Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: Pilot study

David Hasan, Mario Zanaty, Robert M. Starke, Elias Atallah, Nohra Chalouhi, Pascal Jabbour, Amit Singla, Waldo R. Guerrero, Daichi Nakagawa, Edgar A. Samaniego, Nnenna Mbabuike, Rabih G. Tawk, Adnan H. Siddiqui, Elad I. Levy, Roberta Novakovic, Jonathan A White, Clemens M. Schirmer, Thomas G. Brott, Hussain Shallwani, L. Nelson Hopkins

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%–7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Original languageEnglish (US)
Pages (from-to)1468-1477
Number of pages10
JournalJournal of Neurosurgery
Volume130
Issue number5
DOIs
StatePublished - May 1 2019

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Internal Carotid Artery
Blood Pressure
Safety
Endovascular Procedures
Digital Subtraction Angiography
Carotid Arteries
Stroke
Morbidity

Keywords

  • Balloon angioplasty
  • Carotid
  • Occlusion
  • Radiographic classification
  • Stent
  • Stroke
  • Systolic blood pressure
  • Vascular disorders

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery : Pilot study. / Hasan, David; Zanaty, Mario; Starke, Robert M.; Atallah, Elias; Chalouhi, Nohra; Jabbour, Pascal; Singla, Amit; Guerrero, Waldo R.; Nakagawa, Daichi; Samaniego, Edgar A.; Mbabuike, Nnenna; Tawk, Rabih G.; Siddiqui, Adnan H.; Levy, Elad I.; Novakovic, Roberta; White, Jonathan A; Schirmer, Clemens M.; Brott, Thomas G.; Shallwani, Hussain; Nelson Hopkins, L.

In: Journal of Neurosurgery, Vol. 130, No. 5, 01.05.2019, p. 1468-1477.

Research output: Contribution to journalArticle

Hasan, D, Zanaty, M, Starke, RM, Atallah, E, Chalouhi, N, Jabbour, P, Singla, A, Guerrero, WR, Nakagawa, D, Samaniego, EA, Mbabuike, N, Tawk, RG, Siddiqui, AH, Levy, EI, Novakovic, R, White, JA, Schirmer, CM, Brott, TG, Shallwani, H & Nelson Hopkins, L 2019, 'Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: Pilot study', Journal of Neurosurgery, vol. 130, no. 5, pp. 1468-1477. https://doi.org/10.3171/2018.1.JNS172858
Hasan, David ; Zanaty, Mario ; Starke, Robert M. ; Atallah, Elias ; Chalouhi, Nohra ; Jabbour, Pascal ; Singla, Amit ; Guerrero, Waldo R. ; Nakagawa, Daichi ; Samaniego, Edgar A. ; Mbabuike, Nnenna ; Tawk, Rabih G. ; Siddiqui, Adnan H. ; Levy, Elad I. ; Novakovic, Roberta ; White, Jonathan A ; Schirmer, Clemens M. ; Brott, Thomas G. ; Shallwani, Hussain ; Nelson Hopkins, L. / Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery : Pilot study. In: Journal of Neurosurgery. 2019 ; Vol. 130, No. 5. pp. 1468-1477.
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abstract = "OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5{\%}–7{\%} per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13{\%}]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100{\%} cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75{\%} (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75{\%} (6/32; type A: 0/8 [0{\%}]; type B: 1/8 [12.50{\%}]; type C: 3/8 [37.50{\%}], type D: 2/8 [25.00{\%}]). None of these complications led to permanent morbidity or death. Twenty (64.52{\%}) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95{\%}) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.",
keywords = "Balloon angioplasty, Carotid, Occlusion, Radiographic classification, Stent, Stroke, Systolic blood pressure, Vascular disorders",
author = "David Hasan and Mario Zanaty and Starke, {Robert M.} and Elias Atallah and Nohra Chalouhi and Pascal Jabbour and Amit Singla and Guerrero, {Waldo R.} and Daichi Nakagawa and Samaniego, {Edgar A.} and Nnenna Mbabuike and Tawk, {Rabih G.} and Siddiqui, {Adnan H.} and Levy, {Elad I.} and Roberta Novakovic and White, {Jonathan A} and Schirmer, {Clemens M.} and Brott, {Thomas G.} and Hussain Shallwani and {Nelson Hopkins}, L.",
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TY - JOUR

T1 - Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery

T2 - Pilot study

AU - Hasan, David

AU - Zanaty, Mario

AU - Starke, Robert M.

AU - Atallah, Elias

AU - Chalouhi, Nohra

AU - Jabbour, Pascal

AU - Singla, Amit

AU - Guerrero, Waldo R.

AU - Nakagawa, Daichi

AU - Samaniego, Edgar A.

AU - Mbabuike, Nnenna

AU - Tawk, Rabih G.

AU - Siddiqui, Adnan H.

AU - Levy, Elad I.

AU - Novakovic, Roberta

AU - White, Jonathan A

AU - Schirmer, Clemens M.

AU - Brott, Thomas G.

AU - Shallwani, Hussain

AU - Nelson Hopkins, L.

PY - 2019/5/1

Y1 - 2019/5/1

N2 - OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%–7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

AB - OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%–7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

KW - Balloon angioplasty

KW - Carotid

KW - Occlusion

KW - Radiographic classification

KW - Stent

KW - Stroke

KW - Systolic blood pressure

KW - Vascular disorders

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