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Dotter Interventional Institute

Carotid Stenting

Physicians at the Dotter Institute have been active in stent placement for the treatment of disease processes affecting the great vessels of the arch and carotid arteries since 1996. The Neurointerventionalists and Body Interventionalists of the Dotter Staff have been working together with clinical staff of the OHSU stroke team and have established the largest carotid stenting program in the Northwest. Together they have placed nearly 200 stents in 168 patients, including 5 carotid stent-grafts for emergent carotid ruptures from malignancy. They have been the first team in the United States to evaluate several types of stents form placement into the carotid arteries, and their success has led to their participation in two large national multicenter trials, CREST (Carotid Revascularization Endarterectomy Vs. Stent Trial) and ARCHER (Acculink for Revascularization of Carotids in High Risk Patients). The CREST trial is sponsored by the NIH (National Institute of Health) and will soon include the use of a new cerebral protection device, available on to those participants in the trial.

Of the more than 100 patients treated by stent placement in the cervical carotid artery, 8 patients were treated for severe carotid dissection, 2 patients for Fibromuscular Dysplasia, and 5 for malignant involvement of the artery. The remainder have been treated for carotid artery stenosis, judged to be at high risk for the conventional surgical approach. [Fig. 1]

Fig. 1b After stent placement and its dilatation to 6 mm diameter, there is no significant residual stenosis. The minimal circumferential narrowing seen at the distal end of the stent is a common finding, related to spasm, and is not seen on follow-up studies. The apparent curvilinear density seen overlying the proximal 1/3 of the stent is a subtraction artifact.
Fig. 1a 56 year old male with symptomatic focal, high grade cervical carotid stenosis, recurrent post surgical endarterectomy. The external washers are used for sizing reference.

Fig. 1c This self-expanding, nitinol 0.018 Smart Stent (Cordis) was the first of its type placed in the carotid artery in the USA. It measured 9 mm in diameter by 30 mm in length. Clinical follow-up- the patient is doing well with no symptom recurrence for 12 months.

Patients with significant narrowing of the extracranial vertebral and intracranial arteries due to athersclerosis have been found to be at high risk for stroke or death. These narrowings, or stenoses, are in blood vessels too small for surgical treatment, and when patients become symptomatic despite medical therapy, there is currently no viable alternative treatment. Beginning in 1999, Dotter Interventionalists began evaluating coronary stents for the treatment of these high-risk vertebral and intracranial lesions. Though not intentionally designed for this use, the coronary stents were found highly efficient in successful treatment of lesions as high as the basilar artery and supraclinoid internal carotid artery. Dotter interventionalists are currently involved in clinical trials, with the purpose of evaluating a stent designed specifically for the treatment symptomatic intracranial lesions. With this stent, they have successfully treated lesions in both M1 and M2 segments of the middle cerebral artery. [Fig. 2] To date they have accumulated one of the largest experiences in intracranial stent placement. They have treated 50- patients and placed 36 stents in the vertebral and basilar systems, and 16 stents in the petrous and intracranial internal carotid artery.

Fig 2b After placement of a dedicated intracranial stent, the stenosis is completely obliterated. The patient has been without recurrent symptoms for 4 months.
Fig. 2a Symptomatic focal high grade stenosis of the left middle cerebral artery (M1 segment) was an isolated finding.

Fig. 2c The stent is balloon expandable, measures 2.5 mm in diameter, and is 8 mm in length. Note how is closely approximated the curvilinear shape of the native artery.