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Home > Vascular Annual Meeting > chang_identifying_difficult

Identifying Difficult Carotid Anatomy Prior to Carotid Stenting Using Three Dimensional Computed Tomographic Angiography

Robert W. Chang, Philip P. Goodney, Mark C. Wyers, Richard J. Powell.
Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

OBJECTIVES: Difficult carotid anatomy is recognized as an important cause for technical failure and procedural difficulty with carotid artery stenting (CAS). Severe arch and carotid tortuosity can prohibit safe performance of CAS. We assessed tortuosity measured by preoperative CT angiography (CTA) with three dimensional (3-D) reformat imaging as an indicator of clinically determined difficult carotid anatomy.

METHODS: Patients considered for CAS who underwent preoperative CTA with 3-D reformatting were reviewed (n=148). Carotid tortuosity was expressed as a numerical score of the actual 3-D orthogonal measured CCA and extracranial ICA length, divided by the straight line length of these segments (larger score=more tortuous). Patients were then stratified by clinical outcome as: FAILED (technical failure or requiring adjunctive measures such as prefilter buddy wire placement); REFUSED (not offered CAS because of operator judgment of tortuosity, and SUCCESS (successful CAS with no technical complications).

RESULTS: FAILED patients (procedural failure n=9; procedural difficulty n=3) had higher internal, common and total tortuosity indices when compared with SUCCESS patients (n=28) (Table). REFUSED patients (n=17) also had significantly higher carotid tortuosity scores when compared with the SUCCESS group (Table). On univariate analysis, lesion specific variables such as plaque calcification, area stenosis and arch type did not differ between the groups. No patients with a total tortuosity index >20 had successful CAS.

CONCLUSIONS: Difficulty or failure of CAS due to vessel tortuosity can be predicted by use of preoperative tortuosity index calculation which can be automated. This measure also correlates with preoperative subjective assessment of anatomic risk. It may be useful in selecting patients for carotid intervention prior to arteriography, especially for operators with limited experience.

AUTHOR DISCLOSURES: R.W. Chang, None; P.P. Goodney, None; M.C. Wyers, None; R.J. Powell, Boston Scientific.

 
*T test between FAILED and SUCCESS groups.
**T test between REFUSED and SUCCESS groups.