Arq Neuropsiquiat r 2004;62(4):1012-1015
1M édico do Serviço de Neurorradiologia Int ervencionist a do Hospit al Israelit a Albert Einst ein, São Paulo SP, Brazil (HIAE); 2M édico Neurologist a HIAE; 3M édico Universidade Est adual do Rio de Janeiro, Rio de Janeiro RJ, Brazil.
Received 31 M arch 2004. Accept ed 16 July 2004.
Dr. Eduardo Noda Kihara - Serviço de Neuroradiologia Int ervencionist a - Avenida Albert Einst ein 627/4oandar - 05651-901 São Paulo SP - Brasil. E-mail: kihara@einst ein.br
ENDOVASCULAR TREATM ENT OF
CAROTID ARTERY STENOSIS
Ret rospect ive st udy of 79 pat ient s t reat ed w it h
st ent ing and angioplast y w it h and w it hout
cerebral prot ect ion devices
Eduardo Noda Kihara
1, M ario Sergio Duart e Andrioli
1, Eliova Zukerman
2,
M ario Fernando Priet o Peres
2, Pedro Paulo Port o Júnior
2, Paulo Hélio M onzillo
2,
Ivan Hideyo Okamot o
2, Ayrt on Robert o M assaro
2, José Carlos Zirret t a
3.
ABSTRACT - We evaluat e t he result s of st ent ing and angioplast y on carot id bif urcat ion st enot ic lesions using prot ect ion syst ems, emphasizing t he indicat ions and t echnical aspect s. Sevent y-nine pat ient s, mean age 64.5 years w ere t reat ed f rom February,1998 t o M arch, 2003. All pat ient s w ere included in NASCET st udy crit eria. Fort y t hree pat ient s w ere t reat ed w it hout t he prot ect ion syst ems and t hirt y six w ere t reat ed w it h carot id prot ect ion f ilt ering syst em (Angioguard, EPI). Technical success and 6-mont hs carot id Doppler ul-t rasound f ollow -up show ing sul-t enul-t paul-t ency w ere achieved in all paul-t ienul-t s. One major sul-t roke and one deaul-t h due t o int racranial reperf usion bleeding occurred in pat ient s t reat ed w it hout cerebral prot ect ion devices. Only one pat ient present ing hyper perf usion syndrome improving af t er 7 days, w as f ound in t he group t reat ed w it h t he cerebral prot ect ion f ilt er mechanism, no ot her neurologic sympt om or deat h occured in this group. Stenting and angioplasty with protection systems for thromboembolic debris is a safe endovascu-lar met hod t o t reat st enot ic lesions in t he carot id bif urcat ion w it h low morbidit y and mort alit y.
KEY WORDS: carot id art ery st ent , carot id art ery at herosclerosis, endovascular t herapy.
Trat am ent o endovascular das lesões est enót icas em bif urcação carot ídea: est udo ret rospect ivo de 79 pacientes tratados por “stent” e angioplastia com e sem mecanismos de proteção cerebral
RESUM O - Est e est udo most ra a experiência e result ados da t erapêut ica endovascular nas lesões est enót i-cas em bif urcação carot ídea. Ent re f evereiro de 1998 e março de 2003 f oram t rat ados 79 pacient es com ida-des ent re 57 e 72 anos (média 64,5 anos) sendo 45 do masculino e 34 do f eminino. Todos os pacient es en-quadravam-se nos crit érios do est udo “ NASCET” com compromet iment o das art érias carót idas int ernas. Dos 79 pacient es, 43 f oram t rat ados sem os sist emas de prot eção e 36 pacient es f oram t rat ados com sist e-ma de prot eção. Dos 36 pacient es t rat ados com sist ee-ma de prot eção f oram ut ilizados f ilt ros de prot eção (Angioguard e EPI). Observou-se melhora angiográf ica em t odos os 79 pacient es t rat ados. Ult rasom Doppler realizado após 6 meses most rou art érias pérvias em t odos os pacient es. Nos 43 pacient es t rat ados por “ st ent ” /angioplast ia sem a ut ilização de sist emas de prot eção t ivemos um pacient e com déf icit neurológi-co que perdurou por mais de 30 dias (“ st roke major” ) e um óbit o por t ransf ormação hemorrágica devido à reperf usão. Ocorreu síndrome de hiperperf usão em 1 pacient e dos 36 pacient es t rat ados com o sist ema de prot eção, regredindo em 7 dias, sendo que nos demais não houve morbi-mort alidade. A angioplast ia e “ st ent ” no t errit ório carot ídeo com a ut ilização de sist ema de prot eção é um mét odo seguro com reduzi-da morbireduzi-dade e mort alireduzi-dade est ando indicareduzi-da nas lesões est enót icas reduzi-das bif urcações carot ídeas. PALAVRAS-CHAVE: st ent art éria carot ída, at erosclerose carot ídea, t erapêut ica endovascular.
Stroke is one of the leading causes of death wor-lwide. More than 500 000 new strokes occur annual-ly in the United States, and it has been estimated that
carot id art ery disease may be responsible f or 20% t o 30% of t hem1. The annual st roke event rat e f or
sig-Arq Neuropsiquiat r 2004;62(4) 1013
nif icant carot id art ery st enosis ranges f rom 2% t o 5%2. Carot id art ery st enosis usually is ident if ied af
-t er -t ransien-t ischemic a-t -t ack (TIA), bu-t f or many pa-tients, cerebral infarction caused by artery-to-artery embolism or carotid occlusion is the initial event. Pro-gression of asympt omat ic carot id art ery st enosis t o occlusion is unpredict able and can be disast rous; at t he t ime of occlusion, disabling st roke may occur in 20% of patients, and thereafter in 1.5% to 5% annu-ally3. The Nort h American Sympt omat ic Carot id
En-darterectomy Trial4(NASCET), showed beneficial
ef-f ect oef-f carot id endart erect omy in sympt omat ic pa-t ienpa-t s w ipa-t h high-grade caropa-t id spa-t enosis (70 - 99% ). The cumulat ive risk of any ipsilat eral st roke at t w o years w ere 26 percent in t he 331 medical pat ient s and 9 percent in the 328 surgical patients an absolute risk reduct ion of 17 % . For a major or f at al ipsilat e-ral st roke, t he corresponding est imat es w ere 13.1% versus 2.5 % , an absolut e risk reduct ion of 10.6%4.
No beneficial has been found in less than 50% steno-sis5. Since t hen, carot id endart erect omy (CEA) has
been one of the most commonly performed periph-eral vascular procedures and has been considered the most eff ect ive t reat ment f or st roke prevent ion in pat ient s w it h high-grade sympt omat ic or asympt o-mat ic carot id art ery disease (CAD)6,7.
In t he past f ew years carot id angioplast y and st ent ing (CAS) has been proposed as an alt ernat ive endovascular t reat ment8,9. Despit e an increasing
ent husiasm f or t he applicat ion of CAS in t he t reat -ment of CAD and an abundant literature on case se-ries of CAS, only t hree st udies have been published
t o dat e, w hich direct ly compare CEA w it h CAS10-12.
In CAVATAS, t he f irst complet ed, prospect ive mult i-cent er t rial comparing endovascular versus surgical t reat ment f or CAD, a similar major risk and eff ec-t iveness f or CAS compared w iec-t h caroec-t id surgery has recent ly been report ed10.
Percut aneous carot id st ent ing is accomplished w it h an increased incidence of microemboli, as sho-wn by transcranial Doppler monitoring13. These
em-boli are associat ed w it h a higher neurological com-plicat ion rat e and are also recognized as a pot en-t ial cause of periprocedural sen-t roke during endaren-t e-rect omy14.
Cerebral protection with filter devices during carot id art ery st ent ing has been recent ly show n bet -t er resul-t s15-19.
M ult iple cerebral prot ect ion syst ems are availa-ble, from occlusion balloon protection techniques to f ilt er devices placed above t he lesion. The occlusion balloon system is advanced across the area of steno-sis, w it h a small caliber guidew ire, angioplast y is perf ormed w it h t he occlusion balloon inf lat ed. The angioplasty catheter (with its balloon deflated) is ad-vanced just proximal t o t he occlusion balloon. An-gioplast y debris is t hen f lushed int o t he ext ernal ca-rot id circulat ion, w it h t he occlusion balloon def la-t ed, avoiding la-t he f ragmenla-t s f rom reaching la-t he dis-t al circuladis-t ion15-17. The f ilt er prot ect ion mechanism
allow s red blood cells f low, blocking only higher than 100 micra particules. Stenotic lesions can be tre-at ed even if severe cont raltre-at eral disease is pres-ent18,19.
1014 Arq Neuropsiquiat r 2004;62(4)
This study objective is to describe our experience in t he percut aneous endovascular t reat ment of in-t ernal caroin-t id arin-t ery sin-t enosis w iin-t h angioplasin-t y and st ent ing w it h and w it hout cerebral prot ect ion de-vices.
M ETHOD
Sevent y nine pat ient s w ere t reat ed, 49 men, 30 w o-men. Age ranged f rom 57 t o 72 years (mean 64.5). Sixt y t hree pat ient s w ere sympt omat ic w it h higher t han 60% st enosis and sixt een asympt omat ic pat ient s w it h higher t han 80% st enosis w ere t reat ed, 43 pat ient s w ere t reat -ed w it hout prot ect ion mechanisms, f rom February, 1998 t o July, 2001. Af t er August , 2001, all t he procedures w ere perf ormed w it h t he angioguar or EPI f ilt er16,17.
All pat ient s had clinical, neurological, laborat ory and neuroimaging evaluat ion previously t o t he proce-dure. Antiplatelet agregation therapy was started at least 72 hours bef ore it . Local anest hesia at t he f emoral art ery, sedat ion and ant icoagulat ion w it h heparin w ere done during t he procedure. At ropine sulf at e w as administ e-red int ravenously in order t o avoid any abnormal vagal response af t er carot id sinus st ilumulus during t he st ent -ing and angioplast y. Angiography w as done t o assess t he intracranial circulation. Under fluoroscopy (roadmap) the protection system was introduced throughout the stenot-ic lesion, avoidind t raumas and f alse t raject t o t he art ery w all. In severe st enosis, a pre-dilat at ion w it h low prof ile balloon w as done.
Af t er opening t he f ilt er device above t he lesion, st en-t ing implanen-t aen-t ion w as perf ormed. The balloon w as en-t he inf lat ed at t he st enot ic at herome plaque level, decreas-ing it s st enosis af t er def lat ion. Durdecreas-ing t he procedure, t he prot ect ion device w as kept open f or an event ual emboli
t raping. A complet ion angiogram w as t hen obt ained, f or a comparison t o previous images. M echanical reperf u-sion or t hrombolisis w ere available if necessary. Pat ient s w ere cont inuously monit ored at t he int ensive care unit for the first 48 hours. Antiplatelet therapy was prescribed. Tirof iban, a glicoprot ein IIa-IIIb blocker w as used in se-vere cases (irregular lesions, smoking pat ient s). In one pat ient s w it h pos surgical rest enosis Abciximab w as ut i-lized (19). Carot id doppler ult rasound f ollow -up w as ob-t ained unob-t il 6 monob-t hs af ob-t er procedure.
RESULTS
Complet e st enosis rest aurat ion w as obt ained in all 79 pat ient s t reat ed. In t he init ial group (43 pa-t ienpa-t s) pa-t reapa-t ed w ipa-t houpa-t pa-t he propa-t ecpa-t ion syspa-t em, one st roke occurred 24 hours af t er t reat ment , and one pat ient died due t o cerebral haemorrhage. In t he subsequent 36 patients treated with the filter device, only one pat ient s w it h severe st enosis present ed w it h hyperf usion syndrome, discharged 9 days af -t er -t he procedure. No major neurological def ici-t s happened in t he pat ient s t reat ed w it h t he f ilt er device.
Carot id sinus vagal react ion occurred in 5 pa-tients after the first 12 hours, the papa-tients were trea-t ed w itrea-t h atrea-t ropine. Atrea-t trea-t he 6-montrea-t hs carotrea-t id Doppler follow-up no restenosis were found.Six patients had 12-mont hs angiography f ollow -up w it hout int ra-luminal changes (Figs 1, 2, and 3).
DISCUSSION
We observed in our case series a t rend t o less complicat ions in pat ient s t reat ed w it h t he cerebral prot ect ion w it h t he f ilt er device, how ever a def i-nit e answ er f or t he t rue dif f erence in ef f icacy and complicat ions af t er percut aneous t reat ment ver-sus endart erect omy has yet t o be det ermined. On-going t rials such as t he Sapphire and Archer t rials w ill help clarif ying t he issue. The CREST st udy is f ol-low ing 2500 pat ient s t reat ed w it h endart erect o-my or angioplast y and st ent ing of moderat e t o se-vere carot id st enosis pat ient s20.
Ot her mult icent er w orldw ide st udy enrolled 6327 pat ient s t reat ed w it h angioplast y and st ent -ing w it hout cerebral prot ect ion devices, show ed a t echnical success in 98,4% of cases. Ischaemic st ro-kes occurred in 2.7% , t hose w it h neurological de-f icit s last ing more t han 30 days in 1.3% , mort alit y rat e w as 0.7% . Rest enosis rat e in 12-mont hs f ol-low-up was 5.56%.21A recent study of 2038 patients
t reat ed w it h angioplast y and st ent ing w it h cere-bral prot ect ion devices show ed a signif icant reduc-t ion in sreduc-t rokes and morreduc-t alireduc-t y rareduc-t es21.
Arq Neuropsiquiat r 2004;62(4) 1015
In conclusion, percut aneous st ent ing and angio-plast y w it h cerebral prot ect ion devices f or carot id st enot ic lesions, in sympt omat ic w it h higher t han 60% stenosis and asymptomatic patients with high-er t han 80% st enosis, is a saf e and eff icient met hod of t reat ment w it h low morbidit y and mort alit y. Ca-rot id pCa-rot ect ion devices allow ed maint enance of cerebral blood f low during t he procedure reduc-ing t rombo embolic complicat ions and morbidit y rat es.
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