Angioplasty and Stenting for Carotid Artery Near-Occlusion
Carotid near-occlusion (CNO) is the type of severe atherosclerotic stenosis of the internal carotid artery (ICA) with or without collapse of the vessel distally to the narrow part. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), severity of ICA stenosis highly correlates with the risk of stroke, except for cases of extremely critical stenosis > 94%, where the risk is lower, and, according to recent guidelines, conservative treatment is preferable. This consideration is questionable due to the recent data about early stroke recurrence and worldwide practice. Rapid improvement of endovascular technique during the last decade makes carotid angioplasty and stenting (CAS) a feasible option for the treatment of patients with CNO and is widely reported in the literature. However, in uncertain circumstances, more scientific data are necessary to fulfill the gap in indications, terms and risks of CAS for CNO.
The aim. To evaluate the results of the treatment of patients with CNO after CAS.
Materials and methods. Three hundred and fifteen patients were surgically treated at Scientific-Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine due to ICA stenosis between 2010 and 2020. Among them, 39 (12.4%) patients (11 woman / 28 men (age 57.9±2.1 years) had CNO and underwent CAS at our Center. Patient population, clinical and radiological investigations, procedure compli-cations were investigated. Procedure complications (stroke, hemodynamic depression [HD] and hyperperfusion syndrome [HPS]) were meticulously studied. All the patients had routine ultrasound and clinical check 30 days after the procedure.
Results. All the patients with CNO were successfully stented with the improvement of the site of stenosis after CAS, with only minimal residual stenosis in cases of severe HD. We observed two procedural vascular accidents, first patient had transient ischemic attack (TIA) and one had stroke due to middle cerebral artery occlusion after stent placement and further urgent mechanical thrombectomy. The patient had no neurologic decline and was discharged home. We didn’t observe any cases of myocardial infarction (MI) or death in our series during the hospital stay. HD was seen in 13 (33.3%) patients, and mostly resolved after the procedure except for 3 casesthat required prolonged intensive care unit stay. HPS was diagnosed in 2 (5.1%) patients and also didn’t have anyneurologic consequences after supportive care. During 30 days of follow-up, one (2.6%) patient had TIA because of anti-platelets cessation and 1 (2.6%) patient had MI after 1 week since discharge. All control images revealedstents patency without the evidence of critical residual stenosis.
Conclusions. CNO remains important diagnostic and therapeutic challenge. Recent data showed high risk ofrecurrent stroke in case of CNO on best medical therapy, especially at an early stage, but it remains a preferred option according to guidelines. Considering worldwide improvement of stroke rates after CAS in patients with symptomatic ICA stenosis, further studies are warranted to evaluate its risk-benefit in case of CNO, especially with full collapse. Our data shows that CAS with careful preoperative diagnosis and planning is an effective procedure for selected patients with CNO.
2. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. National Institute of Neurological Disorders and Stroke Stroke and Trauma Division. North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators. Stroke. 1991;22(6):816-7. https://doi.org/10.1161/01.str.22.6.816
3. Johansson E, Fox AJ. Carotid Near-Occlusion: A Comprehensive Review, Part 1 – Definition, Terminology, and Diagnosis. AJNR Am J Neuroradiol. 2016;37(1):2-10. https://doi.org/10.3174/ajnr.A4432
4. Akkan K, Ilgit E, Onal B, Cindil E, Solak EP, Oncu F, et al. Endovascular Treatment for Near Occlusion of the Internal Carotid Artery: 30-Day Outcome and Long-Term Follow-Up. Clin Neuroradiol. 2018;28(2):245-52. https://doi.org/10.1007/s00062-016-0546-8
5. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ; Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet.2004;363(9413):915-24.???https://doi.org/10.1016/S0140-6736(04)15785-1
6. Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J,Halliday A, et al. Management of atherosclerotic carotidand vertebral artery disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(1):3-81. https://doi.org/10.1016/j.ejvs.2017.06.021
7. Antonopoulos CN, Giosdekos A, Mylonas SN, Liapis CD. Management of internal carotid artery near-occlusion: the need for updated evidence. Ann Transl Med. 2020;8(19):1263. https://doi.org/10.21037/atm.2020.03.148
8. Lippman HH, Sundt TM Jr, Holman CB. The poststenotic carotid slim sign: spurious internal carotid hypolasia. Mayo Clin Proc. 1970;45(11):762-7.
9. Johansson E, Fox AJ. Carotid Near-Occlusion: A Comprehensive Review, Part 2 – Prognosis and Treatment,Pathophysiology, Confusions, and Areas for Improvement. AJNR Am J Neuroradiol. 2016;37(2):200-4. https://doi.org/10.3174/ajnr.A4429
10. Gu T, Aviv RI, Fox AJ, Johansson E. Symptomatic carotid near-occlusion causes a high risk of recurrent ipsilateral ischemic stroke. J Neurol. 2020;267(2):522-30. https://doi.org/10.1007/s00415-019-09605-5
11. Fox AJ, Eliasziw M, Rothwell PM, Schmidt MH, Warlow CP, Barnett HJ. Identification, prognosis, and management of patients with carotid artery near occlusion. AJNR Am J Neuroradiol. 2005;26(8):2086-94.
12. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Circulation. 2011;124(4):489-532.???https://doi.org/10.1161/CIR.0b013e31820d8d78
13. Johansson E, Fox AJ. Near-occlusion is a common variant of carotid stenosis: study and systematic review. Can J Neurol Sci. 2022;49(1):55-61. https://doi.org/10.1017/cjn.2021.50
14. Batchelder AJ, Saratzis A, Ross Naylor A. Editor’s Choice – Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg. 2019;58(4):479-93. https://doi.org/10.1016/j.ejvs.2019.06.003
15. Shchehlov DV, Svyrydiuk OY, Vyval MB, Sydorenko OF, Nosenko NM, Gudym MS. Simultaneous bilateral angioplasty and stenting for carotid stenosis – a single center experience. J Med Life. 2022;15(2):252-7. https://doi.org/10.25122/jml-2021-0274