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1、ICA stenting,Proven to be an alternative to CEA in ICA stenosis,especially in patients with high surgical risk profilesBut the application of endovascular intervention in cervical ICA occlusion(ICAO)has never been explored,which comprise 15%of patients with ipsilateral TIA or infarction,Paul HL Kao
2、08,The great myth,ICA stenosis causes symptoms through artery-to-artery embolismThe risk of stroke is minimal with ICAO,because there is no flow to carry the emboliIs it true?,Paul HL Kao 08,Prognosis and pathophysiology of ICAO,Cervical ICAO is an important cause of TIA and cerebral infarction and
3、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%Pathophysiology of symptomsEmboli arising from ECA/CCA via collateralsEmboli arising from ICA stump via collaterals(Stump syndrome)Emboli arising from tr
4、ailing thrombi distal to the occlusionHypo-perfusion(hemodynamic insufficiency),Paul HL Kao 08,Treatment options for ICAO,MedicalThe recommended treatment at present,but may be insufficient for certain patientsSurgeryCEAStump ligation/exclusionEC/IC bypassCan be very technically demanding with high
5、periprocedural complicationsAll failed to reduce ipsilateral stroke and are not recommended to ICA CTO in general,Paul HL Kao 08,EC/IC bypass,1377 patients with symptomatic ICA or MCA occlusion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 56 monthsMajo
6、r peri-operative stroke rate as 4.5%Total stroke rates were not different between bypass and medical groupsIn patients with ongoing symptoms after angiographic documentation of ICAO,the benefit of bypass was not shown either,Paul HL Kao 08,NEJM.1985;313:11911200,Review of studies,20 studies in patie
7、nts with TIA or ischemic stroke associated with ICAO,the annual risk of all and ipsilateral stroke were 5.5%and 2.1%Patients 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.2019;28:20842093,Paul HL Kao 08,I
8、dentify the right patient to revascularize,81 ICAO patients with old ipsilateral stroke or TIA,evaluated with PET and followed for 3 yearsStroke 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-a
9、djusted RR=7.3),Paul HL Kao 08,JAMA.2019;280:10551060,NTUH ICAO experience,Endovascular recanalization was attempted in 75 patients with ICAO from October 2019 to Dec 2019,out of 480(15.6%)ICA stentings in the same periodICAO was documented by ultrasound,CTA,or MRAAll patients were followed clinical
10、ly for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologistEnrollment criteriaProgression or recurrence of ipsilateral neurological deficit,orObjective ipsilateral hemispheric ischemia,Paul HL Kao 08,Exemplary case:64M with old RMCA infarct,Baseline,Diamox stress,Fl
11、ow,Paul HL Kao 08,Diamox stress,Baseline,Volume,Perfusion CT imaging for objective ischemia,Paul HL Kao 08,Perfusion CT imaging for objective ischemia,Diamox stress,Baseline,Transit Time,Paul HL Kao 08,CT angiography for path finding,Cervical ICA,Carotid canal,Paul HL Kao 08,Ultrasound evaluation,Ne
12、ck ultrasound and trans-ocular duplex evaluation of OA flow direction before,and 1,6,12 months after procedure by an independent neurologistSuspicion of restenosis by ultrasound mandates angiographic follow-up,Paul HL Kao 08,Exemplary case:64M RICA CTO,Lateral view,IC lateral view,Paul HL Kao 08,Aft
13、er Carotid Wall and Tsunami,AP view,Lateral view,Paul HL Kao 08,3m follow-up,IC AP view,IC lateral vew,Paul HL Kao 08,Partial recovery of perfusion CT at 1 month,Post stress,Post baseline,Pre baseline,Pre stress,Transit time,Paul HL Kao 08,Comparison of CTA at 1 month,Pre,Post,Paul HL Kao 08,Acknowl
14、edged work,Paul HL Kao 08,Demographics(Oct 02-Aug 08),Paul HL Kao 08,Procedural results(Oct 02-Aug 08),Paul HL Kao 08,Clinical outcome(Oct 02-Aug 08),Paul HL Kao 08,The only mortality,Emergent,Baseline,Paul HL Kao 08,Kao HL et al.JACC 2019;49:765,Ophthalmic artery flow evaluation,Good quality trans-
15、ocular duplex can be obtained in 25/30(84%)patients before procedure,and 21/25(83%)showed reversed OA flowPre-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(1
16、3%),both were found re-occluded at 1 month1 patient died at day 3 without post-procedure trans-ocular duplex,Paul HL Kao 08,Kao HL et al.JACC 2019;49:765,Safety issues,Paul HL Kao 08,Baseline,Recanalized,Delayed pseudoaneurysm,Recurrent ischemia,Paul HL Kao 08,BMS across pseudoaneurysm,Paul HL Kao 0
17、8,Ischemia relieved,Paul HL Kao 08,Extravasation,Paul HL Kao 08,Carotid-cavernous fistula,Local hematoma,Endpoints for intervention,For PCIDeath/MIAngina relief,LV function recovery,and TVRFor ICA interventionDeath/strokePhysiological and functional endpointsNeuro-cognitive evaluationChanges in perf
18、usion imaging,such as perfusion CT,MRI,and PET,Paul HL Kao 08,Conclusions,Endovascular recanalization of ICAO is feasible and safeFuture prospective studies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalization of ICAO,Paul HL K
19、ao 08,Its never too late to open a closed door,because the room behind may be full of surprises,Definitions,Atheromatous pseudo-occlusion(APO)String-like residual filling of ICA behind the“occlusion”Retrograde filling of the proximal so-called“occluded”ICA reaching the skull baseChronic total occuls
20、ion(CTO)The occlusion must be documented for at least 1 monthTIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in lengthEstablished filling to the ipsilateral intracranial ICA via A-Com,P-Com,OA,meningeal,or other collaterals,Paul HL Kao 07,Partial recovery of perfusion
21、 CT at 1 month,Pre baseline,Pre stress,Post baseline,Post stress,Flow,Paul HL Kao 07,Partial recovery of perfusion CT at 1 month,Volume,Pre baseline,Post baseline,Pre stress,Post stress,Paul HL Kao 07,Example of complete recovery,Pre stress flow,Post stress flow,Paul HL Kao 08,Example of complete re
22、covery,Pre stress volume,Post stress flow,Paul HL Kao 08,Example of complete recovery,Pre stress transit time,Post stress transit time,Paul HL Kao 08,Cerebral perfusion after ICAO,Stage 0:CPP normal,CBF matched with resting metabolic demand,no regional variation in OEFStage 1:CPP decreased,but CBF maintained by vasodilatation,CBV increasedStage 2:CPP further decreased beyond the capacity of auto-regulation,CBF decreased,regional OEF increased with declined brain function,Paul HL Kao 08,谢谢,
