Free CME Article: The Durability of Carotid Endarterectomy

Background: Carotid endarterectomy is a low-risk treatment for carotid occlusive disease. Recent clinical trials have suggested that carotid angioplasty may be a viable alternative. One important issue that has not been evaluated is the long-term recurrent stenosis rate after either intervention.

Objective: To examine the risk of recurrent stenosis after carotid endarterectomy and to provide long-term data on the durability of carotid endarterectomy.

Methods: A total of 1335 sequential patients were followed up prospectively with annual carotid ultrasonography. All patients were maintained on antiplatelet therapy, and arteriotomies were closed with a patch graft. Operations were performed under general anesthesia with electroencephalographic monitoring and selective shunting. There were no changes in surgical technique during this study.

Ahead of Print: Hybrid Surgery for Symptomatic Chronic Total Occlusion of Carotid Artery

Background and Importance: Although medical treatment has been considered a dogma for chronic total occlusion (CTO) of the carotid artery, use of endovascular recanalization has also been reported. However, there are some difficulties in performing endovascular recanalization. We present the novel technical details and advantages of hybrid surgery for recanalization of symptomatic CTO of the internal carotid artery (ICA).

Clinical Presentation: Three cases with recurrent ischemic attacks due to thrombotic occlusion of the right ICA above bifurcation were successfully treated by this hybrid surgery, combining endarterectomy of the proximal ICA with endovascular angioplasty of the distal ICA. Using this hybrid technique, complete recanalization was achieved in all 3 cases. The follow-up computerized tomographic angiograms (CTA) with perfusion imaging showed improved brain perfusion. At 6-month follow-up, ischemic symptoms had not recurred.

Ahead of Print: Wingspan Stenting for Intracranial Atherosclerotic Stenosis

Background: Intracranial atherosclerotic stenosis (ICAS) is responsible for 9-37% of ischemic strokes.

Objective: To evaluate the clinical outcome and risk factors for in-stent restenosis (ISR) after treatment of ICAS with a Wingspan stent.

Methods: Seventy-seven patients with 79 total target ICAS > 60% (mean, 79.9 +/- 8.4%; symptomatic ICAS, 96.2%) underwent attempted treatment with Wingspan stenting between March 2010 and March 2011. A retrospective review of the prospectively registered data was conducted to assess the risk factors for ISR as well as the clinical outcomes of these patients.

Ahead of Print: Dural Incompetence in Pseudotumor Cerebri

Background: Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing (DSN); however, a complete understanding of the hydrodynamic dysequilibrium is lacking.

Objective: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH.

Methods: Cases of venous sinus stent implantation for IIH were retrospectively reviewed.

Editor Choice: Stent Coiling and Packing Density

Background: Recent reports have shown that stent-assisted coiling (SAC) is associated with lower aneurysm recanalization rates compared with conventional coiling, raising questions about the necessity of achieving high packing density (PD) in stented aneurysms.

Objective: To assess the impact of PD on follow-up obliteration rates of stented aneurysms and attempt to determine the optimal range of PD in SAC.

Methods: This is a retrospective analysis of a single, large, cerebrovascular referral center’s experience over a 5-year period in SAC with the use of Neuroform and Enterprise stents. The rate of complete obliteration on follow-up angiograms was compared for 3 different PD groups: high PD (>22%), moderate PD (12-22%), and low PD (<12%).