1. 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

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

3. 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

4. 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

5. 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

6. 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…

7. 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

8. 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)

9. 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

10. 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

11. Illustrated cases

14. 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
Other options are open surgery and angioplasty in the same session
Importance of hemodynamic insufficiency
Patency of the Willis circle

15. 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 > characteristic of IC stenose determine feasibilty (8 patients)

16. 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

17. Grazie Mille