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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
374
82 Carotid Artery Stenting forSymptomatic Radiation- Induced Carotid Stenosis
investigators have reported satisfactory outcome
of CEA in patients following neck radiation
though a higher incidence of recurrent stenosis/
occlusion following CEA has been reported as
compared to de novo lesions.
Fokkema etal., from a meta-analysis of 533
patients (361 CAS and 172 CEA), observed low
incidence of perioperative neurological decit in
patients with prior history of radiation. Patients
who had CEA had a higher incidence of temporary cranial nerve injury. There was a higher incidence of late neurological decit and carotid
restenosis after CAS [6].
Invited Commentary fromHitinder
S.Gurm, MBBS
Patients with history of radiation therapy to the
head and neck are at high risk of subsequent
carotid artery stenosis. Radiation therapy is
associated with accelerated atherosclerosis, and
these patients present with severe asymptomatic
or symptomatic stenosis 2–15years after getting
radiation treatment. The management of these
patients is compounded by the common presence of concomitant prior neck dissection, long
segments of arterial stenosis, and altered vascular healing that increase surgical complication
rates as well as the risk of restenosis after either
carotid stenting (CAS) or carotid endarterectomy (CEA).
One of the key challenges with providing
denitive guidance for management of these
patients is that the literature is rather limited and
mostly consists of case series from highly experienced centers, reecting the best case scenario.
Most clinicians will care for only a handful of
such patients over their career, and availability of
local expertise should be a major factor in guiding the treatment choice. The main drawback of
CEA in these patients is a higher risk of nerve
injury (reported to be as high as 30% but should
be <10% in the hands of experienced operators)
and wound infections. The higher complication
rates reect the outcome of patients with both
prior radiation and prior neck dissection, and
CAS could be considered as the rst option in
such patients. Patients undergoing CAS are at a
higher risk of restenosis, which usually, but not
always remains asymptomatic and can be managed without repeat intervention in majority of
patients.
Overall, the freedom from death or stroke is
broadly similar with either CEA or CAS, although
the 5-year mortality in these patients is fairly
high and is mostly driven by other comorbid
conditions.
The choice of treatment, as in the patient
described, is thus dependent on local expertise
(both modalities were available to this patient)
and other comorbidities and anatomical factors
(such as the extent of plaque). Embolic protection strategies should always be used when pursuing carotid stenting. It is equally important to
ensure that these patients are treated with appropriate guideline-recommended medical therapy
including statins and antiplatelet therapy, and
other concomitant vascular risk factors such as
hypertension and atrial brillation are managed
aggressively.
References
1. Schulz UGR, Rotwell PM.Transient ischemic attack
mimicking focal motor seizures. Postgrad Med J.
2002;78:246–7.
2. Tallerita T, Oderich ES, Lenzino G, Cloft H, Kallmes
SD, etal. Outcomes of carotid artery stenting were ver-
sus historical surgical controls for radiation-induced
carotid stenosis. J Vasc Surg. 2011;53:629–36.
3. Magne JL, Pirvu A, Sessa C, Cochet H.Carotid artery
revascularization following neck radiation: immedi-
ate and long-term results. Eur J Vasc Endovasc Surg.
2012;43(1):4–7.
4. Kashyap VS, Moore WS, Quinones-Baldrich
WJ.Carotid artery repair for radiation associated ath-
erosclerosis is a safe and durable procedure. J Vasc
Surg. 1999;29(1):90–6.
5. Leseche G, Castier Y, Chataigner O, Francis F, et al.
Carotid artery revascularization through a radiated
eld. J Vasc Surg. 2003;38(2):244–50.
6. Fokkema M, DenHartog AG, Bots ML, Vandertweel
I, et al. Stenting versus surgery in patients with
carotid stenosis after previous cervical radiation
therapy: systemic review and meta-analysis. Stroke.
2012;43:793–801.
Carotid Stenting forCarotid
Interposition Vein Graft Stenosis
83
History andProcedures
A 76-year-old male with history of coronary artery
disease (coronary artery bypass graft), hypertension, hyperlipidemia, prior abdominal aortic aneurysm repair, and thrombocytopenia underwent left
carotid endarterectomy (CEA) for severe stenosis
of the distal common and proximal internal carotid
artery with associated thrombus in December
1995. Patient had associated left external carotid
artery (ECA) occlusion. Non- reversed greater
saphenous vein interposition graft was performed
following distal common and proximal internal
carotid artery resection. Completion arteriogram
showed satisfactory reconstruction.
In September 1999, patient developed transient
monocular blindness and was found to have severe
stenosis at the site of venous valve in the interposition saphenous vein graft segment. Stenosed vein
graft segment was resected and replaced by a short
segment of saphenous vein harvested from the right
groin. Patient developed worsening carotid stenosis
with carotid duplex study on April 23, 2002, showing peak systolic velocity (PSV) of left CCA 38cm/
sec, PSV left ICA = 729 cm/sec, end-diastolic
velocity (EDV) of ICA 267cm/sec, and IC/CCA
ratio=19%. On September 24, 2002, patient underwent carotid stenting for severe proximal anastomotic stenosis (vein graft and native CCA with
cerebral protection) under Boston Scientic EPI: A
Carotid Stenting Trial for High-Risk Patients
(BEACH). Access under local anesthesia through
right femoral Dacron graft was obtained with 6F
sheath. A 5F Vitek catheter was advanced over the
Magic Torque™ wire one (Boston Scientic-Maple
Grove, MN) into the left CCA. Vitek catheter
(Cook, Bloomington, IN, USA) was exchanged for
a 6F 90cm shuttle sheath. Left carotid arteriography was performed (Fig. 83.1). EPI lter was
Fig. 83.1 Showing severe recurrent carotid interposition
vein graft stenosis
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_83
375
376
83 Carotid Stenting forCarotid Interposition Vein Graft Stenosis
deployed under uoroscopic guidance. Pre- stent
angioplasty with 4 × 30 Maverick™ balloon
(Boston Scientic-Maple Grove, MN) was performed. A 10 × 24 mm WALLSTENT® (Boston
Scientic-Maple Grove MN) was deployed followed by post-angioplasty with 6 × 20 mm
AVIATOR® balloon (Boston Scientic-Maple
Grove MN) (Fig.83.2). The procedure was performed under systemic heparinization. Final arteriography showed 10% residual stenosis with
TIMI III ow (Fig.83.3). Intracranial circulation
showed no evidence of distal embolization. A
small amount of debris was removed from lter
wire. The patient did well following carotid
angioplasty and stenting. Carotid duplex study
(October 2002) revealed peak ICA velocity of
86cm/sec and a peak CCA velocity of 120cm/
sec. Stent luminal diameter was 4.7 mm proximally, 5.3mm mid stent, and 4.9 mm distally.
Follow-up carotid duplex scan in March 2003
revealed PSV of CCA 110cm/sec, ICA 83 cm/
sec, and ICA/CCA ratio 0.8%. The patient was
doing well from a neurological standpoint but
expired in July 2003 from complications of
myeloid dysplasia.
Fig. 83.3 Arteriogram showing satisfactory post-carotid
stent arteriogram
Fig. 83.2 Post-carotid stent angioplasty
Discussion
The Sapphire trial (study of angioplasty with protection in patients at high risk for endarterectomy) using smart Nitinol stent (Johnson &
Johnson, Cordis, Warren, New Jersey) randomized 167 patients to carotid stenting and 167 to
CEA arm [1]. Patients treated with CAS had a
post-procedure adverse event (stroke, myocardial
infarction, or death) of 4.4% compared to 9.0%
randomized to surgery (p<0.06) and concluded
that CAS is not inferior to CEA [1]. The result of
carotid revascularization endarterectomy versus
stenting trial (CREST) included 2502 patients in
a randomized controlled fashion. There was a
higher rate of stroke or death within 4years of
References
377
randomization among combined symptomatic
and asymptomatic patients with stenting as compared to CEA (6.4% versus 4.7% p=0.03) with
a difference only observed in the asymptomatic
patients and not when symptomatic patients were
separately examined (8% versus 4.5% p=0.14)
[2, 3]. Rates of myocardial infarction were higher
in patients treated with endarterectomy (2.3%
versus 1.1% p= 0.03). In the long-term follow up, there was no difference in post-op MI, stroke,
and death among both groups [3].
Recurrent carotid stenosis following CEA is
attributed to myointimal hyperplasia (early usually less than 24months) or late atherosclerotic
stenosis thereafter. Overall, 30-day stroke and
death rate of 4.2% for surgical intervention for
recurrent carotid stenosis were reported by
O’Donnell in 48 patients with recurrent carotid
stenosis [4]. Recently, Cho etal. reported 3.1%
incidence of postoperative stroke following 66
redo carotid operations [5]. Although follow-up
in this patient was short as patient expired from
complications of hematologic malignancy, yet
absence of recurrent stenosis at least 6 months
following CAS was documented in this patient.
However, longer follow-up and results of randomized trials will clarify whether CAS for
carotid restenosis and for secondary or tertiary
recurrences is a durable procedure.
References
1. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen
BT, Mishkel GJ, etal. Protected carotid artery, stenting versus endarterectomy in high risk patients. N
Engl J Med. 2004;351:1493–501.
2. Brott TG, Hobson RW, Howard G, Roubin GS.CREST
investigators: stenting versus endarterectomy for
treatment of carotid artery stenosis. N Engl J Med.
2010;363(1):11–23.
3. Broh TG, Howard G, Rouban GS, Mescha JF.CREST
investigators: long term results of stenting versus endarterectomy for carotid artery stenosis. N Engl J Med.
2016;374(11):1011–20.
4. O’Donnell TF, Rodriguez AA, Fortunate JE,
Welch HJ, Mackey WC.Management of recurrent carotid artery stenosis: should asymptomatic lesions be treated surgically? J Vasc Surg.
1996;24:207–12.
5. Cho JS, Pandurangi K, Conrad MF, Shepard AS, Carr
JA, Nypaver TJ, Reddy DJ.Safety and durability of
redo carotid operation: an 11-year experience. J Vasc
Surg. 2004;39:155–61.
Carotid Artery Stenting
forRecurrent Internal Carotid
Artery Stenosis withContralateral
Internal Carotid Artery Occlusion
84
History andProcedures
A 59-year-old male with history of diabetes
mellitus, hypertension, chronic obstructive
pulmonary disease (nicotine abuse), and stable
coronary artery disease underwent right carotid
endarterectomy (CEA) for 90% stenosis of the
right internal carotid artery (ICA) with contralateral ICA occlusion on January 15, 2013,
under general anesthesia with EEG monitoring. Cephalad end of the plaque extended to the
level of C2 vertebral body (Fig. 84.1). Plaque
was unstable with ulceration and intraplaque
hemorrhage. Following endarterectomy, a
bovine pericardial patch was applied. Patient
had satisfactory postoperative course, and
yearly follow-up with carotid duplex imaging showed no evidence of restenosis. In June
2018, patient underwent carotid duplex follow up study which showed high-grade recurrent
stenosis (>80%). This was conrmed by CTA
of the neck. Patient did not experience any
neurological symptoms secondary to recurrent
carotid stenosis.
Fig. 84.1 Showing recurrent stenosis at the cephalad end of the CEA (C2 vertebral body)
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_84
379
380
Fig. 84.2 Post-CAS arteriogram showing patency of the
ICA with minimal residual stenosis
84 Carotid Artery Stenting forRecurrent Internal Carotid Artery Stenosis withContralateral Internal…
Patient underwent carotid artery stenting
(CAS) on July 9, 2018, via right femoral artery
access and insertion of 6 F sheath. This sheath
was exchanged for 7F 90cm long shuttle sheath.
The access to the origin of right common carotid
artery (CCA) was obtained by 5F Vitek catheter
(Cook, Bloomington, IN, USA). A 7×9×40mm
Xact® stent (Abbott Vascular, Abbott Park, IL,
USA) was deployed using lter protection. Preangioplasty was performed using 3.5 × 15 mm
Sprinter® RX balloon (Medtronic, Dublin,
Ireland), and post-angioplasty was performed
using 5.5×20 Viatrac (Abbott Vascular) balloon
with less than 5% residual stenosis (Fig. 84.2).
Patient was last seen in June 2009, and a follow up carotid duplex imaging did not show any evidence of recurrent stenosis.
Discussion
Early restenosis following CEA is often asymptomatic (within rst 2 years) and is most commonly due to myointimal hyperplasia. Late
recurrent stenosis (5 years following CEA) is
more likely due to recurrent atherosclerotic lesion
and can be managed with continuous medical
management, CAS, and redo CEA.The results of
CEA versus stenting trial (CREST) revealed
restenosis rate of 6.3% at 2years and were similar between carotid artery stenting and carotid
endarterectomy. Arhuidese et al. from VQI
database (2003–2015) evaluated 2863 carotid
interventions; 1047 (37%) had redo CEA, and
1816 (63%) underwent CAS [1]. The 30-day
ipsilateral stroke rate comparing CEA versus
CAS was 2.2% versus 1.3% (p=0.09) for asymptomatic patients and 1.2% versus 1.6% (p=0.60)
for symptomatic patients. The 30-day mortality
was 1.3% versus 0.6% (p=0.04), and myocardial
infarction (MI) occurred in 1.4% of CEA versus
1.1% of CAS patients (p=0.443). The incidence
of cranial nerve injury was 4.1% in redo CEA
group, and access site complications occurred in
5.3% of carotid stenting cases. At 1year, there
was no difference in postoperative stroke, MI,
and stroke/death/MI between CEA and CAS
groups. They concluded that redo CEA should be
avoided in patients with multiple comorbidities
(very sick) [1]. Bonati etal. compared long-term
risk of restenosis after stenting or endarterectomy
for CEA restenosis from a secondary analysis of
international carotid stenting study (ICSS) at 50
tertiary care centers in Europe, Australia, New
Zealand, and Canada [2]. Between May 2001 and
October 2008, 1713 patients were assigned into
CAS (737) and redo CEA (793). Moderate restenosis (≥50%) occurred in 274 patients after CAS
(cumulative 5-year restenosis rate) 40.7% and in
217 after CEA (29.6% p≤0.001). Patients with
moderate stenosis had a higher risk of ipsilateral
stroke than did individuals without restenosis in
the overall population (p=0.002). No differences
were noted in the risk of severe restenosis ≥70%
or subsequent stroke between the two groups [2].
In this patient, primary CEA (2013) was a technically challenging operation as the cephalad end
of the plaque was high (upper border of C2 vertebral body), and since the recurrence was primarily at the distal of the endarterectomy site, CAS
was preferred.
References
1. Arhuidese I, Obeid T, Nejim B, Locham S, et al.
Stenting versus endarterectomy after prior ipsilateral
carotid endarterectomy. J Vasc Surg. 2017;65:1–11.
2. Bonati LH, Gregson J, Dobson J, McCabe
DJM. Restenosis and risk of stroke after stenting or
endarterectomy for symptomatic carotid stenosis in
the international carotid stenting study (ICSS): secondary analysis of a randomized trial. Lancet Neurol.
2018;17(7):587–96.
Carotid Stenting andRedo Carotid
Endarterectomy inPatient
withBilateral Recurrent Carotid
Stenosis withType III Aortic Arch
History andProcedures
A 59-year-old male underwent left carotid endarterectomy (CEA) with bovine pericardial patch
on April 13, 2010, for >80% asymptomatic stenosis of the left internal carotid artery (ICA).
Plaque was high and extended above the level of
hypoglossal nerve. In order to get adequate exposure, posterior belly of digastric was mobilized
cephalad, occipital artery was ligated and divided,
and hypoglossal nerve was looped with vessel
loop. At the time of endarterectomy, plaque was
found to be unstable with severe ulceration and
intraplaque hemorrhage. Medical comorbidities
in this patient included ischemic myocardiopathy
secondary to signicant coronary artery disease
and alcohol abuse, diabetes mellitus (Type II),
hypertension, and chronic obstructive pulmonary
disease (COPD). During follow-up evaluation
with carotid duplex imaging, patient was found
to have 80–90% stenosis of the right ICA in April
2017. Because of higher cardiac risk, patient was
recommended right carotid stenting which was
attempted on May 4, 2017.
The right femoral artery was punctured percutaneously, and a 6F sheath was inserted. A Vitek
(Cook Medical, Bloomington, IN) catheter was
used for carotid arteriogram. Arch aortography
had revealed Type III aortic arch (bovine aortic
arch). Bilateral subclavian arteriogram showed
dominant left vertebral artery and hypoplastic
right vertebral artery. Right carotid arteriogram
85
Fig. 85.1 Brachiocephalic arteriogram showing severe
right ICA stenosis
showed 50% stenosis in the right common carotid
artery (CCA) 2cm proximal to its bifurcation and
a 90% eccentric stenosis at the origin of ICA
(Fig. 85.1). Left CCA showed 90% stenosis
(clamp trauma) at the proximal end of the CEA
and 50% stenosis of the distal endarterectomy
site of the left ICA (Fig.85.2). Over the glidewire
in the left external carotid artery (ECA), multiple
catheters were used (GLIDECATH® [Terumo
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_85
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382
85 Carotid Stenting andRedo Carotid Endarterectomy inPatient withBilateral Recurrent Carotid…
USA), and a 7 F shuttle sheath was advanced
using Amplatz Super Stiff wire. Following this, a
NAV 6 lter was deployed and following predilatation with a 3.5 mm balloon catheter,
10× 10 ×30mm Xact® stent (Abbott Vascular)
was deployed in the left CCA, and a postangioplasty was performed with a 6.5 mm balloon with <10% residual stenosis (Fig. 85.3).
Recurrent stenosis in the distal left ICA (at the
distal end of CEA) was not treated as the lesion
was not hemodynamically signicant, and in
order to treat to treat this lesion, two overlapping
stents would have been necessary.
2017, for severe right ICA stenosis with bovine
pericardial patch. Patient developed recurrent
carotid stenosis on the right side, and in April
2019, patient underwent redo right CEA for a
severe ulceration and intraplaque hemorrhage
associated with a recurrent lesion. Following
Fig. 85.2 Recurrent severe CCA stenosis (clamp trauma)
and moderate left ICA stenosis at the apex of
endarterectomy
redo CEA, a long vein patch harvested from the
right greater saphenous vein in the right groin
and upper thigh was performed. Patient had been
followed 6 months with carotid Doppler imaging
and has evidence of recurrent stenosis of 41–59%
Interventional Systems], Quick-Cross
at the distal end of the CEA in the left side.
[Spectranetics], Judkins Right 4 [Oscor]) so that
we can advance shuttle sheath into the
CCA. Glidewire was exchanged for Amplatz
Discussion
Super Stiff™ wire (Boston Scientic). In spite of
multiple attempts, we could not advance the shuttle sheath in to the CCA on the right side.
After failure of multiple attempts, right radial
artery approach was selected with a micropuncture technique; 6F sheath was inserted. Internal
mammary artery catheter was used to gain access
to the right CCA.Again, after multiple attempts,
with the use of different catheters, we were
unable to advance the guidewire into the right
ECA.All catheters and sheaths were not advanced
into the CCA but rather advanced into the arch of
the aorta. After multiple attempts, procedure was
aborted.
In order to improve the collateral ow, carotid
artery stenting (CAS) was performed on May 18,
2017, for recurrent left CCA stenosis by transfemoral approach. Left CCA access was obtained
using 5F Vitek catheter (Cook, Bloomington, IN,
The impact of aortic arch anatomy (kink/
tortuosity/Type III aortic arch) on successful completion of CAS has been previously described [1,
2]. In some patients with difculty in advancing
the shuttle sheath into the proximal CCA, alternate technique such as transbrachial or transradial
access (as in this patient) should be considered
[1]. Transcarotid artery revascularization (TCAR)
uses a direct cut down to expose the CCA in the
base of the neck coupled with cerebral blood ow
reversed as a suitable alternative technique to
transfemoral carotid stenting or CEA in high-risk
patients. Kashyap etal. compared 292 TCAR procedures with CEA in 371 patients. Postoperative
stroke and death were low in both groups and
were similar [2]. The composite end point of
stroke/death/MI at 1-month postoperative was
2.1% in TCAR and 1.7% in CEA group (p=ns).
Patient underwent right CEA on July 19,
References
383
Fig. 85.3 Deployment of left CCA stent
When patients are referred for recurrent carotid
stenosis, the best treatment modality depending
upon plaque morphology, creation of current
lesion, anticipated life expectancy, and anticipated neck “hostility.” Endovascular and open
reconstruction of the stages of the surgery need to
be taken into account in order to determine the
best approach for a particular situation. The timing and type of intervention should be balanced
between the risk of intervention, operator’s experience, and the risk of stroke with medical therapy
alone.
References
1. Madhal S, Rajagopal V, Bhatt DL, Bajezr
CT. Predictors of difcult carotid stenting is determined by aortic arch angiography. J Invasive Cardiol.
2008;20:200–4.
2. Kashyap VS, King AH, Foteh MI, Janko M, etal. A
multi-institutional of transcarotid artery revascularization compared to carotid endarterectomy. J Vasc Surg.
2019;70(1):123–9.
Part XXIV
Iliac Stenting