Distal Internal Carotid Artery Stenting As An Adjunctive Maneuver After Carotid Endarterectomy: Indications, Technique, And Outcomes
Michael A. Ciaramella, MD, Allen D. Hamdan, MD, Mark C. Wyers, MD, Marc L. Schermerhorn, MD, Lars Stangenberg, MD, PhD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVES: Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate endpoint or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario.
METHODS: We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September, 2008 and July, 2022. Procedural details and postoperative follow up were reviewed for each patient.
RESULTS: Six patients were identified during the study period. All were male with an age range from 63-82 years. Five underwent initial CEA for asymptomatic carotid artery stenosis, and one patient presented with amaurosis fugax. Three patients were on duel anti-platelet therapy (DAPT) pre-operatively, whereas two were on aspirin monotherapy, and one was on aspirin and low dose rivaroxaban. Five patients underwent CEA with patch angioplasty and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in two patients and inadequate distal ICA endpoint in four patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery (CCA) and a standard carotid stent was deployed with its proximal aspect landing within the prior endarterectomy. Embolic protection was typically achieved via proximal CCA and external carotid artery (ECA) clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, two patients were found to have cranial nerve injury, likely occurring during the exposure for the initial CEA, as no additional dissection was performed for stent placement. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on DAPT with no further occurrence of stroke, carotid re-stenosis or re-intervention through a median follow up of 17 months.
CONCLUSIONS: Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate endpoint or vessel dissection in a surgically inaccessible region of the ICA.
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