Emergency stenting to treat neurological complications occurring after carotid endarterectomy (original) (raw)
Related papers
endarterectomy Emergency stenting to treat neurological complications occurring after carotid
2010
OBJECTIVES The purpose of this study was to assess the efficacy of emergency stent implantation for the treatment of perioperative stroke after carotid endarterectomy (CEA). BACKGROUND Carotid endarterectomy has been proven safe and effective in reducing the risk of stroke in symptomatic and asymptomatic patients with Ͼ60% carotid artery stenosis. However, perioperative stroke has been reported in 1.5% to 9% of CEA cases. The management of such a complication is challenging. Recently, percutaneous transluminal carotid angioplasty with stent deployment has emerged as a valuable and alternative strategy for the treatment of carotid artery disease. METHODS Between April 1998 and February 2000, 18 of the 995 patients (1.8%) who had CEA in our institution experienced perioperative major or minor neurological complications. Of these, 13 patients underwent emergency carotid angiogram and eventual stent implantation, whereas the remaining five had surgery re-exploration. RESULTS Carotid angiogram was performed within 20 Ϯ 10 min and revealed vessel flow-limiting dissection (five cases) or thrombosis (eight cases). Percutaneous transluminal carotid angioplasty with direct stenting (self-expandable stent) was performed in all 13 cases. Angiographic success was 100%. Complete remission of neurological symptoms occurred in 11 of the 13 patients treated by stent implantation and in one of the five patients treated by surgical re-exploration (p ϭ 0.024). CONCLUSIONS Stent implantation seems to be a safe and effective strategy in the treatment of perioperative stroke complicating CEA, especially when carotid dissection represents the main anatomic problem.
Embolism to the brain during carotid stenting and surgery
Acta chirurgica Belgica
The aim of this study was to assess the prevalence and clinical relevance of microembolism in one hundred unselected patients submitted to 50 carotid endarterectomy (CEA) and 50 carotid stenting (CAS) procedures from January 2005 to January 2006 for hemodynamic lesions of the carotid bifurcation (> 70% stenosis). Material and methods : High-resolution Colour-Flow Mapping (CFM), Transcranial Doppler (TCD), cerebral computed tomography (CT) or magnetic resonance (MR) and four psychometric tests (Mini mental state, Beck depression inventory, Zung anxiety inventory, SF-12) were carried out in the preoperative evaluation in all the patients. In the CEAs loco-regional anesthesia (100%), patch angioplasty (84%) and Pruitt-Inahara shunt (4%) were employed ; in the CASs local anesthesia (100%), three different carotid stents (Precise-Cordis, Acculink-Guidant and Carotid Wallstent-Boston Scientific) and three temporary distal filter protection devices (Angioguard-Cordis, Accunet-Guidant, Filterwire-EZ-Boston Scientific), without pre-dilatation, were employed. TCD monitoring was used intra-operatively and 12 hours post-operatively to evaluate the presence and the number of microembolic events (ME's) and to investigate the efficiency of neuroprotective filter devices. The efficacy of the in situ opened filter was judged evaluating the decrease of mean blood velocity in ipsilateral middle cerebral artery and the reduction rate of microembolic events (number of microemboli detected during the entire procedure/number of microemboli detected during the filter positioning). Diffusion-weighted magnetic resonance imaging (DWI) of the brain was obtained within 24 to 48 hours after the procedures to detect new ischemic brain lesions. Psychometric tests were repeated at the discharge of the patient and after two months to evaluate cognitive faculties. Results : During postoperative period (30 days) and follow-up, no procedure-related death and three regressive minor strokes occurred : 1 in CEA (2%) and 2 in CASs (4%) ; a cranial nerve lesion occurred in CEA (2%). TCD monitoring showed ME's (a mean of five events) in 37 CEAs (74%) and in 50 CASs (100%) (a mean of 60 ME's). In five patients submitted to CAS repeated microemboli occurred during one hour postoperative TCD control (10%). A 10-30% decrease of mean blood velocity basal value was recorded in the ipsilateral middle cerebral artery when the filter device was opened. A mean 70% reduction of ME's was obtained with a cerebral protection system deployed. Postoperative DWI detected new focal ischemic lesions in 24 patients [22 after CAS (44%) (a mean of 5 new ipsi and contra-lateral lesions) , and 2 after CEA (4%). Cognitive capability worsened in 20 patients [18 after CAS (36%) e 2 after CEA (4%)]. Conclusions : Mortality and morbidity rates of patients submitted to CAS are comparable to the results obtained by CEA. A great number of ME's are recorded by TCD during endovascular procedures, more than during open surgery. ME's due to CAS are reduced by filter protection devices, but the cognitive faculties in a great number of "asymptomatic" patients are decreased after CAS.
Management of stroke during carotid angioplasty and stenting
Techniques in Vascular and Interventional Radiology, 2000
Intracranial embolization and resultant ischemic stroke are the primary risks of carotid angioplasty and stenting. Emboli are generated in all cases of angioplasty and stenting; most of these are of little or no clinical significance. There are several other technique-related sources of emboli, most of which are preventable. There are several angiographic and clinical signs of intracranial embolus. A stub of vessel or filling defect is not reliably seen. It is important to assess the extent of these collaterals and the status of the lenticulostdate arteries arising from the proximal middle cerebral artery; they determine the time available for rescue. The first clinical indication of a problem is often a change in the patient's mental status. Focal neurological deficits will not be recognized unless serial neurological examinations are performed. Once it has been determined that an event has occurred, general supportive and monitoring measures should be undertaken. It is important to exclude recent silent infarct, as fibrinolysis is contraindicated in that setting. After this has been excluded, systemic hepadnization and definitive therapy (local intracranial intra-arterial thrombolysis and/or mechanical disruption or thrombus) can be undertaken.
Annals of Vascular Surgery, 2001
In order to maximize the efficacy of carotid endarterectomy (CEA), the rate of perioperative stroke must be kept to a minimum. A recent analysis of carotid surgery at our institution found that most perioperative strokes were due to technical errors resulting in thrombosis or embolization. From 1992 through 1997 we have performed nearly 1200 additional CEAs; the purpose of this study was to examine recent trends in the causes of perioperative stroke, with specific attention to differences in symptomatic and asymptomatic patients. The records of 1041 patients undergoing 1165 CEAs were reviewed from a prospectively compiled database. Analysis of these data showed that a history of preoperative stroke appears to increase the risk of perioperative stroke after CEA. Surgical factors associated with perioperative stroke include an inability to tolerate clamping, use of an intraarterial shunt, and having surgery performed under general anesthesia; these factors are clearly interrelated and only the use of intraarterial shunting remains a risk factor by multivariate analysis. Over half of all perioperative strokes (54%) appear to be caused by intraoperative or postoperative thrombosis and embolization. The patient requiring use of intraarterial shunting and/or with a preoperative stroke most likely has a significant watershed area of brain at increased risk of infarction. However, technical errors are still the most common cause of perioperative stroke in these high-risk patients. Such high-risk patients may manifest clinical stroke from small emboli that may be tolerated by asymptomatic clamptolerant patients. Technical precision and appropriate cerebral protection are particularly critical for successful outcomes in high-risk patients.
Stroke From Carotid Endarterectomy: When and How to Reduce Perioperative Stroke Rate?
European Journal of Vascular and Endovascular Surgery, 2001
Objectives: to analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. Patients and Methods: from January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. , and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. Conclusions: in our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.
Early carotid endarterectomy after acute stroke
Journal of Vascular Surgery, 2004
Purpose: Carotid endarterectomy (CEA) after acute stroke is generally delayed 6 to 8 weeks because of fear of stroke progression. This delay can result in an interval stroke rate of 9% to 15%. We analyzed our results with CEA performed within 1 to 4 weeks of stroke. Methods: Records for all patients undergoing CEA after stroke between 1980 and 2001 were analyzed. Perioperative evaluation included carotid duplex scanning or angiography, and head computed tomography or magnetic resonance imaging. All patients with nonworsening neurologic status, additional brain territory at risk for recurrent stroke, and severe ipsilateral carotid stenosis underwent CEA. Patients were grouped according to time of CEA after stroke: group 1, first week; group 2, second week; group 3, third week; group 4, fourth week. Statistical analysis was performed with the 2 test, logistic regression, and analysis of variance. Results: Two hundred twenty-eight patients underwent CEA within 1 to 4 weeks of stroke. Perioperative permanent neurologic deficits occurred in 2.8% of patients in group 1 (72 procedures), 3.4% of patients in group 2 (59 procedures), 3.4% of patients in group 3 (29 procedures), and 2.6% of patients in group 4 (78 procedures). There was no relationship between location or size of preoperative infarct and time of surgery. Only preoperative infarct size correlated with probability of neurologic deficit after CEA (P < .05).
Ischemic Cerebral Lesions after Carotid Surgery and Carotid Stenting
European Journal of Vascular and Endovascular Surgery, 2007
Objectives. To evaluate the risk of new ischemic cerebral lesions after carotid endarterectomy and carotid stenting and their clinical significance. Methods. Prospective and non-randomized single-center study including 121 patients with symptomatic and asymptomatic significant carotid stenosis. 60 patients were treated by surgery and 61 treated by carotid stenting. Stenting was restricted to patients at high risk for surgery. Neurological examination and Diffusion-Weighted Cerebral Magnetic Resonance (DW-MRI) were performed before and after each procedure. The presence, location and volume of new cerebral lesions were determined. Results. In the surgical group, 2 minor strokes were registered. DW-MRI showed new lesions in 7 patients (11.6%). All except one were located in the ipsilateral anterior circulation.
Focal ischemia of the brain after neuroprotected carotid artery stenting
Acc Current Journal Review, 2004
This study sought to assess the incidence of cerebral ischemia in nonselected patients undergoing neuroprotected carotid angioplasty and stenting (CAS) without preceding multiple-vessel diagnostic angiography. BACKGROUND Protection devices to prevent distal embolization during CAS are presently under clinical investigation. Diffusion-weighted magnetic resonance imaging (MRI) visualizes recent ischemia of the brain and may aid in assessing the efficacy of protection devices.