Abstract
Microembolization to cerebral arteries during percutaneous transluminal carotid angioplasty (PTCA) and stenting is well described, as well as different mural pathology in primary versus post–carotid endarterectomy (CEA) restenosis lesions. The purpose of this study is to investigate possible different patterns of embolization in regards to number and distribution of microembolic signals (high-intensity transient signals (HITS)) in patients with primary carotid stenosis and restenosis after CEA. We used transcranial Doppler (TCD) to monitor the ipsilateral middle cerebral artery (MCA) of 13 patients (13 procedures) with restenosis after CEA and six patients (seven procedures) with primary stenosis of the internal carotid artery (ICA) during PTCA and stenting. All the procedures were performed without protection devices. The total number of HITS recorded in all patients was 2692, including 1563 microemboli in patients with restenosis and 1129 in patients with primary stenosis. The mean number of microemboli per procedure was 120.2 ± 65 and 161.3 ± 70 (p = 0.05) respectively. The average number of microembolic signals during the various stages of PTCA and stenting in the two groups was as follows: 1. Crossing the stenotic region with the guidewire and positioning the balloon inside the stenosis 33 ± 6.9 and 73.4 ± 9.4 (restenosis patients versus primary–stenosis patients, respectively, (p = 0.011); 2. angioplasty, balloon inflation and deflation, 19.l ± 6.9 and 38.9 ± 9.4 (restenosis versus primary lesions, respectively, p = 0.09); 3. stent deployment, 39.5 ± 6.9 and 27.3 ± 9.4 (restenosis versus primary lesions, respectively, p = 0.3); and 4. Post-stent dilatation, 29 ± 6.9 and 21.7 ± 9.4 (restenosis versus primary lesions, respectively, p = 0.53). Microembolic signals are detected through all stages of PTCA and stenting in patients with primary or post-CEA-restenosis lesions. The number of HITS was significantly higher in patients with primary stenosis than with restenosis of ICA in stages prior to stenting. This probably stems from the difference in pathomorphologic structure between the lesions. There was no significant difference between groups during stent deployment and post-stent dilatation. The clinical significance of the phenomenon of microembolism during carotid stenting is still not clear, but our results suggest the importance of using protection devices to reduce the incidence of these events in both primary and post-CEA lesions.
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References
HS Markus A Clifton T Buckenham MM Brown (1994) ArticleTitleCarotid angioplasty: Detection of embolic signal during and after the procedure Strok 25 2403–2406 Occurrence Handle1:STN:280:ByqD28vptVE%3D
G Orlandi S Fanucchi C Fioretti G Acerbi M Puglioli R Padolecchia F Sartucci L Murri (2001) ArticleTitleCharacteristics of cerebral microembolism during carotid stenting and angioplasty alone Arch Neurol 58 1410–1413 Occurrence Handle10.1001/archneur.58.9.1410 Occurrence Handle1:STN:280:DC%2BD3MrjslKnsw%3D%3D Occurrence Handle11559312
T Ohki ML Marin RT Lyon GL Berdejo K Soundararajan M Ohki JG Yuan PL Faries RA Wain LA Sanchez et al. (1998) ArticleTitleEx vivo human carotid artery bifurcation stenting: Correlation of lesion characeristics with embolic potential J Vase Surg 27 463–471 Occurrence Handle1:STN:280:DyaK1c3gs1ejtQ%3D%3D
M Coggia O Goeau-Brissonniere JL Duval JP Leschi M Letort MD Nagel (2000) ArticleTitleEmbolic risk of the different stages of carotid bifurcation balloon angioglasy: An experimental study J Vasc Surg 31 550–557 Occurrence Handle10.1016/S0741-5214(00)90317-3 Occurrence Handle1:STN:280:DC%2BD3c7nsFKluw%3D%3D Occurrence Handle10709069
WD Jordan SuffixJr DC Voellinger DD Doblar NP Plyushcheva WS Fisher HA McDowell (1999) ArticleTitleMicroemboli detected by transcranial Doppler monitoring in patients during carotid angioplasty versus carotid endarterectomy Cardiovasc Surg 7 33–38 Occurrence Handle10.1016/S0967-2109(98)00097-0 Occurrence Handle10073757
HI Manninen HT Rasanen RL Vanninen P Vainio M Hippelainen VM Kosma (1999) ArticleTitlestent placement versus percutaneous transluminal angioplasty of human carotid arteries in cadavers in situ: Distal embolization and findings at intravascular US, MR imaging and histopathologic analysis Radiology 212 483–492 Occurrence Handle1:STN:280:DyaK1MzlvVegug%3D%3D Occurrence Handle10429707
F Crawley J Stygall S Lunn M Harrison MM Brown S Newman (2000) ArticleTitleComparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty Stroke 31 1329–1334 Occurrence Handle1:STN:280:DC%2BD3c3pslSrtQ%3D%3D Occurrence Handle10835452
AJ McCleary M Nelson NM Dearden TA Calvey MJ Gough (1998) ArticleTitleCerebral haemodynamics and embolization during carotid angioplasty in high-risk patients Br J Surg 85 771–774 Occurrence Handle10.1046/j.1365-2168.1998.00723.x Occurrence Handle1:STN:280:DyaK1czjtVakug%3D%3D Occurrence Handle9667704
JC Palmaz G Hunter SN Carson SW French (1983) ArticleTitlePostoperative carotid restenosis due to neointimal fibromuscular hyperplasia. Clinical, angiographic, and pathological findings Radiology 148 699–702 Occurrence Handle1:STN:280:BiyB2svmtVM%3D Occurrence Handle6878688
AD Callow (1996) Surgery of the carotid and vertebral arteries for the prevention of stroke Williams & Wilkins . 385–398
EB Ringelstein DW Droste VL Babikian DH Evans DG Grosset M Kaps HS Markus D Russell M Siebler (1998) ArticleTitleConsensus on microembolus detection by TCD/International Consensus Group on Microembolus Detection Stroke 29 725–729 Occurrence Handle1:STN:280:DyaK1c7msFClsQ%3D%3D Occurrence Handle9506619
InstitutionalAuthorNameNorth American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) ArticleTitleBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis N Engl J Med 325 445–453 Occurrence Handle1852179
InstitutionalAuthorNameMRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis (1991) ArticleTitleEuropean Carotid Surgery Trialists’ Collaborative Group Lancet 337 1235–1243 Occurrence Handle10.1016/0140-6736(91)92916-P Occurrence Handle1674060
WS Moore HJ Barnett HG Beebe EF Bernstein BJ Brener T Brott LR Caplan A Day J Goldstone RW Hobson Suffix2nd et al. (1995) ArticleTitleGuidelines for carotid endarterectomy: A multidisciplinary consensus statement from the ad hoc committee, American Heart Association Stroke 26 188–201 Occurrence Handle1:STN:280:ByqC2c7jt1I%3D Occurrence Handle7839390
. . (2001) ArticleTitleEndovascular versus surgical treatment in patients with carotid stenosis in the carotid and vertebral artery transluminal angioplasty study (CAVATAS): A randomised trial Lancet 357 1729–1737 Occurrence Handle10.1016/S0140-6736(00)04893-5 Occurrence Handle11403808
JS Yadav GS Roubin P King S lyer J Vitek (1996) ArticleTitleAngioplasty and stentinq for restenosia-after carotid endarterectomy: Initial experience Stroke 27 2075–2079 Occurrence Handle1:STN:280:ByiD2Mvlt1Y%3D Occurrence Handle8898819
MH Wholey M Wholey K Mathias GS Roubin EB Diethrich M Henry S Bailey P Bergeron G Dorros G Eles et al. (2000) ArticleTitleGlobal experience in cervical carotid artery stent placement Cathet Cardiovasc Intervent 50 160–167 Occurrence Handle10.1002/(SICI)1522-726X(200006)50:2<160::AID-CCD2>3.3.CO;2-5 Occurrence Handle1:STN:280:DC%2BD3czgtlWntQ%3D%3D
M Henry C Amor M Klonaris I Henry I Masson Z Chati E Leborgne M Hugel (2000) ArticleTitleAngioplasty and stenting of the extracranial carotid arteries Tex Heart Inst J 27 150–158 Occurrence Handle1:STN:280:DC%2BD3M%2FksVamsQ%3D%3D Occurrence Handle10928503
DeklunderG M Roussel JL Lecroart A Prat C Gautier (1998) ArticleTitleMicroemboli in cerebral circulation and alteration of cognitive abilities in patients with mechanical prosthetic heart valves Stroke 29 1821–1826 Occurrence Handle9731602
T Rundek MR Di Tullio RR Sciacca IV Titova JP Mohr S Homma RL Sacco (1999) ArticleTitleAssociation between large aortic arch atheromas and high-intensity transient signals in elderly stroke patients Stroke 30 2983–2686
J Serena T Segura M Castellanos A Davalos (2000) ArticleTitleMicroembolic signal monitoring in Hemispheric acute ischaemic stroke: A prospective study Cerebrovasc Dis 10 278–282 Occurrence Handle10.1159/000016070 Occurrence Handle1:STN:280:DC%2BD3cvgt1Oqtg%3D%3D Occurrence Handle10878432
VL Babikian LR Caplan (2000) ArticleTitleBrain embolism is a dynamic process with variable characteristics Neurology 54 797–801 Occurrence Handle1:STN:280:DC%2BD3c7lt1yhtg%3D%3D Occurrence Handle10690965
DW Droste K Junker F Stogbauer S Lowens M Besselmann B Braun EB Ringelstein (2001) ArticleTitleClinically silent circulating microemboli in 20 patients with carotid or vertebral artery dissection Cerebrovasc Dis 12 181–185 Occurrence Handle10.1159/000047701 Occurrence Handle1:STN:280:DC%2BD3MrmtlSrtQ%3D%3D Occurrence Handle11641581
HJ Jaeger KD Mathias E Hauth R Drescher HM Gissler S Hennigs A Christmann (2002) ArticleTitleCerebral ischemia detected with diffusion weighted MR imaging after stent implantation in the carotid artery Am J Neuroradiol 23 200–207 Occurrence Handle11847042
WS Moore RF Kempczinski JJ Nelson JF Toole (1998) ArticleTitleRecurrent carotid stenosis. Results of the asymptomatic carotid atherosclerosis study Stroke 29 2018–2125 Occurrence Handle1:STN:280:DyaK1cvivFKnuw%3D%3D Occurrence Handle9756575
M Gorlitzer B Heine H Mendel E Gunen J Meinhart A Sisel M Deutsch (2000) ArticleTitleRedo surgery for carotid artery stenosis: When and how? Cardiovasc Surg 8 366–371 Occurrence Handle10.1016/S0967-2109(00)00030-2 Occurrence Handle1:STN:280:DC%2BD3M%2FhvFyjsg%3D%3D Occurrence Handle10959061
AF AbuRahma PA Robinson DA Mullins SM Holt TA Herzog NT Mowery (2000) ArticleTitleFrequency of postoperative carotid duplex surveillance and type of closure: results from a randomized trial J Vase Surg 32 1043–1051 Occurrence Handle10.1067/mva.2000.111281 Occurrence Handle1:STN:280:DC%2BD3M%2FotlSltA%3D%3D
G New GS Roubin SS lyer JJ Viek MH Wholey EB Diethrich LN Hopkins RW Hobson Suffix2nd MB Leort SV Myla et al. (2000) ArticleTitleSafety, efficacy, and durability of carotid artery stenting for restenosis following carotid endarterectoipy: A multicenter study J Endovasc Ther 7 345–352 Occurrence Handle10.1583/1545-1550(2000)007<0345:SEADOC>2.0.CO;2 Occurrence Handle1:STN:280:DC%2BD3cvnvFKltA%3D%3D Occurrence Handle11032252
JG Theron GG Payelle O Coskun HF Huet L Guimaraens (1996) ArticleTitleCarotid artery stenosis: Treatment with protected balloon angioplasty and stent placement Radiology 201 627–636 Occurrence Handle1:STN:280:ByiD1MzmslU%3D Occurrence Handle8939208
AF Aburahma MC Bates PA Stone JT Wulu (2001) ArticleTitlecomparative study of operative treatment and percutaneous transluminal angioplasty/stenting for recurrent carotid disease J Vase Surg 34 831–838 Occurrence Handle10.1067/mva.2001.118591 Occurrence Handle1:STN:280:DC%2BD3Mnksl2qtg%3D%3D
MJ McCarthy IM Loftus MM Thompson L Jones NJ London PR Bell AR Naylor NPJ Brindle (1999) ArticleTitleAngiogenesis and the atherosclerotic carotid plaque: An association between symptomatology and plaque morphology J Vasc Surg 30 261–268 Occurrence Handle1:STN:280:DyaK1MzmslKgtQ%3D%3D Occurrence Handle10436445
PL Whitlow P Lylyk H Londero OA Mendiz K Mathias J Jaeger H Parodi C Schonholz J Milei (2002) ArticleTitleCarotid artery stenting protected with an emboli containment system Stroke 33 1308–1314 Occurrence Handle10.1161/01.STR.0000013947.17575.B3 Occurrence Handle11988608
H Markus (1996) ArticleTitleMicroembolism in cerebral angiography Echocardiography. 13 537–542 Occurrence Handle11442966
DS Baim D Wahr B George MB Leon J Greenberg DE Cutlip U Kaya JJ Popma KK Ho RE Kuntz InstitutionalAuthorNameSaphenous Vein Graft Angioplasty Free of Emboli Randomized (SAFER) Trial Investigators (2002) ArticleTitleRandomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts Circulation 105 1285–1290 Occurrence Handle10.1161/hc1202.105940 Occurrence Handle11901037
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Telman, G., Halabi, M., Kouperberg, E. et al. Microemboli at the Different Stages of Percutaneous Transluminal Carotid Angioplasty and Stenting in Patients with Post–carotid Endarterectomy Restenosis Compared to Primary Stenosis. International Journal of Angiology 13, 37–41 (2004). https://doi.org/10.1007/s00547-004-1008-8
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DOI: https://doi.org/10.1007/s00547-004-1008-8