and a 10-mm V-12 stent graft (Maquet, Rastatt, Germany), respectively. The false lumen was finally occluded by the deployment of a 6-mm vascular plug at the level of LSA re-entry tear, by left transbrachial puncture. The procedure was completed uneventfully. Twelve-month CTA showed exclusion of the false lumen, patency of all supra aortic trunks, and initial shrinkage of the aneurysm. Spot stenting of secondary re-entry tears, already described for visceral branches, seems to be safe and effective also for supra-aortic trunks in selected patients.

Postoperative Dysphagia in Debranching Thoracic Endovascular Aortic Repair with Retroesophageal Carotid-Carotid Bypass

A carotid-carotid bypass is commonly used in debranching thoracic endovascular aortic repair. When the bypass graft is placed in the retroesophageal position, the esophagus may be compressed by the graft from behind. Therefore, dysphagia may occur postoperatively as a serious complication. To avoid this issue, we recommend placing the bypass graft below the cricoid cartilage.

Pilot assessment of a human extracellular matrix-based vascular graft in a rabbit model

BACKGROUND

Herein we describe a small-diameter vascular graft constructed from rolled human amniotic membrane (hAM), with in vitro evaluation and subsequent in vivo assessment of its mechanical and initial biologic viability in the early postimplantation period. This approach for graft construction allows customization of graft dimensions, with wide-ranging potential clinical applicability as a nonautologous, allogeneic, cell-free graft material.

METHODS

Acellular hAMs were rolled into layered conduits (3.2-mm diameter) that were bound with fibrin and lyophilized. Constructs were seeded with human smooth muscle cells and cultured under controlled arterial hemodynamic conditions in vitro. Additionally, the acellular hAM conduits were surgically implanted as arterial interposition grafts into the carotid arteries of immunocompetent rabbits.

RESULTS

On in vitro analysis, smooth muscle cells were shown to adhere to, proliferate within, and remodel the scaffold during a 4-week culture period. At the end of the culture period, there was histologic and biomechanical evidence of graft wall layer coalescence. In vivo analysis demonstrated graft patency after 4 weeks (n = 3), with no hyperacute rejection or thrombotic occlusion. Explants displayed histologic evidence of active cellular remodeling, with endogenous cell repopulation of the graft wall concurrent with degradation of initial graft material. Cells were shown to align circumferentially to resemble a vascular medial layer.

CONCLUSIONS

The vascular grafts were shown to provide a supportive scaffold allowing cellular infiltration and remodeling by host cell populations in vivo. By use of this approach, "off-the-shelf" vascular grafts can be created with specified diameters and wall thicknesses to satisfy specific anatomic requirements in diverse populations of patients.

Intermediate analysis of magnesium alloy covered stent for a lateral aneurysm model in the rabbit common carotid artery

OBJECTIVE

To analyze the outcomes of a magnesium alloy covered stent (MACS) for a lateral aneurysm model in common carotid artery (CCA).

METHODS

In 32 rabbits, a MACS (group A, n = 17) or a Willis covered stent (WCS; group B, n = 15) was inserted and the rabbits were sacrificed 1, 3, 6, or 12 months after stenting. Angiography and intravascular ultrasound (IVUS) were performed at 3, 6, and 12 months. Scanning electron microscopy was performed for six stents in each group at 1, 3, and 6 months, and histopathology and histomorphology were conducted at 3 (n = 4), 6 (n = 4), and 12 (n = 12) months.

RESULTS

Final angiography showed complete occlusion of the aneurysms in 12 cases. IVUS at 6 and 12 months revealed a significant increase in mean lumen area of the stented CCA in group A and also showed greater mean lumen area in group A than in group B. The endothelialization process was quicker in group A than in group B.

CONCLUSION

MACS is effective for occlusion of lateral aneurysms and is superior to WCS in growth of the stented CCA and endothelialization. Further work is needed to make this device available for human use.

KEY POINTS

• The MACS is an effective approach for occlusion of a lateral aneurysm. • IVUS showed that the CCA could grow following degradation of the MACS. • The lumen area of the stented CCA was excellent in MACS. • HE staining displayed the degradation of the magnesium alloy stent. • Combination of IVUS and DSA were applied in this study.

Successful Hybrid Treatment of a Traumatic Rupture of the Left Primitive Carotid Artery in a Polytraumatized Patient: A Case Report

Traumatic injury of the left common carotid is a rare but severe disease, and is an uncommon situation in emergency units. Thoracic aortic lesions are often associated with other injuries, making their treatment challenging. We report the case of a successful hybrid approach to treat this lesion using a total supra aortic vessel debranching and a thoracic endovascular graft to cover the rupture, in a 38-year-old polytraumatized patient. After aortic, abdominal, and orthopedic surgery, the patient recovered well. The 1-year follow-up showed a good result of this hybrid treatment. This technique should be considered in polytraumatized patients with aortic arch lesions.

Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis

Background

Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for the treatment of post-carotid endarterectomy (CEA) stenosis. This study analyzed the efficacy of CAS for post-CEA restenosis, focusing on an analysis of technical and anatomical predictive factors for in-stent restenosis.

Methods

We performed a retrospective monocentric study. We included all patients who underwent CAS for post-CEA restenosis at our institution from July 1997 to November 2013. The primary endpoints were the technical success, the presence of in-stent restenosis >50% or occlusion, either symptomatic or asymptomatic, during the follow-up period, and risk factors for restenosis. The secondary endpoints were early and late morbidity and mortality (TIA, stroke, myocardial infarction, or death).

Results

A total of 153 CAS procedures were performed for post-CEA restenosis, primarily because of asymptomatic lesions (137/153). The technical success rate was 98%. The 30-day perioperative stroke and death rate was 2.6% (two TIAs and two minor strokes), and rates of 2.2% (3/137) and 6.2% (1/16) were recorded for asymptomatic and symptomatic patients, respectively. The average follow-up time was 36 months (range, 6–171 months). In-stent restenosis or occlusion was observed in 16 patients (10.6%). Symptomatic restenosis was observed in only one patient. We found that young age (P = 0.002), stenosis > 85% (P = 0.018), and a lack of stent coverage of the common carotid artery (P = 0.006) were independent predictors of in-stent restenosis.

Conclusion

We identified new risk factors for in-stent restenosis that were specific to this population, and we propose a technical approach that may reduce this risk.

Common carotid pseudoaneurysm after carotid endarterectomy: a case presentation

A patient with a previous history of neck cancer and carotid endarterectomy presents with a pulsatile cervical mass. Further evaluation reveals the presence of a pseudoaneurysm of the common carotid artery. The endovascular treatment options and techniques employed to exclude the pseudoaneurysm are presented and discussed.

Techniques for Preserving Vertebral Artery Perfusion During Thoracic Aortic Stent Grafting Requiring Aortic Arch Landing

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.