Acute carotid artery stenting in high grade

Multicenter clinical trials level 1 evidence favors the application of carotid endarterectomy in symptomatic patients, especially the in the elderly cohort. Carotid artery stenting has been proposed as a possible early alternative in selected patients after onset of ipsilateral neurologic symptoms. It is well known that treatment of acute stroke is time-dependent in patients with acute ischemic stroke caused by high-grade stenosis of the internal carotid artery, but intensive medical treatment in conjunction with intervention to improve stroke severity and clinical outcomes has not been established...

OBJECTIVE: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large-vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: Patients with tandem ICA-ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016...

OBJECTIVE: Carotid interventional trials have strict inclusion and exclusion criteria that make translation of their results to the real-world population challenging. Furthermore, the specialty of the operating surgeon and the role of clinical decision-making are not well studied. This study compares the effectiveness of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) in a real-world setting when the procedure is performed by fellowship-trained vascular surgeons. METHODS: A retrospective study was conducted of all consecutive patients undergoing CEA and CAS performed by vascular surgeons in a large rural tertiary health care system from 2004 to 2014...

Internal carotid artery (ICA) blister aneurysms are rare and challenging to successfully treat, using contemporary surgical or endovascular approaches, without partial or complete compromise of the parent vessel. We describe the use of a resheathable flow diverter, the Pipeline Flex Embolization Device (PFED) to perform stent-assisted coiling of a ruptured supraclinoid ICA blister aneurysm in a 56-year-old female who presented with a high-grade subarachnoid hemorrhage (SAH). The first PFED was deployed across the aneurysm neck to jail a microcatheter within the aneurysm dome, and then, two small coils were delivered into the aneurysm...

This study demonstrates the radiologic and clinical findings, etiologies and intervention strategy in 8 acute ischemic stroke patients with tandem occlusions. The mean age was 57 and mean NIHSS score was 19. Stent-assisted thrombectomy (SAT) was performed on all of the patients. Additionally, 6 patients underwent carotid artery stenting before SAT. Recanalization with TICI≥2b was attained in 7/8 patients. The 90thday median mRS was 2 and mortality was 1/8. The etiologies of the tandem occlusions were either extracranial high grade ICA stenosis/occlusion or cervical ICA dissection...

OBJECTIVE: We investigated whether the cerebral hemodynamic changes of pre- and poststenting in patients with severe carotid stenosis differ by stenosis grades. METHODS: We prospectively recruited patients who underwent carotid artery stenting (CAS) after acute ischemic stroke from June 2014 to December 2015. We compared the mean relative cerebral blood flow (rCBF) changes (measured by whole-brain computed tomography perfusion) pre- and poststenting in patients with high-grade severe stenosis (HGSS) (90%-99%) versus patients with low-grade severe stenosis (LGSS) (70%-89%)...

OBJECTIVE Acute tandem occlusions of the cervical internal carotid artery and an intracranial large vessel present treatment challenges. Controversy exists regarding which lesion should be addressed first. The authors sought to evaluate the endovascular approach for revascularization of these lesions at Gates Vascular Institute. METHODS The authors performed a retrospective review of a prospectively maintained, single-institution database. They analyzed demographic, procedural, radiological, and clinical outcome data for patients who underwent endovascular treatment for tandem occlusions...

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre...

We hereby report a novel technical approach for the treatment of acute stroke with underlying tandem occlusion. The so-called retriever wire supported carotid artery revascularization (ReWiSed CARe) technique, utilizing the wire of a stent-retriever as a guiding wire for carotid artery stenting, is technically feasible in tandem occlusions caused by an internal carotid artery (ICA) dissection or high grade ICA stenosis. This technique eliminates the need to use a long microwire in order to maintain the position inside the true lumen of a dissection...

In cases of acute stroke, differentiation between an occluded and a patent internal carotid artery (ICA) is crucial for diagnosis and management. Although CT angiography (CTA) can be highly accurate in defining high-grade stenosis and ICA occlusions, misleading ICA occlusion patterns are not rare in patients with acute stroke. We investigated the underlying causes of ICA pseudo-occlusions with CTA with respect to digital subtraction angiography. 11 out of 72 patients had pseudo-occlusion on CTA. Of these, there were three cases of tandem occlusions accompanying high-grade ICA stenosis, five cases of Distal ICA bifurcation occlusion as a result of atrial fibrillation, two cases of cervical ICA dissection and one acute thrombosis of the stent...

The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset)...

BACKGROUND: Little is known regarding the endovascular management of acute ischemic stroke (AIS) related to carotid artery dissection (CAD). OBJECTIVE: To report our interventional experience in AIS from CAD and to compare it with conservative treatment of CAD with intravenous thrombolysis (IVT) via systematic review. METHODS: Retrospective analysis of consecutive high-grade steno-occlusive CAD with National Institutes of Health Stroke Scale (NIHSS) >5 and ≤12 hours of last seen normal from 2 tertiary centers...

Extracranial carotid artery occlusion or high-grade stenosis with concomitant intracranial embolism causes severe ischemic stroke and shows poor response rates to intravenous thrombolysis (IVT). Endovascular therapy (EVT) utilizing thrombectomy assisted by carotid stenting was long considered risky because of procedural complexities and necessity of potent platelet inhibition-in particular following IVT. This study assesses the benefits and harms of thrombectomy assisted by carotid stenting and identifies factors associated with clinical outcome and procedural complications...

PURPOSE: Due to high thrombus load, acute stroke patients with tandem obstructions of the extra- and intracranial carotid arteries or the middle cerebral artery show a very limited response to systemic thrombolysis. Interventional treatment with mechanical thrombectomy-often in combination with acute stenting of underlying atherosclerotic stenosis or dissection-is increasingly used. It has been shown that such complex interventions are technically feasible. The lack of optimal management strategies and clinical data encouraged us to review our acute stroke interventions in patient with anterior circulation tandem lesions to determine lesion patterns, interventional approaches, and angiographic or clinical outcomes...

BACKGROUND: The degree of stenosis of carotid arteries is recognized as an important risk factor for ischemic stroke. However, high-grade stenosis does not always cause cerebrovascular events, whereas low- to moderate-grade stenosis may often cause strokes. It has been reported that there is an association between carotid intraplaque hemorrhage (IPH) and new brain ischemic events. CASE PRESENTATION: We present three patients with asymptomatic moderate carotid artery stenosis and carotid IPH who underwent both neurological and MRI at baseline and after at least 1 year's follow-up...

PURPOSE: Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome...

INTRODUCTION: Blood blister-like aneurysms (BBAs) are fragile and difficult to treat. Routine surgical and endovascular treatment methods, such as clipping, clip wrapping, primary coiling, or stent assisted coiling, have relatively high morbidity and mortality rates. In this study, we report clinical and angiographic results for treatment of ruptured BBAs using flow diverter stents. METHODS: We retrospectively reviewed patients who presented with subarachnoid hemorrhages caused by rupture of BBAs and who were treated using flow diverter stents at three neurointervention centers between January 2009 and January 2013...

INTRODUCTION: Acute stroke from occlusion of the intracranial internal carotid artery (ICA) is associated with a poor clinical outcome despite a thrombolytic treatment. The purpose of this study was to evaluate the outcome of mechanical thrombectomy using the Solitaire stent for the treatment of acute stroke patients with intracranial ICA occlusion. METHODS: A total of 104 consecutive patients with acute stroke were treated with mechanical thrombectomy using the Solitaire stent as a first-line intra-arterial treatment...

The incidence of first stroke in Germany is about 200.000, most of which are ischemic. The benefit of stroke unit treatment and systemic thrombolysis has been shown in large randomized trials. Diagnostic work-up besides neurologic examination includes cerebral imaging by CT or MR imaging including angiography, ultrasound of brain supplying arteries, ECG and Holter ECG and - if indicated - transesophageal echocardiography. Aspirin is the cornerstone of early secondary prevention in the acute phase, thereafter secondary prevention is determined by stroke etiology...

Treatment of acute stroke is time-dependent, with the best outcomes resulting from the earliest interventions. However, for patients with acute ischemic stroke due to a high-grade stenosis of the internal carotid artery, despite maximal medical treatment, an effective intervention to improve their neurologic symptoms and clinical outcome has not yet been established. There are two major concerns: first, cerebral revascularization in the acute stage remains challenging because of the possibility that hemorrhagic infarction or hyperperfusion syndrome will occur after revascularization; second, alarms about carotid artery stenting in patients with acute symptoms are related to the fact that, while with carotid endarterectomy the plaque is completely removed, after stenting it is only remodelled and its stabilization is essential to avoid embolic events during the procedure and in the post-operative period...