Internal Carotid Artery Stenting in Patients with Symptomatic Atheromatous Pseudo-Occlusion

Abstract

Angioplasty and stenting of the atheromatous internal carotid artery (ICA), besides in patients with a high surgical risk, may be indicated in specific cases such as contralateral occlusion, acute stroke clinical signs, or atherosclerotic pseudo-occlusion (APO). APO of the ICA is an underrecognized condition due to diagnostic difficulties both with noninvasive methods and even with angiography. Once recognized, there is usually the opportunity for successful revascularization with carotid endarterectomy. However, as the natural history of the APO is poorly characterized, the management of patients remains controversial. While some authors advocate a surgical approach, others consider that APO patients are not at high risk of stroke, making any interventional approach unnecessary. The perioperative risk of stroke in patients with APO is not appreciably greater than in patients with lesser degrees of stenosis and clear recommendation of surgery, although at 2 years that risk seems to be considerably much higher than in the latter patients. Looking for safer interventional procedures is worthwhile. Results of angioplasty and stenting in patients with ICA-APO have not been published yet. We report the results and complications associated with this procedure to address the issue of appropriate management of patients with ICA-APO.

Outcome Evaluation of Carotid Stenting in High-Risk Patients with Symptomatic Carotid near Occlusion

“…Our series of high-risk patients who underwent carotid stenting for symptomatic ICA stenosis, revealed a 29% near occlusion rate. There have been no large clinical trials on PTA and stenting for ICA near occlusion except for a few recent reports of experience with stenting in small group of patients with ICA near occlusion 21,22 . Although those studies included stable and even asymptomatic patients, our study obtained a 92% good outcome at six month even though 27% of our patients had an initial NIHSS (≥ 4) in symptomatic high-risk patients.…”

Carotid Near-Occlusion: A Comprehensive Review, Part 1—Definition, Terminology, and Diagnosis

“…Images from Sekhar et al can be called "near-occlusion with full collapse." "Pseudo-occlusion" has been used for the appearance of a collapsed artery, [1][2][3][4][5][6][7][8][9]11,[13][14][15][16][17][18][19][20][45][46][47][48][56][57][58][59][60][61][62][65][66][67][68][69][70] but also quite literally when diagnosis changed from occlusion to patent after re-review (not necessarily with distal collapse. 10,12,55,63,64,81 String Sign.…”

“…Those who recognized near-occlusion as with and without full collapse have often used with and without the "string sign" to describe this. 2,7,22,24,26 Near-Occlusion. "Nearly occluded" was used by Gabrielsen et al 31 in 1981 to describe a tight carotid stenoses with distal collapse.…”

“…1 Various terms have been used to describe near-occlusion, which can mislead students or those doing literature searches: near-occlusion (or "near total occlusion" [45][46][47][48][49][50][51] ), pseudo-occlusion, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]43,45,47,48,50-70 string sign, 1-5,7,9-13,16,18-20,22,24,26,30, 11,12,18,45 99% stenosis, 66 hairline residual lumen, 20,43 and incomplete occlusion. 1 Calculating percentage stenosis for carotid near-occlusion is fallacious, and near-occlusion assessment is advised before measuring for percentage stenosis.…”

Internal Carotid Artery Stenting in Patients with Near Occlusion: 30-Day and Long-Term Outcome

“…9 So far, only 2 small series of patients with NO treated by CAS have been published. 10,11 Here, we report our experience with 116 patients treated by CAS and followed up prospectively. The issue of the suitability of this procedure in managing patients with NO was addressed by considering intraprocedural complications and 30-day and long-term morbidity and mortality.…”