頸動(dòng)脈慢性完全閉塞后再通的癥狀英文第1頁/共41頁EndovascularRecanalizationofSymptomaticChronicTotalOcclusionofCervicalCarotidArtery第2頁/共41頁ICAstentingProventobeanalternativetoCEAinICAstenosis,especiallyinpatientswithhighsurgicalriskprofilesButtheapplicationofendovascularinterventionincervicalICAocclusion(ICAO)hasneverbeenexplored,whichcomprise15%ofpatientswithipsilateralTIAorinfarctionPaulHLKao08第3頁/共41頁ThegreatmythICAstenosiscausessymptomsthroughartery-to-arteryembolismTheriskofstrokeisminimalwithICAO,becausethereisnoflowtocarrytheemboliIsittrue?PaulHLKao08第4頁/共41頁P(yáng)rognosisandpathophysiologyofICAOCervicalICAOisanimportantcauseofTIAandcerebralinfarctionandshouldnotbeneglectedAnnualriskofipsilateralstrokeinsymptomaticICAOis6-20%AnnualriskofipsilateralstrokeinasymptomaticICAOis2-5%PathophysiologyofsymptomsEmboliarisingfromECA/CCAviacollateralsEmboliarisingfromICAstumpviacollaterals(Stumpsyndrome)EmboliarisingfromtrailingthrombidistaltotheocclusionHypo-perfusion(hemodynamicinsufficiency)PaulHLKao08第5頁/共41頁TreatmentoptionsforICAOMedicalTherecommendedtreatmentatpresent,butmaybeinsufficientforcertainpatientsSurgeryCEAStumpligation/exclusionEC/ICbypassCanbeverytechnicallydemandingwithhighperiproceduralcomplicationsAllfailedtoreduceipsilateralstrokeandarenotrecommendedtoICACTOingeneralPaulHLKao08第6頁/共41頁EC/ICbypass1377patientswithsymptomaticICAorMCAocclusionorhigh-gradeICstenosisrandomizedtoSTA-MCAbypassormedicaltreatmentandfollowedfor56monthsMajorperi-operativestrokerateas4.5%TotalstrokerateswerenotdifferentbetweenbypassandmedicalgroupsInpatientswithongoingsymptomsafterangiographicdocumentationofICAO,thebenefitofbypasswasnotshowneitherPaulHLKao08NEJM.1985;313:1191–1200第7頁/共41頁Reviewofstudies20studiesinpatientswithTIAorischemicstrokeassociatedwithICAO,theannualriskofallandipsilateralstrokewere5.5%and2.1%PatientswithacompromisedCBFmeasuredbyPET,SPECT,TcD,orXeCThaveanevenhigherannualriskofallandipsilateralstroke(12.5%and9.5%)Stroke.1997;28:2084–2093PaulHLKao08第8頁/共41頁Identifytherightpatienttorevascularize81ICAOpatientswitholdipsilateralstrokeorTIA,evaluatedwithPETandfollowedfor3yearsStrokeoccurredin12/39and3/42(p=0.005,age-adjustedRR=6)patientswithandwithoutstage2perfusionfailure,ipsilateralstrokein11/39and2/42(p=0.004,age-adjustedRR=7.3)PaulHLKao08JAMA.1998;280:1055–1060第9頁/共41頁NTUHICAOexperienceEndovascularrecanalizationwasattemptedin75patientswithICAOfromOctober2002toDec2007,outof480(15.6%)ICAstentingsinthesameperiodICAOwasdocumentedbyultrasound,CTA,orMRAAllpatientswerefollowedclinicallyforatleast2monthsafterthediagnosisofICAObyindependentneurologist/cardiologistEnrollmentcriteriaProgressionorrecurrenceofipsilateralneurologicaldeficit,orObjectiveipsilateralhemisphericischemiaPaulHLKao08第10頁/共41頁Exemplarycase:64MwitholdRMCAinfarctBaselineDiamoxstressFlowPaulHLKao08第11頁/共41頁DiamoxstressBaselineVolumePerfusionCTimagingforobjectiveischemiaPaulHLKao08第12頁/共41頁P(yáng)erfusionCTimagingforobjectiveischemiaDiamoxstressBaselineTransitTimePaulHLKao08第13頁/共41頁CTangiographyforpathfindingCervicalICACarotidcanalPaulHLKao08第14頁/共41頁UltrasoundevaluationNeckultrasoundandtrans-ocularduplexevaluationofOAflowdirectionbefore,and1,6,12monthsafterprocedurebyanindependentneurologistSuspicionofrestenosisbyultrasoundmandatesangiographicfollow-upPaulHLKao08第15頁/共41頁Exemplarycase:64MRICACTOLateralviewIClateralviewPaulHLKao08第16頁/共41頁AfterCarotidWallandTsunamiAPviewLateralviewPaulHLKao08第17頁/共41頁3mfollow-upICAPviewIClateralvewPaulHLKao08第18頁/共41頁P(yáng)artialrecoveryofperfusionCTat1monthPoststressPostbaselinePrebaselinePrestressTransittimePaulHLKao08第19頁/共41頁ComparisonofCTAat1monthPrePostPaulHLKao08第20頁/共41頁AcknowledgedworkPaulHLKao08第21頁/共41頁Demographics(Oct’02-Aug‘08)Malesex4889%Age(y)69.2±9.8Hypertension4380%Diabetesmellitus1935%Hyperlipidemia2954%Smoking2852%Prioripsilateralstroke3565%IpsilateralTIA1528%Amaurosisfugax47%ContralateralICAstenosis>50%1935%ProgressionorrecurrenceofneurologicdeficitafterknownICAocclusion3769%PaulHLKao08第22頁/共41頁P(yáng)roceduralresults(Oct’02-Aug‘08)Technicalsuccess3565%Lesionlocation,right/left27/2750%/50%CCAdiameter(mm)7.9±0.6ICAdiameter(mm)5.1±0.5Occlusionlength(mm)27.9±16.2Wirecrossingsuccessful3769%Distalprotectiondeviceusedaftercrossing2773%

PercuSurge/FilterWire17/1063%/37%Post-dilatationballoondiameter(mm)4.5±1.7Post-dilatationpressure(atm)6.8±2.9ECAorificecoveredbystent3492%Finalresidualdiameterstenosis(%)9±7PaulHLKao08第23頁/共41頁Clinicaloutcome(Oct’02-Aug‘08)In-hopsital,n(%)3-mfollow-up,n(%)Death1(1.9)1(1.9)Fatalstroke1(1.9)1(1.9)Othercause00Stroke2(3.7)2(3.7)Majoripsi.00Majornon-ipsi.1(1.9)1(1.9)Minoripsi.1(1.9)1(1.9)Minornon-ipsi.00TIA00ICH/hyperperfusion00Restenosis--4/35(11.4)PaulHLKao08第24頁/共41頁TheonlymortalityEmergentBaselinePaulHLKao08KaoHLetal.JACC2007;49:765第25頁/共41頁OphthalmicarteryflowevaluationGoodqualitytrans-ocularduplexcanbeobtainedin25/30(84%)patientsbeforeprocedure,and21/25(83%)showedreversedOAflowPre-procedureOAflowwasreversein15/22patientsthatwerelatersuccessfullyrecanalizedOAflowwasnormalized1monthafterrecanalizationin12/15(80%)PersistentOAflowreversalin2/15(13%),bothwerefoundre-occludedat1month1patientdiedatday3withoutpost-proceduretrans-ocularduplexPaulHLKao08KaoHLetal.JACC2007;49:765第26頁/共41頁SafetyissuesPaulHLKao08BaselineRecanalized第27頁/共41頁DelayedpseudoaneurysmRecurrentischemiaPaulHLKao08第28頁/共41頁BMSacrosspseudoaneurysmPaulHLKao08第29頁/共41頁IschemiarelievedPaulHLKao08第30頁/共41頁ExtravasationPaulHLKao08Carotid-cavernousfistulaLocalhematoma第31頁/共41頁EndpointsforinterventionForPCIDeath/MIAnginarelief,LVfunctionrecovery,andTVRForICAinterventionDeath/strokePhysiologicalandfunctionalendpointsNeuro-cognitiveevaluationChangesinperfusionimaging,suchasperfusionCT,MRI,andPETPaulHLKao08第32頁/共41頁ConclusionsEndovascularrecanalizationofICAOisfeasibleandsafeFutureprospectivestudieswithlargerpatientnumbersevaluatingsoftendpointsaremandatorytoestablishthebenefitandindicationofrecanalizationofICAOPaulHLKao08第33頁/共41頁It’snevertoolatetoopenacloseddoor,becausetheroombehindmaybefullofsurprises第34頁/共41頁DefinitionsAtheromatouspseudo-occlusion(APO)String-likeresidualfillingofICAbehindthe“occlusion”Retrogradefillingoftheproximalso-called“occluded”ICAreachingtheskullbaseChronictotalocculsion(CTO)Theocclusionmustb