Anatomic/Technical Predictors of Perioperative Clinical Outcomes after Carotid Artery Stenting

Abstract

Only a few studies have reported on the impact of anatomic/technical factors on clinical outcomes of carotid artery stenting (CAS). This study will analyze the effect of these factors on perioperative stroke/death after CAS. This is a retrospective analysis of prospectively collected data on 456 patients with CAS. A logistic regression analysis was used to determine the impact of anatomic factors (lesion length, location, severity, calcification, and arch type) and technical factors (stent type, number, diameter, and length; filter type, filter insertion to recovery time, and pre- and poststent percutaneous transluminal angioplasty [PTA]) on perioperative stroke, death, and myocardial infarction (major adverse events [MAE]). The MAE and stroke rates for the whole series were 4.7% and 2.2%. The stroke rate for asymptomatic patients was 0.46% (P = .01). The MAE rates for patients with transient ischemic attacks (TIAs) were 7% vs 3.2% for other indications (P = .077). The stroke rates for calcific lesions were 6.3% vs 1.2% for noncalcific lesions (P = .046). There were no significant differences in stroke and MAE rates regarding other anatomic features. The stroke rate for patients with dilatation prior to filter insertion with prestent and/or poststent PTA was 9.1% vs 1.8% for patients without (P = .07) and 2.6% for patients with poststenting dilatation vs 0% for patients without (P = .36). MAE rates for patients with poststenting dilatation were 5.6% vs 0% for patients without (P = .0536). MAE rates for patients with Accunet filters (Abbott, Abbott Park, Ill) were 1.9% vs 6.7% for other filters (P = .029). There were no significant differences between stroke and MAE rates regarding stent type, number, diameter, length of stent, and time from filter insertion to recovery time. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for dilatation performed prior to filter insertion, and 1.7 (P = .4413) for PTA performed prior to stenting. It also showed that the MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 (P = .35) for predilatations performed prior to filter insertion, and 2.2 (P = .22) for poststent dilatations. A multivariate analysis showed that patients with TIA indications had an odds ratio of stroke of 15.26 (P = .0113); and patients with dilations performed prior to filter insertion with prestent and/or poststent PTA had an odds ratio of 7.98 (P = .0193). The MAE odds ratio for Accunet vs other filters was 0.27 (P = .0389, Tables I and II). PTA prior to filter insertion had higher stroke rates and poststenting PTA was associated with higher MAE rates. The Accunet filter was associated with lower stroke and MAE rates. There was no correlation between other anatomical/technical variables.Table IPercutaneous transluminal angioplasty (PTA) combination and perioperative stroke and major adverse events (MAEs)DilationStroke, No. (%)MAE, No. (%)None0/260/26Pre-EPD only0/10/1Prestent only0/390/39Poststent only2/130 (1.5)6/130 (4.6)Pre-EPD and present0/20/2Pre-EPD and poststent1/8 (12.5)1/8 (12.5)Prestent and poststent5/192 (2.6)11/192 (5.7)Pre-EPD, prestent and post stent1/11 (9.1)1/11 (9.1)EPD, Embolic protection device. Open table in a new tab Table IILogistic regression analysisUnivariate–early strokeOR95% CIP valueVariablesAge1.03(0.96,1.11).4058Sex (male vs female)0.86(0.23,3.24).8223Hypertension1.04(0.13,8.52).9683Coronary artery disease1.33(0.27,6.51).7215Congestive heart failure1.63(0.4,6.61).4977Hypercholesterolemia1.10(0.23,5.4).9026Renal failure1.00(0.21,4.91).9971Asymptomatic indication0.10(0.01,0.81).031TIA indication13.69(1.7,110.47).014Stroke indication1.10(0.14,9.02).9273Preprocedure stenosis (70-99 vs 50-69)0.56(0.07,4.6).5852Lesion length (≥15 mm)0.96(0.25,3.62).9501Predilatation performed prior to EPD6.09(1.19,31.2).0303Predilatation performed prior to stent1.73(0.43,7.01).4413Univariate–early MI/stroke/deathOR95% UCLP valueVariablesAge1.02(0.97,1.06).5127Sex (male vs female)1.00(0.42,2.38).9913Hypertension0.42(0.15,1.19).101Coronary artery disease1.01(0.39,2.65).981Congestive heart failure0.94(0.34,2.62).9102Hypercholesterolemia0.66(0.26,1.66).3781Renal failure1.34(0.51,3.51).5558Asymptomatic indication0.46(0.19,1.12).0858TIA indication2.04(0.86,4.82).1055Stroke indication0.88(0.2,3.87).8603Preprocedure stenosis (70-99 vs 50-69)0.58(0.13,2.66).4833Lesion length (≥15 mm)0.43(0.17,1.12).0831EPD (Accunet vs other)0.27(0.08,0.95).0413Predilatation performed prior to EPD2.07(0.45,9.45).35Predilatation performed prior to stent1.03(0.44,2.43).9463Poststent dilatation performed2.16(0.63,7.43).2232Multivariate– early strokeOR95% CIP valueVariableTIA indication15.26(1.85,125.66).0113Predilatation performed prior to EPD7.98(1.4,45.43).0193Multivariate– early MI/stroke/deathOR95% LCLP valueVariablesEPD (Accunet vs other)0.27(0.08,0.94).0389CI, Confidence interval; EPD, embolic protection device; LCL, lower confidence interval; MI, myocardial infarction; OR, odds ratio: TIA, transient ischemic attack; UCL, upper confidence interval. 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