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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Cerebral haemodynamics and embolization during carotid angioplasty in high-risk patients
A J McCleary1, M Nelson, N M Dearden
1Department of Vascular Surgery, The General Infirmary at Leeds, UK.
Insights
Carotid angioplasty and stenting in high-risk patients with internal carotid artery stenosis did not show advantages over surgery. Monitoring revealed significant ischemia and embolization, suggesting potential risks outweigh benefits for these stroke-prone individuals.
Area of Science:
- Vascular Surgery
- Interventional Neurology
- Cerebrovascular Disease
Background:
- Patients with >70% symptomatic internal carotid artery (ICA) stenosis and contralateral ICA occlusion face high stroke risk after carotid endarterectomy.
- Carotid angioplasty and stenting (CAS) theoretically offers shorter ischemic times, potentially benefiting this high-risk group.
Purpose of the Study:
- To evaluate the safety and efficacy of CAS in patients with severe symptomatic ICA stenosis and contralateral occlusion.
- To assess hemodynamic ischemia and embolic events during CAS in this specific patient cohort.
Main Methods:
- Nine patients underwent CAS and were monitored using near-infrared spectroscopy, jugular venous oximetry, and transcranial Doppler ultrasonography.
- Monitoring aimed to detect hemodynamic ischemia and embolic events during the procedure.
Main Results:
- Four patients experienced significant ischemia upon guidewire crossing the stenosis.
- All patients showed transient ischemia and embolic showers during balloon inflation, with persistent embolization in three.
- One patient suffered a disabling stroke due to internal carotid artery thrombosis.
Conclusions:
- CAS in high-risk patients with severe ICA stenosis and contralateral occlusion may not offer advantages over conventional surgery.
- The procedure carries risks of hemodynamic ischemia and embolization, potentially negating theoretical benefits.
Background:
Patients with symptomatic internal carotid artery (ICA) stenosis greater than 70 per cent in association with a contralateral ICA occlusion may have an increased risk of stroke following carotid endarterectomy. Such patients might benefit from the theoretically shorter ischaemic time offered by carotid angioplasty and stenting.
Methods:
Nine patients who underwent carotid angioplasty and stenting were monitored using near-infrared spectroscopy, continuous jugular venous oximetry and transcranial Doppler ultrasonography to detect both haemodynamic ischaemia and embolic events.
Results:
Significant ischaemia occurred in four of the nine patients once the stenosis had been crossed by the guidewire (spectroscopy and oximetry). Inflation of the angioplasty balloon resulted in a brief period of ischaemia and showers of emboli in all patients (ultrasonography) and this persisted for more than 3 min after balloon deflation in three patients. One patient had a major disabling stroke due to ICA thrombosis.
Conclusion:
Angioplasty and stenting in these high-risk patients may not confer any advantage over conventional surgery in terms of both haemodynamic ischaemia and embolization.
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