Yabing Wang

Concomitant asymptomatic internal carotid artery and persistent primitive hypoglossal artery stenosis treated by endovascular stenting with proximal embolic protection

The persistent primitive hypoglossal artery (PPHA) is a rare fetal variant of carotid-basilar anastomosis that increases the risk of ischemia and embolic infarction within the posterior cerebral circulation in patients with carotid stenosis proximal to the origin of the PPHA. A man presented with severe stenosis of the right internal carotid artery with extension to the origin of a PPHA. The area of stenosis was at a high position, which contraindicated carotid endarterectomy. Therefore, stenting was performed with proximal reversal of flow embolic protection. The unique anatomic and technical challenges associated with this case are reviewed in detail.

Recanalization of extracranial internal carotid artery occlusion A 12-year retrospective study

This study aimed to summarize therapy experience of carotid endarterectomy, carotid endarterectomy combined with Fogarty catheter embolectomy, and hybrid surgery for the treatment of extracranial internal carotid artery occlusion. The study included 65 patients with extracranial internal carotid artery occlusion who underwent carotid endarterectomy, carotid endarterectomy combined with Fogarty catheter embolectomy, or hybrid surgery in the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China between January 2006 and December 2012. Prior to surgery, all patients underwent perfusion CT or xenon CT to evaluate the occlusion. The procedure for each patient was chosen according to digital subtraction angiography data. The carotid artery was successfully recanalized in 46 of 51 patients who underwent carotid endarterectomy, 9 of 10 patients who underwent carotid endarterectomy combined with Fogarty catheter embolectomy, and 3 of 4 patients who underwent hybrid surgery. In patients with symptomatic carotid artery occlusion, the carotid artery can be recanalized by choosing a treatment procedure based on imaging examination findings.

Superficial Temporal Artery–Middle Cerebral Artery Bypass Surgery for Refractory Symptomatic Intracranial Atherosclerotic Stenosis

OBJECTIVE To evaluate blood flow changes after bypass surgery for refractory symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS We examined a cohort of consecutive patients with symptomatic ICAS. Superficial temporal artery-middle cerebral artery (MCA) bypass was performed in refractory patients with poor perfusion. Angiograms were graded systematically for antegrade, collateral, and bypass flow, and clinical variables were collected preoperatively, at 7 days postoperatively, and 3, 6, and 12 months postoperatively. RESULTS Among 185 consecutive cases with ICAS, 15 patients who were unsuitable for or did not respond to the best medical therapy or stenting underwent bypass surgery. No patients had new ischemic deficits within 7 days postoperatively. The mean follow-up period was 30.2 ± 12.3 months. Within this period, all anastomoses were patent by methods of ultrasound or computed tomography angiography. In 2 patients, stenotic lesions exhibited early postoperative occlusion conversion at 7 days on digital subtraction angiography. In 2 patients, stenotic lesions showed progression of occlusion at 6 and 8 months. The 2 lesions with early occlusion were both located in the MCA. The extent of retrograde blood flow via bypass anastomosis was correlated with early occlusion conversion. CONCLUSIONS For refractory ICAS in patients with compromised hemodynamics, direct bypass might induce early occlusion of a stenotic area. MCA lesions may have a greater tendency toward early occlusion conversion.

A study of carotid endarterectomy in a Chinese population: Initial experience at a single center

OBJECTIVE This retrospective study aimed to evaluate our initial experience with carotid endarterectomy in a Chinese population. METHODS Four hundred and thirty-three patients who underwent carotid endarterectomies at Xuan Wu Hospital Capital Medical University between January 1, 2001, and December 31, 2012, were reviewed. The postoperative 30-day complications were analyzed. Univariate and multivariate logistic regression analyses were used to analyze the factors associated with perioperative stroke and death. RESULTS The overall 30-day complication rates after surgery were 4.08% for death and stroke, 3.63% for cranial nerve injuries, and 3.63% for heart complications. The mean follow-up time was 32.99 months, and only 11 cases required restenosis, including two that were symptomatic (experiencing transient ischemic attacks). In the univariate analysis, a history of cerebral infarction was present preoperatively in 179 patients, of whom 12 (6.70%) had a postoperative stroke or died (P=0.021). Thirty-two patients had a modified Ranking score (mRS)≥ 3, and six (18.75%) of these patients had a postoperative stroke or died (P<0.001). In the multivariate logistic regression, female gender (OR: 4.669; 95% CI: 1.238-17.602; P=0.023), current smoking habits (OR: 3.826; 95% CI: 1.298-11.277; P=0.015), and an mRS ≥ 3 (OR: 1.540; 95% CI: 3.844-40.909; P<0.001) were independent risk factors for perioperative stroke and death. CONCLUSIONS In our single-center study, carotid endarterectomies appeared to effectively prevent and treat the carotid artery stenosis that leads to stroke. Female gender, current smoking habits, and neurological deficits (mRS ≥ 3) increased the perioperative stroke and death rates.

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: experience of a single center and review of literature

OBJECTIVE The optimal treatment of chronic symptomatic total occlusion of the intracranial vertebral artery (ICVA) remains undefined. We report a single-center experience of endovascular recanalization for patients with chronic symptomatic ICVA occlusion who were refractory to medical therapy. METHODS From Jan 2009 to Jan 2017, we retrospectively reviewed 14 consecutive patients presenting with recurrent symptoms attributed to the chronic ICVA occlusion. We searched previous literature using PubMed databases during the same period as comparison. RESULTS Eleven patients out of 14 presented initial symptoms to intervention less than 90days. The occlusion course was extrapolated on simultaneous two-vessel injection angiography or high-resolution MR imaging (HRMRI) in 13 cases. Nine patients had the occlusion beyond the origin of posterior inferior cerebellar artery (PICA) and 5 had the occlusion proximal to the PICA origin. The technical success rate of recanalization was 85.7% (12/14). Two patients (14.3%, 2/14) had peri-procedural complications: 1 developed TIA and 1 presented with perforator occlusion syndrome. Using the keyword-based search, we identified 6 studies at the same period. A total of 34 patients underwent recanalization with the successful recanalization rate at 94.1%, peri-procedural complication rate at 17.6% and mortality at 2.9%, respectively. CONCLUSION Our single-center study illustrated the feasibility and safety of ICVA recanalization. Great care should be taken as revascularization is of high risk. When patient selection, occlusion course and stage as well as neuroimaging evaluation are considered, endovascular recanalization may be a useful therapeutic modality.

Hybrid Technique for the Treatment of Refractory Vertebrobasilar Insufficiencies

BACKGROUND Tortuous or occluded vertebral arteries (VAs) can make the endovascular treatment of vertebrobasilar insufficiency impractical. Bypass surgery is an option, but a craniotomy of the posterior fossa is complicated when physiologic vessels must be abandoned. We report 3 cases of refractory vertebrobasilar insufficiency with different presentations requiring problematic approaches in which the patients were treated by different hybrid strategies. CASE DESCRIPTION Patient 1 had severe stenosis of right VA ostium with right V1 segment tortuosity and was treated by right VA ostium transposition during which the proximal subclavian artery was blocked by a balloon guide catheter. Patient 2 had severe stenosis of the basilar artery and bilateral VA tortuosity. The V1 segment was exposed and cut open so that an available approach for endovascular procedures was created. Patient 3 had bilateral VA occlusion. After exposure of the left V1 segment, recanalization of the left VA was performed by an interventional radiologist and surgeon working together. All patients had improved hemodynamics and symptoms alleviated without major complications. CONCLUSIONS For refractory vertebrobasilar insufficiencies, hybrid operations that combine surgical manipulation of the V1 segment and endovascular techniques can be safe and effective.

E-028 Treatment of endovascular-impractical vertebrobasilar insufficiency with hybrid operation

Background For vertebrobasilar insufficiency, endovascular therapy impracticalness can be resulted from tortuous or occluded VA. We report 3 cases of different situations. Cases presentation Case 1 was a VAO severe stenosis. Right VAO stenting was tried but failed. As the plaque extended to subclavian artery (SubA), proximal SubA was blocked by an dilated 8F balloon catheter, rather than a vascular clamp. Distal SubA and its branches was blocked by aneurysm clips. VAO was too deep to perform endarterectomy. Patient was treated by transposition of VAO. Case 2 was a basilar artery (BA) severe stenosis, complicated by bilateral VAs tortuosity. Patient’s left V1 was exposed and dissociated. Blood flow of proximal left SubA was blocked by a vascular clamp. Then left VA was cut open with a short cleft through which endovascular therapy for BA was possible. A 6F guiding catheter was delivered to V2 segment with the help of a snare. A balloon-expandable stent was deployed at the stenosis of BA. Case 3 had bilateral VAs occlusion and BA fenestration which was suspected as BA severe stenosis preoperatively. Proximal SubA was blocked by dilated balloon guiding catheter. Expose and dissociate left V1, cut it open to disassociate the plaque, but do not take it away immediately. Through the balloon guiding catheter, interventionalist delivered microcatheter to the operating field. Then, along the latent space between plaque and vessel wall, interventionalist and surgeon cooperated to deliver microcatheter (with microwire inside) into the distal lumen. Under monitoring of radiogram, microcatheter was deliver to distal segment of V2. Perform hand-pushing angiography to confirm tip of microcatheter was in the real lumen of VA. Fix microcatheter. Pull the plaque out along with the connected thrombus. Suture the vessel wall. Perform angiography again. Dissection of distal V2 was found, so a balloon-expandable stent was deployed to close it. Results Symptoms of all patients disappeared. Postoperative MRI of case 2 showed small new lesions of high diffusion-weighted imaging (DWI) signal at left cerebellum, but patient had no uncomfortable complaints. Horner’s syndrome happened in case 1 and 2, both were proved to improve at follow-up of 1 month later. Postoperative hospital stay was 5, 3 and 4 days respectively. Conclusions For some endovascular-therapy-impractical vertebrobasilar insufficiencies, including VAO stenosis with V1 tortuosity, BA stenosis with bilateral VAs tortuosity, and BA stenosis with bilateral VAs occlusion, hybrid operations of combining surgical manipulation of V1 and endovascular technique can be safe and Disclosures X. Lu: None. Y. Ma: None. B. Yang: None. Y. Wang: None. P. Gao: None. L. Jiao: None.

Open Retrograde Endovascular Stenting for Left Common Carotid Artery Dissection Secondary to Surgical Repair of Acute Aortic Dissection: A Case Report and Review of the Literature

A 30-year-old male presented with an acute aortic artery dissection (Stanford type A) and underwent total arch replacement using a stented elephant trunk technique. One month later, the patient developed dissections in the innominate and left common carotid artery (CCA). The innominate artery dissection caused occlusion in the right internal carotid artery (ICA) and a major stroke. Dissection of the left CCA progressed and extended to the bifurcation site. Antegrade access for a left carotid intervention was deemed as difficult because of the previously implanted stent and the additional risks of embolic events and dissection enlargement. Hybrid procedures combining left carotid bifurcation exposure and retrograde endovascular stenting were successfully completed. This report is a rare case of retrograde endovascular reconstruction for the left CCA dissection following surgical repair of an aortic artery dissection. Here, we also review previous cases of iatrogenic carotid dissections following surgical intervention.