Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

Introduction : Chronic internal carotid occlusion is responsible for 10–15% ischemic strokes or transit ischemic attacks (TIA). Subsequent ipsilateral ischemic stroke rate is 5.9% per year. However, this risk can increase up to 23% in two years in a subgroup of patients with poor collaterals regardless of medical therapy with antiplatelet or anticoagulant agents. Prevention of subsequent stroke in patients with carotid artery occlusion remains a difficult challenge. Carotid artery stenting (CAS) has recently been considered in its management. However, there is ambiguity on its safety. We aim to evaluate the safety and feasibility of CAS and compared it with medical management. Methods : We performed a systematic review and meta‐analysis to compare long‐term outcome (stroke recurrence) of current carotid occlusion treatments (CAS vs medical therapy). Two independent reviewers performed the screening, data extraction, and quality assessment. A random effects model was used for analysis. Results : A total of 5720 studies were screened. Of these, 11 studies were included in our systematic review and meta‐analysis of proportions. The CAS group has lower proportions of recurrent strokes (5% vs 30%,) after 30 days than medical therapy alone. Additionally, the proportion of periprocedural intracranial hemorrhage was 4.4% (95% CI 2.5 to 6.8) in the CAS group. Conclusions : CAS of the chronically occluded cervical ICA seems to be a safe procedure with lower rates of recurrent stroke in clinical follow up. Future randomized studies are warranted to guide the optimal management of this complex disease.

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Abstract WP33: Reperfusion Therapy in Carotid Artery Occlusion with Collaterals Through the Circle of Willis

Stroke ◽

10.1161/str.48.suppl_1.wp33 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Seong Hwan Ahn ◽

In Sung Choo ◽

Hyun Gu Kang ◽

Ji Yeon Jung ◽

Sang Woo Ha

Keyword(s):

Carotid Artery ◽

Endovascular Treatment ◽

Recurrent Stroke ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Circle Of Willis ◽

Carotid Occlusion ◽

Large Artery ◽

Clinical Worsening

Introduction: In large artery occlusion, endovascular treatment shows better recanalization rate than intravenous tPA alone. In reperfusion therapy, excellent collaterals through the circle of Willis has better prognosis. We hypothesized that intravenous tPA only is comparable to endovascular therapy in carotid occlusion with patent ‘T’. Methods: Between January 2010 and December 2015, in acute stroke patients who had received a reperfusion therapy, carotid artery occlusion with good collateral via the circle of Willis were selected. In all patients, non-contrast CT and CT angiography were conducted before reperfusion therapy and at 24 (+/-6) hours and/or clinical worsening. Stroke severity was assessed with NIHSS at baseline and discharge. The prognosis of reperfusion therapy was assessed by modified Rankin Scales at 3 months. Results: In 529 patients treated by reperfusion therapy, 29 patients (5.5%, male 21, median age 76) had internal carotid artery occlusion with patent ‘T’. In tPA alone (24 patients, 82.8%), baseline NIHSS were non-significantly lower than in endovascular treatment (10 vs 15, p=0.224). Recurrent stroke, which was confirmed with follow up angiography, was developed in 8 of tPA alone. In endovascular treatment, one had a distal embolization. In 22 patients who could be assessed by MRS, 10 patients (45.5%, tPA in 9, IA in 1) had good mRS and 6 patients (27.3%) were expired. Conclusions: Carotid occlusion with good collaterals via the circle of Willis was uncommon. tPA alone resulted in recurrent stroke with clinical worsening. Endovascular treatment may be better option in carotid occlusion with patent ‘T’.

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Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis

World Neurosurgery ◽

10.1016/j.wneu.2018.08.183 ◽

2018 ◽

Vol 120 ◽

pp. 563-571.e3 ◽

Cited By ~ 3

Author(s):

Pavlos Texakalidis ◽

Stefanos Giannopoulos ◽

Damianos G. Kokkinidis ◽

Theofilos Karasavvidis ◽

Leonardo Rangel-Castilla ◽

...

Keyword(s):

Systematic Review ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Meta Analysis ◽

Carotid Occlusion ◽

Carotid Artery Endarterectomy

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Comparison of postoperative results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid artery occlusion: A meta-analysis

Vascular ◽

10.1177/1708538119841232 ◽

2019 ◽

Vol 27 (6) ◽

pp. 595-603 ◽

Cited By ~ 1

Author(s):

Wen-Qiang Xin ◽

Yan Zhao ◽

Tie-Zhu Ma ◽

Yi-Kuan Gao ◽

Wei-Han Wang ◽

...

Keyword(s):

Myocardial Infarction ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Meta Analysis ◽

Carotid Occlusion ◽

Cochrane Library ◽

Post Procedure ◽

Pubmed Database ◽

Significant Difference

Objectives The purpose of this study was to conduct a meta-analysis to systematically compare the safety and efficacy of carotid endarterectomy and carotid artery stenting in contralateral carotid occlusion patients who needed reperfusion. Methods This study retrieved potential academic articles comparing results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid occlusion from the MEDLINE database, the PubMed database the EMBASE database, and the Cochrane Library from January 1990 to May 2018. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results Four retrospective cohort study involving 6252 patients with contralateral carotid occlusion were included in our meta-analysis. During 30-day follow-up, there is significant difference in post-procedure mortality (odds ratio (OR) = 0.476, 95% confidence interval (CI) (0.306–0.740), P = 0.001); no significant differences are not found in post-procedure stroke (risk difference (RD) = 0.002, 95%CI (–0.007 to 0.011); P = 0.631), myocardial infarction (RD = 0.003, 95%CI (–0.002 to 0.008); P = 0.301), and transient cerebral ischemia (RD = 1.059, 95%CI (–0.188 to 5.964); P = 0.948). Conclusions Carotid endarterectomy was associated with a lower incidence of mortality compared to carotid artery stenting for patients with contralateral carotid occlusion. Regarding stroke, myocardial infarction, and transient ischemic attack, there was no significant difference between the two groups. More randomized controlled trials and prospective cohorts are necessary to help further clarify the ideal approach for these patients.

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