Radiation-induced carotid stenosis: perioperative and late complications of surgical and endovascular treatment

Claudio Bianchini Massoni, Mauro Gargiulo, Rodolfo Pini, Gianluca Faggioli, Vittorio Marcucci, Antonio Freyrie, Francesco Vasuri, Gianandrea Pasquinelli, Andrea Stella
Journal of Cardiovascular Surgery 2017, 58 (5): 680-688

BACKGROUND: The surgical treatment of radio-induced carotid stenosis (RICS) is challenging and burdened with high risk of complications. Carotid stenting (CAS) may be a valid alternative, but better approach is still not defined. Two approaches have been assessed in this an observational monocentric study, focusing on perioperative and follow-up complications.

METHODS: From 2005 to 2013, data on patients treated for extracranial carotid stenosis with previous radiotherapy (RT) for head or neck tumor were prospectively collected according to the procedure performed (open repair [OR], endovascular stenting [CAS]). Patient demographics, clinical risk factors, organ of cancer origin, elapsed time from RT, duplex ultrasound (DUS) and clinical presentation of carotid stenosis were preoperatively gathered. Primary outcomes were technical success, 30-day mortality, transient ischemic attack (TIA)/stroke and myocardial infarction (MI). In OR group, laterocervical hematoma and cranial nerve injury were evaluated and, in CAS group, arterial access site complications were considered as well. Secondary outcomes were the mortality, TIA/stroke, restenosis and reintervention during follow-up.

RESULTS: Fifteen RICS were treated in 12 patients (M/F=9/3; median age: 71 years, range: 51-80). OR was performed to treat 8 RICS in 5 patients (M/F=3/2; median age: 65, range: 50-76) and CAS to treat 7 RICS in 7 patients (M/F=6/1; median age: 75, range 59-80). In OR group, all patients were asymptomatic and all plaques were hypoechogenic at DUS with histological features of vulnerable plaque. Technical success was 100%. Thirty-day mortality was 12.5% (1 death for upper airways complication in patient with previous neck surgery). TIA/stroke and MI rate were 0% and cranial nerve injury 12.5%. In CAS group, carotid stenosis was symptomatic in 2(28.6%) cases, all plaques resulted hypoechogenic at DUS. Technical success was 100%. Thirty-day mortality was 0%. TIA occurred in 4 (57.1%) patients. No stroke, MI or access site hematoma occurred in this group. Mean follow-up was 35.5±18.2 months. At 12 and 36 month, freedom from neurological events, restenosis and reintervention was 100%. At 1 and 3 years, survival was 91.7% and 81.5%, respectively. No patient died for carotid-related or cardiovascular causes.

CONCLUSIONS: According with the plaque morphology and the high rate of cerebrovascular complications of CAS, OR should be suggested as the first choice for treatment of RICS in the majority of cases. In patients with previous neck surgery, assessment of airways is necessary before OR to avoid respiratory complications.

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