Surgical treatment of carotid in-stent-restenosis: novel strategy and current management.

BACKGROUND: Associated with increasing use of carotid artery stenting (CAS), the occurrence of late complications is likely to rise. The surgical strategies of CAS complications like in-stent-restenosis (ISR) are not yet to be determined. Thus different situations require individual operative techniques. This study contains our experience in the operative management for significant recurrent carotid stenosis following angioplasty and stent placement. As a novel strategy, we report successful stent removal and endarterectomy with eversion technique (ECEA). METHODS: Four complete stent removals were performed in three patients with three different techniques and anesthesiological protocols (general anesthesia n = 1, regional anesthesia n = 3). First stent removal with excision of common carotid artery (CCA) and internal carotid artery (ICA) following interposition of CCA-ICA with Dacron graft (n = 1). Second carotid endarterectomy with stent removal followed by patch angioplasty (n = 2). Third stent removal and ECEA and thus biological reconstruction without synthetic material (n = 1). Mean operative time was 131 minutes (±19.25). Mean follow-up was 11.5 months (±7.7). As postoperative complications, one major bleeding, one transient neurologic deficit and one postoperative neck hematoma, requiring operative revision, occurred. During a 30-day follow-up, all patients made an uneventful recovery. There was no evidence of restenosis or neurological deficit during the following postoperative controls. A review and comparison of the current surgical management and strategies in the treatment of ISR was also performed (Pubmed). CONCLUSION: Surgical treatment of ISR after CAS is beneficial but in literature infrequently reported. We could demonstrate in this study that even stent removal and ECEA is feasible and safe with durable outcome. The current strategies are therefore extended as well as the reported performance under regional anesthesia. However, surgical treatment in ISR remains a challenging option and larger series are highly recommended.

Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft.

BACKGROUND: A tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy. The underlying cause is an acquired fistula between the brachiocephalic trunk and the trachea, induced by a tracheostomy cannula's mechanical impact. CASE PRESENTATION: A 25-year-old female was admitted with pulsatile bleeding from a tracheostomy. The cause of the bleeding was a tracheo-innominate artery fistula, which was difficult to recognize. Said fistula was treated with implantation of a self-expanding stent-graft. The bleeding stopped immediately after the implantation of the stent-graft. Dual antiplatelet medication with aspirin IV and ticagrelor PO, bridged with a bolus of eptifibatide IV, was started right after the stent deployment. CONCLUSIONS: Endovascular self-expanding stent-graft implantation is a viable treatment option for tracheo-innominate artery fistulae, especially in hemorrhagic emergencies.

The zone 2 concept and distal stent graft positioning in TH 2-3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery.

OBJECTIVES: The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100-160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. METHODS: From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). RESULTS: The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4-5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed. CONCLUSIONS: Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2-3.

Successful interdisciplinary management of the misdeployment of two self-expanding stents into the internal carotid artery: a case report.

INTRODUCTION: With the widespread use of carotid artery stenting, previously unknown technical mistakes of this treatment modality are now being encountered. There are multiple strategies for the treatment of in-stent restenosis. With regard to surgical management, endarterectomy and patch plasty are favored. To the best of our knowledge, this report is the first description of a complete stent removal by the eversion technique. CASE PRESENTATION: We report the case of a 63-year-old Caucasian man with misdeployment of two stents into his stenotic proximal internal carotid artery, resulting in a high-grade mechanical obstruction of the internal carotid artery lumen. With the contralateral internal carotid artery already occluded and associated stenoses of both proximal and distal vertebral arteries, an interdisciplinary therapeutic concept was applied. Bilateral balloon angioplasty and stenting of the proximal and distal stenotic vertebral arteries were carried out to provide sufficient posterior collateral blood flow, followed by successful surgical stentectomy and carotid endarterectomy using the eversion technique. Duplex scanning and neurological assessments were normal over a 12-month follow-up period. CONCLUSIONS: Interdisciplinary treatment is a recommended option to protect patients from further impairment. Further evaluation in larger studies is highly recommended.