Concomitant multiple revascularizations in supra-aortic arteries: short-term results in 50 patients

Abstract

Background and purpose: The outcome for simultaneous revascularization of more than 1 supra-aortic arterial stenosis has not been evaluated because of concerns regarding the increased risk of additional procedures. We evaluated the feasibility and safety of concomitant multiple supra-aortic arterial revascularizations (CMSAR).

Materials and methods: We retrospectively evaluated 50 consecutive patients who underwent CMSARs with angioplasty and stent placement. The study included a separate lesion group (LG) (n = 28), ipsilateral LG (n = 17) including adjacent (n = 6) and remote (n = 11) tandem lesions, and triple LG (n = 5). We assessed the procedural success (defined as residual stenosis <30%) and periprocedural event rate (ER) (minor or major stroke, and death). We compared the ERs in the lesion (ipsilateral vs separate) and symptom (unstable vs stable) pattern groups with the Fisher exact test.

Results: Procedural success was achieved in all patients (50/50). Periprocedural events within 30 days were noted in 5 (10%). ER within 2 days after the procedure was higher in the ipsilateral LG (4/17) than in the separate LG (0/28) (P = .016). Major events consisting of a major stroke and a death occurred in 2 patients in the unstable group (4%) and was more common in the unstable (2 of 7) than in the stable group (0/38) (P = .029). During the mean 11-month follow-up period, there was 1 symptomatic recurrence.

Conclusion: CMSARs are feasible with a high procedural success rate resulting in a favorable short-term outcome. However, they must be carefully performed in ipsilateral LG, especially in patients in the unstable group.

Fig 1.

A 66-year-old man with hypertension and a history of smoking presented with chest pain and vertigo and was found to have multiple stenoses (ipsilateral remote tandem lesions) before coronary artery bypass surgery. A–B, The severe stenosis in the right carotid bulb with undermining ulceration (arrow), was revascularized first (anteroposterior view). C–D, Concomitant severe (more than 70%) stenosis (arrow in C) of the right cavernous segment was also revascularized during the same session. Note antegrade filling of the ophthalmic artery (open arrow in D). The patient underwent coronary artery bypass surgery and had no neurologic symptoms during the 6-month follow-up period.

Fig 2.

A 50-year-old man presented with vertigo, ataxia, and right arm weakness. An angiogram of the left CCA revealed a symptomatic severe stenosis of the left carotid bulb (arrow) (A) and patency after stent placement (B). There were multiple severe stenoses (arrows) of the right CCA (adjacent tandem lesions) (C). Good patency was obtained after concomitant stent placement (D). He underwent additional angioplasty at the right CCA at 18 months because of asymptomatic severe restenosis (not shown) and remains asymptomatic during a 32-month follow-up period.

Fig 3.

A 45-year-old male presented after multiple TIAs. Adjacent tandem lesions of the right MCA, are revealed by the arrows in A and B. A, The initial MRA showed a severe stenosis of right M1 (arrow in A) and failed to demonstrate an adjacent distal tandem lesion because of the decreased signal intensities distal to the first stenotic lesion. B, The oblique CT angiogram shows both severe tandem lesions (arrows) with more than 70% stenosis. C, There was an increased time-to-peak delay on CT perfusion image in the right MCA territory. D, The M1 lesion did not seem to be severe (arrow) on the anteroposterior view of cerebral angiogram due to the marked eccentricity of the M1 lesions. E, Final angiogram after concomitant stenting revealed good patency of the right M1 and improved angiographic flow into the right MCA territory. F, Diffusion-weighted MR imaging performed 2 days later, revealed acute ischemic change in the right caudate nucleus. The newly developed mild extremity weakness (minor stroke) eventually disappeared completely. There was no evidence of restenosis on TCD at 7 months and no symptomatic recurrence during the 17-month follow-up.