Endovascular treatment on Endovascular treatment on tandem lesions of cranial arteriestandem lesions of cranial arteries

Xiao-Long Zhang, MD, PhDXiao-Long Zhang, MD, PhDDepartment of Radiology Department of Radiology

Huashan Hospital,Fudan UniversityHuashan Hospital,Fudan UniversityShanghaiShanghai ，， ChinaChina

ObjectiveObjective

To evaluate the technical and clinical To evaluate the technical and clinical outcomes of patients with symptomatic outcomes of patients with symptomatic atherosclerotic tandem lesions of atherosclerotic tandem lesions of CCACCA ，， ICA, MCA, ACA after elective stent ICA, MCA, ACA after elective stent placement. placement.

Materials Materials From Jan. 2006 to Aug.2009From Jan. 2006 to Aug.2009 9 patients (1 Females and 8 Males)9 patients (1 Females and 8 Males) Average age 63 (52-70) Average age 63 (52-70) Vessels involvedVessels involved ：： CCACCA ，， ICAICA ，， MCAMCA ， ， ACAACA ， ，

VAVA ，， BA, BA, 18 tandem lesions were treated by implantation of 18 tandem lesions were treated by implantation of

stentsstents Average clinical follow up of all patients were 11.3 Average clinical follow up of all patients were 11.3

months (5-24) months (5-24) Four patients accept angiography after 6 months Four patients accept angiography after 6 months

follow upfollow up

Tandem lesions: 9 casesTandem lesions: 9 cases

Proximal Proximal componentcomponent

Distal Distal componentcomponent

CasesCases

Cervical ICACervical ICA Intracranial Intracranial ICA or MCAICA or MCA

44

CCACCA Cervical ICACervical ICA 22

Cervical VACervical VA Intracranial Intracranial VAVA

33

ResultsResults

9 cases including 18 tandem lesions 9 cases including 18 tandem lesions treated by stent implantation were all treated by stent implantation were all technically successful. technically successful.

All patients were free from stoke All patients were free from stoke recurrence in the follow-up and no severe recurrence in the follow-up and no severe complications and/or deaths were related complications and/or deaths were related to the treatment.to the treatment.

Angiography of 1 patient showed in stent Angiography of 1 patient showed in stent restenosis after 6 months followuprestenosis after 6 months followup

QuestionsQuestions

1.Whether the patient should be 1.Whether the patient should be treated by endovascular therapy?treated by endovascular therapy?

2.Proximal and distal lesions, which 2.Proximal and distal lesions, which should be treated first?should be treated first?

3.Should all lesions be treated at the 3.Should all lesions be treated at the same time or by staged procedure?same time or by staged procedure?

1.Whether the patient should be 1.Whether the patient should be treated by endovascular therapy?treated by endovascular therapy?

All patients have clinically lesion-All patients have clinically lesion-related CI/TIA.related CI/TIA.

If left untreated, the lesions will If left untreated, the lesions will result in untoward outcome such as result in untoward outcome such as stroke and death according to stroke and death according to introcranial hemodynamic analysis.introcranial hemodynamic analysis.

The treatment procedural should be The treatment procedural should be possible and low risk according to possible and low risk according to operators evaluation and experienceoperators evaluation and experience

2.Proximal and distal component, 2.Proximal and distal component, which should be treated first?which should be treated first?

1) Tandem lesions in ICA/MCA: The distal 1) Tandem lesions in ICA/MCA: The distal lesion is to be treated first in most cases lesion is to be treated first in most cases due to its higher riskdue to its higher risk

(If the stent implantation of distal lesion is (If the stent implantation of distal lesion is failed, the treatment of the proximal one failed, the treatment of the proximal one maybe unnecessary, unless the ICA lesion maybe unnecessary, unless the ICA lesion effect the guiding plant and may result in effect the guiding plant and may result in embolic event).embolic event).

2) Tandem lesions in VA: The distal lesion is 2) Tandem lesions in VA: The distal lesion is to be treated first (to be treated first (possibility of stent possibility of stent migrationmigration).).

2.1 The situation we should handle the 2.1 The situation we should handle the proximal lesion first: severe stenosis proximal lesion first: severe stenosis or unstable plaque of proximal lesion or unstable plaque of proximal lesion (The lesion in the proximal part will (The lesion in the proximal part will affect the stent implantation of distal affect the stent implantation of distal part and the risk of the plaque part and the risk of the plaque detachment in the proximal lesion detachment in the proximal lesion during the stent implantation of during the stent implantation of distal part will be higher).distal part will be higher).

3.Should all lesions be treated at the 3.Should all lesions be treated at the same time or by staged procedure?same time or by staged procedure?

1.Treatment method may differ 1.Treatment method may differ depending on patientdepending on patient’’s condition, s condition, surgeonssurgeons’’ experience. experience.

2.Staged treatment is preferred if the 2.Staged treatment is preferred if the patient can not tolerant the complex patient can not tolerant the complex procedure for a long duration.procedure for a long duration.

4.How to deal with incidental 4.How to deal with incidental lesions such as an aneurysm?lesions such as an aneurysm?

Aneurysms should always be treated Aneurysms should always be treated first due to its high incidence of first due to its high incidence of death when ruptured and the death when ruptured and the sucessful treatment of aneurysms is sucessful treatment of aneurysms is essential for antiplatelet therapy essential for antiplatelet therapy after stent implantation.after stent implantation.

Case PresentationsCase Presentations

Case 1Case 1

Male, 68y/oMale, 68y/o Vertigo for two monthsVertigo for two months History of DM and HypertensionHistory of DM and Hypertension Cerebral ischemiaCerebral ischemia

Occlusion of R ICA ， Stenosis of L CCA and L ICA

Treatment strategyTreatment strategy

Proximal and distal component, Proximal and distal component, which one to be treated first? which one to be treated first?

Size of Guiding catheter?Size of Guiding catheter? Kinds of protective device and how to Kinds of protective device and how to

retrieve it safely?retrieve it safely?

Distal ： 6F guiding ,Spider ， PTA distal and proximal 6*20 ， and 8F guiding with 0.35 wire, Protégé 8*40

Proximal ：Spider ， Protégé 8*40 5F catheter assistant

Case 2 Case 2 Male, 60 y/oMale, 60 y/o Weakness of left limbsWeakness of left limbs History of hypertension and History of hypertension and

hyperlipidemiahyperlipidemia

Stenosis: Bilateral VA, initial Stenosis: Bilateral VA, initial part of R PICA, L MCA(M1), L part of R PICA, L MCA(M1), L ACA(A1)ACA(A1)

Occlusion: R ICAOcclusion: R ICA

R PICA

Gateway2*15

L VA Gateway 3*15 Wingspan3.5*15

ACA Gateway2.5*9

MCA Gateway3*9 Wingspan 3.5*9

Case 3 Case 3 FemaleFemale ，， 70 y/o70 y/o Stenosis of proximal cervical L ICA Stenosis of proximal cervical L ICA

and C2 segment of L ICA and C2 segment of L ICA Stenosis of R VA origin Stenosis of R VA origin Aneurysm on C2 segment of L ICAAneurysm on C2 segment of L ICA

Treatment Strategy for Case 3Treatment Strategy for Case 3 The patient was treated twiceThe patient was treated twice

1.Tandem lesion including stenosis in 1.Tandem lesion including stenosis in proximal cervical L ICA and C2 proximal cervical L ICA and C2 segment of L ICA accompanied with segment of L ICA accompanied with an aneurysm were treated under an aneurysm were treated under general anesthesia.general anesthesia.

1. Proximal cervical ICA: Spider RX, Protégé 7*30

2. C2: Stenosis-Wingspan 4.5*15 ， AN-coils

2.Two weeks later the patient receive the second treatment under local anesthesia.

RVA:SpiderRX,Gateway4*9,Wingspan4.5*20

ConclusionConclusion

Endovascular therapy of tandem Endovascular therapy of tandem lesions is complex, especially the lesions is complex, especially the choice of treatment strategy.choice of treatment strategy.

Patient specific interventional Patient specific interventional strategy is achievable by balancing strategy is achievable by balancing the risk and the benefit of the the risk and the benefit of the treatment. treatment.

Thank you!Thank you!