Article
Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion: A Prospective, Controlled, Single-Center Study
Vascular and Endovascular Surgery 2014, Vol. 48(4) 305-310 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414525863 ves.sagepub.com
Yi-Ling Fan1, Jie-Qing Wan1, Zheng-Wen Zhou1, Lei Chen1, Yong Wang1, Qing Yao1, and Ji-Yao Jiang1
Abstract Symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment remains a dismal disease when untreated. In this prospective, single-center, controlled study, we investigated the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic ICA occlusion. Forty patients with symptomatic chronically occluded ICA were assigned to receive endovascular recanalization (group A, n ¼ 18) or conservative management (group B, n ¼ 22). The primary end point was 100% complete recanalization of the primary occlusion at 60 minutes, and secondary end points were improvement in neurologic function and cognitive function. Patients in the 2 groups were comparable in demographic and baseline characteristics. Successful recanalization was achieved in 88.9% (16 of 18) of patients with the restoration of Thrombolysis in Myocardial Ischemia/Thrombolysis in Cerebral Ischemia 2 or 3 flow. There was no procedural or new cerebral ischemic event. Improvement in brain perfusion was observed in 12 (12 of 18, 75%) patients on single-photon emission computed tomography. Improvement in neurologic function defined as a reduction of 4 points on the National Institutes of Health Stroke Scale (NIHSS) at 6 months was observed in group A (baseline, 6.83 + 3.01 vs 6 months, 2.61 + 1.20; P < .01) and group B (baseline, 6.05 + 2.75 vs 6 months, 4.77 + 1.69; P < .05). A significant difference in NIHSS scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Improvement in cognitive function defined as an increase of 8 on the Montreal Cognitive Assessment (MoCA) was observed in group A at 3 and 6 months (baseline, 14.67 + 3.56 vs 3 months, 24.17 + 3.55 and 6 months, 24.72 + 2.85; P < .01). Significant improvement in MoCA was also observed in group B (P < .01). Furthermore, a significant difference in MoCA scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Endovascular recanalization is feasible and safe for patients with symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization. Keywords symptomatic chronic ICA occlusion, revascularization, National Institutes of Health Stroke Scale, Montreal Cognitive Assessment
Introduction The natural outcome of symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment is dismal.1-4 There is a direct correlation between the risk of ipsilateral stroke and chronic carotid artery occlusion5; the overall rate of subsequent stroke is 7% per year and 5.9% per year for ischemic stroke ipsilateral to the chronically occluded carotid artery.6 Thromboendarterectomy and other surgical procedures have been attempted for ICA occlusion over the years. Endarterectomy prevents stroke in patients with ICA stenosis, but the success rate in recanalizing occlusions is as low as 34% because of technical difficulties7 and it also appears ineffective for occlusive lesions beyond the acute phase. Surgical bypass
may be a natural resolution for ICA occlusion, although the large-scale international randomized extracranial–intracranial bypass trial failed to show any benefit.8,9 Currently, with the development of endovascular devices, more and more studies have proved that endovascular revascularization may play an
1
Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University Medical College, Shanghai, China Corresponding Author: Ji-Yao Jiang, Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University Medical College, Shanghai 200127, China. Email: [email protected]
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
306
Vascular and Endovascular Surgery 48(4)
important role in treating chronic ICA occlusion.1,3,4 Lin et al3 reported that endovascular recanalization can be performed for symptomatic ICA occlusion, even in the chronic stage of the illness. Successful carotid artery stenting can improve global cognitive function as well as attention and psychomotor processing speed in patients with chronic ICA occlusion. There have been few studies on the efficacy of endovascular recanalization of ICA occlusion compared with conservative medical therapy. In this prospective, single-center, controlled study, we sought to investigate the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic carotid artery occlusion. The primary end point of the study was 100% complete recanalization of the primary occlusion at 60 minutes and the secondary end points were improvement in neurologic function and cognitive function.
Materials and Methods Patients Patients with symptomatic chronic ICA occlusion who sought medical treatment at the Stroke Center of our hospital between January 1, 2008, and April 30, 2012, were prospectively recruited for the current study. Diagnosis of occlusion of the ICA was based on conventional angiography with sufficient contrast medium and a prolonged run. A patient was eligible for the study (1) if the patient was aged 18 years, (2) if his or her National Institutes of Health Stroke Scale (NIHSS) score was 8, (3) if he or she had a Thrombolysis in Cerebral Ischemia (TICI) score of 0 or 1 in an accessible vessel, (4) if no intracerebral hemorrhage was detected on computed tomography (CT) scan, (5) if magnetic resonance imaging study revealed an infarct size .05). Improvement in cognitive function defined as an increase of 8 on the MoCA was observed in patients undergoing endovascular recanalization 3 and 6 months after the procedure (baseline, 14.67 + 3.56 vs 3 months, 24.17 + 3.55 and 6 months, 24.72 + 2.85; P < .05). Significant improvement was also observed in patients receiving conservative medical therapy only (P < .05). Furthermore, a significant difference in MoCA scores was noted between group A and group B at 1, 3, and 6 months after the procedure (P < .05 or .001; Table 3).
Discussion The outcome of symptomatic chronic occlusion of the ICA is severely hampered by the lack of treatment options and the few options available such as endarterectomy and surgical bypass, apart from carrying surgical risks, remains a dismal disease. Grubb et al2 reported that symptomatic carotid artery occlusion patients with hemodynamic impairment are at apparently high risk of subsequent stroke if managed by medical therapy alone. It remains to be determined whether chronically occluded carotid arteries can be revascularized with a favorable outcome compared to conservative medical therapy. Anecdotal evidence suggests that endovascular recanalization by stent placement and angioplasty is effective in symptomatic chronically occluded carotid artery patients. The current study is the first prospective, controlled, single-center study on the feasibility and efficacy of endovascular recanalization in patients with symptomatic chronically occluded carotid artery. We reported an angiographic success rate of 88.9%; in addition, we observed no serious procedure-related adverse events. These findings suggest that the endovascular revascularization approach is safe and feasible and effective for patients with symptomatic chronically occluded carotid artery. One critical consideration in selecting patients for this therapy is the risk of subsequent stroke with medical therapy alone. We selected patients with symptomatic chronically occluded carotid artery with angiographically demonstrable
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
Fan et al
309
Figure 2. Brain perfusion before (A) and after (B) endovascular recanalization in a 35-year-old patient with internal carotid artery (ICA) occlusion. Table 2. The National Institutes of Health Stroke Scale (NIHSS) Scores in Patients With Symptomatic Chronic Occlusion of the Internal Carotid Artery Receiving Endovascular Recanalization (Group A) or Conservative Therapy (Group B).
Baseline Postintervention 1 week 1 month 3 months 6 months
Group A
Group B
P
6.83 + 3.01
6.05 + 2.75
.39
5.89 + 2.35 3.83 + 1.92 3.06 + 1.16 2.61 + 1.20
6.00 + 6.10 + 4.77 + 4.77 +
.89 .04 .02 0
2.73 2.64 1.95 1.69
ICA occlusion and ipsilateral cerebral hypoperfusion on SPECT. These patients typically face an annual risk of 7% for subsequent stroke, which is substantially increased (around 30% per year) when hemodynamic impairment is present distal to the occluded artery. In addition, several technical issues need to be carefully prepared when occluded carotid arteries are considered for endovascular recanalization procedures. These include protection of the cerebral circulation from distal embolism during the procedure and how to pass a guidewire across a long occlusive lesion. We divide occluded carotid arteries into 3 categories according to the length of occlusion. Type 1 occlusion is located at the cervical segment C1, which is easy to manipulate with lesser risk of distal embolism. A single stent may be sufficient to achieve a better outcome. The vessel portion distal to the stent
Table 3. The Montreal Cognitive Assessment (MoCA) Scores in Patients With Symptomatic Chronic Occlusion of the Internal Carotid Artery Receiving Endovascular Recanalization (Group A) or Conservative Therapy (Group B).
Baseline Postintervention 1 week 1 month 3 months 6 months
Group A
Group B
P
14.67 + 3.56
14.91 + 3.39
.83
+ 3.88 + 2.75 + 2.68 + 2.97
.49 .03 0 0
15.33 20.56 24.17 24.72
+ 3.25 + 4.06 + 3.55 + 2.85
16.14 18.18 18.18 19.1
may become narrowed but usually returns to the normal size at 1 to 3 months of follow-up. Type 2 occlusion is located from C1 to the petrous segment C2. Two or more stents are needed to achieve revascularization in type 2 occlusion. Guidewire is easy to control within this portion of the carotid artery as it is straight with less possibility of penetrating the vessel wall. An embolic protection device is useful, but sometimes it could not be used when the stenosis is very hard, and the manipulation of the device is technically difficult. Type 3 originates from C1 to the ophthalmic (C6) or communicating (C7) segment, which is the most difficult to manipulate and carries substantial risks. There are at least 2 major curves in this segment with even more in those who have severe arteriosclerosis, causing more difficulty for manipulation. As this segment is within the cranium, the consequence is enormous
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
310
Vascular and Endovascular Surgery 48(4)
if and once bleeding occurs. Some recent known embolic protection devices are nearly impossible to be placed to the distal part of occlusion. Long manipulation without any protection increases the risk of acute thrombosis. In this scenario, surgical bypass could be a safer approach.8,9 Our current series focused mostly on type 1 and 2 occlusion, and our findings suggest that the endovascular revascularization approach is feasible and safe in these patients. More importantly, compared with patients receiving conservative medical therapy, endovascular recanalization resulted in marked improvement in neurologic and cognitive outcomes. Although both endovascular recanalization and conservative management resulted in noticeable improvement in neurologic and cognitive outcomes with greater benefit seen in endovascular recanalization patients, it remains to be investigated whether endovascular recanalization is associated with reduced risk of subsequent stroke, which, however, requires studies with a larger sample population and a longer follow-up period. In conclusion, endovascular recanalization is feasible and safe for patients with type 1 and 2 symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization. We recommend that the endovascular approach be considered in patients with type 1 and 2 occlusion exhibiting hemodynamic impairment, who may represent the population most likely to benefit from such aggressive therapies without incurring substantial risks. Authors’ Note Yi-Ling Fan and Jie-Qing Wan contributed equally to the work and are cofirst authors. No support from grants and outside funding, drugs, or equipment was used in this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Terada T, Yamaga H, Tsumoto T, Masuo O, Itakura T. Use of an embolic protection system during endovascular recanalization of a totally occluded cervical internal carotid artery at the chronic stage: case report. J Neurosurg. 2005;102(3):558-564. 2. Grubb RL Jr, Derdeyn CP, Fritsch SM, et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA. 1998;280(12):1055-1060. 3. Lin MS, Lin LC, Li HY, et al. Procedural safety and potential vascular complication of endovascular recanalization for chronic cervical internal carotid artery occlusion. Circ Cardiovasc Interv. 2008;1(2):119-125.
4. Kim WH, Min P-K, Kim DJ, Shim WH. Successful carotid stenting for chronic total occlusion of the internal carotid artery. Korean Circ J. 2010;40(6):288-291. 5. Young FB, Weir CJ, Lees KR; GAIN International Trial Steering Committee and Investigators. Comparison of the National Institutes of Health Stroke Scale with disability outcome measures in acute stroke trials. Stroke. 2005;36(10):2187-2192. 6. Toglia J, Fitzgerald KA, O’Dell MW, Mastrogiovanni AR, Lin CD. The mini-mental state examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome. Arch Phys Med Rehabil. 2011;92(5): 792-798. 7. Paty PS, Adeniyi JA, Mehta M, et al. Surgical treatment of internal carotid artery occlusion. J Vasc Surg. 2003;37(4):785-788. 8. Kanamaru K, Araki T, Kawakita F, et al. STA-MCA bypass for the treatment of ischemic stroke. Acta Neurochir Suppl. 2011; 112:55-57. 9. Muroi C, Khan N, Bellut D, Fujioka M, Yonekawa Y. Extracranial– intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience. Br J Neurosurg. 2011; 25(3):357-362. 10. Dewey HM, Sherry LJ, Collier JM. Stroke rehabilitation 2007: what should it be? Int J Stroke. 2007;2(3):191-200. 11. Lin MS, Chiu MJ, Wu YW, et al. Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia. Stroke. 2011;42(10):2850-2854. 12. Miyamoto N, Naito I, Takatama S, Shimizu T, Iwai T, Shimaguchi H. Urgent stenting for patients with acute stroke due to atherosclerotic occlusive lesions of the cervical internal carotid artery. Neurol Med Chir (Tokyo). 2008;48(2):49-56. 13. Sposato LA, Gleichgerrcht E, Manes F. Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia. Stroke. 2012; 43(1):e10. 14. Iwata T, Mori T, Tajiri H, Miyazaki Y, Nakazaki M. Long-term angiographic and clinical outcome following stenting by flow reversal technique for chronic occlusions older than 3 months of the cervical carotid or vertebral artery. Neurosurgery. 2012; 70(1):82-90. 15. Mori T, Kazita K, Chokyu K, Mima T, Mori K. Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol. 2000;21(2): 249-254. 16. Mori T, Fukuoka M, Kazita K, Mori K. Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. AJNR Am J Neuroradiol. 1998;19(8):1525-1533. 17. Levy EI, Hanel RA, Bendok BR, et al. Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis. J Neurosurg. 2002;97(6):1294-1301. 18. Bosiers M, de Donato G, Deloose K, et al. Does free cell area influence the outcome in carotid artery stenting? Eur J Vasc Endovasc Surg. 2007;33(2):135-141.
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion: A Prospective, Controlled, Single-Center Study
Vascular and Endovascular Surgery 2014, Vol. 48(4) 305-310 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414525863 ves.sagepub.com
Yi-Ling Fan1, Jie-Qing Wan1, Zheng-Wen Zhou1, Lei Chen1, Yong Wang1, Qing Yao1, and Ji-Yao Jiang1
Abstract Symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment remains a dismal disease when untreated. In this prospective, single-center, controlled study, we investigated the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic ICA occlusion. Forty patients with symptomatic chronically occluded ICA were assigned to receive endovascular recanalization (group A, n ¼ 18) or conservative management (group B, n ¼ 22). The primary end point was 100% complete recanalization of the primary occlusion at 60 minutes, and secondary end points were improvement in neurologic function and cognitive function. Patients in the 2 groups were comparable in demographic and baseline characteristics. Successful recanalization was achieved in 88.9% (16 of 18) of patients with the restoration of Thrombolysis in Myocardial Ischemia/Thrombolysis in Cerebral Ischemia 2 or 3 flow. There was no procedural or new cerebral ischemic event. Improvement in brain perfusion was observed in 12 (12 of 18, 75%) patients on single-photon emission computed tomography. Improvement in neurologic function defined as a reduction of 4 points on the National Institutes of Health Stroke Scale (NIHSS) at 6 months was observed in group A (baseline, 6.83 + 3.01 vs 6 months, 2.61 + 1.20; P < .01) and group B (baseline, 6.05 + 2.75 vs 6 months, 4.77 + 1.69; P < .05). A significant difference in NIHSS scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Improvement in cognitive function defined as an increase of 8 on the Montreal Cognitive Assessment (MoCA) was observed in group A at 3 and 6 months (baseline, 14.67 + 3.56 vs 3 months, 24.17 + 3.55 and 6 months, 24.72 + 2.85; P < .01). Significant improvement in MoCA was also observed in group B (P < .01). Furthermore, a significant difference in MoCA scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Endovascular recanalization is feasible and safe for patients with symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization. Keywords symptomatic chronic ICA occlusion, revascularization, National Institutes of Health Stroke Scale, Montreal Cognitive Assessment
Introduction The natural outcome of symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment is dismal.1-4 There is a direct correlation between the risk of ipsilateral stroke and chronic carotid artery occlusion5; the overall rate of subsequent stroke is 7% per year and 5.9% per year for ischemic stroke ipsilateral to the chronically occluded carotid artery.6 Thromboendarterectomy and other surgical procedures have been attempted for ICA occlusion over the years. Endarterectomy prevents stroke in patients with ICA stenosis, but the success rate in recanalizing occlusions is as low as 34% because of technical difficulties7 and it also appears ineffective for occlusive lesions beyond the acute phase. Surgical bypass
may be a natural resolution for ICA occlusion, although the large-scale international randomized extracranial–intracranial bypass trial failed to show any benefit.8,9 Currently, with the development of endovascular devices, more and more studies have proved that endovascular revascularization may play an
1
Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University Medical College, Shanghai, China Corresponding Author: Ji-Yao Jiang, Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University Medical College, Shanghai 200127, China. Email: [email protected]
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
306
Vascular and Endovascular Surgery 48(4)
important role in treating chronic ICA occlusion.1,3,4 Lin et al3 reported that endovascular recanalization can be performed for symptomatic ICA occlusion, even in the chronic stage of the illness. Successful carotid artery stenting can improve global cognitive function as well as attention and psychomotor processing speed in patients with chronic ICA occlusion. There have been few studies on the efficacy of endovascular recanalization of ICA occlusion compared with conservative medical therapy. In this prospective, single-center, controlled study, we sought to investigate the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic carotid artery occlusion. The primary end point of the study was 100% complete recanalization of the primary occlusion at 60 minutes and the secondary end points were improvement in neurologic function and cognitive function.
Materials and Methods Patients Patients with symptomatic chronic ICA occlusion who sought medical treatment at the Stroke Center of our hospital between January 1, 2008, and April 30, 2012, were prospectively recruited for the current study. Diagnosis of occlusion of the ICA was based on conventional angiography with sufficient contrast medium and a prolonged run. A patient was eligible for the study (1) if the patient was aged 18 years, (2) if his or her National Institutes of Health Stroke Scale (NIHSS) score was 8, (3) if he or she had a Thrombolysis in Cerebral Ischemia (TICI) score of 0 or 1 in an accessible vessel, (4) if no intracerebral hemorrhage was detected on computed tomography (CT) scan, (5) if magnetic resonance imaging study revealed an infarct size .05). Improvement in cognitive function defined as an increase of 8 on the MoCA was observed in patients undergoing endovascular recanalization 3 and 6 months after the procedure (baseline, 14.67 + 3.56 vs 3 months, 24.17 + 3.55 and 6 months, 24.72 + 2.85; P < .05). Significant improvement was also observed in patients receiving conservative medical therapy only (P < .05). Furthermore, a significant difference in MoCA scores was noted between group A and group B at 1, 3, and 6 months after the procedure (P < .05 or .001; Table 3).
Discussion The outcome of symptomatic chronic occlusion of the ICA is severely hampered by the lack of treatment options and the few options available such as endarterectomy and surgical bypass, apart from carrying surgical risks, remains a dismal disease. Grubb et al2 reported that symptomatic carotid artery occlusion patients with hemodynamic impairment are at apparently high risk of subsequent stroke if managed by medical therapy alone. It remains to be determined whether chronically occluded carotid arteries can be revascularized with a favorable outcome compared to conservative medical therapy. Anecdotal evidence suggests that endovascular recanalization by stent placement and angioplasty is effective in symptomatic chronically occluded carotid artery patients. The current study is the first prospective, controlled, single-center study on the feasibility and efficacy of endovascular recanalization in patients with symptomatic chronically occluded carotid artery. We reported an angiographic success rate of 88.9%; in addition, we observed no serious procedure-related adverse events. These findings suggest that the endovascular revascularization approach is safe and feasible and effective for patients with symptomatic chronically occluded carotid artery. One critical consideration in selecting patients for this therapy is the risk of subsequent stroke with medical therapy alone. We selected patients with symptomatic chronically occluded carotid artery with angiographically demonstrable
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
Fan et al
309
Figure 2. Brain perfusion before (A) and after (B) endovascular recanalization in a 35-year-old patient with internal carotid artery (ICA) occlusion. Table 2. The National Institutes of Health Stroke Scale (NIHSS) Scores in Patients With Symptomatic Chronic Occlusion of the Internal Carotid Artery Receiving Endovascular Recanalization (Group A) or Conservative Therapy (Group B).
Baseline Postintervention 1 week 1 month 3 months 6 months
Group A
Group B
P
6.83 + 3.01
6.05 + 2.75
.39
5.89 + 2.35 3.83 + 1.92 3.06 + 1.16 2.61 + 1.20
6.00 + 6.10 + 4.77 + 4.77 +
.89 .04 .02 0
2.73 2.64 1.95 1.69
ICA occlusion and ipsilateral cerebral hypoperfusion on SPECT. These patients typically face an annual risk of 7% for subsequent stroke, which is substantially increased (around 30% per year) when hemodynamic impairment is present distal to the occluded artery. In addition, several technical issues need to be carefully prepared when occluded carotid arteries are considered for endovascular recanalization procedures. These include protection of the cerebral circulation from distal embolism during the procedure and how to pass a guidewire across a long occlusive lesion. We divide occluded carotid arteries into 3 categories according to the length of occlusion. Type 1 occlusion is located at the cervical segment C1, which is easy to manipulate with lesser risk of distal embolism. A single stent may be sufficient to achieve a better outcome. The vessel portion distal to the stent
Table 3. The Montreal Cognitive Assessment (MoCA) Scores in Patients With Symptomatic Chronic Occlusion of the Internal Carotid Artery Receiving Endovascular Recanalization (Group A) or Conservative Therapy (Group B).
Baseline Postintervention 1 week 1 month 3 months 6 months
Group A
Group B
P
14.67 + 3.56
14.91 + 3.39
.83
+ 3.88 + 2.75 + 2.68 + 2.97
.49 .03 0 0
15.33 20.56 24.17 24.72
+ 3.25 + 4.06 + 3.55 + 2.85
16.14 18.18 18.18 19.1
may become narrowed but usually returns to the normal size at 1 to 3 months of follow-up. Type 2 occlusion is located from C1 to the petrous segment C2. Two or more stents are needed to achieve revascularization in type 2 occlusion. Guidewire is easy to control within this portion of the carotid artery as it is straight with less possibility of penetrating the vessel wall. An embolic protection device is useful, but sometimes it could not be used when the stenosis is very hard, and the manipulation of the device is technically difficult. Type 3 originates from C1 to the ophthalmic (C6) or communicating (C7) segment, which is the most difficult to manipulate and carries substantial risks. There are at least 2 major curves in this segment with even more in those who have severe arteriosclerosis, causing more difficulty for manipulation. As this segment is within the cranium, the consequence is enormous
Downloaded from ves.sagepub.com at CENTRAL MICHIGAN UNIV on January 5, 2015
310
Vascular and Endovascular Surgery 48(4)
if and once bleeding occurs. Some recent known embolic protection devices are nearly impossible to be placed to the distal part of occlusion. Long manipulation without any protection increases the risk of acute thrombosis. In this scenario, surgical bypass could be a safer approach.8,9 Our current series focused mostly on type 1 and 2 occlusion, and our findings suggest that the endovascular revascularization approach is feasible and safe in these patients. More importantly, compared with patients receiving conservative medical therapy, endovascular recanalization resulted in marked improvement in neurologic and cognitive outcomes. Although both endovascular recanalization and conservative management resulted in noticeable improvement in neurologic and cognitive outcomes with greater benefit seen in endovascular recanalization patients, it remains to be investigated whether endovascular recanalization is associated with reduced risk of subsequent stroke, which, however, requires studies with a larger sample population and a longer follow-up period. In conclusion, endovascular recanalization is feasible and safe for patients with type 1 and 2 symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization. We recommend that the endovascular approach be considered in patients with type 1 and 2 occlusion exhibiting hemodynamic impairment, who may represent the population most likely to benefit from such aggressive therapies without incurring substantial risks. Authors’ Note Yi-Ling Fan and Jie-Qing Wan contributed equally to the work and are cofirst authors. No support from grants and outside funding, drugs, or equipment was used in this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Terada T, Yamaga H, Tsumoto T, Masuo O, Itakura T. Use of an embolic protection system during endovascular recanalization of a totally occluded cervical internal carotid artery at the chronic stage: case report. J Neurosurg. 2005;102(3):558-564. 2. Grubb RL Jr, Derdeyn CP, Fritsch SM, et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA. 1998;280(12):1055-1060. 3. Lin MS, Lin LC, Li HY, et al. Procedural safety and potential vascular complication of endovascular recanalization for chronic cervical internal carotid artery occlusion. Circ Cardiovasc Interv. 2008;1(2):119-125.
4. Kim WH, Min P-K, Kim DJ, Shim WH. Successful carotid stenting for chronic total occlusion of the internal carotid artery. Korean Circ J. 2010;40(6):288-291. 5. Young FB, Weir CJ, Lees KR; GAIN International Trial Steering Committee and Investigators. Comparison of the National Institutes of Health Stroke Scale with disability outcome measures in acute stroke trials. Stroke. 2005;36(10):2187-2192. 6. Toglia J, Fitzgerald KA, O’Dell MW, Mastrogiovanni AR, Lin CD. The mini-mental state examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome. Arch Phys Med Rehabil. 2011;92(5): 792-798. 7. Paty PS, Adeniyi JA, Mehta M, et al. Surgical treatment of internal carotid artery occlusion. J Vasc Surg. 2003;37(4):785-788. 8. Kanamaru K, Araki T, Kawakita F, et al. STA-MCA bypass for the treatment of ischemic stroke. Acta Neurochir Suppl. 2011; 112:55-57. 9. Muroi C, Khan N, Bellut D, Fujioka M, Yonekawa Y. Extracranial– intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience. Br J Neurosurg. 2011; 25(3):357-362. 10. Dewey HM, Sherry LJ, Collier JM. Stroke rehabilitation 2007: what should it be? Int J Stroke. 2007;2(3):191-200. 11. Lin MS, Chiu MJ, Wu YW, et al. Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia. Stroke. 2011;42(10):2850-2854. 12. Miyamoto N, Naito I, Takatama S, Shimizu T, Iwai T, Shimaguchi H. Urgent stenting for patients with acute stroke due to atherosclerotic occlusive lesions of the cervical internal carotid artery. Neurol Med Chir (Tokyo). 2008;48(2):49-56. 13. Sposato LA, Gleichgerrcht E, Manes F. Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia. Stroke. 2012; 43(1):e10. 14. Iwata T, Mori T, Tajiri H, Miyazaki Y, Nakazaki M. Long-term angiographic and clinical outcome following stenting by flow reversal technique for chronic occlusions older than 3 months of the cervical carotid or vertebral artery. Neurosurgery. 2012; 70(1):82-90. 15. Mori T, Kazita K, Chokyu K, Mima T, Mori K. Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol. 2000;21(2): 249-254. 16. Mori T, Fukuoka M, Kazita K, Mori K. Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. AJNR Am J Neuroradiol. 1998;19(8):1525-1533. 17. Levy EI, Hanel RA, Bendok BR, et al. Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis. J Neurosurg. 2002;97(6):1294-1301. 18. Bosiers M, de Donato G, Deloose K, et al. Does free cell area influence the outcome in carotid artery stenting? Eur J Vasc Endovasc Surg. 2007;33(2):135-141.
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