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L. Nelson Hopkins

vascular malformations. Today's market for small, compliant, detachable balloons is so small that almost all manufacturers have ceased making them. Nevertheless, the need is still there, hopefully to be met by one of the medical device manufacturers in the not-too-distant future.

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Robert D. Ecker, Maureen T. Donovan and L. Nelson Hopkins

Object

More patients with head and neck cancers who undergo radical neck dissection and adjuvant radiation are experiencing prolonged survival times. Because of their improved survival, patients are living long enough to suffer the delayed effects of radiation therapy. Radiation-induced carotid artery (CA) stenosis in patients with or without radical neck dissection often requires extensive exposure and vessel reconstruction. The aim of this study was to evaluate the efficacy of endovascular treatment as an alternative therapy for radiation-induced CA stenosis.

Methods

Coinciding with the improved longevity of these patients, CA angioplasty and stent placement has become a definitive treatment strategy for this particularly challenging group of individuals. Long lesions are easily addressed with multiple telescoped stents. The tendency toward early restenosis can now be addressed with cutting balloon angioplasty. A review of the authors' institutional database yielded five patients (four men and one woman) with a history of radiation treatment ipsilateral to their CA stenosis. Three of five patients were symptomatic, and the interval between radiation therapy and endovascular treatment ranged from 1 to 47 years (mean 16.6 years). Four of the five patients were treated using distal embolic protection devices, and all patients underwent balloon dilation after stent placement.

Conclusions

As advancements are made in the technology and techniques for CA angioplasty and stent placement, the safety and durability of treatments in patients with radiation-induced atherosclerotic disease will improve.

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Marc R. Mayberg

.5%). Distal protection devices were not used in the current study. Presumably, their use would lower the incidence of cerebral ischemia, although direct proof of this is lacking. The natural history of symptomatic CA stenosis treated medically or by carotid endarterectomy (CEA) is well known. A recent metaanalysis covering more than 6000 patients in the three endarterectomy trials for symptomatic stenosis has yielded data on the natural history and risk factors that were derived from more than 25,000 patient-years of follow up. 6 Although many patients in the current

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Robert D. Ecker, Ramachandra P. Tummala, Elad I. Levy and L. Nelson Hopkins

risk of ipsilateral stroke was 25.3% in the medically treated patients and 16.0% in the surgically treated patients. 2 , 4 The greatest technical risk of CEA in this setting is disruption of the thrombus during exposure of the CCA and ICA. Before the advent of distal embolic protection, stent placement for symptomatic CA lesions containing intraluminal thrombus required crossing the lesion without protection against distal release of emboli. Now devices for distal embolic protection, reversal of flow, and proximal protection by flow arrest are available for

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Robert D. Ecker, Tsz Lau, Elad I. Levy and L. Nelson Hopkins

) symptomatic patients with more than 70% CA stenosis. 11 , 12 Payments for devices and associated procedures are determined by the CMS after FDA approval. The current CMS coverage decision (as of March 17, 2005) allows for reimbursement of CAS treatment costs only in patients with symptomatic stenosis greater than or equal to 70% or for patients enrolled in FDA-sponsored clinical trials. With that coverage decision, CAS placement finally earned legitimacy as a treatment alternative to CEA. Unlike CEA, however, which has a clearly defined 30-day morbidity/mortality rate

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Elad I. Levy, Adnan H. Siddiqui and L. Nelson Hopkins

high rate of recurrent stroke. 4 This has resulted in reinvigoration of endovascular strategies for revascularization of intracranial stenoses. 8 , 9 , 11 , 14 , 21 , 23 , 24 , 26 There are an increasing number of devices specifically designed to meet the challenges of an inhospitable intracranial vasculature and that may be useful for the treatment of intracranial stenoses. The Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Vitesse Intracranial Stent Study for Ischemic Therapy trials are underway to explore

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J Mocco, Ricardo A. Hanel, Jitendra Sharma, Erik F. Hauck, Kenneth V. Snyder, Sabareesh K. Natarajan, Italo Linfante, Adnan H. Siddiqui, L. Nelson Hopkins, Alan S. Boulos and Elad I. Levy

used similar stent systems with comparable technical profiles and delivery systems, manufactured by the same company (Wingspan and Neuroform stent systems, Boston Scientific). The Wingspan system is intended for intracranial stenosis treatment and the Neuroform system for aneurysm neck reconstruction. Recently, a new self-expanding stent has become available to the endovascular community, the Enterprise Vascular Reconstruction Device (Codman Neurovascular/Cordis Corp.). This device uses a catheter-based delivery system that has been suggested to provide improved

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Adnan I. Qureshi, Charlene Knape, John Maroney, M. Fareed K. Suri and L. Nelson Hopkins

patients. 13 At present, several methods of angioplasty and stent devices are being investigated in feasibility trials before large, randomized, multicenter trials are undertaken to compare endoluminal and surgical results of CA revascularization. Stents currently used for endoluminal treatment of CA stenosis are tubular in design. The balloon-expandable Palmaz—Schatz stent (Cordis, Johnson & Johnson Co., Warren, NJ) and Intrastent (Intratherapeutics, St. Paul, MN); and the self-expanding Precise stent (Cordis Neurovascular, Miami Lakes, FL) and Wallstent (Boston

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Mandy J. Binning, Alexander A. Khalessi, Adnan H. Siddiqui, L. Nelson Hopkins and Elad I. Levy

critical first step in what may prove a promising line of inquiry: stent placement for the treatment of traumatic intracranial dissections in children. Disclosure Dr. Hopkins receives research study grants from Abbott (ACT 1 Choice), Boston Scientific (CABANA), Cordis (SAPPHIRE WW), and ev3 (CREATE) and a research grant from Toshiba (for the Toshiba Stroke Research Center); receives royalties from Cordis (for the Angioguard device); has an ownership/financial interest in AccessClosure, Boston Scientific, Micrus, and Valor Medical; serves on the Abbott Vascular

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Hajime Ohta, Sabareesh K. Natarajan, Erik F. Hauck, Alexander A. Khalessi, Adnan H. Siddiqui, L. Nelson Hopkins and Elad I. Levy

, were deployed by telescoping techniques. Most dissections were treated with a closed-cell CA stent (Wallstent or Magic Wallstent, Boston Scientific), except those in a tortuous extracranial CA or an intracranial segment. Other stents used were CA stents (Xpert [Abbott Vascular Devices], Xact [Abbott Vascular Devices], and Precise [Codman Neurovascular]), intracranial self-expanding stents (Wingspan [Boston Scientific], Neuroform [Boston Scientific], and Enterprise [Codman Neurovascular]), coronary balloon-mounted stents (Multilink miniVision [Abbott Vascular Devices