Surgical and endovascular intervention on internal carotid artery near occlusion.

Therapeutic strategy for treating carotid artery near occlusion (CANO) has been controversial. The aim of this study was to review the literature concerning the invasive treatment of atherosclerotic CANO. A review was conducted of the English medical literature from 1980 to 2013 using PubMedand EMBASE database to find studies involving open or endovascular management of CANO. The search identified 20 reports describing invasive treatment of CANO encompassing 770 patients (77.7% men; mean age 66.3±5.2 years). A typical appearance of string sign was noted in nearly 60% of the patients. The vast majority (92.6%) were symptomatic. 479 (62.2%) patients underwent an open procedure, while 291 (38.8%) were treated endovascularly. The technical success rate for the endovascular procedures was 99%, while distal embolic protection devices were applied in most patients (66%). The 30 days procedural stroke rate was 2.1% and 2.4% for open and endovascular repair respectively. During a follow-up period spanning an average of approximately two years the ipsilateral cerebrovascular event rate was 5% and 1.2% for open and endovascular treatmentrespectively. Twenty five (5.2%) restenosis or occlusions were reported for the open procedures, while 13 (5.4%) were also documented for endovascular repair. The current literature concerning the invasive treatment of CANO is weak and cannot support any evidence based recommendation. The necessity to intervene as well as the best therapeutic strategy remains controversial. This review shows that the interventionon symptomatic CANO may consist a relatively safe and effective therapeutic strategy with low perioperative cerebrovascular morbidity for both treatment modalities, although durability and long-term outcomes should be further affirmed. The low incidence of this entity and the dearth of clear evidence support the need for a large multicenter registry to clarify the absolute indications for intervention and define the best therapeutic approach.

The role of ex-vivo gene therapy of vein grafts with Egr-1 decoy in the suppression of intimal hyperplasia.

OBJECTIVES: To test the hypothesis that vein graft intimal hyperplasia can be significantly suppressed by a single intra-operative transfection of the graft with a decoy oligonucleotide (ODN) binding the transcription factor Egr-1. DESIGN: Experimental study. MATERIALS AND METHODS: Jugular vein to carotid artery interposition grafts in rabbits were treated with Egr-1 decoy, mutant decoy ODN, vehicle alone, using a non-distending pressure of 300 mm Hg for 20 min, or were left untreated. All animals were fed a 2% cholesterol diet. The animals were sacrificed after 48h, 6 weeks and 12 weeks. Paraffin-embedded vein sections were subjected to angiometric analysis. RESULTS: Successful delivery of the ODN was confirmed by DAPI staining. Quantitative real-time PCR revealed a 60% decrease of the Egr-1 gene expression in the animals in which the Egr-1 decoy ODN was delivered. Cellular proliferation was also significantly decreased as indicated by the Ki-67 labelling index. An increase in intimal and medial thickness was found in all vein grafts. However, intimal thickness was significantly reduced in the grafts treated with Egr-1 decoy ODN, whereas luminal area was significantly increased. CONCLUSION: A single intra-operative pressure-mediated transfection of vein grafts with Egr-1 decoy ODN significantly suppresses intimal hyperplasia in a rabbit hypercholesterolaemic model.