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L. Nelson Hopkins

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Robert D. Ecker and L. Nelson Hopkins

Since the publication of the retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) in 1998, there has been a significant focus in the neurosurgical literature on the natural history of these lesions. The prospective data from the second part of the ISUIA, which was published in 2003, provided further evidence that small, asymptomatic intracranial aneurysms may have a more benign course than previously believed. With the data from the ISUIA as a reference point, in this paper the authors strive to provide a source of practical clinical data to aid cerebrovascular physicians in the initial decision to treat or observe a patient with a small, asymptomatic intracranial aneurysm. The issues covered will include previous rupture, symptoms other than rupture, aneurysm size, site, and aspect ratio. It is the authors' goal to provide a useful practical framework on the relevant clinical issues as an aid to practitioners treating patients who present with intracranial aneurysms.

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J Mocco and L. Nelson Hopkins

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Marc R. Mayberg

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Herbert L. Cares, Glen H. Roberson, Walter Grand, and L. Nelson Hopkins

✓ The authors report a technique to precisely localize a fistulous opening in the carotid artery. The patient is heparinized and a Prolo catheter is introduced into the internal carotid artery and inflated distal to the approximate site of the fistula. Heparinization allows the balloon to be inflated long enough to obtain and analyze high-quality angiography film without fear of thromboembolism generated by the temporary balloon occlusion. Contrast material injected through the Prolo catheter proximal to the balloon reveals a small segment of cavernous carotid artery between the inflated balloon distally and the fistula proximally. The venous structures are now only faintly opacified and cannot obscure the morbid anatomy of the exact fistulous tear in the carotid artery. If the balloon is placed exactly opposite to the site of the fistula, a standing, stagnant column of dye forms a cast of the cavernous, petrous, and cervical carotid artery. Once the fistula is localized with this method, it may be obliterated by any therapeutic means preferred. If the Prolo catheter is used for intraluminal occlusion, then a transfemoral contralateral carotid angiogram is done before the heparin is reversed to confirm that the balloon has not been placed proximal to the fistula.

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

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

Object. Carotid angioplasty with stent placement has been proposed as an alternative method for revascularization of carotid artery (CA) stenosis. A novel stent with a coiled sheet design (NexStent; EndoTex Interventional Systems, Inc., Cupertino, CA) has been introduced because it provides improved flexibility over conventional tubular designs during navigation through tortuous arterial segments. The authors report the results of a multicenter study in which they evaluated the safety, feasibility, and effectiveness of this stent in the treatment of CA stenosis.

Methods. Enrollment was limited to patients with 70% or more symptomatic or asymptomatic stenosis of the internal CA. The primary end point was a technically successful implantation procedure (delivery of the stent to the target site and retrieval of the delivery device) resulting in less than 30% residual stenosis on angiograms obtained immediately postprocedure and no death or ipsilateral stroke immediately after or within 30 days following the procedure. The secondary effectiveness end point was prevention of an ipsilateral stroke within 31 days to 1 year postprocedure. The tertiary effectiveness end point was less than 70% residual stenosis demonstrated on CA Doppler ultrasonography performed at 6 and 12 months.

Forty-four patients (mean age 71 years, range 51–89 years; 30 patients were men and 18 [41%] had symptomatic stenotic lesions) were treated using 45 NexStents (two stents were placed in one patient). Residual stenosis on postprocedure angiograms was less than 30% in all patients. The 1-month primary end point was achieved in 41 patients (93%). The three major adverse events that occurred within 30 days were one death related to congestive heart failure and two ipsilateral strokes, one of which resulted in death. No ipsilateral stroke occurred between 1 and 12 months postprocedure among 35 patients who completed the follow-up evaluation. Asymptomatic recurrent stenosis was identified in one patient at 6 months postprocedure, requiring the performance of repeated angioplasty.

Conclusions. Placement of the NexStent was feasible and resulted in the effective treatment of patients with CA stenosis, with promising long-term results.

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Giuseppe Lanzino and Pietro Ivo D'Urso

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Adnan I. Qureshi, M. Fareed K. Suri, Gishel New, Daniel C. Wadsworth Jr., Joan Dulin, and L. Nelson Hopkins

Object. Carotid artery (CA) angioplasty with stent placement has been proposed as an alternative technique for revascularization in cases of CA stenosis. In this report the authors review the results of a multicenter Phase I study in which they evaluated the safety and feasibility of using a new self-expanding nitinol stent, the Bard Memotherm, to treat CA stenosis.

Methods. Enrollment was limited to patients in whom there was either 50% or greater symptomatic or 70% or greater asymptomatic stenosis of the internal CA. The primary endpoint was a technically successful implantation procedure (delivery of the stent to the target site and retrieval of the delivery device), resulting in less than 30% residual stenosis demonstrated on immediate postprocedure (control) angiograms, and no incidence of mortality, ipsilateral stroke, Q-wave myocardial infarction, or other major cardiovascular events immediately after or within 30 days following the procedure.

Stent placement was attempted for 73 lesions in 71 patients (mean age 71.3 ± 8.5 years), 43 (61%) of whom were men. The mean degree of stenosis was 82.6 ± 9%. The stenosis was symptomatic in 27 (37%) and asymptomatic in 46 (63%) of 73 lesions. In four procedures the stent could not be delivered or released. The mean residual stenosis observed on angiograms was 3.8 ± 6.9% in the 69 lesions treated with the Bard Memotherm stent; residual stenosis was greater than 30% in one of the 69 procedures. The primary endpoint was achieved in 65 (89%) of the 73 procedures. One patient experienced a major ischemic stroke and another patient died of intracerebral hemorrhage. The overall 1-month stroke rate was 2.7% for 73 attempted procedures. One patient died of pneumonia and acute respiratory distress syndrome, which occurred 3 weeks after the stent procedure and was unrelated to the procedure.

Conclusions. The Memotherm stent can be used to treat patients with CA stenosis and is associated with a low periprocedure complication rate. Long-term follow-up studies are underway to determine the impact of stent placement on the risk of ipsilateral ischemic events.