Continuous daily use of cilostazol prevents in-stent restenosis following carotid artery stenting: serial angiographic investigation of 229 lesions.

BACKGROUND: Several studies have reported that cilostazol (CLS) may reduce in-stent restenosis (ISR) after carotid artery stenting (CAS). However, it is not known for how long CLS must be continued to prevent ISR. METHODS: We retrospectively reviewed a prospectively collected database of patients who underwent elective CAS and follow-up angiography at 3 months and 1 year after the procedure. ISR was defined as stenosis of 50% or greater on digital subtraction angiography. The cumulative incidence rates of angiographic ISR were compared between the three groups, divided according to duration of CLS use : (1) patients who were maintained on CLS for 12 months or more after CAS (12M CLS group, n=70), (2) patients who were treated with CLS for the first 3 months after CAS (3M CLS group, n=23), and (3) patients who did not receive CLS (no CLS group, n=136). RESULTS: A total of 229 lesions in 199 patients were included in our analysis. During a median follow-up of 365 days, ISR was detected in 15 lesions. The cumulative ISR rates overall and in the 12M CLS, 3M CLS, and no CLS groups were 5.6%, 0%, 5.0%, and 8.4%, respectively, at 1 year, and the log rank test showed that there was a significant difference between the three groups (p<0.05). Cox regression analysis demonstrated that the 12M CLS group had a significantly lower risk of ISR than the 3M CLS group (adjusted relative risk (aRR) 3.06e-10, 95% CI 0 to 0.51, p<0.05) and the no CLS group (aRR 1.41e-10, 95% CI 0 to 0.15, p<0.001), whereas no difference was found between the 3M CLS group and the no CLS group. CONCLUSIONS: An overall cumulative ISR rate of 5.6% was documented angiographically at 1 year after CAS. Continuous daily use of CLS (for at least 1 year) may have a beneficial effect on long term prevention of ISR.

[Spontaneous Dilatation of Carotid Artery Stents Three Months after the Procedure, without the Need for Post-CAS Balloon Dilatation].

OBJECTIVE: The aim of this retrospective study was to investigate whether the radial force of a self-expandable stent alone is sufficient to dilate an atherosclerotic carotid artery without the need for post-carotid artery stenting (CAS) balloon dilatation (PCasBD). METHODS: We included in our analysis patients who had undergone (1) elective CAS without PCasBD from January 2012 to March 2014, and (2) follow-up conventional angiography 3 months after CAS. We recorded the patients' baseline characteristics and stent types (open-cell [OP] or closed-cell [CL]). Using the minimum width on the lateral projection, stent diameters (SDs) were measured at the site both post-operatively and 3 months after CAS. RESULTS: Fifty-eight lesions in 55 patients were analyzed. The average age of the patients was 74.4 years;the median SD immediately after CAS was 3.27 mm (interquartile range: 3.09-3.64 mm), while after 3 months it was 3.97 mm (3.58-4.25 mm), a significant increase (p<0.0001). In Regarding OP stents specifically (n=18), the median SD increased from 3.59 to 4.05 mm, while the median diameter of CL stents (n=44) increased from 3.22 to 3.83 mm. The median diameter of OP stents was larger than that of CL stents at both time points (p<0.05), whereas the expansion rate of CL stents was higher. CONCLUSION: All stents had spontaneously dilated by 10% to 20% without PCasBD. The diameter of OP stents was larger than that of CL stents, both immediately and 3 months after CAS.(Received:April 1, 2015, Accepted:August 3, 2015).

[Usefulness of a Transbrachial Guide Sheath Specifically Designed for Direct Common Carotid Artery Cannulation in Common Carotid Artery Stenting].

The transfemoral approach is a common technique for carotid artery stenting(CAS)and involves the risk of distal embolism when a high-grade stenosis occurs at the common carotid artery(CCA). In this study, to minimize the risk of thromboembolic complications, we used a guide sheath that was specifically designed for direct cannulation to the CCA without the use of a guidewire or coaxial catheter. This study included 5 patients who underwent CAS of the CCA by using a guide sheath. Of these patients, 2 had right CCA stenosis and the other 3 had left CCA lesions. In all cases, direct cannulation to the target CCA by using the guide sheath was achieved, and CAS was performed safely. The median time from puncture to the end of the procedure was 61 min(interquartile range: 53-63). No periprocedural complications or cardiovascular events occurred within 30 days after CAS. CAS was safely and successfully performed for CCA stenosis by using the transbrachial guide sheath that was specifically designed for direct cannulation to the CCA.

Anatomical features of the vertebral artery for transbrachial direct cannulation of a guiding catheter to perform coil embolization of cerebral aneurysms in the posterior cerebral circulation.

BACKGROUND: Transbrachial approach is an alternative technique for coil embolization of posterior circulation aneurysms. The purpose of our study was to investigate the anatomical features of the vertebral artery (VA) for transbrachial direct VA cannulation of a guiding catheter (GC) to perform coil embolization of posterior circulation aneurysms. METHODS: Included in retrospective analysis were patients who underwent transbrachial coil embolization of cerebral aneurysms in the posterior cerebral circulation by direct VA cannulation of a GC from 2007 to 2013. Investigated were patient characteristics, preoperative sizes of aneurysms, aneurysms location, the angle formed by the target VA and the subclavian artery (AVS), and the VA diameter at the level of the fourth cervical vertebral body (VAD) in the side of the transbrachial access route. RESULTS: Thirty-one patients with 32 aneurysms met our criteria. The locations of aneurysms were the VA (n = 16), basilar artery (BA) tip (n = 10), BA trunk (n = 3), BA superior cerebellar artery (n = 1), BA anterior inferior cerebellar artery (n = 1), and VA posterior inferior cerebellar artery (n = 1). The right brachial artery was punctured in 27 cases with 28 aneurysms as transbrachial direct cannulation of a GC, and left was in 4 cases with 4 aneurysms. The average AVS, ranging from 45° to 95°, was 77°, and the average VAD, ranging from 3.18 to 4.45 mm, was 3.97 mm. CONCLUSION: For transbrachial direct cannulation of a GC, it seems required that the AVS is about 45° or more and the VAD is about 3.18 mm or more.

Global oxygen extraction fraction by blood sampling to anticipate cerebral hyperperfusion phenomenon after carotid artery stenting.

BACKGROUND: Cerebral hyperperfusion syndrome sometimes occurs after carotid revascularization in patients with severe hemodynamic failure. To prevent cerebral hyperperfusion syndrome, cerebral hyperperfusion phenomenon (CHP) must be detected early. Single-photon emission computed tomography (SPECT) is useful for detecting CHP, but it is impractical on a daily basis. A tool with high availability to find CHP is desired. OBJECTIVE: To investigate whether global oxygen extraction fraction (OEF) by a blood sampling method is useful for indicating CHP after carotid artery stenting (CAS). METHODS: When patients underwent elective CAS from September 2010 to August 2012, we performed blood sampling for OEF calculation and SPECT before and immediately after elective CAS. Data were collected prospectively. OEF was calculated from the cerebral arteriovenous oxygen difference. Cerebral blood flow was measured in the affected middle cerebral artery (MCA) territory and in the ipsilateral cerebellum by SPECT. The ratio of MCA to cerebellar activity was defined as cerebral blood flow in the affected MCA territory divided by cerebral blood flow in the ipsilateral cerebellar hemisphere. Probable CHP was defined as ≥10% increase in the ratio of MCA to cerebellar activity after CAS. The relationship between peri-CAS OEF and probable CHP was evaluated. RESULTS: Of the 96 patients enrolled, 92 patients were analyzed. Probable CHP occurred in 17 patients. Post-CAS OEF was related to probable CHP (P < .01), but pre-CAS OEF was not. The receiver-operating characteristic curve showed that the cutoff value was 45% for probable CHP (P < .001). CONCLUSION: An increase in blood sampling OEF immediately after CAS was related to probable CHP; then the oxygen demand should be reduced.