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1、Endovascular Recanalization of Symptomatic Chronic Total Occlusion of Cervical Carotid Artery,Paul Hsien-Li Kao, MD Assistant Professor National Taiwan University Medical School and Hospital,ICA stenting,Proven to be an alternative to CEA in ICA stenosis, especially in patients with high surgical ri
2、sk profiles But the application of endovascular intervention in cervical ICA occlusion (ICAO) has never been explored, which comprise 15% of patients with ipsilateral TIA or infarction,Paul HL Kao 08,The great myth,ICA stenosis causes symptoms through artery-to-artery embolism The risk of stroke is
3、minimal with ICAO, because there is no flow to carry the emboli Is it true?,Paul HL Kao 08,Prognosis and pathophysiology of ICAO,Cervical ICAO is an important cause of TIA and cerebral infarction and should not be neglected Annual risk of ipsilateral stroke in symptomatic ICAO is 6-20% Annual risk o
4、f ipsilateral stroke in asymptomatic ICAO is 2-5 % Pathophysiology of symptoms Emboli arising from ECA/CCA via collaterals Emboli arising from ICA stump via collaterals (Stump syndrome) Emboli arising from trailing thrombi distal to the occlusion Hypo-perfusion (hemodynamic insufficiency),Paul HL Ka
5、o 08,Treatment options for ICAO,Medical The recommended treatment at present, but may be insufficient for certain patients Surgery CEA Stump ligation/exclusion EC/IC bypass Can be very technically demanding with high periprocedural complications All failed to reduce ipsilateral stroke and are not re
6、commended to ICA CTO in general,Paul HL Kao 08,EC/IC bypass,1377 patients with symptomatic ICA or MCA occlusion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 56 months Major peri-operative stroke rate as 4.5% Total stroke rates were not different betwee
7、n bypass and medical groups In patients with ongoing symptoms after angiographic documentation of ICAO, the benefit of bypass was not shown either,Paul HL Kao 08,NEJM. 1985;313:11911200,Review of studies,20 studies in patients with TIA or ischemic stroke associated with ICAO, the annual risk of all
8、and ipsilateral stroke were 5.5% and 2.1% Patients with a compromised CBF measured by PET, SPECT, TcD, or Xe CT have an even higher annual risk of all and ipsilateral stroke (12.5% and 9.5%),Stroke. 1997;28:20842093,Paul HL Kao 08,Identify the right patient to revascularize,81 ICAO patients with old
9、 ipsilateral stroke or TIA, evaluated with PET and followed for 3 years Stroke occurred in 12/39 and 3/42 (p=0.005, age-adjusted RR= 6) patients with and without stage 2 perfusion failure, ipsilateral stroke in 11/39 and 2/42 (p=0.004, age-adjusted RR= 7.3),Paul HL Kao 08,JAMA. 1998;280:10551060,NTU
10、H ICAO experience,Endovascular recanalization was attempted in 75 patients with ICAO from October 2002 to Dec 2007, out of 480 (15.6%) ICA stentings in the same period ICAO was documented by ultrasound, CTA, or MRA All patients were followed clinically for at least 2 months after the diagnosis of IC
11、AO by in dependent neurologist/cardiologist Enrollment criteria Progression or recurrence of ipsilateral neurological deficit, or Objective ipsilateral hemispheric ischemia,Paul HL Kao 08,Exemplary case: 64M with old RMCA infarct,Baseline,Diamox stress,Flow,Paul HL Kao 08,Diamox stress,Baseline,Volu
12、me,Perfusion CT imaging for objective ischemia,Paul HL Kao 08,Perfusion CT imaging for objective ischemia,Diamox stress,Baseline,Transit Time,Paul HL Kao 08,CT angiography for path finding,Cervical ICA,Carotid canal,Paul HL Kao 08,Ultrasound evaluation,Neck ultrasound and trans-ocular duplex evaluat
13、ion of OA flow direction before, and 1, 6, 12 months after procedure by an independent neurologist Suspicion of restenosis by ultrasound mandates angiographic follow-up,Paul HL Kao 08,Exemplary case: 64M RICA CTO,Lateral view,IC lateral view,Paul HL Kao 08,After Carotid Wall and Tsunami,AP view,Late
14、ral view,Paul HL Kao 08,3m follow-up,IC AP view,IC lateral vew,Paul HL Kao 08,Partial recovery of perfusion CT at 1 month,Post stress,Post baseline,Pre baseline,Pre stress,Transit time,Paul HL Kao 08,Comparison of CTA at 1 month,Pre,Post,Paul HL Kao 08,Acknowledged work,Paul HL Kao 08,Demographics (
15、Oct 02 - Aug 08),Paul HL Kao 08,Procedural results (Oct 02 - Aug 08),Paul HL Kao 08,Clinical outcome (Oct 02 - Aug 08),Paul HL Kao 08,The only mortality,Emergent,Baseline,Paul HL Kao 08,Kao HL et al. JACC 2007;49:765,Ophthalmic artery flow evaluation,Good quality trans-ocular duplex can be obtained
16、in 25/30 (84%) patients before procedure, and 21/25 (83%) showed reversed OA flow Pre-procedure OA flow was reverse in 15/22 patients that were later successfully recanalized OA flow was normalized 1 month after recanalization in 12/15 (80%) Persistent OA flow reversal in 2/15 (13%), both were found
17、 re-occluded at 1 month 1 patient died at day 3 without post-procedure trans-ocular duplex,Paul HL Kao 08,Kao HL et al. JACC 2007;49:765,Safety issues,Paul HL Kao 08,Baseline,Recanalized,Delayed pseudoaneurysm,Recurrent ischemia,Paul HL Kao 08,BMS across pseudoaneurysm,Paul HL Kao 08,Ischemia reliev
18、ed,Paul HL Kao 08,Extravasation,Paul HL Kao 08,Carotid-cavernous fistula,Local hematoma,Endpoints for intervention,For PCI Death/MI Angina relief, LV function recovery, and TVR For ICA intervention Death/stroke Physiological and functional endpoints Neuro-cognitive evaluation Changes in perfusion im
19、aging, such as perfusion CT, MRI, and PET,Paul HL Kao 08,Conclusions,Endovascular recanalization of ICAO is feasible and safe Future prospective studies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalization of ICAO,Paul HL Kao 0
20、8,Its never too late to open a closed door, because the room behind may be full of surprises,Definitions,Atheromatous pseudo-occlusion (APO) String-like residual filling of ICA behind the “occlusion” Retrograde filling of the proximal so-called “occluded” ICA reaching the skull base Chronic total oc
21、culsion (CTO) The occlusion must be documented for at least 1 month TIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in length Established filling to the ipsilateral intracranial ICA via A-Com, P-Com, OA, meningeal, or other collaterals,Paul HL Kao 07,Partial recovery
22、of perfusion CT at 1 month,Pre baseline,Pre stress,Post baseline,Post stress,Flow,Paul HL Kao 07,Partial recovery of perfusion CT at 1 month,Volume,Pre baseline,Post baseline,Pre stress,Post stress,Paul HL Kao 07,Example of complete recovery,Pre stress flow,Post stress flow,Paul HL Kao 08,Example of
23、 complete recovery,Pre stress volume,Post stress flow,Paul HL Kao 08,Example of complete recovery,Pre stress transit time,Post stress transit time,Paul HL Kao 08,Cerebral perfusion after ICAO,Stage 0: CPP normal, CBF matched with resting metabolic demand, no regional variation in OEF Stage 1: CPP decreased, but CBF maintained by vasodilatation, CBV increased Stage 2: CPP further decreased beyond the capacity of auto-regulation, CBF decreased, regional OEF increased with declined brain function,Paul HL Kao 08,