颈动脉慢性完全闭塞后再通的症状

1、颈动脉慢性完全闭塞后再通的症状ICA stentingProven to be an alternative to CEA in ICA stenosis, especially in patients with high surgical risk profilesBut the application of endovascular intervention in cervical ICA occlusion (ICAO) has never been explored, which comprise 15% of patients with ipsilateral TIA or infa

2、rctionPaul HL Kao 08The great mythICA stenosis causes symptoms through artery-to-artery embolismThe risk of stroke is minimal with ICAO, because there is no flow to carry the emboliIs it true?Paul HL Kao 08Prognosis and pathophysiology of ICAOCervical ICAO is an important cause of TIA and cerebral i

3、nfarction and should not be neglectedAnnual risk of ipsilateral stroke in symptomatic ICAO is 6-20%Annual risk of ipsilateral stroke in asymptomatic ICAO is 2-5 %Pathophysiology of symptomsEmboli arising from ECA/CCA via collateralsEmboli arising from ICA stump via collaterals (Stump syndrome)Emboli

4、 arising from trailing thrombi distal to the occlusionHypo-perfusion (hemodynamic insufficiency)Paul HL Kao 08Treatment options for ICAOMedicalThe recommended treatment at present, but may be insufficient for certain patientsSurgeryCEAStump ligation/exclusionEC/IC bypassCan be very technically deman

5、ding with high periprocedural complicationsAll failed to reduce ipsilateral stroke and are not recommended to ICA CTO in generalPaul HL Kao 08EC/IC bypass1377 patients with symptomatic ICA or MCA occlusion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 5

6、6 monthsMajor peri-operative stroke rate as 4.5%Total stroke rates were not different between bypass and medical groupsIn patients with ongoing symptoms after angiographic documentation of ICAO, the benefit of bypass was not shown eitherPaul HL Kao 08NEJM. 1985;313:11911200Review of studies20 studie

7、s 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 CT have an even higher annual risk of all and ipsilateral stroke (12.5% and 9.5%)Stroke. 1997;28:20842093

8、Paul HL Kao 08Identify the right patient to revascularize81 ICAO patients with old ipsilateral stroke or TIA, evaluated with PET and followed for 3 yearsStroke occurred in 12/39 and 3/42 (p=0.005, age-adjusted RR= 6) patients with and without stage 2 perfusion failure, ipsilateral stroke in 11/39 an

9、d 2/42 (p=0.004, age-adjusted RR= 7.3)Paul HL Kao 08JAMA. 1998;280:10551060NTUH ICAO experienceEndovascular recanalization was attempted in 75 patients with ICAO from October 2002 to Dec 2007, out of 480 (15.6%) ICA stentings in the same periodICAO was documented by ultrasound, CTA, or MRAAll patien

10、ts were followed clinically for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologistEnrollment criteriaProgression or recurrence of ipsilateral neurological deficit, orObjective ipsilateral hemispheric ischemiaPaul HL Kao 08Exemplary case: 64M with old RMCA infarctB

11、aselineDiamox stressFlowPaul HL Kao 08Diamox stressBaselineVolumePerfusion CT imaging for objective ischemiaPaul HL Kao 08Perfusion CT imaging for objective ischemiaDiamox stressBaselineTransit TimePaul HL Kao 08CT angiography for path findingCervical ICACarotid canalPaul HL Kao 08Ultrasound evaluat

12、ionNeck ultrasound and trans-ocular duplex evaluation of OA flow direction before, and 1, 6, 12 months after procedure by an independent neurologistSuspicion of restenosis by ultrasound mandates angiographic follow-upPaul HL Kao 08Exemplary case: 64M RICA CTOLateral viewIC lateral viewPaul HL Kao 08

13、After 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 baselinePre stressTransit timePaul HL Kao 08Comparison of CTA at 1 monthPrePostPaul HL Kao 08Acknowledged workPaul H

14、L Kao 08Demographics (Oct 02 - Aug 08)Male sex4889%Age (y)69.2 9.8Hypertension4380%Diabetes mellitus1935%Hyperlipidemia2954%Smoking2852%Prior ipsilateral stroke3565%Ipsilateral TIA1528%Amaurosis fugax47%Contralateral ICA stenosis 50%1935%Progression or recurrence of neurologic deficit after known IC

15、A 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 length (mm)27.916.2Wire crossing successful3769% Distal protection device used after crossing 27 73% PercuSurge/Fi

16、lterWire 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 Kao 08Clinical outcome (Oct 02 - Aug 08)In-hopsital , n (%)3-m follow-up, n (%)Death1 (1.9)1 (1.9) Fatal stroke1 (1

17、.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)Paul HL Kao 08The only mortalityEmergentBaselinePaul HL Kao 08Kao HL et al. JACC 2007;49:765Ophthalmic artery flow eva

18、luationGood quality trans-ocular duplex can be obtained in 25/30 (84%) patients before procedure, and 21/25 (83%) showed reversed OA flowPre-procedure OA flow was reverse in 15/22 patients that were later successfully recanalizedOA flow was normalized 1 month after recanalization in 12/15 (80%)Persi

19、stent OA flow reversal in 2/15 (13%), both were found re-occluded at 1 month1 patient died at day 3 without post-procedure trans-ocular duplexPaul HL Kao 08Kao HL et al. JACC 2007;49:765Safety issuesPaul HL Kao 08BaselineRecanalizedDelayed pseudoaneurysm Recurrent ischemiaPaul HL Kao 08BMS across ps

20、eudoaneurysmPaul HL Kao 08Ischemia relievedPaul HL Kao 08ExtravasationPaul HL Kao 08Carotid-cavernous fistulaLocal hematomaEndpoints for interventionFor PCIDeath/MIAngina relief, LV function recovery, and TVRFor ICA interventionDeath/strokePhysiological and functional endpointsNeuro-cognitive evalua

21、tionChanges in perfusion imaging, such as perfusion CT, MRI, and PETPaul HL Kao 08ConclusionsEndovascular recanalization of ICAO is feasible and safeFuture prospective studies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalizatio

22、n of ICAOPaul HL Kao 08Its never too late to open a closed door, because the room behind may be full of surprisesDefinitionsAtheromatous pseudo-occlusion (APO)String-like residual filling of ICA behind the “occlusion”Retrograde filling of the proximal so-called “occluded” ICA reaching the skull base

23、Chronic total occulsion (CTO)The occlusion must be documented for at least 1 monthTIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in lengthEstablished filling to the ipsilateral intracranial ICA via A-Com, P-Com, OA, meningeal, or other collateralsPaul HL Kao 07Partial recovery of perfusion C