Endovascular repair of In-Tandem carotid stenosis Hubert DESAL1, Hélène LOUBIERE2, Laure AZEMA2, Alain COSTARGENT2, Philippe CHAILLOU2, Philippe PATRA2, Yann GOUEFFIC2 It remain controversial whether patients with severe disease of the ICA and a coexisting stenotic lesion downstream would benefit from a one time endovascular repair XIX Symposium Neuroradiologicum. Bologna 4-9 October 2010 Neuroradiology Department, (2) Vascular Surgery Department CHU de Nantes, France

Disclosures Invited by Boston Scientific (registration, travel and housing) No financial interest

Introduction It remains controversial whether patient would benefit one time treatment. Evidence based for bifurcation carotid stenosis treatment (AHA Guidelines 2002, SPACE, EVA-3S) No randomized study for intracranial stenosis (RT Higashida J Vasc Interv radiol 2005) Daily practice for in-tandem lesion ??? Experience of 80 endarterectomy and 10 intracranial angioplasty per year There is suffisant data from randomize trial to have evidence based medecine for carotid bifurcation stenosis treatment But no consenss xist on intra cranial stenosis When both occur in a same patient It remain controversial whether patients would benefit from one time treatment

Patients & Methods 2006-2010 4 patients, (3 males, 1 female) 48 -78 YO Inclusion criteria: Symptomatic atherosclerotic patients Multidisciplinary indication (vascular surgeon, neurologist, neuroradiologist) When endarteriectomy is indicated but limited by a coexisting stenotic lesion The presence of a tandem lesion can alters the surgeon’s decision to perform an endarterectomy We retropectlvy collected patient treated in our department between 2006 up to now

Patients & methods HTA, dyslipidémie, tabagisme FDRCV ATCD Vasculaires Patient 1 48 yo Male HTA,  dyslipidémie, tabagisme Patient 2 57 yo Male Coronary disease Patient 3 64 yo Male HTA, diabète dyslipidémie, tabagisme Patient 4 78 yo Female HTA, Tableau1 : past history and risk factor Cardiovascular risk factors

Patients & Methods Under GA Arterial monitoring Double antiplatelet + heparin bolus No protection device 6F long introduceur shit Nimodipine perfusion Carotid stenting + angioplasty (aviator) Carotid siphon evoluating technique…

Stenosis caracteristic Patient Côté Symptômes Localisation Symptomes Controlatéraux Lésions Patient 1 Left AVC Bifurcation 70% Petreuse préocclusive Patient 2 Caverneuse 60% Controlateral Occlusion Patient 3 Right AIT Parésie membre inferieur gauche Caverneuse 70% TTT chirugical std Patient 4 AVC ischémique jonctionnel Bifurcation 90% Caverneuse préocclusive Tableau2 : Caractéristiques des sténoses All de tandem lesion were below C4 of the carotid siphon

Patients & Methods Technical success 100% Residual stenosis < 50% No procedural or 1 month morbidity 3,6 days hospitalization except one patient with bradycardia (6 days) Median follow-up: 21,5 months (6 -54)

Treatment No distal protection during the carotid stenting Patient Bifurcation Intracranienne Patient 1 Stenting direct Guidant 7x10x40mm Boa 4x19mm Patient 2 EV3 8x40mm Pharos 4x15mm Patient 3 Post dilatation EV3 8x6x40mm Aviator6x20mm Angioplasty + stenting SprinterLegend 3x15mm Wingspan 4.5x15 Patient 4 Procédure et matériel utilisé No distal protection during the carotid stenting

Follow-up Clinical follow-up 1, 6 months & 1 year Doppler 1,3, 6 months CT angio 6, 12 months and yearly No neurological event during the follow up No in-stent re stenosis

Illustrated cases

Discussion The clinical importance of in-tandem stenosis is still a subject of controversy In France: endarterectomy is the first line treatment for symptomatic stenosis >70% (HAS 2007 www.has-sante.fr) Other options are open surgery and angioplasty in the same session Importance of hemodynamic insufficiency Patency of the Willis circle

Discussion Tsutsumi Neurol Med Chir (Tokyo)2003 > improved cerebral perfusion but… Garcia-bargo Neurologia 2004 > haemorrhage Pyun AJNR 2007 > concomittant multiple revascularizations with 11 in-tandem Cohen Neurol Res 2008 > characteristic of IC stenose determine feasibilty (8 patients)

Conclusion Very small series > no definitive conclusion Endovascular stent assisted angioplasty appears to be a valid alternative for selected patients Success rate and no morbi-mortality But rare incidence in caucasian Is there any place for randomization? Only larger series may confirm these results

Grazie Mille