Gustavo Rajz

Endovascular Stent-Assisted Angioplasty in the Management of Traumatic Internal Carotid Artery Dissections

Background and Purpose— The prognosis of traumatic dissection of the internal carotid artery is worse than for spontaneous dissections. Rapid stenting followed by antiplatelet therapy may prevent complications when anticoagulation therapy is not applicable. Methods— Patients with angiographically proven traumatic carotid artery dissection and hemodynamic significant hemispheric hypoperfusion, or in whom anticoagulant therapy was either contraindicated or failed clinically, were regarded as being at high risk for stroke and were selected for stenting. Results— Ten patients with traumatic dissection underwent stenting. Endovascular treatment reduced mean dissection stenosis from 69% to 8%. During a mean clinical follow-up time of 16 months, none had additional transient ischemic attacks or stroke. Doppler ultrasound studies did not detect any signs of de novo in-stent stenosis. Conclusion— In selected cases of traumatic carotid artery dissections, endovascular stent-assisted angioplasty immediately restored the integrity of the vessel lumen and prevented efficiently the occurrence of new ischemic events, without additional anticoagulation.

Bilateral acute epidural hematoma after evacuation of acute subdural hematoma: brain shift and the dynamics of extraaxial collections.

Abstract Acute epidural hematoma following supratentorial decompressive craniectomy is a very seldom described but serious complication. The occurrence of intraoperative brain swelling may suggest the development of a contralateral hematoma. A unique case of bilateral acute epidural following decompressive craniectomy and evacuation of acute subdural hematoma is presented. Awareness of unexplained elevation of intracranial pressure is of paramount importance when routine immediate postoperative computed tomography is not performed. This case provides insight into the well-known but poorly understood dynamic process of brain shift and extraaxial collections.

Stent-assisted arterial reconstruction of traumatic extracranial carotid dissections.

Abstract Objectives: Dissection of the internal carotid artery is a well-recognized complication of craniocervical trauma with potentially grave neurological outcome in patients with significant ischemic symptoms. Traditional anticoagulation therapy may not be applicable, since anticoagulation is contraindicated in multiple trauma or penetrating injuries. In these circumstances, rapid stenting followed by antiplatelet therapy may be performed. Methods: Patients with angiographically proven traumatic carotid artery dissection were prospectively selected for endovascular stenting according to clinical and radiological criteria. Essentially, patients with hemodynamic significant hemispheric hypoperfusion (as indicated by angiography or perfusion MRI), or in whom anticoagulant therapy failed clinically, or anticoagulation was contraindicated, were considered at high risk for stroke and were selected for stenting. Twelve patients were selected for stenting. Results: In seven patients, multiple stents were implanted. Endovascular treatment reduced mean dissection stenosis from mean 65±33% (range, 10–100%) to mean 7±9% (range, 20–0%). In a mean clinical follow-up of 11.5±6.3 months (range 3–24 months), eight patients improved and four remained stable, and none of the patients had a TIA or stroke. Doppler U/S studies did not detect any signs of de novo in-stent stenosis in any of the patients at a mean follow-up time of 9.2±6.4 months. Conclusions: In selected cases of traumatic dissections of the carotid artery, endovascular stent-assisted angioplasty may immediately restore the integrity of the vessel lumen, even of acutely occluded arteries. This approach efficiently prevented the occurrence of new ischemic events, without additional anticoagulation.

Thrombosis and recanalization of symptomatic nongiant saccular aneurysm

Abstract Complete thrombosis followed by recanalization of giant aneurysms is an infrequent process that has been exceptionally mentioned in relation to nongiant saccular aneurysms. A 25-year-old male presented with a right temporal hematoma and associated subarachnoid hemorrhage. Cerebral angiography revealed a small blister-like dilatation at the right middle cerebral artery bifurcation. The cerebral hematoma was surgically removed and a large thrombosed aneurysm was discovered and was wrapped. Follow-up angiography revealed complete recanalization of the aneurysm with preservation of all the arterial branches and the aneurysm was then completely occluded with detachable coils. This case provides insight into the wellknown but poorly understood dynamic process of thrombosis and recanalization of cerebral aneurysms. The possible role of a cerebral hematoma in the pathogenesis of this process is discussed.

Complete and persistent occlusion of arteriovenous malformations of the mandible after endovascular embolization

Abstract Objective: Arteriovenous malformation (AVM) of the mandible is a rare but potentially life-threatening entity. Traditional treatment involved complex surgical procedures that usually failed to completely cure the malformation without disfigurement and functional difficulties. We report our experience in transarterial and transvenous embolizations of mandibular AVMs using different embolization agents and discuss the potential use of Onyx and new detachable-tip microcatheters. Clinical presentation: Patients presented with progressive mandibular swelling, pain, soft-tissues discoloration and dental misalignment with tooth loosening. Intervention: The AVMs were completely and persistently occluded by endovascular transarterial and transvenous approaches. Conclusion: Less invasive endovascular approaches proved to be highly effective in curing certain types of mandibular AVMs. Every malformation requires a tailored endovascular strategy in terms of approach and selection of an embolizing agent.

Urgent endovascular stent-graft placement for traumatic penetrating subclavian artery injuries

Penetrating injuries may infrequently cause pseudoaneurysms, lacerations and arteriovenous fistulas involving the subclavian artery. These injuries present with life-threatening bleedings, associated regional injuries and critical limb ischemia and although surgery has been considered the treatment of choice, subclavian injuries pose a real surgical challenge. We prospectively examined data of six patients presenting with penetrating subclavian artery injuries that were treated by urgent endovascular stent-graft placements. All stent-grafts were deployed successfully achieving complete exclusion of the pseudoaneurysm, control of bleeding and reconstruction of the injured artery. No procedural complications, stent thrombosis or stent infections occurred during hospitalization. One patient developed stenosis at 7 months, which required angioplasty. The series mean clinical and ultrasound-CTA follow-up is 38+/-19.7 months (range 11-60 months) and 28+/-19.1 months (range 6-58 months), respectively. This series shows the feasibility of endovascular repair by means of stent-grafts for selected patients with acute penetrating injuries of the subclavian arteries. This approach proved to be safe and effective in restoring the arterial lumen and patency, excluding the pseudoaneurysms and controlling the bleeding caused by subclavian lacerations. Mid-term follow-up on stent-graft patency rates are encouraging.

Protected stent-assisted angioplasty in radiation-induced carotid artery stenosis

Abstract Objective: The surgical treatment of radiation-induced carotid stenosis is challenging and presents a high rate of complications. This has led several investigators to propose stent-assisted angioplasty as the treatment of choice for this condition. The aim of this study is to evaluate the potential risks of intra-procedural embolic stroke in this setting using cerebral protection devices. Methods: We describe our recent experience in the endovascular treatment by means of stent-assisted angioplasty with the aid of a filter cerebral protection device of eight patients presenting with radiation-induced carotid stenosis. Results: Procedural success, defined as residual stenosis of less than 30% was obtained in all cases. The mean percentage stenosis was reduced from mean 80±6.3% (range 70–90%) to 13±4% (range 10–20%). Predilation was performed in five cases, post-dilation in all the cases. Mild-to-moderate bradycardia while inflating the balloon was present in three cases and was severe in one case. No patient sustained myocardial infarction, stroke or TIA during the procedure or hospital stay. During a mean clinical follow-up of 16±7.3 months (range 5–25) there were no neurological events. On sonographic follow-up, no patient presented in-stent de novo stenosis. Discussion: Carotid angioplasty with cerebral protection can be performed safely in radiation-induced carotid stenosis with a high technical success rate. With the recent innovations and improvements in angioplasty technique, its indications and results will have to be redefined. Given the complexity and complications of surgical approaches for this condition, and the encouraging results obtained with endovascular techniques, carotid angioplasty emerges as the preferred treatment option.

Vertebral artery pseudoaneurysms secondary to blunt trauma: Endovascular management by means of neurostents and flow diverters

Extracranial vertebral pseudoaneurysms that develop following blunt trauma to the cervical area may have a benign course; however, embolic or ischemic stroke and progressive pseudoaneurysm enlargement may occur. We review the presentation and endovascular management of pseudoaneurysms of the cervical vertebral artery (VA) due to blunt trauma in nine patients (eight male, mean age 27years). Pseudoaneurysms occurred in dominant vessels in seven patients and coexisted with segmental narrowing in six. We favored endovascular intervention during the acute phase only in cases with significant narrowing of a dominant VA, especially when anticoagulation was contraindicated. Four patients were treated during the acute stage (contraindication to anticoagulation, mass effect, severely injured dominant VA/impending stroke); five during the chronic phase (pseudoaneurysm growth, ischemic stroke on aspirin prophylaxis, patient preference). Reconstructive techniques were favored over deliberate endovascular occlusion when dominant vessels were involved. Arterial reconstruction was performed in eight of nine patients using a flow-diverter implant (5 patients), stent-assisted coiling (1), overlapping stent implant (1), or implantation of a balloon-expandable stent (1). Deliberate VA occlusion with coils was performed in one of nine patients due to suboptimal expansion of the stented artery after flow-diverter implant. No neurological complications occurred during follow-up. All cases treated by reconstructive techniques showed complete, persistent pseudoaneurysm occlusion and full arterial patency. Endovascular therapy of traumatic VA pseudoaneurysms using neurostents and flow-diverters resulted in occlusion of the pseudoaneurysms, preservation of the parent vessel, and no periprocedural or delayed clinical complications, supporting the feasibility and safety of the approach.

Protected stent-assisted carotid angioplasty in symptomatic high-risk NASCET-ineligible patients.

Abstract Background and Objectives: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) excluded patients with severe medical, angiographic and neurological risk factors. The aim of this study is to determine the safety and efficacy of protected stent angioplasty in these high-risk patients. Methods: Sixty-eight consecutive symptomatic NASCET-ineligible patients underwent protected stent-assisted carotid angioplasty. Patients were classified according to surgical risk based on Sundt criteria, and stratified for medical therapy according to stroke risk. Twenty-one patients were classified as Sundt grade 3 (30.8%) and 36 patients as grade 4 (52.9%). Results: The procedure was technically successful in all patients, with stenosis averaging 82.1% (range 70–99%) before the procedure and 6.3% (range 0–30%) after treatment. There were no periprocedural deaths or major strokes, but two patients had minor, non-embolic stokes (2.9%). During a mean clinical follow-up of 14.4 months (range 1–30 months), no new neurological events occurred in relation to the treated vascular territory. Conclusions: Carotid angioplasty with cerebral protection can be performed safely in high-risk patients. During the follow-up period, angioplasty was highly effective in terms of stroke prevention and arterial patency.

Protected stent-assisted carotid angioplasty in the management of late post-endarterectomy restenosis.

Abstract Objectives: The high complication rate associated with the surgical treatment of post-carotid endarterectomy restenosis has led several investigators to propose stent-assisted angioplasty as the treatment of choice for this condition. Late restenosis is very infrequent and mainly due to atherosclerotic progression. The aim of this study is to evaluate the potential risk of intraprocedural embolic stroke during stent-assisted angioplasty with cerebral protection devices in these patients. Methods: We describe our recent experience in the endovascular treatment of 10 patients presenting late carotid restenosis by means of stent-assisted angioplasty with the aid of a filter cerebral protection device. Mean elapsed time from surgery to angioplasty was 92±31 months (range 48–144 months). Results: Procedural success was obtained in all the cases. Pre-dilation was performed in six cases, post-dilation in all the cases. The mean percentage stenosis was reduced from mean 77±12% (range 60–95%) to 6.3±6.7% (range 0–17%). Bradycardia while inflating the balloon was mild-to-moderate in seven cases and severe in two. No patient sustained stroke or transient ischemic attack (TIA) during the procedure or during hospital stay. On follow-up, two patients presented with moderate asymptomatic restenosis and were managed conservatively. Discussion: Carotid angioplasty with cerebral protection can be performed safely in late carotid restenosis with a high technical success rate. No clinical embolic complications occurred in this subset of patients. With recent innovations and improvements in angioplasty technique, previous indications for angioplasty in these patients will have to be redefined. Carotid angioplasty seems to be a valuable treatment alternative to conventional surgery in this subset of patients.