Surgical Procedures for. Symptomatic Post-CAS Carotid. Restenosis: Experiences and. Mid-Term Outcomes. Lefeng Qu M.D., Ph.D. Professor of Surgery
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1 Surgical Procedures for Symptomatic Post-CAS Carotid Restenosis: Experiences and Mid-Term Outcomes Lefeng Qu M.D., Ph.D. Professor of Surgery Department of Vascular and Endovascular Surgery, Changzheng Hospital, Second Millitary Medical University, Shanghai, China.
2 Shanghai New Orleans
3 Disclosures Speaker s Bureau: No company Stockholder: No company Honorarium: No company Grant/Research Support: No company Consultant: No company Medical/Scientific Boards: No company
4 Background: Carotid artery stenting (CAS) is booming Ø Within worldwide:increasing publications Ø In China:Increasing surgical volume Publications data from GoPubMed Surgical volume over time in China 1 1. Longde Wang China National Stroke Heart Disease Forum opening ceremony. press conference report.
5 Background: Complications of CAS is various Ø Perioperative complications Filter wire fracture Stent migration Perioperative stroke or death Ø Mid & long-term complications Post-stenting restenosis (PSRS) Common discussed Seldom discussed
6 Background: PSRS is not uncommon Ø High incidence Incidence of restenosis: CAS 3 folds of CEA 1 Incidence of severe restenosis( 80%): 3% - 28% 2, 3 Ø Significant symptoms Symptoms recurrence Symptoms aggravation Ø Etiology Atherosclerosis Arterial myointimal hyperplasia 1. Christiaans MH, Ernst JM, Suttorp MJ, et al. Restenosis after carotid angioplasty and stenting: a follow-up study with duplex ultrasonography. Eur J Vasc Endovasc Surg (2): Chakhtoura EY, Hobson RW 2nd, Goldstein J, et al. In-stent restenosis after carotid angioplasty-stenting: incidence and management. J Vasc Surg (2): 220-5; discussion Reichmann BL, Hellings WE, van der Worp HB, et al. Interprocedural Comparison of Changes in Natural Flow Velocity Patterns in the Internal
7 Background: Symptomatic PSRS should be managed Ø Significance Relieve symptoms Reduce the potential risk of stroke Ø Approach Endovascular procedures Stent relining Surgical procedures Stent/plaque removal
8 Background: Surgical management remains challenging & controversial To restore the direct hemisphere blood supply Ø Stent & plaque removal with extra-cranial carotid reconstruction: 1. Stent/plaque removal and CEA with patchplasty 2. Stent/plaque removal and CEA with eversion technique 3. Segment/plaque excision with graft interposition Ø Stent & plaque unremoval with extra-cranial carotid reconstruction: Extra-cranial Intra-cranial (EC-IC) bypass
9 Background: Surgical management remains challenging & controversial Limited numbers of case series Zheng J, Liu L, Cao Y, et al. Carotid endarterectomy with stent removal in management of in-stent restenosis: a safe, feasible, and effective technique. Eur J Vasc Endovasc Surg, 2014,47(1):8-12.
10 Background: Our experiences of PSRS surgical management Ø Over 4000 cases of Carotid endarterectomy (CEA) 1 Ø 47 PSRS cases treated by different surgical procedures 2 Ø Ø Chief editor of 2 monographs related to CEA Organizer of Chinese Carotid Surgery Forum & International Carotid Surgery Summit (CCS) CEA monographs CCS Lefeng Qu, Jun Bai, et al. Surgical techniques and perioperative management of carotid endarterectomy multi-center clinical experience at home and abroad. Chinese Journal of Neurosurgery. 2014,30(11); Lefeng Qu, Jianjin Wu, et al. Surgical management of post carotid artery stenting restenosis. Chinese Medical Journal. in press.
11 Background: Our experience of PSRS surgical management 1 st choice: Patch carotid endarterectomy (pcea) 2 nd choice: Eversion carotid endarterectomy (ecea) 3 rd choice: Graft interposition carotid endarterectomy (gcea)
12 Objective Study the feasibility, safety and effectiveness of 3 surgical procedures for symptomatic PSRS
13 Methods: Study design Ø From to Ø 47 symptomatic PSRS patients Ø 3 kinds of surgical procedures Ø Mid-term follow-up
14 Methods: Baseline characteristics Ø 47 symptomatic PSRS patients Ø 36 females and 11 males Ø Age ranging from 48 to 82 years (mean 65.7) Ø Multiple symptoms complained in one patient Ø Severe restenosis confirmed via DUS and CTA Symptom contralateral limb weakness 24 (51.1%) dizziness 33 (70.2%) transient ischemic attack (TIA) Lal classification 1 TypeⅠ 13 Type Ⅱ 23 Type Ⅲ 5 Type Ⅳ 4 Type Ⅴ 2 n 12 (25.5%) n 1.Lal BK, Kaperonis EA, Cuadra S, Kapadia I, Hobson RW 2nd. Patterns of in-stent restenosis after carotid artery stenting: classification and implications for long-term outcome. J Vasc Surg (5):
15 Methods: Preoperative evaluation Ø General assessment (Same with routine CEA) Ø Local assessment: Feasibility and procedure selection Doppler ultrasound (DUS) and CTA were necessary 3D-CTA with cervical vertebra: for clamping space & procedure evaluation DSA and CTP not routinely CTA reconstruction Doppler ultrasound DSA
16 Methods: Indications for surgery 1. Stenosis degree > 70% 2. Symptoms had a direct correlation with PSRS Recurrence of pre-cas symptoms Aggravation of new hemisphere ischemia symptoms
17 Methods: Surgical Procedures Before the procedure Ø General anesthesia Ø Shunt Ø Patch Ø Graft
18 Methods: Surgical Procedures 1st choice pcea 1. ICA, CCA longitudinal incision 2. Stent-plaque complex stripping
19 Methods: Surgical Procedures 1st choice pcea 3. Stent-plaque complex removal 4. Dacron patch-angioplasty (MAQUET, INTERVASCULAR, Carotid Patch,Size: 8 7.5mm)
20 Methods: Surgical Procedures 1 st choice:pcea Postoperative view Stent-plaque complex
21 Methods: Surgical Procedures 2nd choice ecea 1. Distal tortuous ICA exposure 2. Initial ICA incision
22 Methods: Surgical Procedures 2nd choice ecea 3. CCA stent-plaque complex stripping 4. ICA stent-plaque complex eversional stripping
23 Methods: Surgical Procedures 2nd choice ecea 5. Anastomotic angioplasty 6. Postoperative view
24 Methods: Surgical Procedures 3 rd choice:gcea 1. Longitudinal endarterectomy failed 2. Segment excision
25 Methods: Surgical Procedures 3 rd choice:gcea CCA side ICA side CCA side ICA side Stent-artery complex
26 Methods: Surgical Procedures 3 rd choice:gcea 3. 6mm PTFE-graft interposition with shunting 4. Postoperative view
27 Methods: Post-operative treatment Ø High risk factor control Smoking Hypertension, hyperlipidemia Diabetes mellitus, et al Ø BMT Anti-platelet Anti-atherosclerosis Anti-intimal hyperplasia & endothelialization promotion
28 Methods: Follow-up Ø DUS : 1 week; 1, 3,6, 12 months; then yearly Ø CTA : 6 months and yearly
29 Results: Surgical procedures Ø All the stents were successfully removed Ø Ø Ø In 11 (23.4%) operations a shunt was deployed Mean bleeding: ml ( ml) Mean operation time: 100.7min (55-176min) Surgical precedure n pcea 23(48.9%) ecea 11(23.4%) gcea 13(27.7%) Ø Mean carotid artery clamping time: 29.1min (12-51min)
30 Results: Perioperative outcomes Within 30 days after the operation Ø Ø Ø No infection, strokes, cranial nerve injury, myocardial infarction or mortalities 3 (6.4%) patients developed neck hematoma 4 (8.5%) patients developed the symptoms of hyperperfusion Symptoms of such as headache, irritability and multi-lingual No intracranial hemorrhage according to the brain CT scan Ø All fully recovered within 1 week
31 Results: Mid-term outcomes Median 22.1 (6-59) months follow-up Ø Symptoms improved 1 Visual, Acoustic, and Neurocognitive Functions Improved Ø No strokes, myocardial infarctions or recurrent restenosis (>50%) on duplex ultrasound imaging or CTA was discovered CTA follow-up 1. Jiaxuan Feng, Lefeng Qu*. Improved visual, acoustic, and neurocognitive functions following carotid endarterectomy in patients with minor stroke from severe carotid stenosis. J Vasc Surg (in press)
32 Discussion: Surgical selection - pcea Features Ø Ø A shunt could be used to make the procedure easier It was evolved from conventional pcea Indications Ø The adhesion between stent-plaque and arterial wall was light and was easily to separate
33 Discussion: Surgical selection - ecea Features Ø Tortuous ICA could be straighten and anastomotic angioplasty could be done within the procedure Ø Time is shorter Indications Ø The adhesion between stent-plaque and arterial wall was light and was easily to separate Ø The stent was short and not in a high position Ø PSRS patients with kinking or tortuous ICA
34 Discussion: Surgical selection - gcea Features Ø A shunt could be used to make the procedure easier Ø Alternative to the situation in which the arterial wall is thin, arterial rupture, severe adhesion between the stent and arterial wall Indications Ø PSRS patients who could not treated by pcea or ecea
35 Conclusion Ø PSRS is not uncommon Ø Severe symptomatic PSRS needs surgical management Ø Carefully preoperative general and local evaluation Ø Individualized surgical procedure selections Ø Feasible, safe, effective and durable
36 Welcome to Shanghai 5 th Chinese Carotid Surgery Forum & International Carotid Surgery Summit 2016 April Shanghai, China
37 Surgical Procedures for Symptomatic Post-CAS Carotid Restenosis: Experiences and Mid-Term Outcomes Lefeng Qu M.D., Ph.D. Professor of Surgery Department of Vascular and Endovascular Surgery, Changzheng Hospital, Second Millitary Medical University, Shanghai, China.
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