Curative Effect Analysis Of Endovascular Intervention And Hybrid Surgery For Chronic Internal Carotid Artery Occlusion And The Exploration Of Imaging Classification

Background:Chronic internal carotid artery occlusion(CICAO)can cause transient ischemic attack(TIA)and ischemic stroke.Carotid artery stenting(CAS),carotid endarterectomy(CEA)combined with endovascular intervention(EI)are effective methods for carotid artery revascularization.At present,the angiography classification system based on digital subtraction angiography(DSA)is used as a guide to judge the feasibility and safety of revascularization.However,the classification system only focuses on the morphological characteristics of vascular lumen and ignores the histological evidence.Purpose:This study consists of two parts:1.To evaluate and compare the efficacy and safety of endovascular intervention and hybrid surgery in the revascularization of symptomatic chronic carotid artery occlusion;2.To explore the characteristics of imaging classification based on preoperative high-resolution magnetic resonance imaging of patients with carotid artery occlusion,and evaluate its clinical value.Methods:In the first part of this study,44 patients who received hybrid surgery and 35 patients who received endovascular intervention in our hospital from May 2016 to June 2022 were included.We summarized and analyzed the clinical data,vascular characteristics,success rate of recanalization surgery,perioperative complications and follow-up data of this group of patients.In the second part of the study,we retrospectively analyzed the data of patients who underwent cervical HRMRI in our hospital from January 2017 to June 2022.40 patients with proximal carotid artery occlusion were finally included in this study,and a new classification system based on HRMRI was established,which was then verified by DSA or postoperative specimens to evaluate the clinical guiding significance of this imaging classification.Results:The first part of the study:there is a statistical difference in high density lipoprotein level between hybrid surgery group and EI group[Median(IQR):hybrid surgery,0.99(0.88-1.18)vs.EI,0.85(0.78-0.98)mmol/L,P=0.001],there was no significant difference in baseline characteristics between the hybrid surgery group and EI group.The recanalization success rate of hybrid surgery was higher than that of El[Hybrid surgery vs.EI,total recanalization success rate:7/44(84.1%)vs.18/35(51.4%),P=0.002;Type A:15/16(93.8%)vs.10/11(90.9%),P=1.000;Type B:9/10(90.0%)vs.5/7(71.4%),P=0.537;Type C:12/15(80.0%)vs.3/12(25.0%),P=0.004;Type D:1/3(33.3%)vs.0/5(0%),P=0.375].There was no significant difference in the incidence rate of perioperative complications between the two types of surgery[Hybrid surgery:7/44(15.9%)vs.El:6/35(17.1%),P=0.883].In addition,there was no significant difference in the incidence rate of death,stroke and restenosis during follow-up.The second part of the study:We have identified four classifications(Type Ⅰ-Ⅳ)based on HRMRI.According to our classification system,20 patients(50.00%)were identified as Type Ⅰ,9 patients(22.50%)were Type Ⅱ,7 patients(17.50%)were Type Ⅲ,and 4 patients(10.00%)were Type Ⅳ.Patients with Type Ⅰ-Ⅲ were treated by hybrid surgery,and the total recanalization success rate was 88.89%(32/36),Patients with Type Ⅳ were treated conservatively.4 patients(44.44%)with Type Ⅱ and 5 patients(71.43%)with Type Ⅲdeveloped dissection during operation.Conclusion:1.For patients with symptomatic CICAO,the successful recanalization rate of hybrid surgery was higher than El.There is no significant difference in safety and restenosis rate between hybrid surgery and EI.2.Histological classification system based on HRMRI:Type Ⅰ is pseudo-occlusion,incomplete occlusion;Type Ⅱ is thrombotic occlusion,the proximal blood vessel is completely occluded,and there is thrombotic tissue in the distal lumen,and the distal occlusion does not reach the petrous segment of ICA;Type Ⅲ is fibrous occlusion,the proximal blood vessels are completely occluded,and there is fibrous tissue in the distal lumen,and the distal occlusion does not reach the petrous segment of ICA;Type Ⅳ is long segment occlusion and complete occlusion,and the distal occlusion reaches above ICA petrous segment.3.The HRMRI classification system for CICAO patients can be used to assist in evaluating the feasibility and risk assessment of vascular recanalization using hybrid surgery.Hybrid surgery can be applied to Type Ⅰ(pseudo occlusion)and Type Ⅱ(thrombotic occlusion)patients with relatively low risk,while patients identified as Type Ⅲ(fibrous occlusion)require more cautious treatment,while Type Ⅳ patients do not recommend any recanalization attempts.