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Published on: May 9, 2013
A Novel Staged Revascularization Strategy for Bilateral Severe Internal Carotid Artery Stenosis at High Risk for
Koji Hashimoto1, Hideyuki Yoshioka1, Kazuya Kanemaru1
1Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan.
Insights
A new staged surgical strategy effectively prevents hyperperfusion syndrome (HPS) in patients with bilateral severe internal carotid artery stenosis. Revascularizing the less affected side first improves blood flow and reduces HPS risk during subsequent treatment.
Area of Science:
- Neurology
- Vascular Surgery
- Cerebrovascular Disease
Background:
- Bilateral severe internal carotid artery stenosis often leads to reduced cerebrovascular reactivity (CVR) due to poor collateral blood flow.
- Revascularization in these patients carries a significant risk of developing hyperperfusion syndrome (HPS).
Purpose of the Study:
- To introduce and evaluate a novel staged surgical strategy for preventing postoperative HPS in patients with bilateral severe internal carotid artery stenosis.
Main Methods:
- Prospective enrollment of patients with bilateral severe cervical internal carotid artery stenosis and CVR of 10% or less on one side.
- Initial carotid artery stenting on the side with milder CVR decrease (lower-risk side).
- Subsequent contralateral carotid endarterectomy or stenting after a 4-8 week interval.
Main Results:
- CVR on the greater-risk side improved to over 10% within one month after the initial procedure in all three cases.
- Regional cerebral blood flow on the contralateral greater-risk side was 114% one day after the second treatment.
- No cases of HPS developed postoperatively.
Conclusions:
- A staged revascularization approach, prioritizing the lower-risk side, is effective in preventing HPS.
- This strategy offers a safe and viable option for managing complex bilateral internal carotid artery stenosis.
Objective:
Since bilateral severe internal carotid artery stenosis often is associated with severely decreased cerebrovascular reactivity (CVR) due to poor collateral blood flow, revascularization carries a high risk for development of hyperperfusion syndrome. In this study, we report a new staged strategy to prevent postoperative hyperperfusion syndrome in such patients.
Methods:
Bilateral severe cervical internal carotid artery stenosis patients with decreased CVR to 10% or less on one side were prospectively enrolled in this study. We first performed carotid artery stenting on the side with the milder CVR decrease (lower-risk side), aiming to improve hemodynamics associated with the severe CVR decrease on the greater-risk side. Then, carotid endarterectomy or carotid artery stenting was performed on the contralateral side after an interval of 4-8 weeks.
Results:
In all 3 cases enrolled in this study, CVR on the greater-risk side improved to 10% or more 1 month after the first treatment. The ratio of regional cerebral blood flow on the contralateral greater-risk side was 114% 1 day after the second treatment, and HPS did not develop in any of the cases.
Conclusions:
Our treatment strategy, in which revascularization on the lower-risk side precedes that on the greater-risk side, is effective for the prevention of HPS in bilateral ICA stenosis patients.
