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ICA stentingnProven to be an alternative to CEA in ICA stenosis,especially in patients with high surgical risk profilesnBut the application of endovascular intervention in cervical ICA occlusion(ICAO)has never been explored,which comprise 15%of patients with ipsilateral TIA or infarctionPaul HL Kao 08ICA stentingProven to be an al1 1The great mythnICA stenosis causes symptoms through artery-to-artery embolismnThe risk of stroke is minimal with ICAO,because there is no flow to carry the embolinIs it true?Paul HL Kao 08The great mythICA stenosis cau2 2Prognosis and pathophysiology of ICAOnCervical ICAO is an important cause of TIA and cerebral infarction and should not be neglectedAnnual risk of ipsilateral stroke in symptomatic ICAO is 6-20%Annual risk of ipsilateral stroke in asymptomatic ICAO is 2-5%nPathophysiology of symptomsEmboli arising from ECA/CCA via collateralsEmboli arising from ICA stump via collaterals(Stump syndrome)Emboli arising from trailing thrombi distal to the occlusionHypo-perfusion(hemodynamic insufficiency)Paul HL Kao 08Prognosis and pathophysiology 3 3Treatment options for ICAOnMedicalThe recommended treatment at present,but may be insufficient for certain patientsnSurgeryCEAStump ligation/exclusionEC/IC bypassCan be very technically demanding with high periprocedural complicationsAll failed to reduce ipsilateral stroke and are not recommended to ICA CTO in generalPaul HL Kao 08Treatment options for ICAOMedi4 4EC/IC bypassn1377 patients with symptomatic ICA or MCA occlusion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 56 monthsnMajor peri-operative stroke rate as 4.5%nTotal stroke rates were not different between bypass and medical groupsnIn patients with ongoing symptoms after angiographic documentation of ICAO,the benefit of bypass was not shown eitherPaul HL Kao 08NEJM.1985;313:11911200EC/IC bypass1377 patients with5 5Review of studiesn20 studies in patients with TIA or ischemic stroke associated with ICAO,the annual risk of all and ipsilateral stroke were 5.5%and 2.1%nPatients with a compromised CBF measured by PET,SPECT,TcD,or Xe CT have an even higher annual risk of all and ipsilateral stroke(12.5%and 9.5%)Stroke.1997;28:20842093Paul HL Kao 08Review of studies20 studies in6 6Identify the right patient to revascularizen81 ICAO patients with old ipsilateral stroke or TIA,evaluated with PET and followed for 3 yearsnStroke occurred in 12/39 and 3/42(p=0.005,age-adjusted RR=6)patients with and without stage 2 perfusion failure,ipsilateral stroke in 11/39 and 2/42(p=0.004,age-adjusted RR=7.3)Paul HL Kao 08JAMA.1998;280:10551060Identify the right patient to 7 7Identify the right patient to revascularizePaul HL Kao 08EC/IC bypassBut the application of endovascular intervention in cervical ICA occlusion(ICAO)has never been explored,which comprise 15%of patients with ipsilateral TIA or infarctionNeuro-cognitive evaluationPhysiological and functional endpointsIdentify the right patient to revascularize004,age-adjusted RR=7.Emboli arising from ICA stump via collaterals(Stump syndrome)3-m follow-up,n(%)17/10Established filling to the ipsilateral intracranial ICA via A-Com,P-Com,OA,meningeal,or other collateralsDelayed pseudoaneurysmICAO was documented by ultrasound,CTA,or MRA20 studies in patients with TIA or ischemic stroke associated with ICAO,the annual risk of all and ipsilateral stroke were 5.ICH/hyperperfusionPaul HL Kao 08Angina relief,LV function recovery,and TVRPaul HL Kao 08Death/strokeNTUH ICAO experiencenEndovascular recanalization was attempted in 75 patients with ICAO from October 2002 to Dec 2007,out of 480(15.6%)ICA stentings in the same periodnICAO was documented by ultrasound,CTA,or MRAnAll patients were followed clinically for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologistnEnrollment criteriaProgression or recurrence of ipsilateral neurological deficit,orObjective ipsilateral hemispheric ischemiaPaul HL Kao 08Identify the right patient to 8 8Exemplary case:64M with old RMCA infarctBaselineDiamox stressFlowPaul HL Kao 08Exemplary case:64M with old R9 9Diamox stressBaselineVolumePerfusion CT imaging for objective ischemiaPaul HL Kao 08Diamox stressBaselineVolumePer1010Perfusion CT imaging for objective ischemiaDiamox stressBaselineTransit TimePaul HL Kao 08Perfusion CT imaging for objec1111CT angiography for path findingCervical ICACarotid canalPaul HL Kao 08CT angiography for path findin1212Ultrasound evaluationnNeck ultrasound and trans-ocular duplex evaluation of OA flow direction before,and 1,6,12 months after procedure by an independent neurologistnSuspicion of restenosis by ultrasound mandates angiographic follow-upPaul HL Kao 08Ultrasound evaluationNeck ultr1313Exemplary case:64M RICA CTOLateral viewIC lateral viewPaul HL Kao 08Exemplary case:64M RICA CTOLa1414After Carotid Wall and TsunamiAP viewLateral viewPaul HL Kao 08After Carotid Wall and Tsunami15153m follow-upIC AP viewIC lateral vewPaul HL Kao 083m follow-upIC AP viewIC later1616Partial recovery of perfusion CT at 1 monthPost stressPost baselinePre baselinePre stressTransit timePaul HL Kao 08Partial recovery of perfusion 1717Comparison of CTA at 1 monthPrePostPaul HL Kao 08Comparison of CTA at 1 monthPr1818Major peri-operative stroke rate as 4.Paul HL Kao 08Paul HL Kao 08ICA stentingStump ligation/exclusionAfter Carotid Wall and TsunamiWire crossing successfulReview of studiesPaul HL Kao 08Occlusion length(mm)Progression or recurrence of neurologic deficit after known ICA occlusionStroke occurred in 12/39 and 3/42(p=0.ExtravasationPaul HL Kao 08Paul HL Kao 08Partial recovery of perfusion CT at 1 monthNeck ultrasound and trans-ocular duplex evaluation of OA flow direction before,and 1,6,12 months after procedure by an independent neurologist1997;28:20842093Amaurosis fugaxUltrasound evaluationICA diameter(mm)Acknowledged workPaul HL Kao 08Major peri-operative stroke ra1919Demographics(Oct 02-Aug 08)Male sex4889%Age(y)69.2 9.8Hypertension4380%Diabetes mellitus1935%Hyperlipidemia2954%Smoking2852%Prior ipsilateral stroke3565%Ipsilateral TIA1528%Amaurosis fugax47%Contralateral ICA stenosis 50%1935%Progression or recurrence of neurologic deficit after known ICA occlusion 3769%Paul HL Kao 08Demographics(Oct 02-Aug 02020Procedural results(Oct 02-Aug 08)Technical success3565%Lesion location,right/left27/2750%/50%CCA diameter(mm)7.90.6 ICA diameter(mm)5.10.5 Occlusion length(mm)27.916.2Wire crossing successful3769%Distal protection device used after crossing 27 73%PercuSurge/FilterWire 17/10 63%/37%Post-dilatation balloon diameter(mm)4.51.7 Post-dilatation pressure(atm)6.82.9 ECA orifice covered by stent34 92%Final residual diameter stenosis(%)97Paul HL Kao 08Procedural results(Oct 02-2121Clinical outcome(Oct 02-Aug 08)In-hopsital,n(%)3-m follow-up,n(%)Death1(1.9)1(1.9)Fatal stroke1(1.9)1(1.9)Other cause00Stroke2(3.7)2(3.7)Major ipsi.00 Major non-ipsi.1(1.9)1(1.9)Minor ipsi.1(1.9)1(1.9)Minor non-ipsi.00TIA00ICH/hyperperfusion00Restenosis-4/35(11.4)Paul HL Kao 08Clinical outcome(Oct 02-Au2222The only mortalityEmergentBaselinePaul HL Kao 08Kao HL et al.JACC 2007;49:765The only mortalityEmergentBase2323Ophthalmic artery flow evaluationnGood quality trans-ocular duplex can be obtained in 25/30(84%)patients before procedure,and 21/25(83%)showed reversed OA flownPre-procedure OA flow was reverse in 15/22 patients that were later successfully recanalizedOA flow was normalized 1 month after recanalization in 12/15(80%)Persistent OA flow reversal in 2/15(13%),both were found re-occluded at 1 month1 patient died at day 3 without post-procedure trans-ocular duplexPaul HL Kao 08Kao HL et al.JACC 2007;49:765Ophthalmic artery flow evaluat2424Safety issuesPaul HL Kao 08BaselineRecanalizedSafety issuesPaul HL Kao 08Bas2525Delayed pseudoaneurysm Recurrent ischemiaPaul HL Kao 08Delayed pseudoaneurysm Recurre2626BMS across pseudoaneurysmPaul HL Kao 08BMS across pseudoaneurysmPaul 2727Ischemia relievedPaul HL Kao 08Ischemia relievedPaul HL Kao 02828EC/IC bypassGood quality trans-ocular duplex can be obtained in 25/30(84%)patients before procedure,and 21/25(83%)showed reversed OA flowProcedural results(Oct 02-Aug 08)Paul HL Kao 08PercuSurge/FilterWirePaul HL Kao 08004,age-adjusted RR=7.After Carotid Wall and TsunamiIdentify the right patient to revascularizeStage 0:CPP normal,CBF matched with resting metabolic demand,no regional variation in OEFNeuro-cognitive evaluationExample of complete recoveryNeuro-cognitive evaluationString-like residual filling of ICA behind the“occlusion”Paul HL Kao 08Amaurosis fugaxCan be very technically demanding with high periprocedural complicationsMajor ipsi.Lateral viewAnnual risk of ipsilateral stroke in symptomatic ICAO is 6-20%Post baselineCervical ICAFatal strokeString-like residual filling of ICA behind the“occlusion”Pathophysiology of symptomsTIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in lengthLateral viewDelayed pseudoaneurysmNTUH ICAO experiencePaul HL Kao 08ECA orifice covered by stentPre stress flowOA flow was normalized 1 month after recanalization in 12/15(80%)Ipsilateral TIALateral viewPaul HL Kao 08Stage 2:CPP further decreased beyond the capacity of auto-regulation,CBF decreased,regional OEF increased with declined brain functionDemographics(Oct 02-Aug 08)Neuro-cognitive evaluationLesion location,right/leftPaul HL Kao 08Kao HL et al.ExtravasationPaul HL Kao 08Carotid-cavernous fistulaLocal hematomaEC/IC bypassCervical ICAExtrav2929Endpoints for interventionnFor PCIDeath/MIAngina relief,LV function recovery,and TVRnFor ICA interventionDeath/strokePhysiological and functional endpointsNeuro-cognitive evaluationChanges in perfusion imaging,such as perfusion CT,MRI,and PETPaul HL Kao 08Endpoints for interventionFor 3030ConclusionsnEndovascular recanalization of ICAO is feasible and safenFuture prospective studies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalization of ICAOPaul HL Kao 08ConclusionsEndovascular recana3131Its never too late to open a closed door,because the room behind may be full of surprisesIts never too late to open a 3232Definitionsn nAtheromatous pseudo-occlusion(APO)String-like residual filling of ICA behind the String-like residual filling of ICA behind the“occlusion”“occlusion”Retrograde filling of the proximal so-called Retrograde filling of the proximal so-called“occluded”ICA reaching the skull base“occluded”ICA reaching the skull basen nChronic total occulsion(CTO)The occlusion must be documented for at The occlusion must be documented for at least 1 monthleast 1 monthTIMI 0 flow behind the occlusion with TIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in discontinuation of ICA lumen at least 5mm in lengthlengthEstablished filling to the ipsilateral intracranial Established filling to the ipsilateral intracranial ICA via A-Com,P-Com,OA,meningeal,or ICA via A-Com,P-Com,OA,meningeal,or other collateralsother collateralsPaul HL Kao 07DefinitionsAtheromatous pseudo3333Partial recovery of perfusion CT at 1 monthPre baselinePre stressPost baselinePost stressFlowPaul HL Kao 07Partial recovery of perfusion 3434Partial recovery of perfusion CT at 1 monthVolumePre baselinePost baselinePre stressPost stressPaul HL Kao 07Partial recovery of perfusion 3535Example of complete recoveryPre stress flowPost stress flowPaul HL Kao 08Example of complete recoveryPr3636Example of complete recoveryPre stress volumePost stress flowPaul HL Kao 08Example of complete recoveryPr3737Example of complete recoveryPre stress transit timePost stress transit timePaul HL Kao 08Example of complete recoveryPr3838Cerebral perfusion after ICAOnStage 0:CPP normal,CBF matched with resting metabolic demand,no regional variation in OEFnStage 1:CPP decreased,but CBF maintained by vasodilatation,CBV increasednStage 2:CPP further decreased beyond the capacity of auto-regulation,CBF decreased,regional OEF increased with declined brain functionPaul HL Kao 08Cerebral perfusion after ICAOS3939
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