Yasha Kadkhodayan, Colin P. Derdeyn, Dewitte T. Cross III and Christopher J. Moran
The goal in this retrospective study was to examine the procedural complication rate for carotid angioplasty and stent placement performed without cerebral protection devices.
Between March 1996 and December 2003, 167 carotid angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients' medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates.
The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days post-procedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01).
Carotid angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.
Avi Mazumdar, Dennis J. Rivet, Colin P. Derdeyn, DeWitte T. Cross III and Christopher J. Moran
This study was conducted to determine whether there is a change in intracranial arterial diameters after verapamil infusion for vasospasm and, if it is present, to determine whether the change occurs in proximal, intermediate, or distal vessels.
The authors measured arterial diameters in all patients treated with intraarterial verapamil at their institutions between August 2003 and September 2004. In all, 18 treatments were examined in 15 patients. Measurements were made before and after verapamil infusion in a blinded fashion with the aid of a magnification loupe at nine predetermined arterial sites on each angiogram. Baseline arterial measurements were made on each patient's initial angiogram and on the angiogram demonstrating spasm prior to endovascular therapy as well in 14 of the patients. Charts were retrospectively reviewed to determine whether the patients benefited from intraarterial vera-pamil.
From the time of the initial angiogram to the time of vasospasm, there was a 21.6% decrease (p = 0.092) in proximal artery diameter, a 47.1% decrease (p < 0.05) in intermediate artery diameter, and a 12.4% decrease (p < 0.05) in distal artery diameter. There were no significant changes in the diameters of proximal, intermediate, or distal vessels after verapamil infusion (mean dose 7.4 mg, range 2.5–10 mg). After infusion of intraarterial verapamil, the proximal vessels showed a 1.1% decrease in diameter, the intermediate vessels showed a 9.4% increase, and the distal vessels showed a 3.3% decrease.
Administration of intraarterial verapamil does not cause a significant increase in the diameter of vasospastic vessels at the administered doses.
Anna Terry, Gregory Zipfel, Eric Milner, DeWitte T. Cross III, Christopher J. Moran, Michael N. Diringer, Ralph G. Dacey Jr. and Colin P. Derdeyn
Over the past decade, low-pressure, flow-directed balloons have been replaced by over-the-wire balloons in the treatment of vasospasm induced by subarachnoid hemorrhage (SAH). The authors assess the procedural safety and technical efficacy of these newer devices.
Seventy-five patients who underwent 85 balloon angioplasty procedures for the treatment of SAH-induced vasospasm were identified from a prospective quality-assurance database. Medical records and angiographic reports were reviewed for evidence of procedural complications and technical efficacy.
No vessel rupture or perforation occurred, but thromboembolic complications were noted in four (4.7%) of the 85 procedures. Balloon angioplasty was frequently attempted and successfully accomplished in the distal internal carotid (100%), proximal middle cerebral (94%), vertebral (73%), and basilar (88%) arteries. Severe narrowing was present in 89 proximal anterior cerebral arteries. Angioplasty was attempted in 41 of these vessels and was successful in only 14 (34%). In 19 of the 27 unsuccessful attempts, the balloon could not be advanced over the wire due to severe vasospasm or unfavorable vessel angle. Follow-up angiography in a subset of patients demonstrated that severe recurrent vasospasm occurred in 15 (13%) of 116 vessels studied after angioplasty.
Over-the-wire balloons involve a low risk for vessel rupture. The anterior cerebral artery remains difficult to access and successfully treat with current devices. Further improvements in balloon design, such as smaller inflated diameters and better tracking, are necessary. Finally, thromboembolic complications remain an important concern, and severe vasospasm may recur after balloon angioplasty.
Ayman A. Elsayed, Christopher J. Moran, DeWitte T. Cross III, Colin P. Derdeyn, Thomas K. Pilgram, James M. Milburn, Ralph G. Dacey Jr. and Michael N. Diringer Jr.
The goal in this study was to determine if there was a change in intracranial venous diameters after endo-vascular treatment of carotid distribution vasospasm caused by subarachnoid hemorrhage.
The venous diameters were measured in all patients who received intraarterial papaverine and/or balloon angioplasty for treatment of vasospasm during the study period of 3 years. To evaluate the veins of Labbé and Trolard, the straight sinus, and the superior sagittal sinus (SSS), measurements were performed in a blinded manner with the aid of a magnification loupe. Predetermined sites were evaluated on angiograms obtained before and after endovascular treatment. Forty-three treatments in 26 patients were included: 18 patients (33 territories) were treated with intraarterial papaverine alone, four (four territories) were treated with balloon angioplasty alone, and four (six territories) were treated with both papaverine infusion and angioplasty.
The mean measured venous diameters increased significantly after addition of papaverine (10.9%), and also after combined papaverine and angioplasty (4.2%). There was no statistically significant increase in the mean venous diameters after angioplasty alone. If the initial intracranial pressure (ICP) was less than 15 mm Hg before treatment, the veins showed a greater tendency to dilate than if the initial ICP measurements were greater than 15 mm Hg. The straight sinus and the SSS increased more in diameter than the veins of Labbé and Trolard. There was no statistically significant correlation between the change in venous diameters with treatment and ICP.
Endovascular treatment produces measurable increases in intracranial venous diameters. However, these changes do not correlate with changes in ICP.