Oderich, Gustavo S.

Purpose: To review the outcomes of retrograde supra-aortic vessel stent (RSAS) placement combined with open carotid or subclavian artery revascularization. Methods: Retrospective review of all consecutive patients between 1995 and 2010, excluding transfemoral procedures or isolated retrograde stent placement. Results: There were 11 patients (9 females, mean age 65 years). Open revascularization included carotid endarterectomy in 6 patients, carotid-subclavian bypass in 3, and carotid-carotid bypass in 2 patients. There were no operative deaths or neurological events. All symptomatic patients improved. Over a mean follow-up of 24 months, One patient developed common carotid artery (CCA) in-stent dissection and symptomatic restenosis treated with subclavian-carotid bypass. Another 3 patients had asymptomatic restenosis of the carotid bifurcation but required no intervention. Conclusions: Retrograde stenting of the common carotid or innominate artery is a safe and effective method to provide inflow in selected patients with severe supra-aortic vessel disease who require concomitant open carotid or subclavian artery reconstructions.

One of the technical limitations of surgeon-modified fenestrated stent grafts is the lack of a diameter-reducing wire, which facilitates catheterization of target branches if there are errors of device design, alignment, or implantation. This article describes a technique of adding a diameter-reducing wire to the modified TX2 fenestrated stent graft for compassionate use in aortic emergencies or high-risk patients who do not have access to manufactured devices. The modified Cook TX2 stent graft was created using reinforced fenestrations with gold nitinol markers. After the TX2 stent was fully unsheathed, one of the nitinol wires located in the inner cannula was withdrawn and redirected externally through and through the fabric of the stent graft. Each Z stent was constrained using the nitinol wire for support and two nonlocking polypropylene loops. The use of a diameter-reducing wire facilitates side branch catheterization by allowing longitudinal and rotational movement to the modified fenestrated stent graft in patients where there is misalignment between the fenestration and the origin of the target vessel.

Background and Purpose— To evaluate the periprocedural outcome after carotid artery stenting with embolic brain protection (EBP+) versus without embolic brain protection (EBP−). Methods— We retrospectively reviewed data from a prospective nonrandomized database of 357 patients who underwent carotid artery stenting in the neuroradiology division of our institution from 1999 to 2009. One hundred five patients underwent angioplasty and stenting without distal protection, whereas 252 were treated with distal protection. Patients were analyzed according to their EBP status (+ or −) for the primary end points of perioperative stroke, death, or myocardial infarction. Results— Unprotected stenting was mostly performed in the early years of this study and this is reflected in significant baseline differences between the two groups. In our earlier experience, carotid artery stenting was used in patients with more significant comorbidities. Diabetes mellitus ( P =0.04), previous coronary artery disease ( P =0.02) and myocardial infarction ( P =0.04), and symptomatic lesion ( P =0.01) were significantly more common in the EBP− cohort. Despite these baseline differences, there were no significant differences in the primary end points (2% in the EBP+ group and 4.8% in the EBP−, P =0.15). The incidence of ipsilateral stroke in the EBP− and in the EBP+ group was 3.8% versus 0.8%, respectively ( P =0.6). There were 2 perioperative deaths (1 in each group) and 4 myocardial infarctions (3 in the EBP+ arm and 1 in the EBP− arm, all non-Q infarcts; P =nonsignificant). Conclusions— In accordance with recent literature, this series cast doubts as to the real effectiveness of distal embolic protection devices in reducing periprocedural complications.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by café au lait macules, neurofibromas, and iris hamartomas. Internal carotid artery aneurysms rarely affect patients with NF-1 but may be associated with rupture or neurologic complications. We report a 42-year-old female patient with NF-1 and a bilobed right internal carotid artery aneurysm extending to C2. The aneurysm was excised with high exposure of the carotid artery and reconstruction was performed using saphenous vein graft. We review the literature relevant to internal carotid aneurysms associated with NF-1.