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Christopher J. Moran - One of the best experts on this subject based on the ideXlab platform.
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Carotid Angioplasty and stenting in the elderly.
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Introduction To investigate the technical success rate as well as the procedural and mid-term complication rates of Carotid Angioplasty and stenting in elderly patients, a group excluded from large randomized endarterectomy trials given their perceived high surgical risk.
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Carotid Angioplasty and stent placement for restenosis after endarterectomy
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Colin P. Derdeyn, Christopher J. Moran, Dewitte T. CrossAbstract:Introduction Recurrent Carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of Carotid Angioplasty and stenting for recurrent stenosis.
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Techniques of Carotid Angioplasty and stenting.
Neuroimaging clinics of North America, 2007Co-Authors: Christopher J. Moran, Dewitte T. Cross, Colin P. DerdeynAbstract:Carotid Angioplasty and stenting (CAS) is an alternative technique to restore a normal lumen for patients who are at high risk for adverse effects with Carotid endarterectomy (CEA). CAS has been shown to be of benefit to several groups of patients who have Carotid disease and who ordinarily are excluded from many CEA trials. Government payors have approved embolic protection devices (EPDs) and stents for the now reimbursable procedure. In fact, the Centers for Medicare and Medicaid Services are now mandating use of the EPDs in CAS to issue payment. The prudent practitioner will carefully select the patients for CAS with EPD and CEA, so that patients will have the safest opportunity to avoid the devastating effects of cerebrovascular accidents.
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Procedure complications of Carotid Angioplasty and stent placement without cerebral protection devices
Neurosurgical focus, 2005Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Object. The goal in this retrospective study was to examine the procedural complication rate for Carotid Angioplasty and stent placement performed without cerebral protection devices. Methods. Between March 1996 and December 2003, 167 Carotid Angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent Angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients’ medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates. The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days postprocedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01). Conclusions. Carotid Angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.
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Outcomes of Carotid Angioplasty and stenting for radiation-associated stenosis.
AJNR. American journal of neuroradiology, 2005Co-Authors: Paul Harrod-kim, Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:BACKGROUND AND PURPOSE: In light of their high surgical risk, Carotid Angioplasty and stent placement may be preferred in patients with radiation-associated Carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after Carotid Angioplasty and stent placement in this small group of high-risk patients. METHODS: Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed Carotid stenosis (mean, 84%; range, 70%–99%) in a total of 19 Carotid arteries, which were treated with Angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5–78 months) with periodic Doppler studies, angiography, CT angiography, or clinically. RESULTS: In the total 19 stented Carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat Angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat Angioplasty and stent placement; 1/19 (5%) had a repeat Angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure. CONCLUSION: Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated Carotid occlusive disease.
Dewitte T. Cross - One of the best experts on this subject based on the ideXlab platform.
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Carotid Angioplasty and stenting in the elderly.
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Introduction To investigate the technical success rate as well as the procedural and mid-term complication rates of Carotid Angioplasty and stenting in elderly patients, a group excluded from large randomized endarterectomy trials given their perceived high surgical risk.
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Carotid Angioplasty and stent placement for restenosis after endarterectomy
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Colin P. Derdeyn, Christopher J. Moran, Dewitte T. CrossAbstract:Introduction Recurrent Carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of Carotid Angioplasty and stenting for recurrent stenosis.
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Techniques of Carotid Angioplasty and stenting.
Neuroimaging clinics of North America, 2007Co-Authors: Christopher J. Moran, Dewitte T. Cross, Colin P. DerdeynAbstract:Carotid Angioplasty and stenting (CAS) is an alternative technique to restore a normal lumen for patients who are at high risk for adverse effects with Carotid endarterectomy (CEA). CAS has been shown to be of benefit to several groups of patients who have Carotid disease and who ordinarily are excluded from many CEA trials. Government payors have approved embolic protection devices (EPDs) and stents for the now reimbursable procedure. In fact, the Centers for Medicare and Medicaid Services are now mandating use of the EPDs in CAS to issue payment. The prudent practitioner will carefully select the patients for CAS with EPD and CEA, so that patients will have the safest opportunity to avoid the devastating effects of cerebrovascular accidents.
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Procedure complications of Carotid Angioplasty and stent placement without cerebral protection devices
Neurosurgical focus, 2005Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Object. The goal in this retrospective study was to examine the procedural complication rate for Carotid Angioplasty and stent placement performed without cerebral protection devices. Methods. Between March 1996 and December 2003, 167 Carotid Angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent Angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients’ medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates. The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days postprocedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01). Conclusions. Carotid Angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.
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Outcomes of Carotid Angioplasty and stenting for radiation-associated stenosis.
AJNR. American journal of neuroradiology, 2005Co-Authors: Paul Harrod-kim, Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:BACKGROUND AND PURPOSE: In light of their high surgical risk, Carotid Angioplasty and stent placement may be preferred in patients with radiation-associated Carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after Carotid Angioplasty and stent placement in this small group of high-risk patients. METHODS: Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed Carotid stenosis (mean, 84%; range, 70%–99%) in a total of 19 Carotid arteries, which were treated with Angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5–78 months) with periodic Doppler studies, angiography, CT angiography, or clinically. RESULTS: In the total 19 stented Carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat Angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat Angioplasty and stent placement; 1/19 (5%) had a repeat Angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure. CONCLUSION: Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated Carotid occlusive disease.
Yasha Kadkhodayan - One of the best experts on this subject based on the ideXlab platform.
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Carotid Angioplasty and stenting in the elderly.
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Introduction To investigate the technical success rate as well as the procedural and mid-term complication rates of Carotid Angioplasty and stenting in elderly patients, a group excluded from large randomized endarterectomy trials given their perceived high surgical risk.
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Carotid Angioplasty and stent placement for restenosis after endarterectomy
Neuroradiology, 2007Co-Authors: Yasha Kadkhodayan, Colin P. Derdeyn, Christopher J. Moran, Dewitte T. CrossAbstract:Introduction Recurrent Carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of Carotid Angioplasty and stenting for recurrent stenosis.
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Procedure complications of Carotid Angioplasty and stent placement without cerebral protection devices
Neurosurgical focus, 2005Co-Authors: Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:Object. The goal in this retrospective study was to examine the procedural complication rate for Carotid Angioplasty and stent placement performed without cerebral protection devices. Methods. Between March 1996 and December 2003, 167 Carotid Angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent Angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients’ medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates. The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days postprocedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01). Conclusions. Carotid Angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.
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Outcomes of Carotid Angioplasty and stenting for radiation-associated stenosis.
AJNR. American journal of neuroradiology, 2005Co-Authors: Paul Harrod-kim, Yasha Kadkhodayan, Dewitte T. Cross, Colin P. Derdeyn, Christopher J. MoranAbstract:BACKGROUND AND PURPOSE: In light of their high surgical risk, Carotid Angioplasty and stent placement may be preferred in patients with radiation-associated Carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after Carotid Angioplasty and stent placement in this small group of high-risk patients. METHODS: Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed Carotid stenosis (mean, 84%; range, 70%–99%) in a total of 19 Carotid arteries, which were treated with Angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5–78 months) with periodic Doppler studies, angiography, CT angiography, or clinically. RESULTS: In the total 19 stented Carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat Angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat Angioplasty and stent placement; 1/19 (5%) had a repeat Angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure. CONCLUSION: Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated Carotid occlusive disease.
Adnan I. Qureshi - One of the best experts on this subject based on the ideXlab platform.
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Abstract TP131: Use of Fixed-Dose Heparin Protocol for Carotid Angioplasty and Stenting in Patients with Symptomatic Carotid Stenosis
Stroke, 2017Co-Authors: M. Fareed K. Suri, Muhammad Shah Miran, Ahmed Riaz, Mohammad Rauf Afzal, Iryna Lobanova, Adnan I. QureshiAbstract:Introduction: Appropriate dosing of anticoagulation during Carotid Angioplasty and stenting remains unstudied. Although 70 units /kg is a commonly used dose, in patients with acute stroke, this dos...
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Use of intravenous abciximab as adjunctive therapy for Carotid Angioplasty and stent placement.
International journal of cardiovascular interventions, 2003Co-Authors: Dinesh Arab, Abutaher M. Yahia, Adnan I. QureshiAbstract:The benefit of intravenous abciximab as an adjunctive to percutaneous coronary intervention has been demonstrated in large-scale randomized studies. The role of intravenous abciximab is being defined in Carotid Angioplasty and stent placement as the procedure is gaining popularity for the treatment of high-grade Carotid stenosis in patients considered high-risk for Carotid endarterectomy. This paper summarizes the pathophysiological basis and the available data for the use of abciximab as an adjunct to Carotid artery stenting. (Int J Cardiovasc Intervent 2003; 5: 61-66)
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Postoperative hypotension after Carotid Angioplasty and stenting: report of three cases
Neurosurgery, 1999Co-Authors: Adnan I. Qureshi, Giuseppe Lanzino, Andreas R. Luft, Demetrius K. Lopes, Richard D. Fessler, Mudit Sharma, Lee R. Guterman, L. Nelson HopkinsAbstract:OBJECTIVE AND IMPORTANCE: Hemodynamic instability after Carotid Angioplasty and stenting is not well recognized. We report three patients who developed sustained hypotension in the postoperative period after successful Carotid Angioplasty and stent placement for internal Carotid artery stenosis in the Carotid sinus region. CLINICAL PRESENTATION: In two patients, hypotension was initially induced by inflation of the Angioplasty balloon. The third patient developed hypotension after completion of the procedure. In all cases, the hypotension persisted for 18 to 33 hours after the procedure. During the postoperative period, two of these patients also developed sinus bradycardia, which, in one patient, was further complicated by a third-degree atrioventricular block. INTERVENTION: The hypotension was successfully treated by intravenous vasopressors or inotropic agents. No permanent neurological or cardiac sequelae were observed. CONCLUSION: Sustained hypotension with or without bradycardia may develop after Carotid Angioplasty and stent placement, presumably as a result of Carotid sinus dysfunction. During the postoperative period, patients should be monitored in settings suited to expeditious management of cardiovascular emergencies.
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Postoperative hypotension after Carotid Angioplasty and stenting : Report of three cases. Commentaries
Neurosurgery, 1999Co-Authors: Adnan I. Qureshi, Giuseppe Lanzino, Andreas R. Luft, Demetrius K. Lopes, Richard D. Fessler, Mudit Sharma, Lee R. Guterman, L. Nelson Hopkins, C. M. Loftus, Robert H. RosenwasserAbstract:OBJECTIVE AND IMPORTANCE: Hemodynamic instability after Carotid Angioplasty and stenting is not well recognized. We report three patients who developed sustained hypotension in the postoperative period after successful Carotid Angioplasty and stent placement for internal Carotid artery stenosis in the Carotid sinus region. CLINICAL PRESENTATION: In two patients, hypotension was initially induced by inflation of the Angioplasty balloon. The third patient developed hypotension after completion of the procedure. In all cases, the hypotension persisted for 18 to 33 hours after the procedure. During the postoperative period, two of these patients also developed sinus bradycardia, which, in one patient, was further complicated by a third-degree atrioventricular block. INTERVENTION: The hypotension was successfully treated by intravenous vasopressors or inotropic agents. No permanent neurological or cardiac sequelae were observed. CONCLUSION: Sustained hypotension with or without bradycardia may develop after Carotid Angioplasty and stent placement, presumably as a result of Carotid sinus dysfunction. During the postoperative period, patients should be monitored in settings suited to expeditious management of cardiovascular emergencies.
Miloš Šurlan - One of the best experts on this subject based on the ideXlab platform.
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Carotid Angioplasty with Cerebral Protection
Acta Clinica Croatica, 2002Co-Authors: Zoran Milosevic, Bojana Žvan, Marjan Zaletel, Miloš ŠurlanAbstract:Background. Carotid endarterectomy (CEA) is widely used in the management of high-grade Carotid stenosis. It is a surgical procedure requiring general anaesthesia and is suitable only for lesions located at or close to the Carotid bifurcation. It may develop complications, such as stroke, death, cranial nerve palsies, wound haematoma and cardiac complications. The risk of complications is increased in patients with recurrent Carotid artery stenosis following CEA, in subjects undergoing radiotherapy to the neck, and in patients with cardiopulmonary disease. The drawbacks of CEA have led physicians to search for alternative treatment options. Carotid Angioplasty and stenting (CAS) is less invasive than CEA. The method is particularly suitable for the treatment of recurrent stenosis after previous CEA and distal internal artery stenosis, which is inaccessible for CEA. CAS does not cause cranial nerve palsies. Moreover, it does not require general anaesthesia and causes lower morbidity and mortality in patients with severe cardiopulmonary disease. The complications of CAS include stroke due to distal immobilisation of a plaque or thrombus dislodged during the procedure, abrupt vessel occlusion due to thrombosis, dissection or vasospasm, and restenosis due to intimal hyperplasia. CAS is a relatively new procedure; therefore, it is essential to establish its efficacy and safety before it is introduced widely into clinical practice. Patients and methods. In Slovenia, we have also started with Carotid Angioplasty by the study: Slovenian Carotid Angioplasty Study (SCAS). We performed CAS in 17 patients (12 males and 5 females) aged from 69 to 82 years. All patients were symptomatic with stenosis greater than 70 %. 10 patients suffered transient ischemic attacks, 4 patients minor strokes and 3 patients amaurosis fugax. Results. Technical success (< 30 % residual stenosis) was achieved in all cases. In 14 patients, no residual stenosis was found, in 2 patients a 15 % residual stenosis persisted and in 1 patient, a 30 % residual stenosis was detected. In 15 patients, CAS was performed without complications, in one patient the hyperperfusion syndrome occurred and in one periprocedural stroke occurred. Conclusions. According to our initial experience on 17 patients CAS could gain more importance in stroke prevention with proper selection of patients with brain ischemia and improved cerebral protection during procedure.
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Carotid Angioplasty with cerebral protection
Radiology and Oncology, 2002Co-Authors: Zoran Milosevic, Bojana Žvan, Marjan Zaletel, Miloš ŠurlanAbstract:Background. Carotid endarterectomy (CEA) is widely used in the management of high-grade Carotid stenosis. It is a surgical procedure requiring general anaesthesia and is suitable only for lesions located at or close to the Carotid bifurcation. It may develop complications, such as stroke, death, cranial nerve palsies, wound haematoma and cardiac complications. The risk of complications is increased in patients with recurrent Carotid artery stenosis following CEA, in subjects undergoing radiotherapy to the neck, and in patients with cardiopulmonary disease. The drawbacks of CEA have led physicians to search for alternative treatment options. Carotid Angioplasty and stenting (CAS) is less invasive than CEA. The method is particularly suitable for the treatment of recurrent stenosis after previous CEA and distal internal artery stenosis, which is inaccessible for CEA. CAS does not cause cranial nerve palsies. Moreover, it does not require general anaesthesia and causes lower morbidity and mortality in patients with severe cardiopulmonary disease. The complications of CAS include stroke due to distal immobilisation of a plaque or thrombus dislodged during the procedure, abrupt vessel occlusion due to thrombosis, dissection or vasospasm, and restenosis due to intimal hyperplasia. CAS is a relatively new procedure; therefore, it is essential to establish its efficacy and safety before it is introduced widely into clinical practice. Patients and methods. In Slovenia, we have also started with Carotid Angioplasty by the study: Slovenian Carotid Angioplasty Study (SCAS). We performed CAS in 17 patients (12 males and 5 females) aged from 69 to 82 years. All patients were symptomatic with stenosis greater than 70 %. 10 patients suffered transient ischemic attacks, 4 patients minor strokes and 3 patients amaurosis fugax. Results. Technical success (
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Cerebral hyperperfusion syndrome after Carotid Angioplasty
Radiology and Oncology, 2002Co-Authors: Zoran Milosevic, Bojana Žvan, Marjan Zaletel, Miloš ŠurlanAbstract:Background. Cerebral hyperperfusion syndrome after Carotid endarterectomy is an uncommon but well-defined entity. There are only few reports of »hyperperfusion injury« following Carotid Angioplasty. Case report. We report an unstable arterial hypertension and high-grade Carotid stenosis in a 58-year-old, right-handed woman. After a stroke in the territory of middle cerebral artery Carotid Angioplasty was performed in the patient. Among risk factors, the long lasting arterial hypertension was the most pronounced. Immediately after the procedure, the patient was stable without any additional neurologic deficit. The second day, the patient had an epileptic seizure and CT revealed a small haemorrhage in the left frontal lobe. Conclusions. The combination of a high-grade Carotid stenosis and unstable arterial pressure is probably an important prognostic factor in the pathogenesis of hyperperfusion syndrome.