Yeqing Jiang and Ruoyu Di contributed equally.
Extracranial supra-aortic dissections (ESADs) with severe stenosis, occlusion and/or pseudoaneurysm presents potential risk of stroke. Endovascular stenting to reconstruct non acute phase ESADs (NAP-ESADs) is an alternative to anticoagulant or antiplatelet therapy. However, its feasibility, safety and efficacy of stenting in NAP-ESADs is unclear. This study aims to investigate the long-term outcomes of the feasibility, safety and efficacy of stenting in NAP-ESADs.
Seventy-four patients with 91 NAP-ESAD vessels with severe stenosis, occlusion and/or pseudoaneurysm presents potential risk of stroke who underwent stent remodeling were enrolled into this respective study from December 2008 to March 2020. Technical success rate, complications, clinical and angiographic results were harvested and analyzed.
Success rate of stent deployment was 99% (90/91) with no procedural mortality or morbidity. Transient ischemic attack occurred in three patients during operation (4.1%, 3/74). Asymptomatic embolisms of distal intracranial vessels were found in two patients (2.7%, 2/74). One hundred and forty-two stents deployed at 85 carotid (135 stents) and six vertebral (seven stents) vessels. Six stent types (Wingspan, 28/135, 20.7%; Solitaire, 10/135, 7.4%; Neuroform, 8/135, 5.9%; LVIS, 2/135, 1.5%; Precise, 75/135, 55.6%; Acculink, 12/135, 8.9%) were deployed at carotid arterial dissection while two types (Wingspan, 5/7, 71.4%; Solitaire 2/7, 28.6%) at vertebral arterial dissection. Digital subtracted angiography (56%, 51/91), computational tomography angiography (41.8%, 38/91) and high resolution magnetic resonance imaging (2.2%, 2/91) were adopted for follow up, with a mean time of 17.2±15.4 months (5–77). All patient modified Rankin Scale scores showed no increase at discharge or follow-up. Angiographically, dissections in 86 vessels in 69 patients (94.5%, 86/91) were completely reconstructed with only minor remnant dissections in four vessels in four patients (4.4%, 4/91). Severe re-stenosis in the stented segment required re-stenting in one patient (1.1%, 1/91).
Stent remodeling technique provides feasible, safe and efficacious treatment of ESADs patients with severe stenosis, occlusion and/or pseudoaneurysm.
Extracranial supra-aortic dissections (ESADs) mainly include carotid arterial dissection (CAD) and vertebral arterial dissection (VAD) estimated at 3–4 per 100000 [
The feasibility, safety and efficacy of endovascular stent remodeling of ESADs were investigated in this present study over the past 12 years in our center.
This study was approved and waived the requirement for informed consent by the Institutional Review Board (IRB) of Huashan Hospital Affiliated to Fudan University (IRB No. KY2019-009). Patients who underwent endovascular treatment for ESAD were enrolled in this respective study in our center between December 2008 and March 2020, including those receiving stent deployment or stent assisted embolization. Indications for the treatment of ESAD included high-grade stenosis (>70%), occluded ESAD and/or a dissecting aneurysm. Demographics, medical history, angiographic details, complications and follow up outcomes were extracted. Dissection etiologies were classified into spontaneous, traumatic, or iatrogenic (intraoperational). Dissections were mainly defined as the presence of pseudoaneurysm, beaded expansion, dual lumen sign, along with stenosis or occlusion from floating intimal flap according to different imaging modalities (computed tomography angiography [CTA], magnetic resonance angiography, high resolution magnetic resonance imaging [HR-MRI], digital subtracted angiography [DSA]) and MRI for intermural hematoma. The location of vessel dissection was divided into common carotid artery (CCA), extracranial internal carotid artery (ICA), and vertebral artery (VA).
Stent selection varied according to dissection location. For CAD lesions in the CCA or cervical segment of the ICA, an Acculink stent (Abbott Vascular, Santa Clara, CA, USA) or Precise stent (Cordis, Miami Lakes, FL, USA) were preferred. For petrosal and cavernous segments of the ICA or VAD segment, a number of different stents were viable (Neuroform3, Wingspan, LVIS [low-profile visualized intraluminal support device], and Solitaire). Generally, distal protection device filters were rarely used to avoid embolism, except for some multiple lumen or high-volume thrombus dissection segments utilized. For tortuous dissections in the ICA cervical segment, guiding-catheter-assisted stenting was recommended.
Procedurally : 1) the guiding catheter is navigated across the dissecting segment supported by a 0.35 wire or dual wire, or a Gateway balloon (Boston Scientific Inc., Marlborough, MA, USA); 2) the stent delivery system is positioned; 3) retrieval of the guiding catheter; and 4) stent deployment to repair any torn intima and straighten the tortuous dissection segment (
General heparinization is performed through a bolus injection of heparin 1250 international units (IU) per 15 kg before procedure. An additional half dose of previous bolus of heparin every hour until at least 1250 IU/h was injected throughout the procedure. For the high-grade stenosis (>70%) or occluded ESAD, postoperative systolic blood pressure (generally 90–120 mmHg) should be monitored strictly to avoid hyper-perfusion syndrome or hemorrhage. The non-acute phase of ESAD was defined as after 8 hours from symptom onset [
Frequencies (percentages [ranges] and means±standard deviations] are used to describe the CAD and VAD cohorts. The increased modified Rankin Scale (mRS) and larger than 2 scores were classified into poor outcomes.
Seventy-four patients (53 male, 71.6%) 91 vessels were retrospectively harvested with mean age 54.3±10.2 years old (range, 30–76). Bilateral dissections in 15 patients (15/74, 20.3%) were collected from 83 single carotid dissections in 68 patients (68/74, 91.9%), while four patients of single VA (4/74, 5.4%) and two patients simultaneously involved carotid and VA (2/74, 2.7%).
Thirty-seven acute stroke patients (50.0%) and 13 transient ischemic attack patients (17.4%) in total had persistent symptoms with a mean time of 77.95±131.32 days (0.25–730) after the initial dissection diagnosis. In addition, 24 dissections (32.6%) embodying repeated dizziness, headache or neck pain with a mean time of 88.79±91.00 days (1–365) were found while patients were being treated for other ipsilateral cerebral artery lesions including intracranial aneurysms and arteriovenous malformations. Dissections were caused: spontaneously in 61 patients and 75 vessels, by trauma (n=7/9), from carotid radiotherapy (4/5) and iatrogenically (2/2).
Dissecting segment mainly presented three morphologic changes : 1) pure stenosis (33/91, 36.3%); 2) occlusion (2/91, 2.2%); and 3) dissecting aneurysm with stenosis or non-stenosis (56/91, 61.5%). For the large dissecting aneurysm, stent assisted coiling was adopted (19/56, 33.9%). For dissection with stenosis and/or small dissecting aneurysm, the stent solely was deployed (37/56, 66.1%;
One hundred and forty-two stents deployed at 85 carotid (135 stents) and six vertebral (seven stents) vessels. Six stent types (Wingspan, 28/135, 20.7%; Solitaire, 10/135, 7.4%; Neuroform, 8/135, 5.9%; LVIS, 2/135, 1.5%; Precise, 75/135, 55.6%; Acculink, 12/135, 8.9%) were deployed at CAD while two types (Wingspan, 5/7, 71.4%; Solitaire 2/7, 28.6%) at VAD. Total overlapped stents were adopted at five vessels for dense -mesh effect in the early stage. For long segment dissections, tandem partial overlapped stenting was deployed at 47 vessels.
DSA (51/91,56%), CTA (38/91, 41.8%), and HR-MRI (2/91, 2.2%) has been followed up with a mean time of 17.2±15.4 months (5–77).
Clinically, no mortality and morbidity were perioperatively occurred (
Angiographically, success rate of stent deployment is 90/91 (99%). Only one patient with very tortuous dissecting segment, partial remodeling was reconstructed via large-profile stent due to difficult accessibility. Complete reconstruction of dissections in 86 vessels (86/91, 94.5%,
Unplanned 30-day hospital readmissions of symptomatic carotid and VA dissection reach the 9.08% and 8.43% respectively while primary cause of readmission was ischemic stroke [
The potential risks associated with endovascular stenting was questioned. Periprocedural complication rate of 1.3% was reported in 140 patients treated endovascularly for ESADs all of which were asymptomatic complication [
Cervical artery dissections could induce several severe clinical consequences with 7.4% mortality rate [
Stent related complications mainly include intra-stent restenosis and stent fracture were reported from other diseases of the atherosclerotic stenosis [
This study has certain limitations. First, this retrospective observational clinical study has 12 years large time span which means that methods of diagnosis, materials, and equipment have changed and these are factors that might affect outcomes. Second, small sample size was visualized. Acute phase ESAD cases were not included in this study due to high basal NIHSS score, more unilateral lesion and relatively poor prognosis. Further larger studies with corresponding improvement will be contribute to elucidate the efficacy and safety of stent remodeling technique.
Stent remodeling technique provides feasible, safe and efficacious treatment of ESADs patients with severe stenosis, occlusion and/or pseudoaneurysm.
No potential conflict of interest relevant to this article was reported.
This type of study does not require informed consent.
Conceptualization : LH, YJ, XZ; Data curation : LG, YJ; Formal analysis : GL; Funding acquisition : XZ; Methodology : YJ, HW; Project administration : LG, XZ; Visualization : LH, YJ; Writing - original draft : YJ; Writing - review & editing : YJ, RD
None
None
This study was supported by the National Nature Science Foundation of China (Grant No. 81771242).
Schematic representation of stent remodeling technique for extracranial supra-aortic dissections : dissections in cervical segment of internal carotid artery (A). 0.35 wire cross the dissecting segment (B). A 6 F envoy guiding catheter cross the dissecting segment (C). Precise stent (6×40 mm) was in position and retrieving the guiding catheter partially (D). Precise stent was deployed (E). Angiography showed stenosis at the proximal of the stent (F). Navigated the guiding catheter into the previous stent lumen (G and H). Acculink 6–8×40 mm stent was deployed tandemly and overlapped partially with previous stent (I). Postoperative and 12 months working projection view revealed favorable remodeling of the dissecting segment respectively (J and K).
Clinical outcomes comparison among preoperative, postoperative and follow up modified Rankin Scale (mRS).
Forty-seven years old male patient with sudden weakness of right limbs and aphasia 3 months ago. Digital subtracted angiography revealed that internal carotid artery (ICA) cervical dissecting aneurysm and stenosis of dissections (A). Postoperative angiography showed segment of the ICA dissections remodeled by two Wingspan stents (4.5×20 mm and 4×20 mm; B). The ICA dissections were repaired well at 12 months follow-up (C).
Forty-three years old male patient with dizziness, diplopia and drowsiness 10 days ago. Diffusion-weighted imaging demonstrated bilateral acute infarctions in basal ganglion region (A). DSA revealed that occlusive cervical segment of the left ICA compensated by external carotid artery (B). Postoperative angiography showed segment of the ICA dissections remodeled by Wingspan 3.5×15 mm, Precise 6×40 mm and Acculink 6–8×40 mm stent (C). Three months follow-up CTA revealed patency of the dissecting segment (D). Forty-five months follow-up CTA and DSA demonstrated the asymptomatic intrastent severe restenosis (white arrow; E and F). Postoperative angiography showed the intrastent restenosis remodeled by Precise 6×30 mm stent (G). DSA : digital subtracted angiography, ICA : internal carotid artery, CTA : computational tomography angiography.
General characteristics of the 74 patients with 91 extracranial arterial dissections
Baseline characteristic | Value |
---|---|
Age (years) | 54.3±10.2 (30–76) |
Gender, male | 53 (71.6) |
Location of dissection | |
Vertebral artery | 6 (6.6) |
Carotid artery | 85 (93.4) |
Etiology | |
Spontaneous | 75 (82.4) |
Traumatic | 9 (9.9) |
Iatrogenic | 2 (2.2) |
Carotid radiotherapy | 5 (5.5) |
Drinking | 21 (28.4) |
Smoking | 19 (25.7) |
Hypertension | 29 (39.2) |
Diabetes | 13 (17.6) |
Morphological manifestation | |
Pure stenosis | 33 (36.3) |
Occlusion | 2 (2.2) |
Aneurysm with or without stenosis | 56 (61.5) |
Values are presented as mean±standard deviation (range) or number (%)
Outcomes of stent remodeling treatment for ESADs
Outcome | Value |
---|---|
Primary | |
Mortality or morbidity | 0 (0.0) |
Secondary | |
Complete remodeling rate | 86 (94.5) |
Minor remnant dissections | 4 (4.4) |
Restenosis | 1 (1.1) |
Adverse events | |
Intraoperative TIA | 3 (4.1) |
Embolism | 2 (2.7) |
Values are presented as number (%). ESADs: extracranial arterial dissections, TIA : transient ischemic attack