RESUMO
It is important to examine the ocular hemodynamic changes after carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with internal carotid artery stenosis (ICAS). We aimed to compare the differences in retinal and optic nerve head blood flow after 2 surgical methods. The ipsilateral eyes of 34 patients who had over 50% ICAS with no ocular findings and 30 healthy controls were included in the study. Foveal avascular zone vessel density in the superficial retinal capillary plexus, deep retinal capillary plexus (DCP), and radial peripapillary capillary plexus (RPCP) were measured with an optical coherence tomography angiography device. These measurements were repeated 1 month after CAS or CEA in patients with ICAS. The preoperative and postoperative values of the patients were compared both within themselves and with the control group. When patients with ICAS were compared with the control group, lower vessel density values were found in the DCP parafovea, RPCP whole image, and peripapillary regions both before and after the procedure. There was no significant difference in terms of other parameters. Furthermore, there was no significant difference in any parameter examined between the pre- and postprocedural values of the patients who underwent CAS and CEA. DCP and RPCP are mostly affected in patients with ICAS. We observed that after application of the CAS and CEA methods, the effects on ocular blood flow were similar.
Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas , Stents , Tomografia de Coerência Óptica , Humanos , Estenose das Carótidas/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Endarterectomia das Carótidas/métodos , Tomografia de Coerência Óptica/métodos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Vasos Retinianos/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Disco Óptico/irrigação sanguínea , Disco Óptico/diagnóstico por imagemRESUMO
"Low-lying" posterior communicating artery (PCoA) aneurysms require great attention in surgical clipping due to their distinct anatomical characteristics. In this study, we propose an easy method to immediately recognize "low-lying" PCoA aneurysms in neurosurgical practice. A total of 89 cases with "low-lying" PCoA aneurysms were retrospectively analyzed. All patients underwent preoperative digital subtraction angiography (DSA) examinations and microsurgical clipping. Cases were classified into the "low-lying" and regular groups based on intraoperative findings. The distance- and angle-relevant parameters that reflected the relative location of the aneurysms and tortuosity of the internal carotid artery were measured using 3D-DSA images. The data were sequentially integrated into a mathematical analysis to obtain the prediction model. Finally, we proposed a novel mathematical formula to preoperatively predict the existence of "low-lying" PCoA aneurysms with great accuracy. Neurosurgeons might benefit from this model, which enables them to directly identify "low-lying" PCoA aneurysms and make appropriate surgical decisions accordingly.
Assuntos
Angiografia Digital , Aneurisma Intracraniano , Procedimentos Neurocirúrgicos , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Angiografia Digital/métodos , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Idoso , Angiografia Cerebral/métodos , Modelos Teóricos , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagemAssuntos
Artéria Carótida Interna , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Microcirurgia/métodos , Doenças das Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/diagnóstico por imagem , Ligadura/métodos , Instrumentos Cirúrgicos , Procedimentos Neurocirúrgicos/métodos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: Carotid artery stenting (CAS) under flow reversal with dual protection using a proximal balloon and distal filter has been an established procedure for internal carotid artery (ICA) stenosis. This study investigates the effect of external carotid artery (ECA) occlusion on outcomes of CAS and ICA flow under flow reversal. METHODS: We reviewed 231 cases of CAS under flow reversal with ECA occlusion and 32 without. In the last 14 of 32 cases, the flow in the ICA under flow reversal was analyzed by ultrasound. The collateral index, which was defined as the total value of the maximum diameters of the ipsilateral anterior cerebral artery at the A1 segment and the anterior communicating artery, as well as those of the ipsilateral posterior cerebral artery at the P1 segment and the ipsilateral posterior communicating artery, and the maximum diameter of the ipsilateral ECA were correlated with the flow direction in the ICA. RESULTS: There was no significant difference in the outcome of CAS between the groups with or without ECA occlusion. Among the 14 cases without ECA occlusion, antegrade flow in the ICA was observed in 6 cases (42.9â¯%). The group with the antegrade flow in the ICA exhibited a significantly lower collateral index (5.08±0.33 vs 6.71±0.28, p=0.01) and a significantly larger ECA diameter (4.66±0.51â¯mm vs 3.21±1.24â¯mm, p=0.01) than the group with the stagnant or retrograde flow in the ICA. CONCLUSIONS: The outcomes of CAS under flow reversal were acceptable even without ECA occlusion. The ECA occlusion may not be necessary for CAS under dual protection; however, distal filter protection should be used even under flow reversal.
Assuntos
Artéria Carótida Interna , Estenose das Carótidas , Stents , Humanos , Idoso , Masculino , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Feminino , Estenose das Carótidas/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Pessoa de Meia-Idade , Resultado do Tratamento , Idoso de 80 Anos ou mais , Artéria Carótida Externa/diagnóstico por imagem , Circulação Cerebrovascular/fisiologia , Estudos RetrospectivosRESUMO
BACKGROUND: At times, a regulation internal carotid artery-posterior communicating artery junction (ICA-P-Comm) aneurysm becomes a surgical hurdle owing to its close proximity to the anterior clinoid process, an immovable ICA and a concealed dominant P-Comm artery arising from the aneurysm neck. METHOD: A 70 year old patient with a low lying ICA-P-Comm aneurysm underwent a "tailored" intradural clinoidectomy for aneurysm clipping. CONCLUSION: A tailored anterior clinoidectomy to expose "just enough" allows a proximal ICA control in a suitable area, mobility of an atherosclerotic ICA and exposes the P-Comm artery origin which are essential in safe clipping of these aneurysms.
Assuntos
Artéria Carótida Interna , Aneurisma Intracraniano , Idoso , Humanos , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Procedimentos Neurocirúrgicos/métodos , Osso Esfenoide/cirurgia , Osso Esfenoide/diagnóstico por imagem , Resultado do TratamentoRESUMO
BACKGROUND: Moyamoya disease, a progressive occlusive arteriopathy mainly affecting the supraclinoid internal carotid artery, leads to abnormal "Moyamoya vessels" and ischemic events in children due to decreased cerebral blood flow. Surgery, especially indirect revascularization, is suggested for pediatric Moyamoya cases. METHOD: We present the Encephalo-Duro-Mio-Synangiosis (EDMS) technique, illustrated with figures and videos, based on 14 years' experience performing 71 surgeries by the senior author (SGJ) and the Moyamoya Interdisciplinary Workteam at "Prof. Dr. J. P. Garrahan" Pediatric Hospital. CONCLUSION: EDMS is a simple and effective treatment for Moyamoya disease, enhancing procedure precision and safety, reducing associated risks, complications, and improving clinical outcomes.
Assuntos
Revascularização Cerebral , Doença de Moyamoya , Humanos , Doença de Moyamoya/cirurgia , Doença de Moyamoya/diagnóstico por imagem , Revascularização Cerebral/métodos , Criança , Resultado do Tratamento , Angiografia Cerebral/métodos , Masculino , Feminino , Adolescente , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagemRESUMO
To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6-48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion.
Assuntos
Artéria Carótida Interna , Estenose das Carótidas , Endarterectomia das Carótidas , Placa Aterosclerótica , Humanos , Masculino , Feminino , Idoso , Placa Aterosclerótica/cirurgia , Placa Aterosclerótica/patologia , Placa Aterosclerótica/complicações , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/patologia , Pessoa de Meia-Idade , Estenose das Carótidas/cirurgia , Estenose das Carótidas/patologia , Estenose das Carótidas/complicações , Endarterectomia das Carótidas/métodos , Resultado do Tratamento , Procedimentos Endovasculares/métodos , Idoso de 80 Anos ou mais , Fatores de RiscoRESUMO
BACKGROUND: Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS: Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS: Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS: Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.
Assuntos
Artéria Cerebral Anterior , Aneurisma Intracraniano , Tromboembolia , Humanos , Aneurisma Intracraniano/cirurgia , Artéria Cerebral Anterior/cirurgia , Artéria Cerebral Anterior/diagnóstico por imagem , Tromboembolia/prevenção & controle , Tromboembolia/epidemiologia , Tromboembolia/etiologia , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Masculino , Procedimentos Endovasculares/métodos , Idoso , Artéria Carótida Interna/cirurgia , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/epidemiologiaRESUMO
BACKGROUND: Incidental diagnosis of saccular aneurysms is more common with the advent of imaging techniques. Because of the severe morbidity and mortality that they can cause, treatment is chased for them, either microsurgical treatment or endovascular, even when they are diagnosed incidentally. Carotid cave aneurysms are rare, and they seem to have a more benign course compared to other intracranial aneurysms, probably related to the physical enveloping effect of the surrounding structures. Yet, their microsurgical treatment is a serious challenge technically for the neurosurgeon, with its severe morbidity and mortality for the patient. Endovascular techniques have their risks, too. PURPOSE: In this paper, we analyzed and presented our series of incidentally diagnosed carotid cave aneurysms. MATERIALS AND METHODS: The age, gender of patients, the size, laterality, and MR angiographic follow-up of aneurysms were reported. Their clinical results were noted. RESULTS: Fifty-six patients who had incidentally been diagnosed with 59 carotid cave aneurysms were followed up. No patient was microsurgically treated, but 15 patients had endovascular treatment for 15 aneurysms. The mean size of 15 treated aneurysms was 4.6 ± 2.1 (range = 2-10) mm, and it was 3.0 ± 1.5 (range = 1.7-10) mm for the untreated aneurysms (n = 44). There was no significant difference between the follow-up times of the treated and untreated groups (P = 0.487). The median follow-up of 59 aneurysms in 56 patients was 52 (mean = 49.6 ± 27.9, range = 1-124) months, with a total follow-up of 244 aneurysm years. None of the patients had subarachnoid hemorrhage related to carotid cave aneurysms during follow-up, and none of the aneurysms had shown growth. Two patients who had endovascular treatment had ischemic complications with minor neurologic deficits. CONCLUSION: Follow-up can be a reasonable option for the incidental aneurysms that are located and confined to the carotid cave. Additionally, TOF might be a reliable method for follow-up imaging of carotid cave aneurysms.
Assuntos
Procedimentos Endovasculares , Achados Incidentais , Aneurisma Intracraniano , Humanos , Masculino , Feminino , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Idoso , Adulto , Doenças das Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/patologiaRESUMO
BACKGROUND: Carotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. METHODS: This study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. RESULTS: A total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20-2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10-2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. CONCLUSIONS: Distal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.
Assuntos
Infarto Encefálico , Estenose das Carótidas , Stents , Humanos , Masculino , Feminino , Idoso , Stents/efeitos adversos , Estudos Retrospectivos , Estenose das Carótidas/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Pessoa de Meia-Idade , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/patologia , Imagem de Difusão por Ressonância Magnética/métodosRESUMO
OBJECTIVE: Unruptured posterior communicating artery (Pcom) aneurysms cause oculomotor nerve palsy (ONP). However, the time course of recovery after aneurysm repair remains unclear. We aimed to evaluate the ONP course after clipping and coiling for unruptured Pcom aneurysms. METHODS: We retrospectively reviewed the medical records of 25 consecutive patients with ONP due to unruptured Pcom aneurysms, undergoing aneurysm repair at our institution during 2010-2022. We analyzed the clinical data, angiographic results, and surgical complications. The time to ONP recovery was evaluated using the Kaplan-Meier method. RESULTS: This study included 14 patients undergoing surgical clipping and 11 undergoing endovascular coiling. The two groups exhibited no significant differences in complete or partial ONP percentage or in symptom presentation (ptosis, diplopia, ocular paralysis, pupillary light reflex disorder, or mydriasis). All patients achieved complete or partial recovery during the follow-up period. The median time to partial or complete improvement in ONP was significantly shorter for clipping compared to coiling (2 days vs. 33 days; P = 0.009). Preoperative partial and complete ONP were stratified; clipping improved significantly earlier than coiling in the complete ONP group (P = 0.010). In the early treatment group (based on the median duration of treatment), clipping resulted in earlier improvement than coiling (P = 0.014). In the small aneurysm group (based on the median of the aneurysm maximum diameter), clipping resulted in earlier improvement than coiling (P = 0.005). CONCLUSION: In ONP caused by an unruptured Pcom aneurysm, clipping may provide faster recovery than coiling, particularly in cases of early onset, complete palsy, and small aneurysms.
Assuntos
Procedimentos Endovasculares , Aneurisma Intracraniano , Doenças do Nervo Oculomotor , Recuperação de Função Fisiológica , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/complicações , Feminino , Masculino , Doenças do Nervo Oculomotor/etiologia , Doenças do Nervo Oculomotor/cirurgia , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Estudos Retrospectivos , Idoso , Adulto , Resultado do Tratamento , Artéria Carótida Interna/cirurgia , Procedimentos Neurocirúrgicos/métodos , Doenças das Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/complicações , Complicações Pós-Operatórias/etiologiaRESUMO
The intracranial segment of the internal carotid artery located inside the skeleton structure of skull base or inside the skull has clear anatomical landmarks and fixed anatomical structure. However, the parapharyngeal segment of the internal carotid artery located outside the cranial is surrounded by soft tissues, lacks clear and recognizable anatomical landmarks and sometimes has anatomical variation, which is closely related to transnasal endoscopic surgery. Intraoperative accidental injury can lead to serious complications or even death. Currently, clinical anatomical studies related to the parapharyngeal segment of the internal carotid artery under transnasal endoscopic surgery mainly focus on its anatomical variation and anatomical landmarks. This article reviews on these two aspects in order to provide anatomical reference for surgeons to reduce surgical risks during transnasal endoscopic surgery.
Assuntos
Artéria Carótida Interna , Base do Crânio , Humanos , Artéria Carótida Interna/cirurgia , Base do Crânio/cirurgia , Endoscopia , CadáverRESUMO
Given recent advances in the delivery of novel antitumor therapeutics using endovascular selective intraarterial delivery methods in neuro-oncology, there is an urgent need to develop methods for intracarotid injections in mouse models, including methods to repair the carotid artery in mice after injection to allow for subsequent injections. We developed a method of intracarotid injection in a mouse model to deliver therapeutics into the internal carotid artery (ICA) with two alternative procedures. During injection, the needle is inserted into the common carotid artery (CCA) after tying a suture around the external carotid artery (ECA) and injected therapeutics are delivered into the ICA. Following injection, the common carotid artery (CCA) can be ligated, which limits the number of intracarotid injections to one. The alternative procedure described in this article includes a modification where intracarotid artery injection is followed by injection site repair of the CCA, which restores blood flow within the CCA and avoids the complication of cerebral ischemia seen in some mouse models. We also compared the delivery of bone marrow-derived human mesenchymal stem cells (BM-hMSCs) to intracranial tumors when delivered through intracarotid injection with and without injection site repair following the injection. Delivery of BM-hMSCs does not differ significantly between the methods. Our results demonstrate that injection site repair of the CCA allows for repeat injections through the same artery and does not impair the delivery and distribution of injected material, thus providing a model with greater flexibility that more closely emulates intracarotid injection in humans.
Assuntos
Isquemia Encefálica , Neoplasias Encefálicas , Humanos , Camundongos , Animais , Artéria Carótida Interna/cirurgia , Artéria Carótida Primitiva , Artérias Carótidas , Artéria Carótida ExternaRESUMO
PURPOSE: The internal carotid artery (ICA) is a region with a high incidence for small- and medium-sized saccular aneurysms. However, the treatment relies heavily on the surgeon's experience to achieve optimal outcome. Although the finite element method (FEM) and computational fluid dynamics can predict the postoperative outcomes, due to the computational complexity of traditional methods, there is an urgent need for investigating the fast but versatile approaches related to numerical simulations of flow diverters (FDs) deployment coupled with the hemodynamic analysis to determine the treatment plan. METHODS: We collected the preoperative and postoperative data from 34 patients (29 females, 5 males; mean age 55.74 ± 9.98 years) who were treated with a single flow diverter for small- to medium-sized intracranial saccular aneurysms on the ICA. The constraint-based virtual deployment (CVD) method is proposed to simulate the FDs expanding outward along the vessel centerline while be constrained by the inner wall of the vessel. RESULTS: The results indicate that there were no significant differences in the reduction rates of wall shear stress and aneurysms neck velocity between the FEM and methods. However, the solution time of CVD was greatly reduced by 98%. CONCLUSION: In the typical location of small- and medium-sized saccular aneurysms, namely the ICA, our virtual FDs deployment simulation effectively balances the computational accuracy and efficiency. Combined with hemodynamics analysis, our method can accurately represent the blood flow changes within the lesion region to assist surgeons in clinical decision-making.
Assuntos
Artéria Carótida Interna , Aneurisma Intracraniano , Humanos , Feminino , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/fisiopatologia , Resultado do Tratamento , Hemodinâmica/fisiologia , Idoso , Análise de Elementos Finitos , Simulação por Computador , Stents , Angiografia CerebralRESUMO
OBJECTIVE: In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. METHODS: In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. RESULTS: The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CONCLUSIONS: CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.
Assuntos
Estenose das Carótidas , Stents , Humanos , Masculino , Feminino , Idoso , Estenose das Carótidas/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Acidente Vascular Cerebral/epidemiologia , Idoso de 80 Anos ou mais , Artéria Carótida Interna/cirurgia , Fatores de Risco , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/instrumentaçãoRESUMO
BACKGROUND: Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. METHODS: We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. RESULTS: Six patients were identified during the study period. All were male with an age range of 63 to 82 years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17 months. CONCLUSIONS: Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.
Assuntos
Artéria Carótida Interna , Estenose das Carótidas , Endarterectomia das Carótidas , Stents , Humanos , Endarterectomia das Carótidas/efeitos adversos , Masculino , Idoso , Estudos Retrospectivos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Estenose das Carótidas/complicações , Pessoa de Meia-Idade , Resultado do Tratamento , Idoso de 80 Anos ou mais , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Fatores de Tempo , Fatores de Risco , Inibidores da Agregação Plaquetária/uso terapêutico , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentaçãoRESUMO
OBJECTIVE: Report on a case of pseudoaneurysm which was caused by injury of the internal carotid artery (ICA) during endoscopic endonasal surgery (EES), which was followed by rebleeding after treatment with a Willis covered stent. METHODS: A woman, aged 68, underwent EES for the treatment of a pituitary adenoma. During the surgery, the right ICA was injured, and successfully hemostasis by packed with cottonoid and gelatin sponge. Besides, cerebral angiography was performed in the interventional operating room for the purpose of discovering the formation of a pseudoaneurysm in the cavernous sinus segment of ICA, which was treated with a covered stent. After successfully placing the covered stent, the patient was promptly transferred to the general operating room for the removal of the cottonoid and to address the bleeding once again. The authors employ crushed muscles and cottonoid to locally compress and stop bleeding. Owing to concerns about the risk of rebleeding in the patient, after stent implantation, the patient did not utilize antiplatelet drugs. After the surgery, the patient developed occlusion of the right ICA and massive cerebral infarction in the right hemisphere. Dehydration, anti-infection, rehabilitation, hyperbaric oxygen, as well as related treatments, were given. The cottonoid was removed in EES 2 months postsurgery, and no instances of bleeding were observed. Six months after surgery, the patient had clear consciousness and hemiplegia in the left limb, with a Glasgow Outcome Scale score of 4. RESULTS: The ICA was injured during EES, which resulted in the formation of a pseudoaneurysm, the Willis stent was adopted for treatment, and there was a risk of rebleeding after the nasal packing (cottonoid, crushed muscles) was removed immediately. CONCLUSIONS: The ICA was injured during EES after bleeding was controlled by packing with cottonoid, crushed muscles, etc, subsequently, the patient was given intravascular treatment, it is advised to make thorough preparations and, after a suitable period, remove nasal packing in the hybrid operating room to address unexpected situations and unforeseen circumstances.
Assuntos
Lesões das Artérias Carótidas , Artéria Carótida Interna , Neoplasias Hipofisárias , Stents , Humanos , Feminino , Lesões das Artérias Carótidas/etiologia , Lesões das Artérias Carótidas/cirurgia , Lesões das Artérias Carótidas/terapia , Neoplasias Hipofisárias/cirurgia , Idoso , Artéria Carótida Interna/cirurgia , Adenoma/cirurgia , Endoscopia/métodos , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Falso Aneurisma/terapia , Falso Aneurisma/diagnóstico por imagem , Angiografia Cerebral , Recidiva , Complicações Intraoperatórias/etiologiaRESUMO
BACKGROUND: To differentiate between pseudo occlusion (PO) and true occlusion (TO) of internal carotid artery (ICA) is important in thrombectomy treatment planning for patients with acute ischemic stroke. Although delayed contrast filling has been differentiated carotid PO from TO, its application has been limited by the implementations of multiphasic computed tomography angiography. In this study, we hypothesized that carotid ring sign, which is readily acquired from single-phasic CTA, can sufficiently differentiate carotid TO from PO. METHODS: One thousand four hundred and twenty patients with anterior circulation stroke receiving endovascular therapy were consecutively recruited through a hospital- and web-based registry. Two hundred patients with nonvisualization of the proximal ICA were included in the analysis after a retrospective screening. Diagnosis of PO or TO of the cervical segment of ICA was made based on digital subtraction angiography. Diagnostic performances of carotid ring sign on arterial-phasic CTA and delayed contrast filling on multiphasic computed tomography angiography were evaluated and compared. RESULTS: One-hundred twelve patients had ICA PO and 88 had TO. Carotid ring sign was more common in patients with TO (70.5% versus 6.3%; P<0.001), whereas delayed contrast filling was more common in PO (94.9% versus 7.7%; P<0.001). The sensitivity and specificity of carotid ring sign in diagnosing carotid TO were 0.70 and 0.94, respectively, whereas sensitivity and specificity of delayed contrast filling was 0.95 and 0.92 in judging carotid PO. CONCLUSIONS: Carotid ring sign is a potent imaging marker in diagnosing ICA TO. Carotid ring sign could be complementary to delayed contrast filling sign in differentiating TO from PO, in particular in centers with only single-phasic CTA.
Assuntos
Doenças das Artérias Carótidas , Estenose das Carótidas , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Angiografia por Tomografia Computadorizada/métodos , Estudos Retrospectivos , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Angiografia Digital/métodosRESUMO
We report the first case of a juvenile nasal angiofibroma (JNA) fed by multiple arteries from the internal carotid artery (ICA), removed without complications by temporarily blocking the ICA with two balloons. An early adolescent with JNA underwent preoperative embolisation of feeding arteries arising from the external carotid artery (ECA) (University of Pittsburgh Medical Centre classification IV). Endoscopic resection was attempted once but discontinued due to massive bleeding (7000 mL). 17 months later, the JNA had grown to fill both nasal cavities. Repeated preoperative embolisation of the feeders from the ECA was performed, followed by surgery combined with endoscopic and external incision. Intraoperatively, two balloons were inserted into the right ICA, which were inflated at the proximal and distal sites of the feeder vessels to cut-off blood flow to the tumour. The tumour was almost completely resected with 6270 mL of blood loss and no postoperative neurological deterioration.
Assuntos
Angiofibroma , Oclusão com Balão , Embolização Terapêutica , Neoplasias de Cabeça e Pescoço , Neoplasias Nasofaríngeas , Adolescente , Humanos , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Angiofibroma/complicações , Resultado do Tratamento , Neoplasias Nasofaríngeas/complicações , Neoplasias de Cabeça e Pescoço/complicações , Artéria Carótida Externa/cirurgiaRESUMO
OBJECTIVE: The aim of this study is to analyze oncologic outcomes and complications rate after common or internal carotid artery (CCA/ICA) resection for head and neck squamous cell carcinoma (HNSCC). METHODS: This study was conducted in conformity with the PRISMA statement. A systematic review and pooled analysis was performed for overall survival (OS), disease specific survival (DSS) (primary outcomes), and perioperative death rate (secondary outcome). RESULTS: A total of 276 patients (males: 76.7%, n = 191/249) with a median age of 59 years (n = 239/276; 95% CI 55.0-61.7) who underwent CCA/ICA resection for HNSCC were included. The median follow-up time was 11 months (n = 276). Estimated pooled OS rates (95% CI) at 1 and 2 years were 52.7% (46.9-59.2) and 29.8% (24.3-36.5), respectively. The median OS (95% CI) was 14 months (12-17). Estimated pooled DSS rates (95% CI) at 1 and 2 years were 58.6% (52.7-65.2) and 34.6% (28.5-41.9), respectively. The median DSS (95% CI) was 16 months (14-19). The perioperative death rate was 6.9% (n = 19/276). CONCLUSIONS: CCA/ICA resection should be considered as a treatment option for accurately selected patients. Multicentric prospective studies are recommended to develop a predictive score guiding the decision-making process.