RESUMEN
PURPOSE: To review the neurological complications associated with extracranial carotid artery stenting and to preliminarily assess techniques used to manage these complications. METHODS: Between April 1994 and August 2000, 450 patients (270 men; mean age 70.2 years, range 27-89) had stents implanted to treat 472 cervical carotid artery stenoses. Over half (257, 57%) of the patients were symptomatic. A variety of stents were implanted percutaneously after predilation of the lesion; a third of the patients received glycoprotein IIb/ IIIa inhibitors intraprocedurally in addition to a standard oral antiplatelet regimen (aspirin and ticlopidine or clopidogrel). Occurrence and management of neurological complications within the 30-day periprocedural period were reviewed. RESULTS: There were 14 (3.1%) transient ischemic attacks (TIAs), 10 (2.2%) minor strokes, and 3 (0.7%) major strokes. Among 6 (1.3%) procedure-related deaths, 4 had neurological causes. The total stroke and death rate was 4.2% (n = 19). All the TIAs, 4 of which occurred between 1 and 14 days poststenting, were treated medically, as were the minor strokes, 3 of which occurred >24 hours after stenting. Only 2 minor stroke patients had mild residual upper extremity motor deficits. Intra-arterial thrombolytic therapy was administered in 5 cases (2 major strokes survivors and 3 patients who suffered a neurologically-related death); occlusions were identified in the proximal middle cerebral artery (MCA) in 3 and the distal MCA in 2. Angiographic improvement was noted in 4 (80%), but only the 2 (40%) with distal MCA occlusions did well clinically. CONCLUSIONS: Neurological complications following carotid artery stenting are inevitable. The occurrence of minor strokes >24 hours following stenting may indicate a possible late embolic phenomenon, which warrants investigation. Likewise, the marginal efficacy of intra-arterial thrombolytic therapy demonstrates an inability to lyse embolic plaque and underscores the need for effective distal protection.
Asunto(s)
Arteria Carótida Común/cirugía , Estenosis Carotídea/complicaciones , Estenosis Carotídea/cirugía , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/terapia , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Stents/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Arteria Carótida Común/diagnóstico por imagen , Cuello del Útero/irrigación sanguínea , Análisis de Falla de Equipo , Seguridad de Equipos , Femenino , Estudios de Seguimiento , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/terapia , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/mortalidad , Complicaciones Posoperatorias/mortalidad , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapia , Análisis de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
We provide an overview of recent developments in carotid interventional technique and equipment, including new stents and emboli protection devices. The newer self-expanding stents lessen the problem of external stent compression associated with balloon expandable stents, but precise deployment and the matching (by length) of stents to lesions remain problematic. We also discuss emerging pharmacologic strategies for cerebral protection in stroke. Multiple randomized clinical trials and multicenter registries are under way to compare percutaneous with surgical strategies for the treatment of carotid stenosis. These include the evaluation of emboli protection devices, and, to a lesser degree, intravenous glycoprotein IIb/IIIa antagonists. Other clinical trials are aimed towards refining the ability to stratify patients by risk, in order to identify the subsets that would benefit most from these complex and expensive procedures.
Asunto(s)
Estenosis Carotídea/terapia , Angioplastia de Balón , Estenosis Carotídea/cirugía , Embolia/prevención & control , Endarterectomía Carotidea , Humanos , StentsRESUMEN
Our purpose was to study the effectiveness of thrombolytic therapy in treating acute, subacute, and chronic arterial occlusions in a multicenter retrospective study. Intraarterial urokinase infusion was performed in 235 patients for occluded native arteries. There were 70 (30%) with acute and 26 (5%) with subacute occlusions, and 141 (59%) with chronic symptoms for longer than 3 mo. Complete thrombolysis was achieved in 60 (86%) of the acute, 20 (77%) of the subacute, and 106 (75%) of the chronic occlusions. Adjunctive interventional procedures were performed as needed. Long-term follow-up revealed a primary patency of 87%, 85%, and 76% for the acute, subacute, and chronic occlusion groups, respectively. We conclude that the rate of complete thrombolysis of chronic occlusions proved slightly more efficient for acute and virtually the same for subacute occlusions. Long-term follow-up demonstrated a higher failure rate with chronic than with acute occlusions, probably due to worsened peripheral vascular runoff.
Asunto(s)
Arteriopatías Oclusivas/tratamiento farmacológico , Pierna/irrigación sanguínea , Activadores Plasminogénicos/administración & dosificación , Terapia Trombolítica , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Enfermedad Aguda , Anciano , Angiografía , Angioplastia , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Enfermedad Crónica , Endarterectomía , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intraarteriales , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Trombectomía , Resultado del TratamientoRESUMEN
PURPOSE: To study the feasibility and safety of endovascular stenting of cervical carotid artery stenosis. METHODS: Between April 1994 and May 1997, 108 consecutive patients (58 men; mean age 70.1 years) with > or = 70% carotid stenosis were treated with percutaneous stent implantation under a protocol that featured independent neurological review. Forty-four percent were asymptomatic. Over half the lesions (59%) were in the internal carotid artery; the mean stenosis was 86%. Palmaz stents were implanted without cerebral protection following preliminary balloon dilation; two Wallstents were used in long lesions. RESULTS: Carotid stents were successfully placed in 108 of 114 (95%) lesions. Of the 6 technical failures, 5 were access related and 1 was due to seizures during balloon dilation. Two major (1.8%) and 2 minor (1.8%) strokes occurred (3.7% stroke rate for 108 patients; 3.5% in 114 procedures), all in symptomatic patients, one of whom died. There were 5 (4.4%) transient ischemic attacks and 2 (1.8%) brief seizure episodes during dilation. One patient died of a cardiac event on day 20. The all stroke or death rate was 5.3% based on 114 arteries at risk (5.6% in 108 patients). In the mean 6-month follow-up (range 1 to 36) of 97 eligible patients, 3 (3.1%) died from unrelated causes. There was 1 restenosis (1.0%) from a stent compression, which was successfully redilated. There were no neurological sequelae, cranial palsies, or cases of stent or vessel thrombosis in follow-up. CONCLUSIONS: The use of stents in the treatment of cervical carotid occlusive disease appears feasible, effective in the short term, and without excessive risk of periprocedural stroke.
Asunto(s)
Estenosis Carotídea/cirugía , Stents , Adulto , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Cateterismo , Angiografía Cerebral , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/mortalidad , Trastornos Cerebrovasculares/prevención & control , Endarterectomía Carotidea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Complicaciones Posoperatorias , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: To assess the long-term results of directional atherectomy (DA) for femoropopliteal artery atherosclerotic lesions and to compare the results to those previously reported for percutaneous transluminal balloon angioplasty (PTA). MATERIALS AND METHODS: Eight-four percutaneous DA procedures performed on 75 patients between July 1988 and August 1992 were retrospectively reviewed and evaluated for technical and initial clinical success. Long-term patency was assessed with a combination of ankle-brachial index measurements and angiography. RESULTS: Initial technical success was achieved in 77 of 84 procedures (92%). Follow-up of 72 patients was obtained, including 74 of the 84 (88%) DA procedures with a mean follow-up of 17.4 months (range 1-48 months). Primary patency was 78% at 1 year and 57% at 2 years. Patients with diabetes, complete luminal occlusion, or limb salvage situations had significantly lower patency. CONCLUSIONS: Femoropopliteal artery DA can be performed safely with a high technical and initial clinical success. Long-term patency is improved when compared with published series for PTA. With this improvement in mind, DA may have a place in the treatment of focal infrainguinal stenoses.
Asunto(s)
Angioplastia de Balón , Arteriosclerosis/terapia , Aterectomía , Arteria Femoral , Arteria Poplítea , Análisis Actuarial , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/diagnóstico por imagen , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Grado de Desobstrucción VascularRESUMEN
Percutaneous transluminal angioplasty was performed via an antegrade popliteal puncture. This technique was utilized because the patient had a superficial femoral artery occlusion and coexistent popliteal stenoses, with the occlusion unable to be traversed in the usual common femoral artery antegrade approach. To our knowledge, this technique has not been described in the literature. The clinical utility of this approach and important anatomical considerations will be discussed.
Asunto(s)
Angioplastia de Balón/métodos , Arteria Poplítea , Punciones/métodos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Three patients underwent percutaneous transluminal angioplasty for treatment of subclavian artery stenosis producing the coronary artery steal syndrome. Technical success and immediate relief of angina were achieved in all three patients. Clinical follow-up ranged from 4 to 16 months. One patient developed clinical evidence of restenosis. Subclavian artery angioplasty may be a safe and efficacious technique for the treatment of the coronary artery steal syndrome.
Asunto(s)
Angina de Pecho/terapia , Angioplastia de Balón , Circulación Coronaria/fisiología , Arteria Subclavia , Anciano , Angina de Pecho/epidemiología , Angina de Pecho/etiología , Constricción Patológica/complicaciones , Constricción Patológica/epidemiología , Constricción Patológica/terapia , Femenino , Estudios de Seguimiento , Humanos , Anastomosis Interna Mamario-Coronaria , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Factores de TiempoRESUMEN
Superior vena cava syndrome can be effectively palliated with the use of intravascular stents. Adjunctive modalities which may be utilized prior to stent placement are thrombolytic therapy and balloon angioplasty. Six patients with an underlying malignancy were treated with these modalities. Complete resolution of symptoms occurred in five patients, and partial resolution occurred in the sixth. Two of the patients who had initial, complete resolution of symptoms had recurrences. One involved rethrombosis of the superior vena cava which occurred twice and required percutaneous thrombectomy, and the second involved restenosis requiring a percutaneous transluminal angioplasty of the SVC just distal to the stent. Both of these patients with second procedures, again, had complete resolution of symptoms. Intravascular stents are a valuable additional treatment of superior vena cava syndrome.
Asunto(s)
Angioplastia de Balón , Células Neoplásicas Circulantes , Cuidados Paliativos , Stents , Síndrome de la Vena Cava Superior/terapia , Adulto , Anciano , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flebografía , Recurrencia , Síndrome de la Vena Cava Superior/diagnóstico por imagen , Síndrome de la Vena Cava Superior/mortalidad , Tasa de Supervivencia , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificaciónRESUMEN
Substantial interest exists in the development of reperfusion and recanalization devices that would aid in the management of both peripheral vascular and coronary artery occlusive disease. Several of these devices are now in multicenter investigative trials. The atherolytic reperfusion wire incorporates a 0.035-inch guide wire with a modified tip to recanalize the lumen through the totally obstructed vascular segment. Clinical experience in the initial 12 patients has been successful. The Kensey catheter, a high-speed rotational recanalization device, has been used in 110 patients in a multicenter trial. Technical success has been reported in 77% of the patients and clinical success in 55% of the patients, with follow-up periods of 3 months to 1 year. The transluminal extraction catheter (TEC) is a torque-controlled atherectomy catheter that incorporates an aspiration device into a distal rotational cutter. Consequently, distal embolization has not been a clinical problem in the 95 patients treated with the TEC catheter for peripheral vascular disease. Technical success has been accomplished in 87 (92%) patients. Three-month follow-up studies in 16 patients showed that restenosis occurred in four, two of whom had undergone combined atherectomy and angioplasty.
Asunto(s)
Angioplastia de Balón/instrumentación , Arteriopatías Oclusivas/terapia , Cateterismo Periférico/instrumentación , Reperfusión/instrumentación , Arteriopatías Oclusivas/cirugía , HumanosAsunto(s)
Enfermedad de Crohn/diagnóstico por imagen , Esofagitis/diagnóstico por imagen , Fístula Traqueoesofágica/diagnóstico por imagen , Adulto , Tos/etiología , Enfermedad de Crohn/complicaciones , Diarrea/etiología , Esofagitis/complicaciones , Femenino , Humanos , Radiografía , Fístula Traqueoesofágica/etiologíaRESUMEN
A prospective study of 16 patients with hemoptysis was conducted over a 2 1/2-year period. Technetium-99m sulfur colloid (Tc-SC) and technetium-99m-labeled red blood cells (Tc-RBC) were sequentially used to identify the general area of bleeding. Tc-SC accurately located the bleeding area in 3 patients and Tc-RBC identified the bleeding area in 8; there were no false-positive studies. Tc-SC scans were positive at 6-10 minutes and all patients had positive Tc-RBC studies. In general, the scans accurately located the source of bleeding as determined by bronchoscopy and/or surgery. Because of the small sample, statistically significant differences between both techniques were not ascertained. Both Tc-SC and Tc-RBC may prove to be helpful, minimally invasive imaging procedures for determining the general area of hemorrhage in patients with clinically significant hemoptysis. Although a trend suggests that Tc-RBC is a more sensitive method, further comparison is needed for corroboration.
Asunto(s)
Hemoptisis/diagnóstico por imagen , Azufre Coloidal Tecnecio Tc 99m , Adulto , Anciano , Broncoscopía , Eritrocitos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía , CintigrafíaRESUMEN
Eighteen patients who had elevated serum calcium and parathormone levels were prospectively studied with intravenous digital subtraction angiography (DSA). Intravenous DSA of the neck and mediastinum was performed in the anteroposterior, the left anterior, and the right anterior oblique projections. The study was considered positive if an abnormal blush or blood supply was noted. Upon operation, 14 patients were confirmed to have parathyroid adenomas, of whom five had positive preoperative DSA examinations. Four patients were followed medically (three negative DSA, one positive DSA). A positive intravenous DSA may be useful to guide neck explorations for parathyroid adenomas; however, the low sensitivity of the study may limit its screening potential.
Asunto(s)
Adenoma/diagnóstico por imagen , Angiografía Cerebral , Neoplasias de las Paratiroides/diagnóstico por imagen , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Técnica de SustracciónAsunto(s)
Embolización Terapéutica/efectos adversos , Hemorragia/terapia , Enfermedades Vaginales/terapia , Fístula Vesicovaginal/etiología , Adenocarcinoma/complicaciones , Femenino , Esponja de Gelatina Absorbible , Hemorragia/etiología , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias , Neoplasias del Cuello Uterino/complicaciones , Enfermedades Vaginales/etiología , Neoplasias Vaginales/complicacionesRESUMEN
A case of small bowel infarction owing to balloon-induced thrombosis of the superior mesenteric artery is described. The tendency of thrombosis to occur when the balloon is inserted via the ascending aorta is discussed. This possibility necessitates obtaining lateral roentgenograms of the balloon tip before closure of the sternum.
Asunto(s)
Circulación Asistida/efectos adversos , Intestino Delgado/irrigación sanguínea , Contrapulsador Intraaórtico/efectos adversos , Oclusión Vascular Mesentérica/diagnóstico por imagen , Aortografía , Puente de Arteria Coronaria , Femenino , Humanos , Persona de Mediana Edad , Infarto del Miocardio/terapiaRESUMEN
The Doppler ultrasonic blood velocity detector was used to determine the location and patency of non-palpable femoral and brachial arteries, facilitating their percutaneous puncture. This technique was used to achieve a more optimal demonstration of the peripheral circulation distal to aorto-iliac occlusive disease as well as for retrograde catheter angiography of vascular beds distal to more central stenoses or occlusions. This technique may also aid in percutaneous puncture for emergency angiography in hypotensive patients, percutaneous transluminal angioplastsy, or femoral vein punctures.