Revista Română de Anatomie funcțională și clinică, macro- și microscopică și de AntropologieVol. XIII Nr. 3 2014 CLINICAL ANATOMY [625433]

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Revista Română de Anatomie funcțională și clinică, macro- și microscopică și de AntropologieVol. XIII – Nr. 3 – 2014 CLINICAL ANATOMY
PERIPROCEDURAL COMPLICATIONS OF THE CAROTID
ARTERY STENTING
R. Stănciulescu1, B. Dorobăț2, A. Dimitriade2, L. Stănciulescu3, C. Panțu1, F . M. Filipoiu1
1. University of Medicine of Pharmacy „Carol Davila”, Bucharest
Department of Morphological Sciences
Anatomy Discipline
2. Emergency Hospital of Bucharest, Bucharest
Interventional Radiology Department University
3. Institute of Oncology, Bucharest
PERIPROCEDURAL COMPLICATIONS OF THE CAROTID ARTERY STENTING (Abstract):
Studies for short and long-term complications in the treatment of internal carotid artery stenosis
reported that carotid artery stenting was as effective as carotid artery endarterectomy in the
middle-term prevention of stroke. The present report is part of an ongoing study that evaluates the
treatment choice such as carotid artery stenting or carotid artery endarterectomy for increased
degree of carotid stenosis. The study contains 192 consecutive carotid artery stenting procedures
for the same number of patients, 102 men and 90 women, with an average age of 65.7 years (range
between 45–85 years) treated from January 2012 to March 2014. The stenting procedures were
performed on 71 patients with symptomatic carotid artery stenosis, with a severity of ≥50%, and
121 asymptomatic patients with a stenosis severity of ≥70%. The interventional procedure was
chosen in the presence of high-risk conditions for surgery or at patient request. The rate of peripro –
cedural complications in our study was mostly related to hemodynamic instability, in particular
the changes of arterial tension which was observed in several cases ( 8 cases (4.16%) of arterial
hypotension episodes, 7 (3,64%) cases of arterial hypertension episodes and 9 (4,68%) cases of
bradycardia) and neurological events regarding 8 (4.16%) patients which developed transient is –
chemic attack, lasting less than 24 h. This report highlights the safety and low rate of peripro –
cedural complications associated with this carotid artery stenting. Key words : INTERNAL CA –
ROTID ARTERY , CAROTID ARTERY STENTING
INTROD UCTION
In recent years, carotid artery stenting (CAS)
has gained recognition as a less invasive treat –
ment modality to prevent stroke. The recent
studies show that CAS can be performed with
excellent results as a 30-day-stroke death rate
of 2.2%–4.8% (1,2,3). However, in the peri­
procedural outcome, carotid endarterectomy
(CEA) was superior to CAS, although CAS has
gained an overall acceptance in treating a sub –
set of patients, such as those with radiation
induced carotid stenosis, those with restenosis
after CEA and surgical high-risk patients.
Regarding the treatment of symptomatic pa –
tients randomized studies comparing CAS and
CEA reported that CAS w as as effective as CEA in the middle-term prevention of stroke
(4, 5).
MATERIALS AND METHODS
The present report is part of an ongoing
study that evaluates the treatment of choice such
as CAS or CEA for increased degree of ca –
rotid stenosis.
The study contains 192 consecutive CAS
procedures for the same number of patients,
102 men and 90 women, with an average age of
67,7 years (range between 45–85 years) treated
from January 2012 to March 2014.
The study was approved by the local ethics
committee and prior to the procedure written
informed cons ent was obtained from all treated
patients.

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Periprocedural Complications of the Carotid Artery StentingRESULTS
The stenting procedures were performed on
71 patients with symptomatic carotid artery ste –
nosis, with a severity of ≥50%, and 121 asymp­
tomatic patients with a stenosis severity of
≥70%. The interventional procedure was cho –
sen in the presence of high-risk conditions for
surgery or at patient request.
The majority of lesions were atherosclerotic
one 187 ( 94.79%) (from which 5 cases were
post endarterectomy restenosis), 3 patients
(1,56%) were having traumatic dissection of
internal carotid artery (ICA) and in 2 cases
(1,04%) there was a history of neck irradiation.
In 13 (6,77%) cases the stenosis was ≥95%
of the vessel diameter and for 1 1 (5,72%) pa –
tients there was reported complete occlusion of
both carotid arteries. Also for 19 (9,89%) pa –
tients the controlateral carotid artery was oc –
cluded and 3 (1,56%) patients were previously
treated with stenting of the controlateral ca –
rotid artery.
Regarding the artery in which the stent was
implanted there were 87 (45,31%) procedures
done at the level of right ICA; 92 (47,91%)
left ICA; 4 (2.08%) right external carotid ar –
tery (ECA); 7 (3,64%) left ECA and 2 (1.04%)
at the level of the right common carotid artery. Dilation of the stenosis prior to stent im –
planta tion was performed in 99 (51,56 %) proce –
dures, using balloon diameters from 2.5 to 3.5
mm. Post-dilation after the stent deployment
was performed in 85 ( 44,27%) procedures,
using balloon diameters from 3.5 to 7.0 mm.
Regarding stent type deployed an open-cell
stent was used in 126 (65,62%) cases and a
closed­cell stent in 76 (39,58%) patients, re –
spectively.
The majority of stents used ( 96,88% ) were
self­expanding and in 3,12% of the cases bal –
loon-expandable stents were implanted.
Embolic protection was performed in 85
procedures (44,27%).
The interventions were done under local
anesthesia via a right transfemoral artery ac –
cess. In just one case the arterial access was
performed through the right brachial artery due
to the condition of the patient (Leriche syn –
drome) – Fig. 1.
DISCUSSION
Regarding access-site complications, only 6
(3.12%) cases of mild hematomas were ob –
served and no other complications which re –
quired surgical revision or blood transfusion
were reported. Our results are similar with Fig. 1. Selective catheterization of the left ICA through a right brachial arterial access for a patients
suffering from Leriche syndrome

340
R. Stănciulescu et al.other stu dies like Taha MM et all 2.4% and
Gray W A et al 2.6% (6, 7), which described
a similar range of access -site complications.
Hemodynamic instability, in particular the
changes of arterial tension was observed in
several cases: 8 cases (4.16%) of arterial hy –
potension episodes, 7 (3,64%) cases of arterial
hypertension episodes and 9 (4,68%) cases of
bradycardia.
The bradycardia emerged mostly after post-
dilations and it required 1 mg of atropine which
was administrated intravenously with good cli-
nical results.
Transient sinus bradycardia is relatively
common responses to balloon dilatation of ca –
rotid bifurcation lesions, particularly during
post-dilatation stenting (8). This phenomenon
is less commonly observed with treatment of
re-stenotic lesions following CEA because the
receptors may have been denervated by the sur –
gical dissection.
Our result of hypotensive episodes were
similar to other previous studies like Groschel
et al. (9) study that reported it in 4.9% of the
cases but hypertension was less frequent in our
group than previous studies where it occurred
in up to 40% of all CAS patients (10). Another favorable finding in our study is
that our patients did not developed typical symp-
toms of a hyperperfusion syndrome, which is
associated with arterial hypertension and can
be a potentially life threatening syndrome. Also
none of the patients had an myocardial infarc –
tion, but this might be related to the single
center nature of the study.
Regarding the neurological complications
there were 8 (4.16%) patients in our group that
developed transient ischemic attack, lasting less
than 24 h.
Symptomatic distal embolisation is described
as a most frequent and important complication
of CAS (1 1) in the majority of the studies, being
caused by the release of material (thrombotic,
necrotic or atherosclerotic) from the site of the
lesion during the intervention (12,13) or from
a disruption of cerebral blood flow and it is
reported with a range that varies from 1.3% to
10.7% in different studies (13,14, 15). Even if
it is has an important degree of variability in
different medical centers our results for this
type of complication are similar with some
studies like V os et all 5.6% (16). No major
stroke was reported in our group.
As particular cases in one procedure the
atherosclerotic plaque migrated to the distal
Fig. 2. A.Aneurysm of the right middle cerebral artery (red arrow) found after CAS of the right ICA
(blue arrow). B. Aneurysm treated with coil embolization (red arrow) and previous CAS of the right
ICA (blue arrow).

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Periprocedural Complications of the Carotid Artery Stentingpart of the stent, therefore a second stent was
implanted and a proper result was obtained.
Also one o f the patients, with previous sur –
gical treatment of ICA stenosis, during the
stenting procedure a dissection of the arterial
wall was observed and a second stent was im –
planted with an appropriate result.
In one of the procedures after the deploy –
ment of the stent into the ICA and the come-
back of the normal cerebral flow, the control
angiography highlighted an aneurysm of the
right middle cerebral artery, which was embo –
lized after one week period ( Fig. 2).
For the patients with occlussion of both ca –
rotid arteries the stent deployment was done at
the level of the external carotid arteries, with
important improvement of the cerebral blood
flow due to the anastomoses between the exter –
nal and internal carotid arteries (Fig. 3).CONLCUSIONS
The rate of periprocedural complications in
our study was mostly related with hemody –
namic instability and none of the patients died
during in-hospital stay. This study highlights
the safety and low rate of periprocedural com –
plications associated with this CAS.
Patients who undergo this procedure have
been discharged the following days and require
little or no convalescent period, which lead to
an important patient satisfaction.
More randomized clinical trials from differ –
ent medical centers will help determine if CAS
is as safe as CEA for the management of ath –
erosclerotic carotid disease.
This study was a single center experience
an it has some limitations being a nonrand –
omized study and it should be cautious in ex –
tending these results to other centers.
Fig. 3. Stent deployment at the level of the external carotid
artery (blue arrow) and improvement of the cerebral blood flow
(red arrow)
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