ABSTRACT
OBJECTIVE: To correct the historical notion that permeates throughout the neurointerventional surgical literature that Dr Barney Brooks was the founder of the specialty. MATERIAL AND METHODS: Both articles written by Dr B Brooks and all pertinent literature dealing with neurointerventional treatment of the carotid-cavernous sinus fistula (CCSF) were reviewed. RESULTS: The notion that Dr B Brooks was the first to use the embolization method to treat the CCSF was based on misinterpretation of his papers published in 1930 and on 'second generation' references used by subsequent authors. CONCLUSION: Dr B Brooks never described embolization of the CCSF by a 'free' piece of muscle introduced into the internal carotid artery (ICA).
Subject(s)
Carotid-Cavernous Sinus Fistula/history , Embolization, Therapeutic/history , Neurosurgery/history , Publishing/history , Carotid-Cavernous Sinus Fistula/therapy , History, 19th Century , History, 20th Century , HumansABSTRACT
BACKGROUND: The distal-balloon protection system is being evaluated for its efficacy in preventing embolic neurological events during carotid stenting (CAS). We sought to determine the effect of this system on the frequency of the Doppler-detected microembolic signals (MES) during CAS. METHODS: Using transcranial Doppler, we compared the frequency of MES during CAS in 2 groups; 39 patients without distal protection and 37 with the distal-balloon protection system (GuardWire, Percusurge, Sunnyville, CA). There was no significant difference in the clinical or angiographic characteristics between the 2 groups. Three phases with increased MES counts were identified during the unprotected CAS; stent deployment, predilation, and postdilation (mean+/-SD: 75+/-57, 32+/-36, and 27+/-25, respectively). RESULTS: The distal-balloon protection significantly reduced the frequency of MES during CAS (MES-counts: 164+/-108 in the control vs 68+/-83 in the protection group, p=0.002) particularly during these 3 phases. MES in the protection group were detected predominantly during sheath placement, guidewire manipulation and during the distal-balloon deflation. CONCLUSIONS: Three phases with increased MES counts were identified during the unprotected CAS, e.g. stent deployment, predilation and postdilation. The distal-balloon protection system significantly reduced the frequency of MES during CAS, particularly during these 3 phases.
Subject(s)
Balloon Occlusion/instrumentation , Balloon Occlusion/methods , Blood Vessel Prosthesis Implantation/adverse effects , Carotid Artery Diseases/surgery , Intracranial Embolism/etiology , Intracranial Embolism/prevention & control , Postoperative Complications , Stents/adverse effects , Aged , Aged, 80 and over , Carotid Artery Diseases/diagnostic imaging , Cerebral Angiography , Female , Humans , Intracranial Embolism/diagnostic imaging , Male , Middle Aged , Severity of Illness Index , Treatment Outcome , Ultrasonography, Doppler, TranscranialABSTRACT
A 61-year-old man underwent carotid stenting with the distal-balloon protection system for symptomatic carotid artery stenosis. During the procedure, progressive elevation of the systolic blood pressure occurred, reaching a peak of 220 mm Hg immediately following deflation of the distal balloon. This was associated with severe headaches and progressive deterioration in the mental status to a coma. Head CT scan showed massive subarachnoidal hemorrhage contralateral to the stented side and a secondary intracerebral hemorrhage. Despite immediate successful blood pressure control, his condition deteriorated and he died 2 days later.
Subject(s)
Carotid Artery, Internal/surgery , Carotid Stenosis/complications , Carotid Stenosis/surgery , Catheterization/instrumentation , Stents/adverse effects , Subarachnoid Hemorrhage/etiology , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/instrumentation , Humans , Male , Middle Aged , Postoperative Complications/etiologyABSTRACT
BACKGROUND AND PURPOSE: Ambulatory procedures increase patient comfort and enhance cost-effectiveness. We sought to determine the feasibility and safety of ambulatory carotid stenting. METHODS: A selected group of patients was admitted and discharged the same day after the carotid stenting procedure. Immediate and short-term outcomes are reported. RESULTS: A total of 98 ambulatory carotid stenting procedures (98 hemispheres in 92 patients) were performed. There were 66 men (72%), and the mean age was 70+/-9 years. Of the patients, 28% had neurological symptoms related to the treated artery within 3 months before the procedure. Sixteen percent of the patients had prior carotid endarterectomy, 4% had prior ipsilateral neck radiation, and 8% had complete occlusion of the contralateral internal carotid artery. Successful access site hemostasis was ensured in all patients with suture-mediated vascular closure devices in 96 (98%) and manual compression in 2. Clinical follow-up was available for 96% of the patients at a mean time of 6+/-4 months. There were no neurological events, deaths, repeated procedures, or major access site complications. CONCLUSIONS: Ambulatory carotid stenting is both safe and feasible. This approach will enhance the applicability of the procedure by increasing patient comfort and potentially reducing procedural costs.
Subject(s)
Ambulatory Care Facilities , Ambulatory Surgical Procedures , Blood Vessel Prosthesis Implantation , Carotid Artery Diseases/surgery , Stents , Aged , Ambulatory Surgical Procedures/adverse effects , Blood Vessel Prosthesis Implantation/adverse effects , Carotid Artery Diseases/diagnostic imaging , Feasibility Studies , Female , Follow-Up Studies , Hemostasis, Surgical , Humans , Male , Patient Selection , Stents/adverse effects , Time Factors , Treatment Outcome , UltrasonographyABSTRACT
BACKGROUND: The distal-balloon protection system is being evaluated for its efficacy in preventing embolic neurological events during carotid stenting (CAS). We sought to determine the effect of this system on the frequency of Doppler-detected microembolic signals (MES) during CAS. METHODS AND RESULTS: Using transcranial Doppler, we compared the frequency of MES during CAS in 2 groups: 39 patients without distal protection and 37 who used the distal-balloon protection system (GuardWire). There were no significant differences in the clinical or angiographic characteristics between the 2 groups. Three phases with increased MES counts were identified during unprotected CAS; these were stent deployment, predilation, and postdilation (75+/-57, 32+/-36, and 27+/-25 METS, respectively). The distal-balloon protection significantly reduced the frequency of MES during CAS (MES counts: 164+/-108 in the control versus 68+/-83 in the protection group; P=0.002), particularly during these 3 phases. MES in the protection group were detected predominantly during sheath placement, guidewire manipulation, and distal-balloon deflation. CONCLUSION: Three phases with increased MES counts were identified during unprotected CAS (eg, stent deployment, predilation, and postdilation). The distal-balloon protection system significantly reduced the frequency of MES during CAS, particularly during these 3 phases.
Subject(s)
Blood Vessel Prosthesis Implantation/methods , Carotid Artery Diseases/surgery , Catheterization/methods , Intracranial Embolism/prevention & control , Stents , Aged , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Catheterization/adverse effects , Catheterization/instrumentation , Female , Humans , Intracranial Embolism/diagnostic imaging , Intracranial Embolism/etiology , Intraoperative Period , Male , Prospective Studies , Stents/adverse effects , Subarachnoid Hemorrhage/etiology , Survival Rate , Treatment Outcome , Ultrasonography, Doppler, TranscranialABSTRACT
PURPOSE: To describe a potential route for embolization to the middle cerebral artery (MCA) during carotid stenting with the distal balloon protection system. CASE REPORT: An 82-year-old man with symptomatic severe carotid artery stenosis underwent elective carotid stenting with distal-balloon protection. Despite complete occlusion of the distal internal carotid artery, frequent emboli were detected in the ipsilateral MCA by transcranial Doppler (TCD) during the procedure. Intracranial angiography, performed during the distal-balloon protection, revealed filling of the MCA through collaterals from the ipsilateral external carotid artery. The procedure was successfully completed without complications. The patient remains asymptomatic at 6 months. CONCLUSIONS: During carotid stenting with distal-balloon protection, asymptomatic embolization into the ipsilateral MCA may occur through collateral circulation. The clinical significance of these emboli is uncertain.
Subject(s)
Balloon Occlusion/instrumentation , Carotid Artery, Internal/surgery , Carotid Stenosis/therapy , Collateral Circulation/physiology , Embolization, Therapeutic , Stents , Aged , Aged, 80 and over , Embolization, Therapeutic/methods , Humans , Male , Middle Cerebral Artery/surgeryABSTRACT
Recurrent stenosis post-carotid endarterectomy (CEA) is not a solitary or unusual phenomenon. Compared to the initial CEA, the reoperation is often more technically challenging and frequently results in local and neurological complications. Carotid artery angioplasty with stenting (CAS) is currently being investigated as an alternative to carotid endarterectomy. In our study, ninety-nine patients underwent CAS in 110 arteries. Procedural success was 99% (109/110). Our results show that CAS treatment in post-CEA restenosis, especially with improved technique and distal protection, is safe with a low neurological complication rate, without any "local" complications and without any cranial nerve palsies. This study suggests that the future primary mode of treatment of post-CEA restenosis might be carotid stenting rather than surgery.
Subject(s)
Angioplasty, Balloon , Carotid Stenosis/therapy , Endarterectomy, Carotid , Stents , Aged , Carotid Stenosis/surgery , Female , Humans , Male , Middle Aged , RecurrenceABSTRACT
BACKGROUND: Carotid stenting is a less invasive percutaneous procedure than carotid endarterectomy for the treatment of carotid stenosis. Reports suggest that it can be performed with periprocedural complication rates similar to those of carotid endarterectomy. The purpose of this study was to determine short- and long-term outcomes in the largest prospective cohort of carotid stenting patients. METHODS AND RESULTS: This study followed 528 consecutive patients (604 hemispheres/arteries) undergoing carotid stenting. There was a 0.6% (n=3) fatal stroke rate and 1% (n=5) nonstroke death rate at 30 days. The major stroke rate was 1% (n=6), and the minor stroke rate was 4.8% (n=29). The overall 30-day stroke and death rate was 7.4% (n=43). Over the 5-year study period, the 30-day minor stroke rate improved from 7.1% (n=7) for the first year to 3.1% (n=5) for the fifth year (P:<0.05 for trend). The best predictor of 30-day stroke and death was age >/=80 years. After the 30-day period, the incidence of fatal and nonfatal stroke was 3.2% (n=31). On Kaplan-Meier analysis, the 3-year freedom from ipsilateral or fatal stroke was 92+/-1%. CONCLUSIONS: Experience from a single group of operators demonstrates that carotid stenting can be performed with an acceptable 30-day complication rate. Late follow-up also demonstrates a low rate of fatal and nonfatal stroke. These results suggest that carotid stenting may be comparable to carotid endarterectomy, and it underscores the clinical equipoise and premise for the National Institute of Health-supported, randomized Carotid Revascularization Endarterectomy Versus Stent Trial comparing carotid stenting with carotid endarterectomy.
Subject(s)
Carotid Arteries/surgery , Carotid Stenosis/surgery , Stents , Age Factors , Aged , Aged, 80 and over , Carotid Stenosis/mortality , Carotid Stenosis/pathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Postoperative Complications , Stroke/etiology , Survival Rate , Time Factors , Treatment OutcomeABSTRACT
Patients may develop simultaneous symptoms of atherosclerotic vascular disease from different arterial beds. A concurrent minimally invasive approach to the management of these clinical situations may be an advantage over conventional surgical procedures. This study describes two separate case series of patients undergoing coronary/peripheral (n = 38) and peripheral/peripheral procedures (n = 10). Technical and clinical success was achieved in all patients. There were two periprocedural complications (retroperitoneal bleed and septicemia) in the coronary/peripheral series and no complications in the peripheral/peripheral series. We also present five case reports to illustrate the utility of hybrid procedures in various clinical settings. This study suggests that the use of simultaneous or sequential minimally invasive procedures appears to be a safe and feasible strategy for the treatment of patients with symptoms from more than one vascular bed. Cathet Cardiovasc Intervent 2001;52:154-161.
Subject(s)
Arterial Occlusive Diseases/surgery , Arteriosclerosis/surgery , Cardiac Surgical Procedures , Aged , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/surgery , Female , Humans , Male , Middle Aged , Minimally Invasive Surgical Procedures , Radiography , Renal Artery Obstruction/surgery , Stents , Subclavian Artery/surgeryABSTRACT
There is an increasing trend to rely on duplex ultrasound rather than angiography to measure an internal carotid artery stenosis. The aim of this study was to determine the validity of ultrasound assessment of carotid stenosis performed in community based vascular laboratories. We compared ultrasound with angiography in 225 patients referred to us for carotid intervention. Mild lesions were diagnosed by ultrasound with a sensitivity of 54%, specificity of 89%, and a positive predictive value of 89% compared with angiography. Severe lesions had a sensitivity of 93%, a specificity of 67%, and a positive predictive value of 45%. Receiver operator characteristic curves demonstrated the optimal ultrasound cut-off value of 66% stenosis as a predictor of >60% stenosis measured angiographically, is associated with a false positive rate of 38%, and a false negative rate of 9%. Similarly, if a cut-off of 76% on ultrasound is used to predict >70% stenosis measured angiographically, it would be associated with a 29% false positive rate and a false negative rate of 11%. Despite the value of non-invasive testing for carotid disease, duplex ultrasonography performed in non-accredited and some accredited laboratories may produce highly variable results. Using ultrasound as the sole diagnostic test to determine the severity of a carotid stenosis may result in a high number of inappropriate operations and a large proportion of patients who may not be offered treatment due to false negative diagnoses.
Subject(s)
Angiography/methods , Carotid Artery, Internal , Carotid Stenosis/diagnostic imaging , Ultrasonography, Doppler, Duplex/methods , Aged , Female , Humans , Logistic Models , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , ROC Curve , Reproducibility of Results , Sensitivity and Specificity , Severity of Illness IndexABSTRACT
PURPOSE: To document the feasibility of brachial artery access for carotid stenting with distal-balloon protection of the internal carotid artery (ICA). TECHNIQUE: Via percutaneous access to the brachial artery, a large double-curve catheter is advanced into the aortic arch over a hydrophilic guidewire to cannulate the left common carotid artery. Following sheath exchange, a GuardWire distal-protection balloon is positioned within the left ICA distal to the stenosis. The lesion is dilated, followed by deployment and dilation of a self-expanding stent. Transcranial Doppler monitoring shows only scarce microembolic signals during the procedure. CONCLUSIONS: Carotid stenting with distal balloon protection via the brachial artery appears feasible as an alternative to standard femoral access.
Subject(s)
Balloon Occlusion/methods , Carotid Artery, Internal , Carotid Stenosis/therapy , Stents , Aged , Balloon Occlusion/instrumentation , Brachial Artery , Carotid Artery, Internal/diagnostic imaging , Carotid Stenosis/diagnostic imaging , Catheterization , Feasibility Studies , Humans , Male , RadiographyABSTRACT
PURPOSE: To present the results of a multicenter registry established to collect data on carotid stent procedures in patients with restenosis following carotid endarterectomy. METHODS: The procedural details, outcomes, and late follow-up results were collected from 14 centers in the United States. Thirty-day and late stroke and death rates were analyzed. RESULTS: Three hundred and thirty-eight patients (201 men; 71 +/- 8 years) underwent carotid stenting in 358 arteries. The average duration from carotid endarterectomy was 5.5 +/- 7.3 years. Sixty-one percent of the patients were asymptomatic. The overall 30-day stroke and death rate was 3.7%. The minor stroke rate was 1.7% (6/358), and the major nonfatal stroke rate was 0.8% (3/358). The fatal stroke rate was 0.3% (1/358), and the nonstroke-related death rate was 0.9% (3/338). There was 1 (0.3%) fatal and 1 (0.3%) nonfatal stroke during the follow-up period. The overall 3-year rate of freedom from all fatal and nonfatal strokes was 96% +/- 1% (+/- SE). CONCLUSIONS: Carotid artery stenting can be performed in patients with restenosis following carotid endarterectomy with 30-day complication rates comparable to those of most published studies on repeat carotid endarterectomy. Results of late follow-up suggest that this technique is durable and efficacious.
Subject(s)
Carotid Stenosis/therapy , Endarterectomy, Carotid , Stents , Aged , Female , Humans , Male , Postoperative Complications , Recurrence , Safety , Treatment OutcomeABSTRACT
BACKGROUND AND PURPOSE: Carotid endarterectomy (CEA) is one of the most frequently performed operations in the United States. To offer patients a less invasive means to achieve the same goal, carotid artery stenting (CAS) is investigated as an alternative treatment to CEA. METHODS: Three hundred ninety patients underwent CAS, with 451 vessels treated. CAS was performed using a coaxial system with a 7F 90-cm sheath for predilation, stent placement, and stent dilation. Pretreatment antiplatelet therapy was administered. We currently practice same-day admissions and 23-hour discharges. RESULTS: The technical success rate was 98%. The 30-day mortality/morbidity rates were as follows: death, 1.7% (two [0.5%] neurologic and five [1.2%] systemic] major strokes, 0.9% (two of four were related to the intervention); minor strokes, 5.5%. Among 25 patients who suffered minor strokes, 14 achieved complete recovery. On an annual basis, the incidence of minor stroke declined from 6.8% (1994-1995), to 5.8% (1995-1996), 5.3% (1996-1997), and then 4% (1997-1998), with no major strokes or neurologic deaths occurring during the 1997 to 1998 period. CONCLUSION: CAS is an effective treatment for carotid stenosis. With proper selection of patients and meticulous technique, complication rates compare favorably with those of CEA.
Subject(s)
Carotid Arteries , Carotid Stenosis/therapy , Stents , Adult , Aged , Aged, 80 and over , Carotid Arteries/diagnostic imaging , Carotid Stenosis/diagnostic imaging , Female , Humans , Male , Middle Aged , Radiography, Interventional , Stents/adverse effectsABSTRACT
The technique of carotid stenting has undergone significant refinement since its introduction and continues to improve as experience with the procedure matures and more suitable equipment becomes available. Improved stent designs and the utilization of cerebral protection devices are expected to significantly impact on the technique, its ultimate outcomes, and widespread application. In using the currently available technology for carotid stenting, patient selection and meticulous attention to procedural details are very important in minimizing embolic events. In this article, we provide a comprehensive practical discussion of the state-of-the-art carotid stenting techniques that have allowed us to maintain low event rates.
Subject(s)
Carotid Arteries/surgery , Stents , Equipment Design , Humans , Patient Selection , Preoperative Care , Vascular Surgical Procedures/methodsABSTRACT
PURPOSE: To present our experience with carotid artery stenting as an alternative treatment to endarterectomy in patients with radiation-induced carotid artery occlusive disease. METHODS AND RESULTS: Fourteen patients (10 males; mean age 61 years, range 52 to 79) underwent percutaneous stenting of 15 carotid arteries for severe radiation-induced extracranial stenoses. Technical success was achieved in all patients, with reduction of the mean stenosis from 77% +/- 6% to 8% +/- 2%. In 2 patients, ipsilateral vertebral artery lesions were stented concomitantly. One patient had a minor stroke after the procedure but recovered fully in 2 days. No other complications were encountered. Nine (64%) patients had 6-month follow-up imaging (angiography or duplex scanning) that showed no evidence of restenoses (obstruction > or = 50%). At 18 +/- 2 months, 3 (21%) patients had died from unrelated causes. No neurological events occurred, and no repeat carotid artery interventions were required in the remaining patients. CONCLUSIONS: Carotid stenting is an effective treatment option for severe radiation-induced carotid artery occlusive disease.
Subject(s)
Carotid Stenosis/etiology , Carotid Stenosis/therapy , Radiation Injuries/complications , Stents , Carotid Artery, Common , Carotid Artery, Internal , Carotid Stenosis/diagnostic imaging , Feasibility Studies , Female , Humans , Male , Middle Aged , Prospective Studies , RadiographySubject(s)
Carotid Artery, Internal , Carotid Stenosis/therapy , Peptides/administration & dosage , Platelet Aggregation Inhibitors/administration & dosage , Stents , Aged , Angiography , Carotid Stenosis/diagnostic imaging , Combined Modality Therapy , Eptifibatide , Follow-Up Studies , Humans , Infusions, Intravenous , Male , Severity of Illness Index , Treatment Outcome , Vascular PatencyABSTRACT
Carotid stenting is a percutaneous, minimally invasive treatment for carotid stenosis. It does not carry the surgical risks of carotid endarterectomy and therefore can be applied to the elderly and to patients with comorbidities. Complications and late events appear low.
Subject(s)
Atherectomy/instrumentation , Atherectomy/mortality , Carotid Artery Diseases/therapy , Endarterectomy/mortality , Aged , Atherectomy/methods , Carotid Artery Diseases/diagnostic imaging , Carotid Artery Diseases/mortality , Endarterectomy/methods , Female , Humans , Male , Middle Aged , Radiography , Sensitivity and Specificity , Stents , Survival Analysis , Survival Rate , Treatment OutcomeABSTRACT
PURPOSE: To examine the impact of age upon the development of neurological and major systemic complications during or after carotid artery stenting. METHODS: We reviewed the complications that occurred in patients undergoing elective carotid stent implantation between September 1994 and August 1996. The study population was then divided into 3 groups according to age: > or = 80 (group A), 75 to 79 (group B), and < or = 74 (group C) years. The rates of death, major and minor stroke, and myocardial infarction were compared among the groups, as well as with the rates reported by the major carotid endarterectomy (CEA) trials. RESULTS: During the study period, 182 patients (216 vessels) were treated with carotid stenting. There were 19 (10.4%) complications: 1 (0.5%) death, 2 (1.1%) major strokes, 15 (8.2%) minor strokes, and 1 (0.5%) myocardial infarction. Neurological complications were clearly related to increased age with rates of 25.0% in group A versus 8.6% in group C (p = 0.042). The overall per patient rate of death or major stroke was 1.6% (1.4% per vessel). CONCLUSIONS: Increasing age has a negative impact on the rate of complications in carotid stent patients. However, the majority of those complications are minor. The relative roles of medical therapy, stenting, and CEA in patients > 80 years of age must await the results of randomized trials.