Carotid artery stenting according to the tailored-CAS algorithm is associated with a low complication rate at 30 days: data from the TARGET-CAS study

BACKGROUND

The rate of early complications of carotid artery stenting (CAS) should not exceed 3% in asymptomatic and 6% in symptomatic patients. However, some recent studies/registries failed to reach this threshold, fueling a debate on the role of CAS in the treatment of patients with carotid artery stenosis.

AIM

To evaluate 30-day safety of CAS using different embolic protection devices and different stent types according to the tailored-CAS algorithm and to identify risk factors for complications.

METHODS

Between 2002 and 2010, we performed 1176 CAS procedures in 1081 patients (age 38-86 years, mean 66.3 ± 8.4 years, 51.5% symptomatic) according to the tailored-CAS algorithm that included extracranial ultrasound and computed tomography angiography to select the most appropriate embolic protection device (EPD) and stent type. Proximal EPD and closed-cell (CC) stents were preferentially used for high-risk lesions (HR - soft/thrombus-containing/tight/ulcerated, 36.14% of all lesions) and in symptomatic patients.

RESULTS

Procedural success rate was 99.8%. In symptomatic patients, proportion of HR lesions was higher (41.1%) than in the asymptomatic group (30.8%, p = 0.001) and the usage of CC stents (76.2% vs 71.7%, p = 0.103) and proximal EPD (P-EPD, 34.8% vs 27.7% among asymptomatic patients, p = 0.010) was more frequent. CC stents were used in 82.4% of CAS procedures involving HR lesions (vs 69.1% for non-HR lesions, p < 0.01), and P-EPD were used in 83.1% of procedures involving HR lesions (vs 2.5% for non-HR lesions, p < 0.001). In-hospital complications included 6 (0.55%) deaths, 1 (0.08%) major stroke and 19 (1.61%) minor strokes. No myocardial infarctions (MI) were noted. Among 7 (0.59%) cases of hyperperfusion syndrome, 2 were fatal. Thirty-day complication rate (death/any stroke/MI) was 2.38%. Age > 75 years was a predictor of death (p = 0.015), and prior neurological symptoms were a predictor of death/stroke (p = 0.030). There were 4 cases of periprocedural embolic cerebral artery occlusion, all treated with combined intracranial mechanical and local thrombolytic therapy.

CONCLUSIONS

CAS with EPD and stent type selection on the basis of thorough non-invasive diagnostic work-up (tailored- -CAS) is safe. Advanced age was associated with an increased risk of death and the presence of prior neurological symptoms was a predictor of death/stroke at 30 days. With the tailored-CAS approach, high-risk lesion features (soft/thrombus- -containing/tight/ulcerated) are eliminated as a risk factor. Hyperperfusion syndrome is a severe CAS complication which may lead to intracranial bleeding and death. Acute, iatrogenic embolic cerebral artery occlusion is rare and may be managed by combined intracranial mechanical and local thrombolytic therapy.

Transoesophageal echocardiography can help distinguish between patients with "symptomatic" and "asymptomatic" patent foramen ovale

BACKGROUND

Incidence of patent foramen ovale (PFO) has been estimated at 25% in the general population and 6% for larger defects. Data on the relationship between PFO morphology and the risk of stroke are limited. PFO closure has become a common practice in many centres, although recent guidelines limit indications for such treatment to patients with cryptogenic (recurrent) stroke.

AIM

To investigate whether PFO morphology assessed by transoesophageal echocardiography (TOE) differed between patients with symptoms and those who had an asymptomatic PFO.

METHODS

We analysed 88 consecutive patients (48 female, 40 male; mean age 36.1 ± 16.2 [range 18-59] years) who underwent TOE before transcatheter PFO closure due to a cryptogenic cerebrovascular event (Group I) and compared them to 88 consecutive patients (49 female, 39 male; mean age 35.7 ± 14.2 [range 18-57] years) with an asymptomatic PFO found incidentally on TOE (Group II). The diagnosis of stroke was based on the occurrence of a new acute focal neurological deficit, with neurological signs and symptoms persisting for >24 h, subsequently confirmed by computed tomography and/or magnetic resonance imaging. Multiplane TOE was conducted as per guidelines using commercially available instruments. The interatrial septum was viewed in the transverse midoesophageal 4-chamber view and the longitudinal biatrial-bicaval view. PFO was diagnosed with intravenous injections of agitated saline while the patient was at rest and during the Valsalva manoeuvre. We analysed PFO size (resting and maximal separation of the septum primum and secundum during the Valsalva manoeuvre), tunnel length (maximal overlap of the septum primum and secundum), presence of an atrial septal aneurysm (excursion 〉 15 mm), shunt severity (mild: 3-5, moderate: 6-25, severe 〉 25 microbubbles) and prominence of the Eustachian valve.

RESULTS

The two groups did not differ with respect to age and sex distribution. Group I showed larger PFO size (maximal separation 3.9 ± 1.4 vs. 1.3 ± 1.3 mm, p 〈 0.0001), longer tunnel length (14 ± 6 vs. 12 ± 5.5 mm, p 〈 0.05) and a greater frequency of atrial septal aneurysm (55% vs. 15%, p 〈 0.0001) compared to Group II (controls). Group I was also characterised by a higher proportion of large PFOs (≤ 4 mm; 50% vs. 18%, p 〈 0.001) and severe shunt (40% vs. 2%, p 〈 0.0001).

CONCLUSIONS

PFO in symptomatic patients is larger in size, has a longer tunnel and is more frequently associated with atrial septal aneurysm. Asymptomatic patients with PFO characteristics similar to that seen in stroke patients require more careful clinical evaluation. It may be debated whether such patients should be recruited to prospective trials to evaluate indications for PFO closure in stroke prevention.

Treatment strategies in severe symptomatic carotid and coronary artery disease

Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD.

We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI).

The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE – death, stroke or MI) reaches 10–12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4–4.5%.

No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Evaluation of cerebral circulation in patients with significant carotid artery stenosis

BACKGROUND

A significant proportion of ischaemic stroke episodes are caused by atherosclerotic lesions in extracranial arteries. Assessment of haemodynamical profile of cerebral arteries in both symptomatic and asymptomatic patients with carotid artery stenosis is of clinical importance.

AIM

To assess haemodynamic changes in cerebral arteries in patients with significant internal carotid artery (ICA) stenosis.

METHOD

Patients (n=109) were divided into the following groups: group I (GI) - 42 subjects (64.6+/-9.0 years) with asymptomatic ICA stenosis > or =70%; and group II (GII) - 67 subjects (63.4+/-7.1 years) after stroke. The control group consisted of 30 patients (60.3+/-8.9 years) without significant stenoses of extracranial arteries on USG and angiography. In all cases ultrasonographic evaluation of flow velocities and directions in cerebral arteries within the circle of Willis and collateral flow was performed.

RESULTS

The severity of ICA stenosis did not differ significantly between GI and GII. Patients in GI had flow velocity in the middle cerebral artery (MCA) increased by 15.7% and by 40.8% in the anterior cerebral artery (ACA) contralateral to the ICA stenosis (p<0.001 and p<0.001), whereas in GII no significant changes in flow velocity in these arteries were observed in comparison with the control group. Patients in the groups I and II had lower flow velocities in MCA ipsilateral to the ICA stenosis, however values for GII patients were significantly lower than in GI patients (p<0.001). The presence of collateral circulation through the anterior and posterior communicating arteries (ACoA and PCoA) was similar in GI and GII; however, the flow velocities in the ipsilateral MCA and ACA were significantly higher in asymptomatic patients (GI). The frequency of active collateral circulation through both ACoA and PCoA increased along with the increase of ICA stenosis severity (p=0.003; p<0.001).

CONCLUSIONS

Collateral flow in the circle of Willis in subjects with ICA stenosis occurs equally often in symptomatic and asymptomatic patients; however, it is more efficient in patients without symptoms. The rate of development of collateral circulation depends on ICA stenosis severity. The important role in maintaining collaterals within the circle of Willis is played by ACoA, although in some patients MCA may also be supplied by PCoA.

[Carotid artery stenting with proximal or distal brain protection: early outcome]

BACKGROUND

Stroke is the third cause of death and a leading cause of disability. Significant atherosclerotic carotid artery stenosis is associated with as many as one in five strokes. Recent randomized trials have shown that percutaneous carotid artery stenting (CAS) is at least as effective and safe as surgery.

AIM

To evaluate the early outcome of CAS performed with brain protection systems in a large series of consecutive patients.

METHODS

From January 2001 to April 2004, 132 patients (age 63 +/- 8 years, 99 symptomatic and 90 with co-existing coronary artery disease, 36 women) with carotid artery stenosis were treated in our Institution. All patients underwent independent neurological assessment and non-invasive imaging (extra- and intracranial duplex Doppler and CT angiography, brain CT) before the procedure to tailor the brain protection system to the patient and lesion. Proximal (Parodi Anti-Emboli System, Mo.Ma) or distal (Percusurge/Guardwire, filters i.e. Angioguard, EPI FilterWire, Accunet, Spider, NeuroShield) neuroprotection was applied respectively in 42 (31%) and 93 (69%) cases. Clinical evaluation was performed on discharge and at 30 days.

RESULTS

Procedural success rate was 130/132 (98.6%). The degree of stenosis (expressed as % diameter reduction, QCA) decreased from 76.3 +/- 10.6 to 16.9 +/- 9.1 (p < 0.001) while the minimal lumen diameter increased from 1.48 +/- 0.67 to 3.72 +/- 0.71 mm (p < 0.001). In the peri-procedural period, 5 (3.7%) patients had TIA and 1 (0.7%) had hyperperfusion syndrome with a small haemorrhagic stroke, but with a complete clinical recovery. There were no deaths, myocardial infarctions nor any major strokes. On discharge no patients had neurological deterioration as compared to the admission status. At 30 days there were no new cardiac or neurological events.

CONCLUSIONS

Our results show that percu-taneous CAS--when performed with brain protection--has a high success rate and a very low complication rate. It is conceivable that the patient/lesion-tailored application of a particular neuroprotection system importantly contributes to the favourable early outcome of CAS.

Use of the Parodi Anti-Emboli System and Transient Subclavian Steal for Cerebral Protection During Emergent Vertebral Artery Recanalization

PURPOSE

To report the use of the Parodi Anti-Emboli System (PAES) for cerebral protection during emergent vertebral artery recanalization.

CASE REPORT

A 56-year-old chimney sweep was referred with recurrent episodes of vertigo and gait ataxia. Left vertebral artery (LVA) flow was barely detectable on duplex Doppler, and brain computed tomography revealed a small infarct in the posterior inferior cerebellar artery territory. Angiography showed subtotal ostial stenosis of the LVA with poor distal flow and possible thrombus. Due to a high risk of distal embolization with percutaneous treatment, anticoagulation was initiated, and the lesion was to be re-evaluated in 2 to 3 weeks. However, 2 days later, the patient developed severe, aggravating headache, gait and left-limb ataxia, horizontal nystagmus, and vomiting. Emergent angiography showed a total ostial LVA occlusion. The PAES was employed to elicit a temporary subclavian steal during percutaneous LVA recanalization, thus protecting the brain from embolization. The ostial LVA was successfully recanalized and stented, with immediate symptom cessation.

CONCLUSIONS

The PAES can be successfully applied in the subclavian artery to prevent distal embolization during emergent vertebral artery recanalization. Since a significant proportion of vertebral strokes are embolic, PAES may play a novel role in the treatment of acute cerebellar stroke.

[Cognitive impairment and cardiovascular disease risk factors. Project CASCADE Kraków. V. Disorders of higher cerebral functions in elderly people (65-78 years old)]

Higher cortical dysfunctions, like dysphasia, dysgnosia and dyspraxia, relatively frequent in the elderly, are related to progressive neurodegenerative or vascular disorders with dementia. The aim of the study was to assess the prevalence and the intensity of higher cerebral dysfunctions in the population over 65 years and to investigate the association between these disorders and the presence of other neurological abnormalities, i.e. extrapyramidal signs, primitive reflexes as well as cognitive impairment assessed by Mini-Mental State Examination (MMSE). There were 92 women and 90 men, aged from 65-78 years included in the study. All patients were interviewed for the presence of vascular risk factors. The battery of 21 detailed test of higher cerebral functions testing speech, calculation, reading, writing, praxia and gnosia were performed in each person. Extra-pyramidal signs and primitive reflexes were also examined. Among the disorders of higher cortical functions, slight dyspraxia was the most frequent (33.7%). Finger dysgnosia, dyscalculia and dysgraphia were found less frequently. 25.4% of studied group abnormally performed at least two tests assessing higher cortical functions and when compared with normal persons, they presented significantly more frequent the extrapyramidal signs (63.9% vs. 46.9%, respectively) and had significantly frequent impaired cognitive functions (p < 0.05). Patients with higher cortical dysfunction, when compared with other persons, had more frequent primitive reflexes (p < 0.05). The results of the study showed that slight disorders of higher cortical functions were found in about 25% of studied population; they were more frequent in people with cognitive impairment, primitive reflexes and extrapyramidal signs.

[Cognitive impairment and cardiovascular disease risk factors. Project CASCADE Kraków. VI. Magnetic resonance imaging of the aging brain in elderly persons (65-78 years old)]

Magnetic resonance imaging (MRI) is the most sensitive non-invasive method for the detection of brain lesions. The aim of the study was to examine the prevalence of brain abnormalities (white matter lesions, atrophy, and infarction) on MRI in an elderly population. Sample of 174 men and women, aged from 65 to 78 years, was examined. MRI scans were made using a mobile MRI 1.0 Tesla machine (Siemens). Imaging was performed with standard spin-echo sequences (slice thickness 5-6 mm thick and 20% gap): proton density, T1 and T2 images. All MRI scans were read using standardized methodology of assessment of deep white matter lesions, periventricular lesions, cortical atrophy and infarction. Medium subcortical white matter lesions (4-10 mm) were present in 55% participants. Large subcortical white matter lesions (> or = 10 mm) were observed in 27% people, 24% had periventricular white matter lesions (score > or = 3), 83% had cortical atrophy (score > or = 4) and 18% had at least 1 infarct. Frequency of cortical atrophy increased gradually by age group (p < 0.01). The cortical atrophy, deep and periventricular white matter lesions were more frequent only in the oldest group (75-78 years).

[Fabry's disease--late diagnosis in men with chronic nephropathy and skin changes]

We report a case of Fabry's disease, diagnosed in a 39-year-old patient treated for 4 years because of glomerulonephritis. The disease manifested itself by the presence of typical petechiae-like skin lesions in the bathing trunk area (angiokeratoma), eye changes, paresthesia, and--in additional investigations--mild proteinuria, lowered creatinine clearance, along with changes in the central nervous system. A biopsy of the kidney revealed the presence of foamy cells in all glomeruli, and in electron microscopy multilamellar bodies (zebra bodies). The diagnose of the disease was confirmed by a marked decrease in leucocyte alpha-galactosidase activity. An early diagnosis of non-inflammatory character of Fabry's disease allows to avoid an unnecessary immunosuppressive treatment.

[Sneddon syndrome--case report]

We report a case of Sneddon syndrome in a 39-year-old woman who developed recurrent cerebral ischaemic events associated with livedo racemosa. We describe clinical and radiological features of this rare vasculopathy and laboratory findings essential for differential diagnosis.