Hybrid surgery for symptomatic chronic near-total or total occlusion of the internal carotid artery.
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ABSTRACT:
SUBMITTER: Wang CM
PROVIDER: S-EPMC8116031 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background:Internal carotid artery occlusion (ICAO) is a relatively uncommon but important cause of transient ischemic attack and cerebral infarction. The majority of cases of symptomatic ICAO requires surgical treatment. In this study we performed an investigation of the efficacy and safety of hybrid surgery which is a surgical method for symptomatic chronic complete ICAO. Methods:Fifty-five patients with symptomatic chronic ICAO treated by hybrid surgery from 2016 to 2019 were included. We recorded and analyzed the patients' clinical characteristics, angiographic data, recanalization rate, complications, and outcomes. Catheter angiography or computed tomography angiography was used to assess the patency of the recanalized ICA during follow-up. Results:The total success rate of recanalization was 78.2% (43/55). The occlusions were significantly shorter in the success than failure group (5.40 ± 1.50 vs. 7.56 ± 0.99 cm, respectively; P < 0.001). The median duration of ICA occlusion was significantly shorter in the success than failure group (90 vs. 200 days, respectively). The success rates of distal ICA recanalization at the petrous segment or below, cavernous segment, and clinoid segment or above were 100, 33.3, and 14.3%, respectively (P < 0.001). Multivariate analysis showed that the level of distal ICA reconstitution was the only factor affecting the recanalization success rate. Periprocedural complications included hyperperfusion syndrome (n = 1) and laryngeal nerve injury (n = 1). ICA reocclusion occurred in one patient (2.3%). Significant postoperative improvement in symptoms was observed in the success group, with a median modified Rankin scale score of 0 at the 3-month follow-up compared with before recanalization (median, 1) (P<0.001). Conclusion:Hybrid surgery might be safe and effective for patients with symptomatic chronic complete ICAO. The level of distal ICA reconstitution is a predictor of successful recanalization in hybrid operations.
| S-EPMC7199050 | biostudies-literature
Project description:Near occlusion of internal carotid artery (ICA) is a rare and easily misdiagnosed condition and the decision for revascularisation still remains controversial. We conducted an updated meta-analysis in order to investigate outcomes after carotid endarterectomy (CEA), carotid artery stenting (CAS) or best medical treatment (BMT) in patients with near-occlusion of the ICA. We also aimed to investigate the role of time as a potential moderator of the near-ICA occlusion-stroke rate association. A multiple electronic health database search on articles published up to November 2019 was performed. The pooled stroke rate after CEA, CAS and BMT were calculated. We also investigated transient ischemic attack (TIA), stroke-related death, myocardial infarction (MI), any cause of death and ICA restenosis crude rates (%). A total of 33 articles were finally deemed eligible. The pooled stroke rate was 1.52% [95% confidence interval (CI): 0.09-4.02%] after CEA, 1.80% (95% CI: 0.61-3.40%) after CAS and 8.39% (95% CI: 3.39-14.80%) after BMT. Out of 896 CEA patients, we recorded 22 TIAs (2.5%), 33 all-cause deaths (3.7%), 5 stroke-related deaths (0.6%) and 6 MIs (0.7%). Concerning outcomes after 603 CAS patients, we recorded 7 TIAs (1.2%), 56 all-cause deaths (9.3%), 4 stroke-related deaths (0.7%) and 22 MIs (3.6%). Among 263 patients who were treated with BMT, we found 16 TIAs (6.1%), 10 all-cause deaths (3.8%), no stroke-related death, and no MI. Crude restenosis rate during follow-up was 9.0% (54/601) for CEA and 4.1% (24/592) for CAS patients. No significant effect of publication year upon stroke rate after CEA was recorded. However, there was a significant reversed association between pooled stroke rate after CAS and publication year (P=0.05). A statistically significant reversed association between pooled stroke rate after BMT and publication year was also recorded (P<0.01). The results of this updated meta-analysis revealed high stroke rate for patients with near-occlusion of ICA who treated only with BMT, while intervention seemed to be safe and effective. A downward trend in the stroke rates over time after CAS and BMT was also discovered. These highlight that patients with near-occlusion of ICA should be included and investigated in future studies.
| S-EPMC7607099 | biostudies-literature
Project description:BackgroundGuidelines recommend treating patients with an internal carotid artery near occlusion (ICANO) with best medical therapy (BMT) based on weak evidence. Consequently, patients with ICANO were excluded from randomized trials. The aim of this individual-patient data (IPD) meta-analysis was to determine the optimal treatment approach.MethodsA systematic search was performed in MEDLINE, EMBASE and the Cochrane Library databases in January 2018. The primary outcome was the occurrence of any stroke or death within the first 30 days of treatment, analysed by multivariable mixed-effect logistic regression. The secondary outcome was the occurrence of any stroke or death beyond 30 days up to 1 year after treatment, evaluated by Kaplan-Meier survival analysis.ResultsThe search yielded 1526 articles, of which 61 were retrieved for full-text review. Some 32 studies met the inclusion criteria and pooled IPD were available from 11 studies, including some 703 patients with ICANO. Within 30 days, any stroke or death was reported in six patients (1·8 per cent) in the carotid endarterectomy (CEA) group, five (2·2 per cent) in the carotid artery stenting (CAS) group and seven (4·9 per cent) in the BMT group. This resulted in a higher 30-day stroke or death rate after BMT than after CEA (odds ratio 5·63, 95 per cent c.i. 1·30 to 24·45; P = 0·021). No differences were found between CEA and CAS. The 1-year any stroke- or death-free survival rate was 96·1 per cent for CEA, 94·4 per cent for CAS and 81·2 per cent for BMT.ConclusionThese data suggest that BMT alone is not superior to CEA or CAS with respect to 30-day or 1-year stroke or death prevention in patients with ICANO. These patients do not appear to constitute a high-risk group for surgery, and consideration should made to including them in future RCTs of internal carotid artery interventions.
| S-EPMC6593672 | biostudies-literature
Project description:ObjectivesThe optimal treatment choice of chronic carotid artery occlusion (CAO) remains inconclusive. This study was aimed at exploring the safety and effectiveness of hybrid surgery in the treatment of CAO and at determining predictors for successful recanalization.MethodsIn this study, we enrolled 37 patients with CAO who underwent hybrid surgical treatment during the period 2016-2018. We extracted and analyzed patients' demographic data, disease characteristics, surgical success rates, perioperative complications, and prognosis.ResultsA total of 37 patients with symptomatic CAO underwent hybrid surgical treatment. Thirty cases (81.1%) were successfully recanalized, while seven were not. Blood reflux after carotid endarterectomy occurred in 18 patients (60%) of the success group and 1 (14.3%) of the failure group (OR, 9.0; 95% CI, 0.95-54.5; P = 0.042). The rate of distal ICA reconstruction below the clinoid segment was 20 (66.7%) in the success group and 1 (14.3%) in the failure group (OR, 12.0; 95% CI, 1.3-113.7; P = 0.029). In patients with successful recanalization, no ischemic events occurred after surgery and during follow-up, but restenosis of >50% was found in one case. In the failure group, two patients experienced recurrent ischemic events during follow-up. Perfusion imaging in successful recanalization cases is significantly improved, preoperative I/C ratio was 1.44 (IQR 1.27-1.55), and postoperative 1.12 (IQR 1.05-1.23). National Institutes of Health Stroke Scale (NIHSS) score of successful recanalization cases was 5.35 (2.26) before surgery and 2.03 (1.40) at 6 months (P < 0.01).ConclusionHybrid surgery might be a safe and effective way to treat CAO. Distal internal carotid artery reconstruction to below the clinoid segment and blood reflux after carotid endarterectomy are predictors of successful recanalization.
| S-EPMC7723474 | biostudies-literature
Project description:Background: Revascularization surgery sometimes can achieve recanalization in patients with internal carotid artery occlusion (ICAO). High-resolution vessel wall magnetic resonance imaging (HRVWI) is a feasible technique to give detailed characteristics of the vessel wall, which may help to identify patients that carry higher success rates and more suitable for revascularization surgery. Objective: To examine the association between HRVWI characteristics of ICAO and the success rate of revascularization surgery in ICAO patients. Methods: We conducted a retrospective analysis of 31 ICAO recanalization patients enrolled from October 2017 to May 2019. The clinical data of patients and lesions were collected and analyzed. Results: A total of 31 ICAO patients were enrolled in this study. No significant differences were found between recanalization success and recanalization failure groups with regard to occlusion length, distal end of the occluded segment, and the treatment applied. The ipsilateral-to-contralateral diameter ratios (I/C ratios) of C1 or C2 and the diameter of C7 were positively related to recanalization success. A two-factor predictive model was constructed, and the I/C ratio of C2 < 0.86 and the diameter of C7 < 1.75mm were separately assigned 1 point. The ICAO patients who scored 0, 1, or 2 points had a risk of 5.6% (1/18), 55.6% (5/9), or 100% (4/4) to fail in the recanalization. Conclusions: The I/C ratios of C1 or C2 and the diameter of C7 are predictive factors of a revascularization surgery success in ICAO patients. A risk stratification model involving C2 and C7 was constructed for future clinical applications.
| S-EPMC8451719 | biostudies-literature
Project description:Symptomatic carotid artery disease is a significant cause of ischemic stroke, and these patients are at high risk for recurrent vascular events. Patients with symptoms of stroke or transient ischemic attack attributable to a significantly stenotic vessel (70-99% luminal narrowing) should be treated with intensive medical therapy. Intensive medical therapy is a combination of pharmacologic and lifestyle interventions consistent with best-known practices as follows: initiation of antiplatelet agent or anticoagulation if medically indicated, high potency statin medication, blood pressure control with goal blood pressure of greater than 140/90, Mediterranean-style diet, exercise, and smoking cessation. Further, patients who have extracranial culprit lesions should be considered for revascularization with either carotid endarterectomy or carotid angioplasty and stenting depending on several factors including the patient's anatomy, age, gender, and procedural risk. Based on current evidence, patients with symptomatic intracranial stenosis should be managed with intensive medical therapy, including the use of dual antiplatelet therapy with aspirin and clopidogrel for the first 90 days following the ischemic event. While the literature has shown a stronger benefit of revascularization of extracranial symptomatic disease among certain subgroups of patients with greater than 70% stenosis, there is less benefit from revascularization with endarterectomy in patients with moderate stenosis of 50-69% if the surgeon's risk of perioperative stroke or death rate is greater than 6%.
| S-EPMC5496976 | biostudies-other
Project description:BackgroundAcute tandem cervical dissecting internal carotid artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating, and the optimal treatment strategy for this condition has not been established yet.Case descriptionA 45-year-old male presented with aphasia and right hemiparesis preceded by neck pain. Computed tomography showed a high-density signal along the left MCA, suggesting extensive emboli. Magnetic resonance angiography demonstrated tandem occlusion of the left cervical ICA and intracranial MCA with minimal diffusion-weighted imaging lesion. Emergent surgical embolectomy was performed, and long intracranial MCA emboli were retrieved with collateral cross-flow restoration. The cervical ICA was exposed, and dissection was confirmed. The cervical ICA was ligated, and superficial temporal artery (STA)-MCA anastomosis was added. Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia. At the 6(th) postoperative month, follow-up studies demonstrated a robustly patent STA-MCA bypass and no additional ischemic lesion on T2-weighted imaging.ConclusionsSurgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.
| S-EPMC4697205 | biostudies-literature
Project description:Background:The development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting. Methods:Five patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque. The stents were telescopically placed via true channel of the dissection. Safety of the procedure was evaluated with 30-day stroke and death rate. Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography. Results:All CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA. After stenting, successful dissection reconstruction with TICI 3 was achieved in all patients, with complete (n = 4) or partial CCF (n = 1) obliteration. No patient had CCF syndrome, stroke, or death during follow-up of 6 to 37?months; but one patient had pulsatile tinnitus, which resolved 1 year later. Angiography at 6 to 24?months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients. Conclusions:Intraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction. Self-expanding stenting through true channel of the dissection, serving as implanting stent-autograft, may be an optimal therapy for the atypical CCF complication from ICAO surgery.
| S-EPMC7398240 | biostudies-literature
Project description:Rigorous screening and good imaging would help perform surgery on carotid artery occlusion CAO safely and effectively. The purpose of this study was to retrospectively evaluate carotid endarterectomy (CEA) recanalization in patients with common carotid artery occlusion (CCAO) or internal carotid artery occlusion (ICAO) with color Doppler flow imaging (CDFI). A total of 59 patients undergoing CEA were enrolled. According to the results of CEA, the patients were divided into successful recanalization (group A) and unsuccessful recanalization (group B) groups. The original diameter, lesion length, proximal-to-distal diameter ratio and echo characteristics of the lesion within the lumen of the carotid artery were recorded before CEA and compared between the two groups. In regards to the achievement of repatency by CEA, the overall success rate was 74.6% (44/59), the success rate in CCAO patients was 75.9% (22/29) and the success rate in ICAO patients was 73.3% (22/30). There was no significant difference in the success rates between the CCAO and ICAO patients (χ2 = 0.050, P = 0.824). The overall rate of stroke and death within 30 postoperative days was 5.1% (3/59). For the CCAO patients, the lesion length in group A was shorter than that in group B (t = 3.221, P = 0.004). For the ICAO patients, the original diameter of the distal ICA was broader (t = 6.254, P = 0.000) and the proximal-to-distal ICA diameter ratio was smaller (t = 8.036, P = 0.000) in group A than in group B. The rate of recanalization for lumens with a homogeneous echo pattern (hypoecho or isoecho) was significantly higher than that for lumens with echo heterogeneity for both the CCAO and ICAO patients (χ2 = 14.477, P = 0.001; χ2 = 10.519, P = 0.003). However, for both the CCAO and ICAO patients, there was no difference in the rate of recanalization between patients with hypoecho and isoecho lesions (χ2 = 0.109, P = 0.742; χ2 = 0.836, P = 0.429). The original diameter, proximal-to-distal ICA diameter ratio, lesion length and echo characteristics may affect the success of CEA recanalization in patients with CCAO and ICAO. CDFI is helpful in screening patients with carotid artery occlusion and may improve the success rate of CEA.
| S-EPMC4670099 | biostudies-literature
Project description:OBJECTIVE:Retinal artery occlusion (RAO) is rarely seen as a complication in patients undergoing carotid artery stenting (CAS); hence, its characteristics have not been documented in detail. This study aimed to investigate the incidence of this complication and the related risk factors, focusing on differences in ophthalmic artery (OA) supply (whether by the external or internal carotid artery [ECA or ICA]) prior to CAS procedures. MATERIALS AND METHODS:We retrospectively examined 342 patients who underwent CAS for severe and/or symptomatic carotid artery stenosis between January 2009 and December 2017. Cumulative medical records and radiologic data were assessed. RAO was confirmed by photography and fluorescent angiography of the fundus, which were performed by an ophthalmologist. In all patients, distal filter systems of various types were applied as cerebral protection devices (CPDs) during procedures. Univariate and multivariate analyses were conducted to identify the risk factors for RAO after CAS. RESULTS:Symptomatic RAO was observed in six patients (1.8%), of which five (6.8%) were ECA-dominant group members (n = 74). In a binary logistic regression analysis, OA supply by the ECA (odds ratio [OR], 9.705; 95% confidence interval [CI], 1.519-62.017; p = 0.016) and older age (OR, 1.159; 95% CI, 1.005-1.336; p = 0.041) were identified as significant risk factors in patients with RAO after CAS. ECA-supplied OA was also associated with the severity of ipsilateral ICA stenosis (p = 0.001) and ulcerative plaque (p = 0.021). CONCLUSION:In procedures performed using ICA distal filtering CPD systems, RAO as a complication of CAS (performed for severe stenosis) showed a relationship to ECA-supplied OA. For older patients, simultaneous use of ICA-ECA CPDs might help prevent such complications.
| S-EPMC6791816 | biostudies-other