Improvement in cerebral hemodynamics after carotid angioplasty.
ABSTRACT Carotid percutaneous transluminal angioplasty ( PTA) may offer an alternative treatment to carotid endarterectomy. However, in contrast to carotid endarterectomy, which has been shown to normalize impaired cerebral hemodynamics, the effects of carotid PTA are unknown. Therefore, we prospectively studied the effect of carotid PTA on both perioperative and postoperative cerebral hemodynamics.
Eleven patients undergoing carotid PTA for symptomatic carotid artery stenosis were prospectively studied. Transcranial Doppler recordings from the ipsilateral middle cerebral artery (MCA) were performed during the procedure. In addition, MCA blood flow velocity and CO2 reactivity were determined before PTA and at 2 days, 1 month, and 6 months after procedure. The results were compared with those in 11 similar patients undergoing carotid endarterectomy in whom measurements were performed before and 1 month after the operation.
During carotid PTA, in 2 of 11 patients during passage of the balloon catheter through the stenosis, MCA blood flow velocity fell transiently. In 6 of 11 patients there was a reduction in flow velocity (>50%) during balloon deflation, but this lasted only a few seconds. After the procedure there was a significant improvement in ipsilateral hypercapnic reactivity: preoperative value, 59.8+/-42.2% (mean+/-SD); 2 days, 77.9+/-31.4%; 1 month, 88.7+/-45.0%; 6 months, 89.8+/-33.9%; and (ANOVA P=.003) preoperative value versus 1 month, P<.02; versus 6 months, P<.02. In all cases in which reactivity was significantly impaired preoperatively, it returned to the normal range. Pulsatility index also increased significantly: preoperative value, 0.827+/-0.251 (mean+/-SD); 2 days, 0.992+/-0.262 (P=.002). Contralateral MCA hypercapnic reactivity also improved after carotid PTA. There was a similar improvement in ipsilateral hypercapnic reactivity after carotid endarterectomy.
Carotid PTA results in a normalization of impaired hemodynamics, as assessed by CO2 reactivity. The degree of improvement is similar to that seen after carotid endarterectomy.
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ABSTRACT: Der Schlaganfall ist in den westlichen Industrielndern die dritthufigste Todesursache und die hufigste Ursache einer bleibenden Pflegebedrftigkeit. Er beruht auf einer zerebralen Minderperfusion, meist in Folge intra- oder extrakranieller Gefverschlsse, und wird in seiner Schwere von der individuellen Ausprgung der verfgbaren Kollateralgefe beeinflusst. Im Herzen und in der peripheren Zirkulation konnte experimentell wie klinisch nachgewiesen werden, dass arterielle Minderperfusionen durch die therapeutische Induktion der Arteriogenese — dem adaptativen Wachstum der Kollateralarterien — gemindert oder verhindert werden kann. Um diesen Therapieansatz fr das ZNS nachzuweisen, wurde der Einfluss und Verlauf der zerebralen Arteriogenese whrend chronischer Minderdurchblutung des Gehirns untersucht. Die medikamentse Stimulation der Kollateralgefbildung mit dem Wachstumsfaktor GM-CSF (Granulozyten-Makrophagen-Kolonie-stimulierender Faktor) fhrte hierbei zu einer signifikanten Zunahme des Durchmessers von intrakraniellen Arterien, einer signifikanten Verbesserung der zerebralen hmodynamischen Reserve und einer signifikanten Reduktion des Energiedefizits nach hmodynamisch induziertem Schlaganfall. Die therapeutisch induzierte Arteriogenese ist ein viel versprechender neuer Ansatz zur Prophylaxe zerebraler Ischmien bei Patienten mit stenosierenden Geferkrankungen.Stroke is the leading cause of disability and a major cause of death in Germany and the western world. Ischemic stroke involves different pathophysiologic mechanisms such as thromboembolic vascular occlusion, cerebral micro- or macroangiopathy, extracranial arterial stenosis, and cardiac embolism. Experimental and clinical studies have shown that arteriogenesis, the adaptive growth of pre-existing collateral arteries, can be therapeutically enhanced in peripheral circulation and the heart. We examined the consequences to time course and hemodynamics of brain arteriogenesis in a chronic hypoperfusion model following systemic administration of the hemopoietic growth factor called granulocyte macrophage colony stimulating factor (GM-CSF). Treatment with GM-CSF led to the growth of intracranial collateral arteries, which improved the cerebral hemodynamic reserve and significantly reduced energy failure when brains were additionally challenged by hypotension. Therapeutically induced arteriogenesis may be of considerable interest for preventing infarction in patients with uncompensated cerebrovascular disease.Der Nervenarzt 02/2006; 77(2):215-220. · 0.80 Impact Factor
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ABSTRACT: In the era of evidence-based medicine, doctors rely on clinical trials to guide their decisions. The best method of treating carotid stenosis is still debatable after six decades from the first carotid surgical revascularization performed. Despite the conduct and publication of dozens of trials on carotid revascularization, the truth remains shaggy. The interpretation of these trials is influenced by the design, inclusion criteria, credentialing of the operators and even their specialties. We will try to discuss the trials of carotid endarterectomy and carotid artery stenting trying to reach a conclusion of where is the truth regarding carotid revascularization. We will discuss the trials of CEA versus medical therapy, then the initials registries of CAS, then the trials that compared CEA against CAS, we will elaborate on the two techniques in peculiar situations and finally we will give a short notice about ongoing trials and future directions.Carotid Artery Disease - From Bench to Bedside and Beyond, 1st edited by Rita Rezzani, 01/2014: chapter Update on Carotid Revascularization: Evidence from Large Clinical Trials: pages 105-124; INTECH., ISBN: 978-953-51-1214-3