Transcarotid artery revascularization (TCAR) stenting or angioplasty for intracranial carotid artery stenosis: Case series and novel application

Abstract

Background: Carotid artery stenting is associated with a higher rate of stroke compared to carotid endarterectomy (CEA). This is likely due to procedural emboli resulting from plaque disruption. The transcarotid artery revascularization (TCAR) method aims to reduce the stroke rate by flow-reversal. TCAR, which has yet to be utilized for intracranial atherosclerotic disease (ICAD), may be particularly valuable given the lack of surgical treatment options for intracranial arterial stenosis.

Objective: Presented here are five cases of angioplasty or stenting that demonstrate the feasibility of TCAR for intracranial Internal Carotid Artery (ICA) stenosis treatment.

Methods: Five cases were reviewed retrospectively and summarized using PROCESS and CARE guidelines.

Results: All patients who underwent intervention between the petrous and ophthalmic segment of the ICA had no new neurologic deficit nor detected embolic stroke. One patient experienced an asymptomatic 5 mm hemorrhage on postoperative routine Computed Tomography (CT) head imaging.

Conclusions: This highlights a new method for treating intracranial ICA stenosis with a potentially reduced stroke risk. Given the historically higher stroke rates for cervical ICA stenting compared to carotid artery endarterectomy, this method may improve the previously higher stroke rates in endovascular carotid artery treatment, compared to CEA. Although this series is small, it illustrates a novel use for a rising technique that should be further evaluated in a larger study to validate its efficacy as a new treatment modality for surgically inaccessible intracranial disease.

Keywords: TCAR; carotid artery angioplasty; carotid artery stenosis; carotid artery stent; intracranial stenosis.

Figure 1.

Case 1 and 2 (a) preoperative lateral view DSA left internal carotid artery (ICA) with 75% C2 stenosis. (b) Case 1 - Lateral view DSA Post-stenting and angioplasty at the C2-C3 ICA segments. (c) Case 1 - Magnetic Resonance Imaging (MRI) apparent diffusion coefficient image and (d) diffusion-weighted image demonstrating subacute left anterior cerebral artery infarct. (e) Case 2 - Preoperative left anterior-posterior view DSA with C1 ICA high-grade stenosis. (f) Case 2 - Anterior-posterior view DSA post-stent placement.

Figure 2.

Preoperative and postoperative cerebral DSA for cases 3 and 4 (a) case 3 – anterior-posterior view DSA demonstrates left C2 ICA stenosis (75%) and C3 ICA stenosis (65%). (b) Case 3 – Anterior-posterior view DSA post-angioplasty. (c) Case 4 – Anterior-posterior view DSA preoperative left internal carotid artery (ICA) with 70% stenosis. (d) Case 4 – Lateral DSA post-angioplasty at the C4 ICA segments.

Figure 3.

Preoperative and postoperative cerebral DSA for case 5 – right ICA with 80% in-stent stenosis with occluded aneurysm (a) preoperative anterior-posterior DSA (b) postoperative anterior-posterior DSA (c) preoperative lateral DSA (d) postoperative lateral DSA.