颈动脉慢性完全闭塞后再通的症状英文

1、Endovascular Recanalization of Symptomatic Chronic Total Occlusion of Cervical Carotid ArteryICA stenting Proven to be an alternative to CEA in ICA stenosis, especially in patients with high surgical risk profiles But the application of endovascular intervention in cervical ICA occlusion (ICAO) has

2、never been explored, which comprise 15% of patients with ipsilateral TIA or infarctionPaul HL Kao 08The great myth ICA stenosis causes symptoms through artery-to-artery embolism The risk of stroke is minimal with ICAO, because there is no flow to carry the emboli Is it true?Paul HL Kao 08Prognosis a

3、nd pathophysiology of ICAO Cervical ICAO is an important cause of TIA and cerebral infarction and should not be neglected Annual risk of ipsilateral stroke in symptomatic ICAO is 6-20% Annual risk of ipsilateral stroke in asymptomatic ICAO is 2-5 % Pathophysiology of symptoms Emboli arising from ECA

4、/CCA via collaterals Emboli arising from ICA stump via collaterals (Stump syndrome) Emboli arising from trailing thrombi distal to the occlusion Hypo-perfusion (hemodynamic insufficiency)Paul HL Kao 08Treatment options for ICAO Medical The recommended treatment at present, but may be insufficient fo

5、r certain patients Surgery CEA Stump ligation/exclusion EC/IC bypass Can be very technically demanding with high periprocedural complications All failed to reduce ipsilateral stroke and are not recommended to ICA CTO in generalPaul HL Kao 08EC/IC bypass 1377 patients with symptomatic ICA or MCA occl

6、usion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 56 months Major peri-operative stroke rate as 4.5% Total stroke rates were not different between bypass and medical groups In patients with ongoing symptoms after angiographic documentation of ICAO, th

7、e benefit of bypass was not shown eitherPaul HL Kao 08NEJM. 1985;313:11911200Review of studies 20 studies in patients with TIA or ischemic stroke associated with ICAO, the annual risk of all and ipsilateral stroke were 5.5% and 2.1% Patients with a compromised CBF measured by PET, SPECT, TcD, or Xe

8、CT have an even higher annual risk of all and ipsilateral stroke (12.5% and 9.5%)Stroke. 1997;28:20842093Paul HL Kao 08Identify the right patient to revascularize 81 ICAO patients with old ipsilateral stroke or TIA, evaluated with PET and followed for 3 years Stroke occurred in 12/39 and 3/42 (p=0.0

9、05, age-adjusted RR= 6) patients with and without stage 2 perfusion failure, ipsilateral stroke in 11/39 and 2/42 (p=0.004, age-adjusted RR= 7.3)Paul HL Kao 08JAMA. 1998;280:10551060NTUH ICAO experience Endovascular recanalization was attempted in 75 patients with ICAO from October 2002 to Dec 2007,

10、 out of 480 (15.6%) ICA stentings in the same period ICAO was documented by ultrasound, CTA, or MRA All patients were followed clinically for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologist Enrollment criteria Progression or recurrence of ipsilateral neurologic

11、al deficit, or Objective ipsilateral hemispheric ischemiaPaul HL Kao 08Exemplary case: 64M with old RMCA infarctBaselineDiamox stressFlowPaul HL Kao 08Diamox stressBaselineVolumePerfusion CT imaging for objective ischemiaPaul HL Kao 08Perfusion CT imaging for objective ischemiaDiamox stressBaselineT

12、ransit TimePaul HL Kao 08CT angiography for path findingCervical ICACarotid canalPaul HL Kao 08Ultrasound evaluation Neck ultrasound and trans-ocular duplex evaluation of OA flow direction before, and 1, 6, 12 months after procedure by an independent neurologist Suspicion of restenosis by ultrasound

13、 mandates angiographic follow-upPaul HL Kao 08Exemplary case: 64M RICA CTOLateral viewIC lateral viewPaul HL Kao 08After Carotid Wall and TsunamiAP viewLateral viewPaul HL Kao 083m follow-upIC AP viewIC lateral vewPaul HL Kao 08Partial recovery of perfusion CT at 1 monthPost stressPost baselinePre b

14、aselinePre stressTransit timePaul HL Kao 08Comparison of CTA at 1 monthPrePostPaul HL Kao 08Acknowledged workPaul HL Kao 08Demographics (Oct 02 - Aug 08)Male sex4889%Age (y)69.2 9.8Hypertension4380%Diabetes mellitus1935%Hyperlipidemia2954%Smoking2852%Prior ipsilateral stroke3565%Ipsilateral TIA1528%

15、Amaurosis fugax47%Contralateral ICA stenosis 50%1935%Progression or recurrence of neurologic deficit after known ICA occlusion 3769%Paul HL Kao 08Procedural results (Oct 02 - Aug 08)Technical success3565%Lesion location, right/left27/2750%/50%CCA diameter (mm)7.90.6 ICA diameter (mm)5.10.5 Occlusion

16、 length (mm)27.916.2Wire crossing successful3769% Distal protection device used after crossing 27 73% PercuSurge/FilterWire 17/10 63%/37% Post-dilatation balloon diameter (mm)4.51.7 Post-dilatation pressure (atm)6.82.9 ECA orifice covered by stent34 92% Final residual diameter stenosis (%)97Paul HL

17、Kao 08Clinical outcome (Oct 02 - Aug 08)In-hopsital , n (%)3-m follow-up, n (%)Death1 (1.9)1 (1.9) Fatal stroke1 (1.9) 1 (1.9) Other cause00Stroke2 (3.7)2 (3.7) Major ipsi.00 Major non-ipsi.1 (1.9) 1 (1.9) Minor ipsi.1 (1.9) 1 (1.9) Minor non-ipsi.00TIA00ICH/hyperperfusion00Restenosis-4/35 (11.4)Pau

18、l HL Kao 08The only mortalityEmergentBaselinePaul HL Kao 08Kao HL et al. JACC 2007;49:765Ophthalmic artery flow evaluation Good quality trans-ocular duplex can be obtained in 25/30 (84%) patients before procedure, and 21/25 (83%) showed reversed OA flow Pre-procedure OA flow was reverse in 15/22 pat

19、ients that were later successfully recanalized OA flow was normalized 1 month after recanalization in 12/15 (80%) Persistent OA flow reversal in 2/15 (13%), both were found re-occluded at 1 month 1 patient died at day 3 without post-procedure trans-ocular duplexPaul HL Kao 08Kao HL et al. JACC 2007;

20、49:765Safety issuesPaul HL Kao 08BaselineRecanalizedDelayed pseudoaneurysm Recurrent ischemiaPaul HL Kao 08BMS across pseudoaneurysmPaul HL Kao 08Ischemia relievedPaul HL Kao 08ExtravasationPaul HL Kao 08Carotid-cavernous fistulaLocal hematomaEndpoints for intervention For PCI Death/MI Angina relief

21、, LV function recovery, and TVR For ICA intervention Death/stroke Physiological and functional endpoints Neuro-cognitive evaluation Changes in perfusion imaging, such as perfusion CT, MRI, and PETPaul HL Kao 08Conclusions Endovascular recanalization of ICAO is feasible and safe Future prospective st

22、udies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalization of ICAOPaul HL Kao 08Its never too late to open a closed door, because the room behind may be full of surprisesDefinitions Atheromatous pseudo-occlusion (APO) String-li

23、ke residual filling of ICA behind the “occlusion” Retrograde filling of the proximal so-called “occluded” ICA reaching the skull base Chronic total occulsion (CTO) The occlusion must be documented for at least 1 month TIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in

24、 length Established filling to the ipsilateral intracranial ICA via A-Com, P-Com, OA, meningeal, or other collateralsPaul HL Kao 07Partial recovery of perfusion CT at 1 monthPre baselinePre stressPost baselinePost stressFlowPaul HL Kao 07Partial recovery of perfusion CT at 1 monthVolumePre baselineP

25、ost baselinePre stressPost stressPaul HL Kao 07Example of complete recoveryPre stress flowPost stress flowPaul HL Kao 08Example of complete recoveryPre stress volumePost stress flowPaul HL Kao 08Example of complete recoveryPre stress transit timePost stress transit timePaul HL Kao 08Cerebral perfusi

26、on after ICAO Stage 0: CPP normal, CBF matched with resting metabolic demand, no regional variation in OEF Stage 1: CPP decreased, but CBF maintained by vasodilatation, CBV increased Stage 2: CPP further decreased beyond the capacity of auto-regulation, CBF decreased, regional OEF increased with dec

27、lined brain functionPaul HL Kao 08ICA stenting Proven to be an alternative to CEA in ICA stenosis, especially in patients with high surgical risk profiles But the application of endovascular intervention in cervical ICA occlusion (ICAO) has never been explored, which comprise 15% of patients with ipsilateral TIA or infarctionPaul HL Kao 08Identify the right patient to revascularize 81 ICAO patients with old ipsilateral stroke or TIA, evaluated with PET and fo