Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.

OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Iliac artery stenosis complicating iliac vein stenting in a patient with a history of radiation and cancer: case report and literature review.

Radiation-associated venous stenosis is not as well described in the literature as radiation-induced arteritis and is mainly limited to case reports. Treatment of radiation-associated venous stenosis may be challenged by the patient's comorbidities, such as cancer, compressive tumor, or secondary thrombophilia. The endovascular treatment of venous occlusions is now widespread and is usually the preferred modality. This is especially true for lesions of the iliac venous system. However, the development of arterial stenosis after iliac vein stenting has not previously been reported in the literature as a complication. We present a case of left common iliac artery stenosis developing immediately after left iliac vein stenting for stenosis that developed secondary to extensive pelvic surgery and targeted radiotherapy. This case report illustrates the challenges in treating an iliac vein stenosis in a hostile pelvis, reports a previously unidentified complication of iliac vein stenting, documents the first reported cases of using kissing balloons in an artery and adjacent venous segment, and reviews the literature in regard to iliac vein and inferior vena cava stenting in patients with a history of neoplasm and radiation treatment.

Clinical Outcomes of Non-Stent-Based Interventions for Symptomatic Below-the-Knee Peripheral Artery Disease in the Excellence in Peripheral Artery Disease (XLPAD) Registry.

For endovascular treatment of below-the-knee (BTK) peripheral artery disease (PAD), independently adjudicated real-world outcomes comparing non-stent-based balloon angioplasty (percutaneous transluminal angioplasty) and adjunctive treatments with or without a concomitant ipsilateral femoropopliteal (FP) artery intervention are scarce. A total of 1,060 patients from the multicenter XLPAD registry who underwent non-stent-based BTK PAD intervention between 2006 and 2021 were included. The primary outcome was the 1-year incidence of major adverse limb events (MALEs), a composite of all-cause death, any amputation, or clinically driven repeat revascularization. A total of 566 patients underwent BTK and 494 BTK + FP interventions; 72% were men, with a mean age of 68.4 ± 10.9 years. Diabetes mellitus was more prevalent in the BTK-only group (76.5% vs 69%, p = 0.006). Mean Rutherford class was 4.2 ± 1.18; chronic limb-threatening ischemia was more frequent in the BTK group (55.3% vs 49%, p = 0.040). Moderate to severe calcification was more frequent in the BTK + FP group (21.2% vs 27.1%, p = 0.024), as was lesion length (110.6 ± 77.3 vs 135.4 ± 86.3 mm, p <0.001). Nearly 81% of lesions were treated with percutaneous transluminal angioplasty. Drug-coated balloon (1.6% vs 14%, p <0.001) and atherectomy (38% vs 58.5%, p <0.001) use was more frequent in the BTK + FP group. The rate of procedural success was higher in the BTK + FP group (86% vs 91%, p = 0.009), with amputation being the most common complication at 3.3% within 30 days after the procedure. The rates of 1-year MALE (21.2% vs 22.3%, p = 0.675) and mortality (4.6% vs 3.4%, p = 0.3) were similar between the BTK and BTK + FP groups. Nonstent treatment for BTK PAD with concomitant FP intervention leads to high procedural success and similar rates of 1-year MALE compared with isolated BTK intervention. Condensed Abstract: The vast majority of below-the-knee (BTK) peripheral artery disease (PAD) interventions are performed with balloon angioplasty. Presence of inflow femoropopliteal PAD in patients who undergo BTK interventions can affect the outcome of the procedure. This report explores immediate procedural success and major adverse limb events at 1 year after balloon angioplasty treatment for isolated BTK PAD and in patients who underwent an additional femoropopliteal PAD intervention.

Intravascular lithotripsy during transcarotid arterial revascularization for highly calcified lesions in high-risk patients.

Transcarotid arterial revascularization (TCAR) with flow reversal offers a less invasive option for carotid revascularization in high-risk surgical patients. TCAR has been shown to have similar complication rates for stroke and mortality compared with carotid endarterectomy and lower complication rates compared with transfemoral carotid artery stenting. A relative contraindication for carotid stenting includes heavily calcified lesions. Intravascular lithotripsy has been approved for use in other vascular beds for endovascular treatment of heavily calcified lesions. In the present report, we have demonstrated the application of intravascular lithotripsy for heavily calcified carotid lesions, enabling treatment with TCAR for those who otherwise might be at high risk of transfemoral carotid artery stenting or carotid endarterectomy.

Effects of radiation and MediPort placement on the development of thoracic outlet syndrome.

We present a patient who exemplifies the interplay of factors contributing to the development of venous-type thoracic outlet syndrome. The patient was treated with both radiation and chemotherapy for squamous cell carcinoma in the head and neck region; radiation and chemotherapy have been known to damage the vascular system. Multimodality treatment is necessary to achieve good long-term results in these complex patients.

Effectiveness of treatment of innominate artery stenosis with retrograde supra-aortic stent using a flow reversal stent system.

We present the case of a 71-year-old man with critical stenosis of the innominate artery after previously undergoing bilateral carotid artery endarterectomies. We used an open retrograde approach of the right carotid artery to stent the innominate artery lesion employing the new ENROUTE Transcarotid Stent System with flow reversal.

Repair of a mycotic aneurysm of the infrarenal aorta in a patient with HIV, using a Palmaz stent and autologous femoral vein graft.

With the widespread use of endovascular surgery, aneurysms can be managed selectively with the use of stent grafts. Standard treatment of mycotic aneurysms usually requires resection and extraanatomic bypass. Although stent graft repair of a mycotic femoral aneurysm with autologous graft has been reported, we present a case of an infrarenal mycotic aneurysm in a patient with the human immunodeficiency virus (HIV) that was successfully treated with a novel endovascular approach.

Prospective evaluation of endoluminal venous stents in the treatment of the May-Thurner syndrome.

The May-Thurner syndrome is an acquired stenosis of the left common iliac vein causing pain, edema, or deep venous thrombosis (DVT). The patency and behavior of endoluminal venous stents for this condition was evaluated in this study. Patients with the May-Thurner lesion treated with endoluminal stenting from 1997 to 2000 were evaluated according to an institutional review board-approved protocol. Wallstents (n = 14) or Smart stents (n = 1) were placed into the left common iliac. Patency was evaluated with duplex ultrasonography using a 5 mHz linear array probe (HP 4500) at 6-month intervals. Our results showed that treatment of the May-Thurner syndrome with endoluminal stenting is associated with low morbidity and high patency rates. Longitudinal evaluation of this group of patients is ongoing to confirm these findings.

Management of carotid body paragangliomas and review of a 30-year experience.

Carotid body tumors are rare neoplasms and must be considered in the evaluation of all lateral neck masses; early surgical removal has been recommended. In this study, the medical records of 29 patients with 34 carotid body paragangliomas who were treated at our institution between 1971 and 2001 were retrospectively reviewed. An overview is provided of this lesion, including diagnosis, classification, metastatic potential, possible secretory function, operative techniques, and nonsurgical methods of management. Carotid body tumors may be familial and are more often bilateral in these instances; five patients (17%) had bilateral tumors in this series. The criterion for malignancy is demonstrated by metastatic tumor in lymph nodes or distant organs. Three patients (10%) had malignant tumors, one with hepatic metastases. One patient (3%) in our series exhibited abnormal serotonin production. Vascular reconstruction was necessary in eight cases (28%). No stroke occurred, however, two arterial thromboses (7%), five permanent cranial nerve deficits (17%), and one death (3%) from massive pulmonary embolism were seen. Our experience demonstrates that early operative management is warranted to avoid the possibility of eventual metastasis and progressive local invasion to the point of inoperability.