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The morning session of day 2 of the 2019 edition of the SLICE meeting focussed on chronic internal carotid artery (ICA) occlusion. After laying out the pathology, its aetiology and prevalence, Dr Caroline Arquizan, reminded us that chronic ICA occlusion may cause in some cases ipsilateral ischemic stroke – its potential mechanism may be a spontaneous recanalization, thromboembolism from the ICA stump or ECA collaterals, or hemodynamic insufficiency – or chronic hypoperfusion of the brain tissue with cognitive impairment which can be quickly assessed at bedside by the MoCA test. Whereas acute stroke with or without a tandem occlusion of an intracranial artery systematically justifies IVT and/or endovascular treatment of the occluded ICA, subacute or chronic symptoms may also benefit from endovascular carotid artery repair with significant improvement of the perfusion parameter and reversion of the cognitive impairment.
Then Prof. Vincent Costalat focussed on the technical aspect of endovascular recanalization of chronic ICA occlusion. This is done by creating a neo-lumen inside the occluded segment by performing an iatrogenic dissection with a 5 Fr Merit catheter over a 0.014’’ Asahi guidewire, re-entering the true lumen distal to the dissection and stabilizing the construct with stents.
The whole procedure is done through a balloon guiding catheter (BCG) under flow arrest by balloon inflation. The stents are protected against clotting by intraoperative tirofiban relayed by a double antiplatelet therapy. Prof. Costalat explained that thanks to the presence of the carotid sheath the ICA is protected against rupture during the dissection.
The technique is limited for distal occlusions close to the ophthalmic artery, since re-entry in the true lumen is not safely feasible and can be complicated by brain reperfusion syndrome with oedema and/or haemorrhage. Nevertheless, before attacking the occlusion, he advocated to optimize the collateral blood supply.
Prof. Costalat illustrated the problem of ICA occlusion responsible for an acute stroke with the first recorded stroke case of the day. Since access failed from the groin the intervention was done by a right brachial access with a Chaperon guiding-catheter placed in the left CCA allowing angioplasty and stenting of the short occlusion at the level of the carotid bifurcation.
In the afternoon session, Prof. Laurent Spelle and Dr Christian Mihalea presented the second recorded stroke case of the day, an acute right M1 occlusion, that was quickly and completely recanalized with the so-called “BADASS” technique associating a BCG, a DAC and a stent retriever in the first pass and the patient recovered completely on the table.
Nevertheless, an iatrogenic ICA dissection had occurred at the lower cervical segment and was treated with a carotid Wallstent. This gave us the occasion to discuss the antiplatelet protocol used at the Bicêtre hospital. The patient being under IVT, a flat panel CT rules out intracranial haemorrhage and an IV loading dose of 500 mg of aspirin is given to the patient 10 minutes prior to stent placement. Six hours later, the patient has a new CT scan and a loading dose of Ticagrelor is given.
After a very interesting presentation of a paediatric stroke case by Dr Francisco Mont’Alverde, the other two recorded stroke cases of the day from Bern were an A2 occlusion on a stenotic arterial lesion with failed recanalization and a tandem occlusion.
The day was concluded with two presentations dealing with intracranial chronic stenosis or occlusions. Prof. Tran Chi Cuong from Vietnam, reminded us that patients with very progressive and chronic intracranial occlusion and good collateral circulation do not systematically require MT and can have favourable outcome on medical treatment alone. Prof. Raoul Nogueira shared with us his experience in treating intracranial stenosis in acute phase of ischemic stroke. Though in most patients MT alone is sufficient to achieve stable recanalization some cases require rescue angioplasty and stenting.
The medical management implies loading the patient with aspirin and clopidogrel as soon as an intracranial stenosis is suspected on the medical history or case presentation.
Prof. Nogueira warned us not to use intraprocedural heparin which he found to be associated with severe haemorrhagic complications and to use and to use Tirofiban instead if needed.
After a very dense day the congress attendees met at the well-deserved cocktail on the beach at the Mediterranean Sea.
Léon IKKA