Multicenter Experience with Stenting for Symptomatic Carotid Web

Background: A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs. Methods: Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup. Results: Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41–61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0–11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4–35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3–19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3–18) and revealed no stenosis. Conclusions: Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

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Carotid Web Phenotype Is Uncommonly Associated With Classic Fibromuscular Dysplasia: A Retrospective Observational Study

Stroke ◽

10.1161/strokeaha.121.036188 ◽

2021 ◽

Author(s):

Vera Sharashidze ◽

Raul G. Nogueira ◽

Alhamza R. Al-Bayati ◽

Nirav Bhatt ◽

Fadi B Nahab ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Fibromuscular Dysplasia ◽

Internal Carotid ◽

Filling Defect ◽

High Yield ◽

Conventional Angiography ◽

Posterior Aspect ◽

Carotid Bulb ◽

Ischemic Attack

Background and Purpose: Carotid web (CaW) is an intimal form of fibromuscular dysplasia (FMD) involving the carotid bulb which has been increasingly recognized as a potential cause of recurrent ischemic strokes. It is overlooked as a separate entity and often dismissed if no coexistent signs of classic FMD changes are observed. We aim to evaluate the frequency of classic FMD in high-yield vascular territories in patients with symptomatic CaW. Methods: This was a retrospective analysis of a symptomatic CaW database of 2 comprehensive stroke centers (spanning September 2014–October 2020). The diagnosis of a CaW during a stroke workup was defined as the presence of a shelf-like linear filling defect in the posterior aspect of the carotid bulb on computed tomography angiography in patients with acute ischemic stroke or transient ischemic attack of undetermined cause after a thorough evaluation. Neck computed tomography angiography and renal conventional angiography images were independently evaluated by two readers blinded to the laterality and clinical details to inspect the presence of underlying classic FMD. Results: Sixty-six patients with CaW were identified. Median age was 51 years (interquartile range, 42–57), and 74% were women. All patients had neck computed tomography angiography (allowing for bilateral vertebral and carotid evaluation), whereas 47 patients had additional digital subtraction angiography (which evaluated 47 carotids ipsilateral to the stroke and 10 contralateral carotids). Internal carotid artery classic FMD changes were noted in only 6 out of 66 (9%) in the ipsilateral carotids. No contralateral carotid or vertebral artery classic FMD changes were observed. Renal artery catheter-based angiography was obtained in 16 patients/32 arteries and only 1 patient/2 renal arteries demonstrated classic FMD changes. Conclusions: CaW phenotype is uncommonly associated with classic FMD changes. Coexistent classic FMD does not constitute a useful marker to corroborate or exclude CaW diagnosis.

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Intravascular Ultrasound in Carotid Web

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015387 ◽

2019 ◽

Vol 12 (5) ◽

pp. 531-534 ◽

Cited By ~ 3

Author(s):

Sara Hassani ◽

Raul G Nogueira ◽

Alhamza R Al-Bayati ◽

Rajesh Sachdeva ◽

Michael McDaniel ◽

...

Keyword(s):

Intravascular Ultrasound ◽

Fibromuscular Dysplasia ◽

Case Series ◽

Filling Defect ◽

Vessel Occlusion ◽

Posterior Aspect ◽

Guide Catheter ◽

Carotid Bulb ◽

The Common ◽

Clear Differentiation

BackgroundCarotid web (CaW) is a shelf-like linear filling defect in the posterior aspect of the internal carotid bulb, representing an intimal variant of fibromuscular dysplasia. The diagnosis of CaW is traditionally restricted to digital subtraction angiography (DSA), CT/MR angiography (CTA/MRA), and Duplex ultrasonography. In this series of patients with acute ischemic stroke, we evaluated the potential utility of intravascular ultrasound (IVUS) in further characterizing suspected CaWs.MethodsThis is a case series of three patients with suspected CaW who underwent DSA for treatment or investigation of large vessel occlusion strokes. In all cases the stroke investigation failed to identify an alternative cause, and the stroke etiology was attributed to a symptomatic CaW. The procedure consisted of positioning a guide catheter in the common carotid artery, navigating the IVUS probe distal to the carotid bulb, and then retracting the probe with a manual pullback. The acquired images were then reviewed in an independent workstationResultsIn two of the three cases, IVUS showed an isoechoic-to-hyperechoic focal eccentric area at the posterior carotid bulb, consistent with CaW. The endoluminal protrusion was inconspicuous on IVUS due to the low resolution of ultrasound not allowing a clear differentiation between fibrosis, thrombosis, and atherosclerosis. No abnormalities commonly associated with atherosclerotic disease or dissections were noted. The CaW could not be depicted in the third patient.ConclusionThe use of IVUS in the diagnosis of CaW may have limited relevance. Continued investigation of other imaging modalities for accurate CaW diagnosis is recommended.

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Carotid Stenting for Treatment of Symptomatic Carotid Webs: A Single-Center Case Series

Interventional Neurology ◽

10.1159/000486537 ◽

2018 ◽

Vol 7 (5) ◽

pp. 233-240 ◽

Cited By ~ 6

Author(s):

Waleed Brinjikji ◽

Ronit Agid ◽

Vitor M. Pereira

Keyword(s):

Stent Placement ◽

Case Series ◽

Carotid Bifurcation ◽

Posterior Wall ◽

Carotid Stenting ◽

Filling Defect ◽

Stroke Recurrence ◽

Single Center ◽

Recurrence Rates ◽

Symptomatic Carotid

Background and Purpose: Carotid webs are an increasingly recognized cause of acute ischemic stroke, particularly in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report a single-center case series of carotid stenting for treatment of symptomatic carotid webs. Materials and Methods: Consecutive patients undergoing stent placement for treatment of symptomatic carotid webs were included. Carotid webs were defined as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on CTA. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications, and stroke recurrence rates. Descriptive statistics are reported. Results: A total of 4 patients were treated. Their mean age was 44 years (range 30–50). Three patients were female and 1 was male. All patients were symptomatic presenting with ipsilateral transient ischemic attacks or stroke. Patients were placed on dual antiplatelet therapy with ticagrelor and aspirin prior to the procedure. There were no ischemic or hemorrhagic complications. Three patients had postoperative bradycardia, 1 of whom required atropine immediately following stenting. No patients had recurrent ischemic events. Conclusions: Stent placement for treatment of carotid webs can be performed safely. Further studies are needed to confirm our findings.

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Obstructed Flow

10.1093/med/9780190495541.003.0011 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Early Period ◽

Carotid Stenting ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Ischemic Attack

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

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Treatment of carotid stenosis: surgery and stent in comparison

European Heart Journal Supplements ◽

10.1093/eurheartj/suab099 ◽

2021 ◽

Vol 23 (Supplement_E) ◽

pp. E91-E94

Author(s):

Rocco Giudice ◽

Claudio Spataro

Keyword(s):

Endovascular Treatment ◽

Carotid Stenosis ◽

Carotid Stenting ◽

Perioperative Outcomes ◽

Controlled Clinical Trials ◽

Safe Alternative ◽

Symptomatic Carotid ◽

Asymptomatic Patients ◽

Symptomatic Carotid Stenosis

Abstract Carotid stenosis in the extracranial tract determines 10–15% of all ischaemic strokes. The aim of treatment, therefore, is to prevent major neurological events. Carotid endarterectomy surgery has proved effective in this regard, with various randomized studies that have demonstrated its validity in both symptomatic and asymptomatic patients. As an alternative, since the late 1990s, the endovascular treatment of carotid stenosis by stenting has gradually established itself. Numerous controlled clinical trials have compared surgery and carotid stenting in terms of perioperative outcomes (death, stroke, and myocardial infarction within 30 days of the procedure) and stroke prevention ipsilateral to the lesion treated during follow-up, evaluating both symptomatic and asymptomatic patients. From the systematic review of the data, it is legitimate to state that stenting may represent a safe alternative to conventional surgery in patients with symptomatic carotid stenosis under the age of 70, while endarterectomy is clearly safer and more effective than endovascular treatment for symptomatic older patients. On the other hand, as regards asymptomatic patients, the available evidence is limited and further data are needed to compare the two methods and to compare them with the best current medical therapy in order to draw conclusions.

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Surgical and Endovascular Management of Arteriovenous Malformation: Case Series from a Single Center

Vascular ◽

10.2310/6670.2007.00032 ◽

2007 ◽

Vol 15 (3) ◽

pp. 134-140 ◽

Cited By ~ 3

Author(s):

Mohamed A. Elsharawy ◽

Khaled M. Moghazy

Keyword(s):

Arteriovenous Malformation ◽

Case Series ◽

Surgical Excision ◽

Preoperative Embolization ◽

Conventional Angiography ◽

Ethanol Sclerotherapy ◽

Superselective Embolization ◽

Endovascular Approach ◽

A Prospective Study

Management of arteriovenous malformation (AVM) remains a major challenge to vascular surgeons. A multidisciplinary approach was introduced in our hospital to manage these cases from October 2003 to date. This is a report of our experience in their management. A prospective study was done on all patients with symptomatic AVM admitted to our unit between October 2003 and May 2006. All patients had preoperative duplex scanning and magnetic resonance imaging with or without conventional angiography. A multidisciplinary team assessed and treated these cases according to the type of malformation. Thirty-two cases were included in this study, with a mean follow-up of 18.3 months. Of these, 20 cases were predominantly venous and treated with surgical excision ( n = 14) or ethanol sclerotherapy ( n = 6). Twelve cases were predominantly arterial or arteriovenous shunting; 10 were treated with preoperative embolization followed by surgical excision and the remaining 2 with superselective embolization alone. The overall complication rate was high (31%). However, all were minor and settled down conservatively. No recurrence was observed in the early follow-up period. Management of AVM by a surgical and endovascular approach can deliver excellent results, with acceptable morbidity and no recurrence in the early follow-up period.

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Safety and feasibility of carotid revascularization in patients with cerebral embolic strokes associated with carotid webs and histopathology revisited

Interventional Neuroradiology ◽

10.1177/1591019920980271 ◽

2020 ◽

pp. 159101992098027

Author(s):

S Mathew ◽

Darrell D Davidson ◽

J Tejada ◽

M Martinez ◽

J Kovoor

Keyword(s):

Fibromuscular Dysplasia ◽

Recurrent Stroke ◽

Case Series ◽

Carotid Revascularization ◽

Symptomatic Carotid ◽

Patient Demographics ◽

Male Patients ◽

The Mean ◽

Ischemic Attack

Introduction Carotid web is increasingly recognized as the cause of ischemic embolic strokes in younger patients. The best way to treat carotid web is debatable and carotid artery stenting (CAS) has been reported as a treatment for the carotid web in only a few case series. In this study we evaluate the safety and feasibility of CAS in symptomatic carotid webs and examined the histopathology of a carotid web. Materials and methods At our institution between 2017 and 2019, 10 consecutive patients with symptomatic carotid webs were treated. We retrospectively analyzed the data for patient demographics, clinical presentation, imaging, treatment methodology and follow up. Results All the patients had presented with ipsilateral embolic stroke. The mean age at presentation was 50 years (range 37–71) with seven female and three male patients. All patients underwent CAS except one patient who underwent carotid endarterectomy (CEA). In one stented patient, there was significant hypotension in the post-procedural period lasting a week. The patients were followed for a mean of 5.5 months (range one day-12 months). No recurrent stroke or transient ischemic attack (TIA) occurred. Surgical pathological studies confirmed fibromuscular dysplasia in one specimen. Conclusion In our experience CAS for carotid web is feasible and safe in patients presenting with ischemic embolic strokes.

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