,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,Endovascular Recanalization of Symptomatic Chronic Total Occlusion of Cervical Carotid Artery,Paul Hsien-Li Kao,MD,Assistant Professor,National Taiwan University Medical School and Hospital,Endovascular Recanalization of,1,ICA stenting,Proven to be an alternative to CEA in ICA stenosis,especially in patients with high surgical risk profiles,But 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 08,ICA stentingProven to be an al,2,The great myth,ICA stenosis causes symptoms through artery-to-artery embolism,The risk of stroke is minimal with ICAO,because there is no flow to carry the emboli,Is it true?,Paul HL Kao 08,The great mythICA stenosis cau,3,Prognosis and pathophysiology of ICAO,Cervical ICAO is an important cause of TIA and cerebral infarction and should not be neglected,Annual risk of ipsilateral stroke in symptomatic ICAO is 6-20%,Annual risk of ipsilateral stroke in asymptomatic ICAO is 2-5%,Pathophysiology of symptoms,Emboli arising from ECA/CCA via collaterals,Emboli arising from ICA stump via collaterals(Stump syndrome),Emboli arising from trailing thrombi distal to the occlusion,Hypo-perfusion(hemodynamic insufficiency),Paul HL Kao 08,Prognosis and pathophysiology,4,Treatment options for ICAO,Medical,The recommended treatment at present,but may be insufficient for certain patients,Surgery,CEA,Stump ligation/exclusion,EC/IC bypass,Can be very technically demanding with high periprocedural complications,All failed to reduce ipsilateral stroke and are not recommended to ICA CTO in general,Paul HL Kao 08,Treatment options for ICAOMedi,5,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 months,Major peri-operative stroke rate as 4.5%,Total stroke rates were not different between bypass and medical groups,In 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,EC/IC bypass1377 patients with,6,Review of studies,20 studies in patients 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,Review of studies20 studies in,7,Identify the right patient to revascularize,81 ICAO patients with old ipsilateral stroke or TIA,evaluated with PET and followed for 3 years,Stroke 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-adjusted RR=7.3),Paul HL Kao 08,JAMA.2019;280:10551060,Identify the right patient to,8,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 period,ICAO was documented by ultrasound,CTA,or MRA,All patients were followed clinically for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologist,Enrollment criteria,Progression or recurrence of ipsilateral neurological deficit,or,Objective ipsilateral hemispheric ischemia,Paul HL Kao 08,NTUH ICAO experienceEndovascul,9,Exemplary case:64M with old RMCA infarct,Baseline,Diamox stress,Flow,Paul HL Kao 08,Exemplary case:64M with old R,10,Diamox stress,Baseline,Volume,Perfusion CT imaging for objective ischemia,Paul HL Kao 08,Diamox stressBaselineVolumePer,11,Perfusion CT imaging for objective ischemia,Diamox stress,Baseline,Transit Time,Paul HL Kao 08,Perfusion CT imaging for objec,12,CT angiography for path finding,Cervical ICA,Carotid canal,Paul HL Kao 08,CT angiography for path findin,13,Ultrasound evaluation,Neck ultrasound and trans-ocular duplex evaluation of OA flow direction before,and 1,6,12 months after procedure by an independent neurologist,Suspicion of restenosis by ultrasound mandates angiographic follow-up,Paul HL Kao 08,Ultrasound evaluationNeck ultr,14,Exemplary case:64M RICA CTO,Lateral view,IC lateral view,Paul HL Kao 08,Exemplary case:64M RICA CTOLa,15,After Carotid Wall and Tsunami,AP view,Lateral view,Paul HL Kao 08,After Carotid Wall and Tsunami,16,3m follow-up,IC AP view,IC lateral vew,Paul HL Kao 08,3m follow-upIC AP viewIC later,17,Partial recovery of perfusion CT at 1 month,Post stress,Post baseline,Pre baseline,Pre stress,Transit time,Paul HL Kao 08,Partial recovery of perfusion,18,Comparison of CTA at 1 month,Pre,Post,Paul HL Kao 08,Comparison of CTA at 1 monthPr,19,Acknowledged work,Paul HL Kao 08,Acknowledged workPaul HL Kao 0,20,Demographics(Oct 02-Aug 08),Male sex,48,89%,Age(y),69.2 9.8,Hypertension,43,80%,Diabetes mellitus,19,35%,Hype