Carotid Angioplasty And Stenting Procedures Research Articles

Long-term imaging follow-up to evaluate restenosis in patients with carotid stenosis after angioplasty and stenting.

Stent patency after carotid angioplasty and stenting (CAS) correlates not only with stroke prevention but also with improvements in cognition and quality of life by positively influencing cerebral perfusion. The long-term outcomes of CAS after more than 5 years have still not been well described. This retrospective study was designed to evaluate the stent patency and significant restenosis (SR) after CAS with more than 5 years of follow-up. Between 2006 and 2012, 118 patients with carotid stenosis who underwent 131 CAS procedures with regular annual imaging follow-up for more than 5 years were enrolled. We evaluated their demographic characteristics and the risk factors related to stent restenosis. Patients with SR (restenosis ≥ 50%) were compared with those with no significant restenosis (NSR, patency or restenosis < 50%) to identify the restenosis predictors and restenosis-free survival. Of the 131 CAS procedures, 16.0% (21/131) had SR. A history of head and neck radiotherapy (HNRT) was a predictor for SR (HR, 6.352; 95% CI, 2.504-16.112; p < 0.001) and was associated with shorter restenosis-free survival (log-rank test p value < 0.001, median time of restenosis-free survival was 38 months). Left-sided stenting was an associated factor for SR (HR, 3.007; 95% CI, 1.068-8.467; p = 0.037) with a trend of less restenosis-free survival (log-rank test p value 0.067). Both HNRT and left-sided carotid stenosis were predictors of SR after CAS in more than 5 years of long-term follow-up. Restenosis-free survival was significantly shorter in patients with prior HNRT than in patients without previous irradiation treatment. We suggest close follow-up and aggressive medical treatment for patients with prior HNRT and left-sided carotid stenosis undergoing CAS.

Hemodynamic events during carotid stenting are associated with significant periprocedural stroke and adverse events

BackgroundThere are limited data on the impact of carotid angioplasty and stenting (CAS)-related changes in blood pressure, heart rate, and preprocedural medications on periprocedural stroke in contemporary, real-world practice. This study evaluates the risk attributable to the CAS-related hemodynamic events and the impact preprocedural medications have on mitigating this risk in a large, population-based cohort. MethodsWe studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. Kaplan-Meier, multivariable logistic, and Cox regression analyses were used to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural stroke (IPPS), 30-day, and 1-year stroke. ResultsOf the 13,698 CAS procedures studied, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. IPPS was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension and 1.4 vs 1.0% (P = .19) for bradycardic vs nonbradycardic patients. Periprocedural hypertension was associated with a four-fold increase in IPPS (adjusted odd ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.24-9.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P = .007) increases in IPPS among patients with carotid symptoms. There was 76% decrease in IPPS for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Unlike preprocedural beta-blockers and angiotensin-converting enzyme inhibitors, prophylactic antibradyarrhythmic agents conferred a 58% reduction in IPPS among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P = .006). The periprocedural hemodynamic events were also associated with 7.7-fold increase in myocardial infarction (aOR, 7.70; 95% CI, 4.77-12.45; P < .001), a 2.2-fold increase in 30-day mortality (aOR, 2.24; 95% CI, 1.61-3.12; P < .001), and a 16% increase in length of stay (aOR, 1.16; 95% CI, 0.04-2.28; P = .042). The occurrence of these hemodynamic events is higher in patients with prior cardiac disease and the difference in periprocedural outcomes extended to 1 year. ConclusionsPeriprocedural hemodynamic events are associated with an increase in periprocedural stroke, myocardial infarction, death, and length of stay. Periprocedural hypertension in all patients; hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in IPPS. Prophylactic antibradyarrhythmic agents are associated with decrease in bradycardia and IPPS. These results heighten the need to anticipate and promptly address these CAS-related hemodynamic events, especially in susceptible patients.

Preprocedural Neutrophil to Albumin Ratio Predicts In-Stent Restenosis Following Carotid Angioplasty and Stenting

Background and purposeIn-stent restenosis (ISR) is unfavorable to the long-term efficacy of carotid angioplasty and stenting (CAS). Inflammation plays a critical role in the development of ISR. The aim of the study was to investigate whether neutrophil to albumin ratio (NAR) is a predictor of ISR in patients undergoing CAS. MethodsWe retrospectively recruited patients who underwent CAS. These patients were divided into restenosis group and nonrestenosis group. NAR was examined prior to the CAS procedure. Clinical and radiographic assessments were performed at 6 months and annually after the procedure. ISR was defined as greater than or equal to 50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR following CAS. ResultsDuring a mean follow-up period of 14.6 months, a total of 459 treated arteries (in 427 participants) were enrolled, among which 72 (15.7%) developed ISR. On multivariate analysis, baseline NAR greater than or equal to13.4, residual stenosis, lesion length, and baseline glucose level were associated with ISR (hazard ratio 1.94[95% confidence interval (CI), 1.08-3.49], 1.09[95% CI, 1.07-1.12], 1.04[95% CI, 1.01-1.06], and 1.01[95% CI, 1.00-1.02], respectively). ConclusionElevated preprocedural NAR may be a predictor of ISR in patients undergoing CAS.

IP107. Hemodynamic Events During Carotid Stenting Are Associated with Significant Periprocedural Stroke

This study evaluates the risk attributable to the hemodynamic events that occur during carotid angioplasty and stenting (CAS) and the impact that preprocedural and prophylactic medications have on mitigating this risk in a large, population-based cohort of patients. We studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural, 30-day, and 1-year stroke. There were 13,698 CAS procedures studied. Of these, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. Immediate periprocedural stroke was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension, and 1.4% vs 1.0% for bradycardic vs nonbradycardic patients (P = .19). Periprocedural hypertension was associated with a fourfold increase in immediate periprocedural stroke (adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). Periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.24-9.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P = .007) increases, respectively, in immediate periprocedural stroke among patients with carotid symptoms. There was a 76% decrease in immediate periprocedural stroke risk for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Preprocedural beta blockers and angiotensin-converting enzyme inhibitors had no significant impact on immediate periprocedural stroke. However, prophylactic use of antibradyarrhythmic agents conferred a 58% reduction in immediate periprocedural stroke among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P = .006). The periprocedural differences in outcomes extended into the long term (Figs 1 and 2). Periprocedural hypertension in all patients and hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in immediate periprocedural stroke. Prophylactic administration of antibradyarrhythmic agents is associated with a decrease in the incidence of bradycardia and immediate periprocedural stroke. These results heighten the need to anticipate and promptly address these hemodynamic changes during and after CAS to further improve the risk profile of this procedure for the benefit of our patients.Fig 2Freedom from stroke up to 1 year for all patients who were bradycardic vs nonbradycardic in the periprocedural period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature.

ObjectiveTo compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device.MethodsA systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%.ResultsIn the 25 articles included in this study, the number of stroke events was 326 (2.0%) in protected CAS and 142 (3.4%) in unprotected CAS. The use of cerebral protection device significantly decreased stroke after CAS (odds ratio [OR] 0.633, 95% confidence interval [CI] 0.479–0.837, p=0.001). In the publication bias analysis, Egger’s regression test disclosed that the intercept was -0.317 (95% CI -1.015–0.382, p=0.358). Regarding symptomatic patients (four studies, 539 CAS procedures), the number of stroke was six (1.7%) in protected CAS and 11 (5.7%) in unprotected CAS. The protective effect against stroke events by cerebral protection device did not have a statistical significance (OR 0.455, 95% CI 0.151–1.366, p=0.160).ConclusionThe use of protection device significantly decreased stroke after CAS. However, its efficacy was not demonstrated in symptomatic patients. Routine use of protection device during CAS should be critically assessed before mandatory use.

Mean Platelet Volume as a Predictor for Restenosis After Carotid Angioplasty and Stenting.

Platelet aggregation plays a vital role in the development of in-stent restenosis (ISR) after carotid angioplasty and stenting (CAS). Mean platelet volume (MPV) has been suggested as an index of platelet reactivity. This study aimed to investigate the association between MPV and ISR in CAS patients. A total of 261 patients with CAS were enrolled. MPV was measured before CAS procedure. Digital subtraction angiography, computed tomographic angiography, or duplex ultrasonography was performed at 6 months and annually after the procedure. ISR was defined as ≥50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR after CAS. Of the 261 patients with CAS, 46 (17.6%) were determined with ISR during a mean follow-up of 12.1±16.1 months (range, 2.1-120.7). On multivariate analysis, baseline MPV >10.1 fL (hazard ratio, 3.20; 95% confidence interval, 1.28-8.03), lesion length (hazard ratio, 1.05; 95% confidence interval, 1.02-1.08), residual stenosis (hazard ratio, 1.07; 95% confidence interval, 1.05-1.10), and baseline glucose (hazard ratio, 1.01; 95% confidence interval, 1.00-1.02) were associated with ISR. Elevated MPV may be associated with ISR after CAS. Patients with high preprocedural MPV may benefit from an intensified antiplatelet therapy after CAS.

Restenosis after carotid artery stenting.

As a common etiology for ischemic stroke, atherosclerotic carotid stenosis has been targeted by vascular surgery since 1950s. Compared with carotid endarterectomy, carotid angioplasty and stenting (CAS) is almost similarly efficacious and less invasive. These advantages make CAS an alternative in treating carotid stenosis. However, accumulative evidences suggested that the long-term benefit-risk ratio of CAS may be decreased or even neutralized by the complications related to in-stent restenosis (ISR). Therefore, investigating the mechanisms and identifying the influential factors of ISR are of vital importance for improving the long-term outcomes of CAS. As responses to intrinsic and extrinsic injuries, intimal hyperplasia and vascular smooth muscle cell proliferation have been regarded as the principle mechanisms for ISR development. Due to the lack of consensus-based definition and consistent follow-up protocol, the reported incidences of ISR after CAS varied widely among studies. These variations made the inter-study comparisons of ISR largely illogical. To eliminate restenosis after CAS, both surgery and endovascular procedures have been attempted with promising results. For preventing ISR, drug-eluting stents and antiplatelets have been proposed as potential solutions.

Plaque morphology detected with Duplex ultrasound before carotid angioplasty and stenting (CAS) is not a predictor of carotid artery in-stent restenosis, a case control study

BackgroundIn-stent restenosis (ISR) is an important factor endangering the long-term safety and efficacy of carotid artery angioplasty and stenting (CAS). It is plausible that soft vulnerable plaques are more likely to be injured during CAS procedure and are therefore more likely to initiate the cascade finally leading to ISR. The aim of this study was to investigate if plaque morphology detected by a simple applicable Duplex ultrasound score before CAS can be used as a predictor for ISR.MethodsWithin a prospectively collected single-centre CAS database of 281 patients (comprising 300 arteries) with high-grade carotid artery stenosis, who underwent CAS between May 2003 and January 2013, we conducted a nested case–control study. Plaque morphology before CAS was analysed by a blinded investigator and each parameter of the Total Plaque Risk Score (TPRS) as well as the whole score was evaluated with regard to its diagnostic validity for ISR.ResultsWe analysed the data of 10 patients with ISR and 50 patients without ISR. There were no significant differences with respect to baseline characteristics, vascular risk factors, and degree of stenosis between patients with and without ISR. The duration of follow-up was longer in patients with ISR (p = 0.024) and these patients were more likely to show increased PSV (p = 0.012) immediately after CAS than patients without ISR. Neither individual parameters of the TPRS score nor the score as a whole were suitable as a diagnostic test for ISR development.ConclusionsIn the present study we could demonstrate that the non-contrast enhanced DUS of the pre-interventional plaque formation cannot be used as a predictor for the development of ISR. Evaluating a more sophisticated, but not routinely available approach e.g. by ultrasound based plaque perfusion imaging or CT based plaque analysis could be helpful in the future in order to assess the role of plaque morphology in the context of ISR development.

Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with primary procedures. Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database. End points included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge, and restenosis ≥ 70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome. Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%; P = .8) and symptomatic patients (6.6% vs 5.8%; P = 1.0). No significant difference in restenosis ≥ 70% was identified between redo CEA and CAS after prior CEA (5.2% vs 3.0%; P = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .8). In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA. However, regardless of symptom status, the risk of reintervention was increased compared with patients undergoing primary CEA.

Results of carotid angioplasty and stenting are equivalent for critical versus high-grade lesions in patients deemed high risk for carotid endarterectomy

BackgroundTo examine outcomes of carotid angioplasty and stenting (CAS) in patients with critical carotid stenosis who are deemed high risk for carotid endarterectomy. MethodsMedical records were retrospectively analyzed for patients undergoing CAS between September 2002 and March 2011 at a single institution. Patients were classified as having either critical (≥90%) or high-grade (70%–89%) carotid stenosis based on angiography. The primary composite end point was stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke during the follow-up period. ResultsA total of 245 patients underwent 257 CAS procedures during the study period. Fifty-one percentage (n = 130) of cases involved critical stenosis (66.2% male; mean age, 71 ± 10 y), with the remaining group (n = 127) involving high-grade stenosis (67.7% male; mean age, 71 ± 9 y). Symptomatic carotid disease was present in 25% of the critical stenosis and 31% of the high-grade stenosis groups (P = 0.33). Chronic obstructive pulmonary disease was more commonly found in the high-grade stenosis group (20% versus 8%, P = 0.01). No difference was observed between the groups relative to other baseline demographic characteristics, presence of contralateral carotid occlusion, stent diameter or length, maximum balloon diameter or length, use of embolic protection device, or procedural duration. Technical success was achieved in all cases. There was no difference in the need to predilate before the introduction of the filter or stent based on the degree of stenosis. We found no difference in the primary composite end point between the high-grade or critical stenosis groups (7.1% versus 7.7%, P = 0.74), or there were no differences between the individual components of the composite end point. Mid-term survival was similar between the two groups at a mean follow-up period of 2.4 y. ConclusionsDespite concerns regarding the potential for increased neurologic complications, our data demonstrate that patients with high-grade and critical stenosis are able to safely undergo CAS and achieve similar periprocedural outcomes and mid-term prognosis.

Comparison Between Proximal Versus Distal Protection Devices in 287 Cases of Carotid Revascularization Using Angioplasty and Stenting: Periprocedure Complications, Morbidity, and Mortality

Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs. This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared. Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients. Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis

ObjectiveEarly intervention is desirable in patients presenting with stroke or transient ischemic attack (TIA) referable to carotid artery stenosis because of the high incidence of recurrent ischemic events within 48...

Incidence, predictors, and outcomes of hemodynamic instability following carotid angioplasty and stenting

To explore the incidence, predictors, and outcomes of hemodynamic instability (HI) following carotid angioplasty and stenting (CAS). We retrospectively evaluated data on 257 CAS procedures performed in 245 patients from 2002 to 2011 at a single institution. The presence of periprocedural HI, as defined by hypertension (systolic blood pressure >160 mm Hg), hypotension (systolic blood pressure <90 mm Hg), and/or bradycardia (heart rate <60 beats per minute), was recorded. Clinically significant HI (CS-HI) was defined as periprocedural HI lasting greater than 1 hour in total duration. Logistic regression was used to analyze the role of multiple demographic, clinical, and procedural variables. Mean age was 70.9 ± 9.9 years (67% male). HI occurred following 84% (n = 216) of procedures. The incidence of hypertension, hypotension, and bradycardia was 54%, 31%, and 60%, respectively. Sixty-three percent of cases involved CS-HI. Recent stroke was an independent risk factor for the development of CS-HI (odds ratio, 5.24; confidence interval, 1.28-21.51; P = .02), whereas baseline chronic obstructive pulmonary disease was protective against CS-HI (odds ratio, 0.34; confidence interval, 0.15-0.80; P = .01). Patients with CS-HI were more likely to experience periprocedural stroke compared to other patients (8% vs 1%; P = .03). There were no significant differences in the incidence of mortality or other major complications between those with and without CS-HI. HI represents a common occurrence following CAS. While the presence of periprocedural HI alone did not portend a worse clinical outcome, CS-HI was associated with increased risk of stroke. Expeditious intervention to prevent and manage CS-HI is of critical importance in order to minimize adverse clinical events following CAS.

Malignant Emboli on Transcranial Doppler During Carotid Stenting Predict Postprocedure Diffusion-Weighted Imaging Lesions

Carotid angioplasty and stenting (CAS) has a higher incidence of periprocedural stroke compared with endarterectomy. Identifying CAS steps with the highest likelihood of embolization may have important implications. We evaluated CAS safety by correlating the findings of procedural transcranial Doppler with postprocedure diffusion-weighted imaging (DWI) lesions. In this prospective study, transcranial Doppler monitoring was performed during CAS procedures, which were divided into 11 steps. Embolic signals on transcranial Doppler were counted and classified based on the relative energy index of microembolic signals into microemboli ≤ 1 or malignant macroemboli >1. Poststenting MRI was performed in all cases. A negative binomial regression model was used to evaluate the predictive value of transcranial Doppler emboli for new DWI lesions. Thirty subjects were enrolled. Seven of 30 subjects (23.3%) were asymptomatic. The median embolic signal count was 212.5 (108 microemboli and 80 malignant macroemboli). Stent deployment phase showed the highest median embolic signals count at 58, followed by protection device deployment at 30 (P=0.0006). Twenty-four of 30 (80%) had new DWI lesions on post-CAS MRI. The median DWI count was 4 (interquartile range 7). Two of 30 (6.7%) had new or worsening clinical deficits post-CAS. For every malignant embolus, the expected count of DWI lesions increases by 1% ( 95% confidence interval, 0%-2%; P=0.032). We observed a high incidence of embolic signals during CAS procedure, especially, when devices were deployed. Most subjects developed new DWI lesions, but only 6.7% had deficits. Malignant macroemboli predicted new DWI lesions.

Prevention of Hemodynamic Instability in Extra-Cranial Carotid Angioplasty and Stenting Using Temporary Transvenous Cardiac Pacemaker

Hemodynamic instability is a common condition during extra-cranial carotid angioplasty and stenting (CAS). We evaluated the safety and efficacy of prophylactic placement of temporary cardiac pacemaker during extra-cranial CAS for the prevention of hemodynamic instability. For this, forty-seven carotid artery stents were deployed in 41 high-risk patients. Temporary transvenous cardiac pacemakers were inserted before CAS procedure. The pacers were set to capture a heart rate <60 bpm. Clinical symptoms, blood pressure, heart rate, and pacing activation were monitored and data were collected. We found that pacing occurred in 25 carotid lesions during balloon predilatation; pacemakers were activated transiently in 25 patients. The longest pacing continued for 1 day. Among cases with pacemaker activation, 1 patient developed post-procedural symptomatic hypotension that lasted for 4 days. No related complications were observed. It was, therefore, concluded that pacing was technically effective in producing electrical ventricular responses and was hemodynamically effective in 25 carotid lesions which underwent balloon predilatation. The prophylactic use of a temporary transvenous cardiac pacemaker during CAS was rapid and effective in controlling peri-operative hemodynamic instability and preventing stroke and other complications. The prophylactic use of temporary pacemaker is particularly recommended for patients at high risk for developing hemodynamic instability.

Intracranial Hemorrhage Is Much More Common After Carotid Stenting Than After Endarterectomy

Intracranial hemorrhage (ICH) is a rare and devastating complication of carotid revascularization. We sought to determine the prevalence of, type of, and risk factors associated with ICH among recipients of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) within the National Inpatient Sample (NIS). Postoperative cases of ICH after CEA (International Classification of Disease 9th edition [ICD-9]: 38.12) or CAS (ICD-9: 00.63) were retrieved from the 2001 to 2008 NIS. Clinical presentation (asymptomatic versus symptomatic), discharge status, in-hospital mortality, demographics, and hospital characteristics were extracted from NIS data. Charlson indices of comorbidity were determined based on ICD-9 and clinical classification software codes. Multivariate regression was used to determine the impact of revascularization procedure type and symptom status on adverse outcomes, including ICH, in-hospital mortality, and unfavorable discharge status. Among 57,663,486 NIS hospital admissions, 215,012 CEA and 13,884 CAS procedures were performed. Symptomatic presentations represented the minority of CEA (N=10,049; 5%) and CAS cases (N=1251; 10%). ICH occurred significantly more frequently after CAS than CEA in both symptomatic (4.4% versus 0.8%; P<0.0001) and asymptomatic presentations (0.5% versus 0.06%; P<0.0001). Multivariate regression suggested that symptomatic presentations (versus asymptomatic) and CAS procedures (versus CEA) were both independently predictive of 6-fold to 7-fold increases in the frequency of postoperative ICH. ICH was independently predictive in a 30-fold increased risk of mortality before discharge. CAS procedures are associated with elevated adverse outcomes, including ICH, in-hospital death, and unfavorable discharges, especially among symptomatic presentations.

Inflammation and In-Stent Restenosis: The Role of Serum Markers and Stent Characteristics in Carotid Artery Stenting

BackgroundCarotid angioplasty and stenting (CAS) may currently be recommended especially in younger patients with a high-grade carotid artery stenosis. However, evidence is accumulating that in-stent restenosis (ISR) could be an important factor endangering the long-term efficacy of CAS. The aim of this study was to investigate the influence of inflammatory serum markers and procedure-related factors on ISR as diagnosed with duplex sonography.MethodsWe analyzed 210 CAS procedures in 194 patients which were done at a single university hospital between May 2003 and June 2010. Periprocedural C-reactive protein (CRP) and leukocyte count as well as stent design and geometry, and other periprocedural factors were analyzed with respect to the occurrence of an ISR as diagnosed with serial carotid duplex ultrasound investigations during clinical long-term follow-up.ResultsOver a median of 33.4 months follow-up (IQR: 14.9–53.7) of 210 procedures (mean age of 67.9±9.7 years, 71.9% male, 71.0% symptomatic) an ISR of ≥70% was detected in 5.7% after a median of 8.6 months (IQR: 3.4–17.3). After multiple regression analysis, leukocyte count after CAS-intervention (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.02–1.69; p = 0.036), as well as stent length and width were associated with the development of an ISR during follow-up (OR: 1.25, 95% CI: 1.05–1.65, p = 0.022 and OR: 0.28, 95% CI: 0.09–0.84, p = 0.010).ConclusionsThe majority of ISR during long-term follow-up after CAS occur within the first year. ISR is associated with periinterventional inflammation markers and influenced by certain stent characteristics such as stent length and width. Our findings support the assumption that stent geometry leading to vessel injury as well as periprocedural inflammation during CAS plays a pivotal role in the development of carotid artery ISR.

Endovascular management of symptomatic carotid stenosis combined with kinking

To study the necessity, feasibility, security of carotid angioplasty and stenting (CAS) for symptomatic carotid stenosis combined with kinking. Twelve patients with symptomatic carotid stenosis and kinking demonstrated by digital subtraction angiography (DSA) received CAS from December 2003 to December 2009. There were 9 male and 3 female patients, age ranged from 59 to 77 years (mean 69.3 years). All the patients' clinical, imaging, intervention and follow up data were collected and analyzed. All CAS procedures were successfully performed with 14 self-expandable stents placed. The mean degree of stenosis was reduced from 85.6% before stenting to 11.2% after stenting, the angle of kinking, according to Metz' category, were improved from less than 90° to more than 120° in each case. No perioperative procedure related stroke and transient ischemic attack (TIA) occurred. The clinical symptoms and signs of cerebral ischemia were improved or disappeared for all patients. During follow-up of these 12 patients for 6 to 72 months, one patient experienced ipsilateral carotid territory TIA and another patient experienced contralateral carotid territory TIA. DSA follow up of 5 patients demonstrated 1 case with in-stent restenosis and arterial kinking remote to the stent of internal carotid artery. CAS were performed again and CT angiography follow up demonstrated no kinking and restenosis 2 years after the intervention. Duplex scan of the other 7 patients demonstrated neither kinking nor restenosis. CAS seems to be feasible and safe for the patients with symptomatic kinking and stenosis, and maybe helpful to lower the risk of cerebral ischemia, but further study is needed.

Determinants of Embolic Risk During Angioplasty and Stenting

Carotid angioplasty and stenting (CAS) has proven to be a potential alternative to carotid endarterectomy in the treatment of severe carotid disease. Patient selection has emerged as a means of optimizing the outcomes of CAS. To determine whether the presence of preprocedural neurologic symptoms and having a history of coronary artery disease (CAD) are associated with greater embolic risk during CAS through analysis of the embolic debris captured within protective filters. A total of 233 consecutive CAS procedures were performed between 2003 and 2009. Particles of embolic debris within the filters were quantified by photomicroscopy and video imaging software. Particulate size was determined by measuring the length along the longest axis. Preprocedural neurologic symptoms included transient ischemic attack, cerebrovascular accident, and amaurosis fugax. History of CAD included prior myocardial infarction, coronary artery bypass grafting, congestive heart failure, or abnormal stress test. Of the 137 (58.8%) filters that were analyzed (mean age, 71.3 ± 9.1 years, 56.9% male), 52 (38.0%) and 80 (58.4%) filters were from symptomatic and CAD patients, respectively. Filters of symptomatic (S) patients contained both a greater number and larger mean particle size compared with those of asymptomatic (AS) patients (S: 15.8 ± 13.5 particles vs. AS: 9.8 ± 8.7 particles, P = 0.002; S: 507 ± 389 μm vs. AS: 398 ± 181 μm, P = 0.03; respectively). Filters from CAD patients also had a greater number of particles, but trended toward smaller minimum size than those in non-CAD patients (CAD: 14.4 ± 12.8 particles vs. non-CAD: 8.8 ± 7.4 particles, P = 0.002; CAD: 167 ± 172 μm vs. 228 ± 203 μm, P = 0.06). These findings suggest that the presence of preprocedural neurologic symptoms and a history of CAD are associated with increased embolization during CAS. Therefore, the benefit of carotid stenting should be tempered by the potential for increased perioperative events in both symptomatic and CAD patients.

Retinal Embolization During Carotid Angioplasty and Stenting: Periprocedural Data and Follow-Up

The purpose of this study was to prospectively evaluate the incidence of retinal emboli during carotid angioplasty and stenting (CAS) and to correlate emboli with clinical findings and transcranial Doppler (TCD)-detected cerebral embolic load. Between 2001 and 2005, 33 CAS procedures in 32 patients (23 [72%] male, 19 [58%] symptomatic, mean age 72.5 years [range 54.6 to 83.9]) scheduled for CAS were included in this study. Bilateral fundoscopy with retinal photography was performed by an experienced ophthalmologist immediately before, immediately after (fundoscopy only), and 1 day after the procedure and again at long-term follow-up (mean 37 months). Visual field testing was performed before CAS and again at long-term follow-up. TCD-detected cerebral emboli were stratified to five procedural phases: wiring, predilatation, stent placement, postdilatation, and cerebral protection device (CPD) use (if applicable). To establish correlation between TCD data and retinal embolization, Mann-Whitney test was used, and P < 0.05 was considered statistically significant. All procedures were performed successfully. In five of 33 procedures (15%), new retinal emboli were found. Two of the procedures with emboli had small retinal infarcts. Three of five were performed using CPDs versus seven of 28 that had no retinal emboli (P = not significant). Two of four patients (50%) with previous radiation therapy to the neck had new retinal emboli versus three of 29 patients (10%) who had no previous radiation therapy (P = 0.038). None of the other patient characteristics was associated with retinal embolization. In 30 (91%) of patients with an adequate acoustic temporal window for TCD monitoring, there was no statistically significant correlation between TCD data and the incidence of retinal emboli. No visual field defects were found. On long-term follow-up, all retinal emboli and retinal infarcts had resolved. Retinal embolization during CAS is not uncommon, and it occurs in both protected and unprotected procedures. Most retinal emboli are clinically silent.