Treatment and Predictors of Recurrent Internal Carotid Artery In-Stent Restenosis

2021 ◽  
Vol 55 (4) ◽  
pp. 374-381
Author(s):  
Zsuzsanna Mihály ◽  
Miklós Vértes ◽  
László Entz ◽  
Edit Dósa
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Protective Factor ◽  
Internal Carotid ◽  
Multiple Logistic Regression Analysis ◽  
Stent Restenosis ◽  
Imaging Characteristics ◽  
Treatment Type ◽  
Best Medical Treatment ◽  
In Stent Restenosis

Purpose: We aimed to examine the effectiveness of different therapeutic options for and to identify the possible risk factors of recurrent internal carotid artery (ICA) in-stent restenosis (ISR). Methods: Forty-six ICA ISRs, which were reintervened at least once, were retrospectively analyzed regarding clinical and imaging characteristics, as well as invasive treatment type (percutaneous transluminal angioplasty [PTA] with a plain balloon, PTA with a drug-eluting balloon [DEB], re-stenting) used. Results: The median follow-up was 29.5 months (IQR, 8.5-52.8 months) in patients who underwent reintervention for ICA ISR. Stent occlusion occurred in 3 patients (6.5%). One ISR recurrence was noted in 10 patients (21.7%); reintervention was carried out in 7 cases (7/10 [70%]; PTA, N = 5; PTA with a DEB, N = 1; re-stenting, N = 1), while 3 patients (3/10; 30%) received best medical treatment. Two ISR recurrences were observed in 3 patients (6.5%); all of them underwent reintervention (PTA, N = 1; PTA with a DEB, N = 2). Three ISR recurrences were seen in 1 patient (2.2%), who was treated with PTA. No recurrence was observed in those patients, who had DEB treatment. Multiple logistic regression analysis revealed statin therapy to be a protective factor against recurrent ISR (OR, 0.17; 95% CI, 0.03-0.84; P = .029). Conclusion: Our study suggests that PTA with a DEB is the most effective for the treatment of recurrent ISR, and confirms the importance of statin use in patients who have had a carotid reintervention.

Carotid Duplex Velocity Criteria Revisited for the Diagnosis of Carotid In-Stent Restenosis

Vascular ◽  
2007 ◽  
Vol 15 (3) ◽  
pp. 119-125 ◽  
Author(s):  
Ali F. AbuRahma ◽  
Damian Maxwell ◽  
Kris Eads ◽  
Sarah K. Flaherty ◽  
Tabitha Stutler
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Ct Angiography ◽  
Carotid Arteries ◽  
Internal Carotid ◽  
Carotid Angiography ◽  
Residual Stenosis ◽  
Stent Restenosis ◽  
The Mean ◽  
In Stent Restenosis

Carotid percutaneous transluminal angioplasty/stenting has become an accepted treatment modality for carotid artery stenosis in high-risk patients. There has been an ongoing debate regarding which duplex ultrasound (DUS) criteria to use to determine the rate of in-stent restenosis. This prospective study revisits DUS criteria for determining the rate of in-stent restenosis. In analyzing a subset of 12 patients (pilot study) who had both completion carotid angiography and DUS within 30 days, 10 patients with normal post-stenting carotid angiography (< 30% residual stenosis) had peak systolic velocities (PSVs) of the stented internal carotid artery (ICA) of ≤ 155 cm/s and two patients with ≥ 30% residual stenosis had internal carotid artery (ICA) PSVs of > 155 cm/s. Eighty-three patients who underwent carotid stenting as part of clinical trials were analyzed. All patients underwent post-stenting carotid DUS that was done at 1 month and every 6 months thereafter. PSVs and end-diastolic velocities of the ICA and common carotid artery were recorded. Patients with PSVs of the ICA of > 140 cm/s underwent carotid computed tomographic (CT) angiography. The perioperative stroke rate was 1.2%. When the old DUS velocity criteria for nonstented carotid arteries were applied, 54% of patients had ≥ 30% restenosis (PSV of > 120 cm/s), but when our new proposed DUS velocity criteria for stented arteries were applied (PSV of > 155 cm/s), 33% had ≥ 30% restenosis at a mean follow-up of 18 months ( p = .007). The mean PSVs for patients with normal stented carotid arteries based on CT angiography, were 122 cm/s versus 243 cm/s for ≥ 30% restenosis and 113 cm/s versus 230 cm/s for ≥ 30% restenosis based on our new criteria. The mean PSVs of in-stent restenosis of 30 to < 50%, 50 to < 70%, and 70 to 99%, based on CT angiography, were 205 cm/s, 264 cm/s, and 435 cm/s, respectively. Receiver operating curve analysis demonstrated that an ICA PSV of > 155 cm/s was optimal for detecting ≥ 30% in-stent restenosis, with a sensitivity of 100%, a specificity of 90%, a positive predictive value of 74%, and a negative predictive value of 100%. The currently used carotid DUS velocity criteria overestimated the incidence of in-stent restenosis. We propose new velocity criteria for the ICA PSV of > 155 cm/s to define ≥ 30% in-stent restenosis.

scholarly journals Stent-in-Stent Endovascular Correction in Right Internal Carotid Artery Restenosis: a Clinical Case

2021 ◽  
Vol 11 (1) ◽  
pp. 33-40
Author(s):  
T. N. Khafizov ◽  
R. R. Khafizov ◽  
I. E. Nikolaeva ◽  
I. A. Idrisov ◽  
E. E. Abkhalikova ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Clinical Case ◽  
Internal Carotid ◽  
Neointimal Hyperplasia ◽  
Stress Factors ◽  
Stent Restenosis ◽  
Correction Technique ◽  
Clinically Significant ◽  
In Stent Restenosis

Background. Carotid artery restenosis is a rare complication of carotid stenting. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reveals an in-stent restenosis rate of 0–6 %, a fairly low value given an extensive study sampling of patients. Restenosis still lacks an adequate explanation in endovascular carotid surgery. Intravascular ultrasound visualisation, drug-coated balloons, stent reimplantation or reconstructive surgery have actively been used since relatively recently to tackle restenosis. Drug-coated balloons may fail in certain cases due to hampered restenosis angioplasty in a markedly rigid neointimal hyperplasia. Surgical reconstruction also possessed drawbacks, mostly due to obstacles in the stent removal and the procedure infeasibility in high-risk surgical patients.Materials and methods. The article describes a clinical case of stent-in-stent restenosis correction with drug-coated balloon-expandable re-stenting of right internal carotid artery and a long-term prognosis estimation with optical coherence tomography.Results and discussions. This tactic was adopted due to haemodynamically and clinically significant internal carotid artery restenosis, the patient’s denial of carotid endarterectomy and insufficiently effective balloon angioplasty. The choice of the correction technique was conclusive basing on a negative stent deformation testing that showed the lack of deforming stress factors at internal carotid artery restenosis. Intravascular imaging greatly enhances our ability to understand and assess endovascular processes.Conclusion. We consider clinically significant restenoses in previously stented carotid arteries as requiring further research effort, with the clinical case presented describing an individual solution.

scholarly journals Thrombus Imaging Characteristics and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

Stroke ◽  
2019 ◽  
Vol 50 (8) ◽  
pp. 2057-2064 ◽  
Author(s):  
Bruna G. Dutra ◽  
Manon L. Tolhuisen ◽  
Heitor C.B.R. Alves ◽  
Kilian M. Treurniet ◽  
Manon Kappelhof ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Common Odds Ratio ◽  
Imaging Characteristics

Background and Purpose— Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment. Methods— The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other. Results— In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0–5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07–1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94–0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, −14.7; 95% CI, −24.2 to −5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, −8.5; 95% CI, −14.5 to −2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9–11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00–1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4–4.9 for proximal M1 occlusion compared with internal carotid artery occlusion). Conclusions— Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.

scholarly journals Imaging Findings of Multiphase CT Angiography of Acute Internal Carotid Artery Occlusion Within 6-Hour Time-Window After Thrombectomy and Its Clinical Implication

2020 ◽  
Vol 17 (4) ◽  
Author(s):  
Chun-Chao Huang ◽  
Chao-Liang Chou ◽  
Wei-Ming Huang ◽  
Zong-Yi Jhou ◽  
Yung-Pin Hwang ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Balloon Angioplasty ◽  
Internal Carotid ◽  
Time Window ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Imaging Findings ◽  
Imaging Characteristics

Background: Intra-arterial thrombectomy (IAT) is one of the mainstream treatments for acute ischemic stroke. As relatively little evidence on extracranial internal carotid artery (ICA) occlusions exists in the literature, we share our experiences after using IAT for intracranial and extracranial ICA occlusions. We further clarify the imaging characteristics of multiphase computed tomography angiography (CTA) and share the experience of balloon angioplasty in acute ICA occlusion. Objectives: To investigate the imaging findings of multiphase CTA and the clinical conditions and outcomes of acute ICA occlusions at different segments after IAT. Patients and Methods: All participants receiving IAT for acute stroke with isolated ICA occlusions were included, obtained from three hospitals between June 2016 and November 2018. An imaging review for non-enhanced computed tomography (CT), multiphase CTA, and angiography was conducted. Epidemiological and clinical data were reviewed. Further comparisons were evaluated between the occlusion side from the C6 to C7 segments and C1 to C5 segments of the ICA. Results: The average age of the patients was 73.0 years, and the initial National Institutes of Health Stroke scale (NIHSS) score was 18.6. Nineteen percent of cases had good outcomes. Good reperfusion results were achieved in 50% of cases. Compared to the group with occlusion from C6-C7, the group with occlusion from C1-C5 had a relatively good Alberta Stroke Program Early CT score (ASPECTS) in the A1 phase of the multiphase CTA, and more patients had a good collateral. Three cases received a balloon angioplasty for a concurrent proximal cervical ICA tight stenosis, and all cases had good reperfusion results. Conclusion: Distal occlusion of the ICA demonstrates lower ASPECTS and a worse collateral on multiphase CTA. A multiphase CTA with an extended scan range in the A2 and A3 phases is able to exclude pseudo-occlusion of the ICA. Balloon angioplasty is helpful for concurrent proximal cervical ICA tight stenosis.

ANGIOGRAPHIC PATTERNS OF WINGSPAN IN-STENT RESTENOSIS

Neurosurgery ◽  
2008 ◽  
Vol 63 (1) ◽  
pp. 23-28 ◽  
Author(s):  
Felipe C. Albuquerque ◽  
Elad I. Levy ◽  
Aquilla S. Turk ◽  
David B. Niemann ◽  
Beverly Aagaard-Kienitz ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Percutaneous Transluminal Angioplasty ◽  
Internal Carotid ◽  
Transluminal Angioplasty ◽  
Stent Restenosis ◽  
Stenosis Severity ◽  
Percutaneous Transluminal ◽  
In Stent Restenosis ◽  
Supraclinoid Internal Carotid Artery

ABSTRACT OBJECTIVE A classification system developed to characterize in-stent restenosis (ISR) after coronary percutaneous transluminal angioplasty with stenting was modified and applied to describe the appearance and distribution of ISR occurring after Wingspan (Boston Scientific, Fremont, CA) intracranial percutaneous transluminal angioplasty with stenting. METHODS A prospective, intention-to-treat, multicenter registry of Wingspan treatment for symptomatic intracranial atherosclerotic disease was maintained. Clinical and angiographic follow-up results were recorded. ISR was defined as greater than 50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent(s) and greater than 20% absolute luminal loss. ISR lesions were classified by angiographic pattern, location, and severity in comparison with the original lesion treated. RESULTS Imaging follow-up (3–15.5 months) was available for 127 intracranial stenotic lesions treated with Wingspan percutaneous transluminal angioplasty with stenting. Forty-one lesions (32.3%) developed either ISR (n = 36 [28.3%]) or complete stent occlusion (n = 5 [3.9%]) after treatment. When restenotic lesions were characterized using the modified classification system, 25 of 41 (61.0%) were focal lesions involving less than 50% of the length of the stented segment: three were Type IA (focal stenosis involving one end of the stent), 21 were Type IB (focal intrastent stenosis involving a segment completely contained within the stent), and one was Type IC (multiple noncontiguous focal stenoses). Eleven lesions (26.8%) demonstrated diffuse stenosis (&gt;50% of the length of the stented segment): nine were Type II with diffuse intrastent stenosis (completely contained within the stent) and two were Type III with proliferative ISR (extending beyond the stented segment). Five stents were completely occluded at follow-up (Type IV). Of the 36 ISR lesions, 16 were less severe or no worse than the original lesion with respect to severity of stenosis or length of the segment involved; 20 lesions were more severe than the original lesion with respect to the segment length involved (n = 5), actual stenosis severity (n = 6), or both (n = 9). Nine of 10 supraclinoid internal carotid artery ISR lesions and nine of 13 middle cerebral artery ISR lesions were more severe than the original lesion. CONCLUSION Wingspan ISR typically occurs as a focal lesion. In more than half of ISR cases, the ISR lesion was more extensive than the original lesion treated in terms of lesion length or stenosis severity. Supraclinoid internal carotid artery and middle cerebral artery lesions have a propensity to develop more severe posttreatment stenosis.

Safety and mid-term outcome of endovascular therapy for internal carotid artery disease: a 15-year experience at a single-centre angiology institution

VASA ◽  
2013 ◽  
Vol 42 (3) ◽  
pp. 196-207 ◽  
Author(s):  
Tareq Ibrahim ◽  
Sebastian Karmann ◽  
Tibor Schuster ◽  
Massimiliano Fusaro ◽  
Ilka Ott ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Endovascular Therapy ◽  
Internal Carotid ◽  
Carotid Artery Disease ◽  
Single Centre ◽  
Term Outcome ◽  
Stent Restenosis ◽  
Asymptomatic Patients ◽  
Artery Disease

Background: Endovascular therapy of carotid artery disease has emerged as a potential alternative to endarterectomy and its clinical practise dramatically increased in many parts of the world. This study aims to determine the safety and mid-term outcome of carotid artery stenting (CAS) within a 15-year carotid program at a single-centre institution. Patients and methods: We retrospectively analysed all CAS-procedures performed at our institution between 1995 and 2009. Results: During the observation period, a total of 497 CAS procedures were attempted in 460 patients with stenoses of the internal carotid artery of which 187 (37.6 %) were symptomatic and 310 (62.4 %) were asymptomatic. CAS was successful in 479 (96.4 %) cases and success rate significantly increased throughout the study (p < 0.001). The periprocedural complication rate for death, stroke, and transient ischemic attack (TIA) was 0.4 %, 1.2 %, and 2.6 %, respectively, and the cumulative event rate did not differ between symptomatic and asymptomatic patients (4.8 % vs. 3.9 %; p = 0.62). Age was the only significant predictor for the occurrence of any periprocedural adverse event (OR 2.08 [1.22 - 3.54]; p = 0.007). During a median follow-up of 24 [1; 141] months, the rate of stroke, TIA, and in-stent restenosis was 1.0 %, 2.2 %, and 2.7 %, respectively. Conclusions: Data from this large observation in everyday clinical patients demonstrate that endovascular therapy in carotid artery disease can be performed safely and with mid-term outcomes comparable to carotid endarterectomy.

scholarly journals Surgical treatment of a patient with stent restenosis in the mouth of the general carotid artery and the proximal department of the internal carotid artery

2019 ◽  
Vol 23 (3) ◽  
pp. 104 ◽  
Author(s):  
A. N. Kazantsev ◽  
N. N. Burkov ◽  
A. R. Shabayev ◽  
A. N. Volkov ◽  
E. V. Ruban ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Conflict Of Interest ◽  
Internal Carotid ◽  
Systemic Blood Pressure ◽  
Subclavian Steal Syndrome ◽  
Mechanical Prosthesis ◽  
National Medical ◽  
Stent Restenosis ◽  
Proximal Internal Carotid Artery

<p>The results of surgical intervention on a patient with stent restenosis at the mouth of the common carotid artery (CCA) and proximal internal carotid artery (ICA) are presented herein. In 2013, the patient underwent stenting of the CCA and ICA. One month later, the aortic valve was replaced with a mechanical prosthesis MedEng-23 (MedEng, Penza, Russia) and mammarocoronary anastomosis with an envelope artery was performed under extracorporeal circulation. After the intervention, the patient regularly received 3.75 mg of warfarin, and was under the observation of a cardiologist. In 2018, the patient suffered a transient ischaemic attack. Subsequent examination of the patient revealed sub-occlusion of the left subclavian artery and signs of vertebral–subclavian steal syndrome on the left, and confirmed patency of the mammarocoronary shunt in envelope artery. The patient underwent carotid–subclavian shunting using the BASEX (A.N. Bakulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia) (8-mm prosthesis. Nine months after the patient underwent carotid–subclavian shunting, 85% restenosis was observed in the stent of the left ICA using control multi-spiral computed tomography with angiography (MSCT AG). The patient also exhibited up to 94% restenosis of the stent of the left ICA, occlusion of the right ICA, and up to 81% stenosis of the proximal anastomosis of the carotid–subclavian shunt. The patient underwent surgery for the removal of the following: the stent from the ICA with endarterectomy from the CCA, ICA with arterial plastic patches from the xenopericardium and prosthesis on the left (8-mm Vascutek prosthesis, Vascutek Ltd., UK). The brain was protected by raising the patient’s systemic blood pressure to 180/90 mm Hg. During the postoperative period, MSCT AG was performed to image the ICA. The MSCT AG images indicated that the prosthesis was passable. Presently, no clear standards exist for achieving revascularisation in this category of patients. The present clinical case emphasised the requirement for the detailed observation of patients after reconstructive interventions in different arteries as well as the possibility of surgically correcting the revealed lesions.</p><p>Received 13 August 2019. Revised 8 November 2019. Accepted 9 November 2019.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Author contributions</strong><br />Drafting the article: A.N. Kazantsev<br />Literature review: R.Yu. Lider<br />Illustrations: A.R. Shabayev, A.N. Volkov<br />Critical revision of the article: N.N. Burkov, A.I. Anufriyev<br />Preoperative patient preparation: A.R. Shabayev, E.V. Ruban<br />Postoperative care: A.N. Volkov<br />Neurological examination: E.V. Ruban<br />Final approval of the version to be published: A.N. Kazantsev, N.N. Burkov, A.R. Shabayev, A.N. Volkov, E.V. Ruban, R.Yu. Lider, A.I. Anufriyev</p>

Pseudoaneurysm of the left internal carotid artery following tonsillectomy

VASA ◽  
2011 ◽  
Vol 40 (6) ◽  
pp. 491-494 ◽  
Author(s):  
Vávrová ◽  
Slezácek ◽  
Vávra ◽  
Karlová ◽  
Procházka
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Rare Complication ◽  
Left Internal Carotid Artery ◽  
Acute Tonsillitis ◽  
Artery Pseudoaneurysm ◽  
Complete Occlusion ◽  
Endovascular Approach ◽  
Deep Neck Infections

Internal carotid artery pseudoaneurysm is a rare complication of deep neck infections. The authors report the case of a 17-year-old male who presented to the Department of Otorhinolaryngology with an acute tonsillitis requiring tonsillectomy. Four weeks after the surgery the patient was readmitted because of progressive swallowing, trismus, and worsening headache. Computed tomography revealed a pseudoaneurysm of the left internal carotid artery in the extracranial segment. A bare Wallstent was implanted primarily and a complete occlusion of the pseudoaneurysm was achieved. The endovascular approach is a quick and safe method for the treatment of a pseudoaneurysm of the internal carotid artery.

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