Carotid Artery Angioplasty And Stenting Research Articles

The Comparative Effects of Ticagrelor and Clopidogrel on Arterial Injury and In-Stent Restenosis and Thrombosis of Carotid Artery in Atherosclerotic Rabbits

Introduction - Carotid artery angioplasty and stenting (CAS) is expanding as a method to treat carotid artery disease worldwide. Until now a combination of aspirin and clopidogrel has been used pre and post CAS. Ticagrelor, a P2Y (12) inhibitor, has an important role in coronary artery angioplasty. There is lack of evidence about the impact of ticagrelor on carotid artery disease and CAS. Our aim was the comparative evaluation of ticagrelor and clopidogrel on carotid balloon-injury and in-stent restenosis (ISR) and thrombosis in rabbits. Methods - After a pharmacokinetic study to standardise the appropriate dose of ticagrelor, we enrolled 48 New Zealand White rabbits. They were fed a high-cholesterol diet for 8 weeks prior to and up to 4 weeks following interventions in the right carotid artery (RCA). Aspirin was administered orally (10mg/kg/day) to all rabbits, beginning 7 days before the procedures and continued until euthanasia (4 weeks later). At 8th week of age, all rabbits were randomly assigned into the following equivalent (N=12) groups: A1) Balloon injury and clopidogrel (30 mg/kg/day), A2) Balloon injury and ticagrelor (21mg/kg bd), B3) Balloon injury and CAS and clopidogrel (30 mg/kg/day), B4) Balloon injury and CAS and ticagrelor (21mg/kg bd). During CAS a balloon expandable 2,25x8 mm bare metal stent was implanted in the RCA. Before euthanasia optical coherence tomography (OCT) and angiography were carried out to evaluate the patency of both carotid arteries. Blood samples to measure platelet aggregation and lipid profile were obtainedas well. Rabbits were then immediately euthanized and both carotid arteries (right-RCA and left-LCA) were excised for histological analysis. Results - Among groups, no significant differences were seen regarding balloon injury, stent implantation success rates and platelet aggregation measurements (p>0.05). All groups had similar lipid levels (total cholesterol, triglycerides) and weight by the end of the study. Notably, 3 rabbits in the B3 group appeared with thrombotic total occlusion of the carotid stents and were excluded from morphometric analysis. None such episode was observed after CAS in ticagrelor-treated rabbits. In balloon injury rabbits, the OCT-calculated neointimal areas in RCAs were: A1: 4.20±0.96mm2, A2: 3.78±1.31mm2, p=0.781, while the mid-stent neointimal areas were: B1: 1.74±0.51mm2 and B2: 1.45±0.62mm2, p=0.654. The histological findings in balloon-injured rabbits were in agreement with those from OCT analysis, since the percentage of intima/(media + intima)(%) in RCA did not differ between groups: A1 (68.48±12.31%) vs A2 (64.22±13.22%) (p=0.812). Importantly the atherosclerotic lesions in non-injured LCAs did not differ between all groups (p>0.1). Conclusion - In atherosclerotic rabbits undergoing carotid artery balloon injury with or without stent implantation, clopidogrel and ticagrelor seemed to be equally effective in terms of neointimal formation and ISR prevention. . Importantly, ticagrelor treatment prevented thrombotic stent occlusions compared to clopidogrel treatment. Further studies are needed to clarify the impact of P2Y(12) inhibitors on carotid in-stent restenosis and thrombosis in humans.

Abstract WP16: Symptomatic Retinal Artery Occlusion After Carotid Artery Angioplasty and Stent: Incidence and Related Risk Factors

Background: Retinal arterial occlusion (RAO) is one of the rare complications developed after carotid artery angioplasty and stenting (CAS). Therefore, RAO after CAS has not well been documented yet. The aim of this study is to investigate the incidence and risk factor of symptomatic RAO after CAS, focusing on comparing the difference depending on whether ophthalmic artery (OA) before CAS was supplied from external or internal carotid artery (ECA or ICA) Method: A total of 342 patients with carotid stenosis were retrospectively reviewed, each subjected to CAS for severe and/or symptomatic stenosis from January 2009 to December 2017. Cumulative medical records and radiologic data were assessed. RAO was confirmed by fundus photography and fluorescent angiography performed by ophthalmologist. All patients were grouped by supply of OA from which artery, either ICA or ECA dominant. In all patients, distal filter systems with various types were applied as cerebral protection device (CPD) during procedure. Univariate and multivariate analyses were conducted to identify risk factors for RAO after CAS. Result: Symptomatic RAO was observed in 6 patients (1.4%), whom 5 (6.8%) were in ECA dominant group (n=74). In binary logistic regression analysis, OA supplied from ECA (OR, 15.345; 95% CI, 1.061-147.112) and older age (OR, 1.245; 95% CI, 1.035-1.498) were the significant factors related to RAO after CAS. OA supplied from ECA was associated with severity of ipsilateral ICA stenosis (p<0.001), decreased vascular reservoir (p=0.029), common carotid artery involvement (p=0.024), and ulcerative plaque (p=0.006). Conclusion: Under usage of distal filtering system on ICA as CPD, CRO after CAS for severe stenosis was related to OA supplied from ECA. In those patients with old-age, simultaneous ICA-ECA protective CPD might be helpful to prevent RAO after CAS.

Prediction of persistent hemodynamic depression after carotid angioplasty and stenting using artificial neural network model

ObjectivesTo assess and compare predictive factors for persistent hemodynamic depression (PHD) after carotid artery angioplasty and stenting (CAS) using artificial neural network (ANN) and multiple logistic regression (MLR) or support vector machines (SVM) models. Patients and methodsA retrospective data set of patients (n=76) who underwent CAS from 2007 to 2014 was used as input (training cohort) to a back-propagation ANN using TensorFlow platform. PHD was defined when systolic blood pressure was less than 90mmHg or heart rate was less 50 beats/min that lasted for more than one hour. The resulting ANN was prospectively tested in 33 patients (test cohort) and compared with MLR or SVM models according to accuracy and receiver operating characteristics (ROC) curve analysis. ResultsNo significant difference in baseline characteristics between the training cohort and the test cohort was observed. PHD was observed in 21 (27.6%) patients in the training cohort and 10 (30.3%) patients in the test cohort. In the training cohort, the accuracy of ANN for the prediction of PHD was 98.7% and the area under the ROC curve (AUROC) was 0.961. In the test cohort, the number of correctly classified instances was 32 (97.0%) using the ANN model. In contrast, the accuracy rate of MLR or SVM model was both 75.8%. ANN (AUROC: 0.950; 95% CI [confidence interval]: 0.813–0.996) showed superior predictive performance compared to MLR model (AUROC: 0.796; 95% CI: 0.620–0.915, p<0.001) or SVM model (AUROC: 0.885; 95% CI: 0.725-0.969, p<0.001). ConclusionsThe ANN model seems to have more powerful prediction capabilities than MLR or SVM model for persistent hemodynamic depression after CAS. External validation with a large cohort is needed to confirm our results.

Changes in Ocular Hemodynamics after Carotid Artery Angioplasty and Stenting (CAAS) in Patients with Different Severity of Ocular Ischemic Syndrome

ABSTRACTPurpose: To evaluate the effects of carotid artery angioplasty and stenting (CAAS) on patients who were diagnosed with ocular ischemic syndrome (OIS).Methods: Sixty-four eyes of 64 OIS patients with ipsilateral internal carotid artery stenosis ≥70% were included in the study. The study eyes were divided into two groups according to the presence of iris neovascularization: NVI-absent group and NVI-present group, with 32 eyes, respectively. All patients received ocular treatment modality according to the presence of non-perfusion area (pan-retinal photocoagulation) and intraocular pressure (medical treatment included timolol maleate eye drops combined with brinzolamide eye drop; trabeculectomy and cyclophotocoagulation). All patients went through CAAS surgery for treatment of internal carotid artery stenosis. Best-corrected visual acuity (BCVA); intraocular pressure (IOP), slit lamp examination, iris fluorescence angiography, fundus fluorescein angiography and color Doppler ultrasound of the internal carotid artery (ICA), ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (PCA) were performed pre-operatively and 1 month, 3 months, 6 months, and 12 months post-operatively.Results: There was no significant BCVA change postoperatively in the NVI-absent group, while postoperative BCVA in the INV-present group decreased significantly. There was no significant BCVA difference at pre-operative and 1month post-operative follow-up between the two groups. However, post-operative BCVA of NVI-present group starting from 3-months follow-up was significantly worse than NVI-absent group. Arm-retinal artery circulation time and arteriovenous circulation time decreased significantly in NVI-absent group, while showed no statistical difference in NVI-present group during the 12-months follow-up. Postoperative peak systolic velocity (PSV) of the ophthalmic artery, the central retinal artery, and short posterior ciliary artery showed significant increases at 1 month, 3 months, 6 months and 12 months follow-up in both groups.Conclusion: CAAS can greatly improve ocular blood in OIS patients with and without iris neovascularization. However, CAAS improved BCVA only in patients without iris neovascularization.

Staged carotid artery angioplasty and stenting for patients with high-grade carotid stenosis with high risk of developing hyperperfusion injury: a retrospective analysis of 44 cases

BackgroundHyperperfusion syndrome (HPS) is a rare but potentially a life-threatening complication after carotid artery angioplasty and stenting (CAS). Staged CAS has been an alternative to prevent HPS.Materials and methods44 of...

The Association of Publication of Center for Medicaid and Medicare Services Guidelines for Carotid Artery Angioplasty and Stenting (CAS) and CREST Results on the Utilization of CAS in Carotid Revascularization

Since the 2004 approval of carotid artery angioplasty and stenting (CAS), there have been 2 seminal publications about CAS reimbursement (Center for Medicaid and Medicare Several guidelines [CMSG]; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored trends in CAS utilization after these publications nationally. The most recent datasets of the nationwide inpatient sample (NIS) was queried for patients undergoing carotid revascularization. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three-time intervals related to CMSG and CREST publication were selected 2005-2008, 2008-2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS utilization for overall samples and for neurologically asymptomatic and symptomatic cases. The majority (95%) of the carotid revascularizations were performed on asymptomatic patients. Overall, CAS utilization constituted 12.5% of carotid revascularization procedures with a significant period increase of CAS; from 9.4% to 14%; P < 0.001. There was a small but significant decrease in the rate of CAS utilization after CMSG were published corresponding to a 2% decline in the odds ratio (OR) of CAS per quarter (OR, 0.98; 95% confidence interval, 0.97-0.99; P = 0.001). After CREST, CAS utilization continued to increase in both NIS but the rate of increase did not change significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality and postoperative stroke were independently and significantly higher for CAS patients in both overall and within the symptomatic cohorts. In all 3 periods of the study, and compared to carotid endarterectomy, the odds of mortality and postoperative stroke were significantly higher among patients who underwent CAS. Although overall utilization of CAS increased since 2005, it was not uniformly associated by the publication of CMSG or CREST. Despite increased utilization, the odds of adverse outcomes were independently higher among CAS patients.

Standards of practice and reporting standards for carotid artery angioplasty and stenting

Every year almost 800 000 people in the USA suffer a new or recurrent stroke, and stroke is the third leading cause of death with over 140 000 deaths in...

Carotid Artery Angioplasty and Stenting for Patients Less than 70 Years-of-Age

Recent studies have suggested that carotid artery angioplasty and stenting (CAS) is a safe alternative to carotid endarterectomy (CEA) in average risk patients <70 years of age. We examined a consecutive series of patients who underwent CAS in order to determine the influence of patient age on outcome. A retrospective, longitudinal cohort study of consecutive patients who underwent CAS at St. Michael's Hospital, Canada between January 2001 and November 2010 was performed. The outcome measures were 30-day stroke and 30-day composite death, stroke and acute myocardial infarction (MI). Patients were stratified based on age <70 and ≥ 70 years. One hundred and fifty-nine patients underwent 165 CAS procedures. The 30-day risk of stroke was 3.8% while the composite outcome of death/stroke/MI was 8.2%. When stratified by age <70 and ≥ 70 years, the 30-day stroke rate was 0% versus 7.4% (p=0.03), and the composite outcome of death/stroke/MI was 2.6% versus 13.6% (p=0.02), respectively. Patients <70 years of age undergoing CAS have a low rate of major complications, comparing favourably with historical CEA adverse event rates, and supporting the recent carotid stenosis literature that in the younger population CAS has a similar complication rate compared to CEA.

Treating symptomatic carotid artery disease: deciding between carotid artery stenting and carotid endarterectomy – balancing the risks

Ischemic stroke is the third leading cause of death in the USA [1,2] and is an important cause of major morbidity and mortality both in the USA and worldwide. Carotid artery disease amenable to revascularization accounts for 5–12% of new strokes [3,4]. Carotid artery angioplasty and stenting (CAS) has evolved as an alternative therapeutic option for the treatment of extracranial carotid artery occlusive disease and the concept was first introduced in 1980 by Kerber et al. [5]. The initial problems associated with carotid angioplasty included vessel recoil and dissection and have been successfully addressed with the use of stents. The problems of luminal narrowing due to external compression forces and torsion, have been greatly reduced by the use of self-expanding stents, and distal embolization has been reduced by the use of embolic protection devices. However, CAS has raised much controversy regarding its safety, efficacy and criteria for patient selection.

National Utilization and Outcome of Carotid Artery Revascularization in Octogenarians

The benefits of carotid endarterectomy (CEA) and carotid artery angioplasty and stenting (CAS) in octogenarians remain unclear. Octogenarians were excluded from seminal CEA trials. CAS may have increased complications in this patient cohort. The objective of this study was to examine the national utilization and outcome of CEA and CAS in octogenarians. The Nationwide Inpatient Sample (2004-2005) was utilized. ICD-9 codes were used to identify CEA and CAS cases. Outcomes included in-hospital stroke and death. Comparisons were performed between older and younger patients. Analysis was performed among octogenarians to identify whether improved outcomes were noted with either procedure. A total of 54,658 cases were analyzed; 10,826 were in octogenarians (19.8%). Octogenarians who underwent carotid procedures were more likely to be female (45.6% vs 41.5%, P < .001) and to die in the hospital (1.0% vs 0.6%, P < .001) than younger patients who underwent carotid procedures. There were no overall differences in the prevalence of preoperative symptoms (5.4% vs 5.3%), the use of CAS as opposed to CEA (6.0% vs 5.8%), or the overall rate of periprocedural stroke (1.1% vs 1.1%) between octogenarians and younger patients. However, asymptomatic octogenarians were more likely to undergo CAS (as opposed to CEA) than asymptomatic younger patients (10.1% vs 5.7%, P < .001). In separate analysis of octogenarians alone, it was noted that they had a significantly higher rate of periprocedural stroke with CAS than with CEA (2.2% vs 1.1%, P < .01). The increased rate of stroke with CAS as opposed to CEA was noted in both asymptomatic (1.9% vs 0.9%, P = .04) and symptomatic (5.2% vs 2.3%, P = .18) octogenarians. Nationally, octogenarians comprise nearly 20% of patients undergoing carotid revascularization procedures, despite concern regarding the benefits of these procedures in older patients, particularly when asymptomatic. In spite of additional specific concerns regarding the complication rate of CAS in patients older than 80 years of age, asymptomatic octogenarians underwent CAS as opposed to CEA significantly more frequently than younger patients. However, their periprocedural stroke rate overall was equally low when compared to younger patients. Furthermore, among octogenarians, the rate of periprocedural stroke was significantly higher with CAS than with CEA, and this remained a significant finding when asymptomatic cases were separately examined. CEA may be the treatment of choice for properly selected octogenarians, unless compelling reasons exist to perform CAS.

Interventional Management of Asymptomatic Extracranial Carotid Stenosis

Carotid artery stenosis is a major risk factor for stroke and transient ischemic attack. Although carotid endarterectomy is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS)-proven by large randomized clinical trials and rigorous registries and supported by improving stent designs, embolic protection, and increasing neurointerventionalist experience-is developing into a safer and more efficacious method of stroke prevention. Today, protected CAS is approved for symptomatic and asymptomatic patients with severe carotid stenosis with high surgical risk. We reviewed recently published data regarding new developments in the use of protected CAS, particularly in patients with carotid stenosis who are either asymptomatic or at low surgical risk.

Outcome of Carotid Artery Interventions Among Female Patients in the United States, 2004-2005

The benefit of carotid endarterectomy (CEA) in women has been questioned, particularly in asymptomatic cases, and an increased in perioperative stroke in women after CEA has been noted. The outcome of carotid artery angioplasty and stenting (CAS) has not been extensively evaluated in women. Our objective was to examine the national outcome of CEA and CAS in female patients.

Carotid Endarterectomy or Carotid Artery Stenting? Matching the Patient to the Intervention

Extracranial carotid disease accounts for approximately 25% of ischemic strokes. Although carotid endarterectomy (CEA) is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS) is continually developing into a safer and more efficacious method of stroke prevention and has gained popularity as an alternative to CEA. Recent trials have reported clinical equipoise between CEA and CAS. There are certain patient characteristics that can increase the risk of adverse outcomes for both CEA and CAS. Proper patient selection is the key to successful outcomes when deciding the optimal treatment for carotid stenosis. Patients must be individualized, and a specific risk-benefit ratio must be formulated for CEA, CAS, and best-medical therapy (BMT). Ultimately, optimizing medical therapy and using CEA and CAS as complementary therapies rather than competing ones will likely achieve the best patient outcomes.

Early outcomes after carotid angioplasty with stenting performed by neurologists.

Aims:To evaluate the results of carotid artery angioplasty and stenting (CAS) in treating extracranial carotid artery stenosis performed by neurologists in our center and compare the results with other large published series.Materials and Methods:Data for all patients who underwent CAS from January 2003 through November 2007, was retrieved from the Nanjing Stroke Registry. Perioperative and post-procedural complications within 30 days following stenting were analyzed and compared with that from other series. A total number of 75 patients were enrolled, with a mean age of 65.9 ± 8.8 years, and 64 (85.3%) of them were male.Results:Procedural success was achieved in 74 patients (98.7%). Pre-treatment stenosis was 73.8 ± 14.9 and post-treatment residual stenosis was less than 10%. Thirty-four patients (45.3%) had bilateral carotid artery disease and seven (9.3%) had tandem stenosis. The neurological complication rate was 3.9% (one major and two minor strokes). Bradycardia in four (5.3%) and hypotension in 13 (17.3%) were observed during procedures. Using the Fischer’s exact t test, the complication rate compared with the large published series did not reveal any statistically significant difference (P > 0.05).Conclusions:We conclude that neurologists, with adequate training, can develop and add this technical skill to the existing cognitive skill of vascular neurology and safely perform stenting.

Stent migration as a late complication following carotid angioplasty and stenting

A 69-year-old male patient with severe asymptomatic carotid artery stenosis was treated percutaneously with implant of two self-expandable stents in the right carotid overlapped to each other by 5 mm. The 15-month follow-up colour-Doppler ultrasound (CDU) revealed a severe stenosis in the target vessel and an image suggesting migration of the distal stent. Physical examination, laboratory test, CDU, carotid angiography, quantitative carotid angiography (QCA), brain computed tomography (CT). Migration of the distal stent associated with severe stenosis on the unsupported arterial segment. Carotid artery angiography, QCA, antithrombotic therapy, carotid artery angioplasty and stenting (CAS).

Carotid endarterectomy in high-risk Arab patients

Carotid artery angioplasty and stenting (CAS) has developed quickly and has started to replace carotid endarterectomy (CE) in high-risk cases. However, there are conflicting reports about the results of CAS in such cases. The current study was undertaken to assess the results of CE in high-risk Arab patients over two years at a single center. The study was performed on all Arab patients referred to King Fahd Hospital of the University for CE with high risk for surgery from August 2004 to August 2006. High-risk factors were recorded. The primary end points were the occurrence of stroke, myocardial infarction and death in the first 30 postoperative days and in follow-up for one year. Thirty-one CE procedures were performed in 29 high-risk Arab patients. Twenty-five patients had severe ischemic heart disease and were prepared for coronary artery bypass grafting. One patient (3%) had preoperative cardiac arrest and after resuscitation developed stroke. One patient died (3%) suddenly nine months after surgery. No recurrence or stroke was recorded over a one-year follow-up period. This short report showed that CE can be performed safely in high-risk Arab patients.

A Review of the Trials Comparing Carotid Endarterectomy and Carotid Angioplasty and Stenting

In the last decade, carotid artery angioplasty and stenting (CAS) has gained popularity as an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, particularly in patients who are at high operative risk. CAS offers the advantage of being a less invasive procedure, potentially minimizing the risks of wound complications and cranial nerve injury, which may translate into shorter length of hospitalization and less resource utilization. Since the advent of CAS, several randomized controlled trials and carotid stent registry trials have been conducted comparing the outcomes of CEA with those of CAS for the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This review will summarize the results of randomized controlled trials (CAVATAS, WALLSTENT, SAPPHIRE, EVA-3S, SPACE, and CaRESS) as well as pivotal carotid registry studies (ARCHeR, BEACH, CAPTURE, CASES-PMS, CREATE, and CABernET) intended to evaluate the safety and efficacy of CEA and CAS in treatment of carotid stenosis. In addition, it will provide a preview of the current ongoing and future trials examining the safety, applicability, and indications of CAS and CEA (CREST, CAVATAS-2, ACT 1, and TACIT).

Carotid artery stenting: Identification of risk factors for poor outcomes

Age greater than 80 has been identified as a risk factor for complications, including stroke and death, in patients undergoing carotid artery angioplasty and stenting (CAS). This study evaluates other potential predictors of perioperative complications in patients undergoing CAS. All cerebrovascular endovascular procedures performed by the vascular surgery division at our university hospital between July 2003 and December 2005 were retrospectively examined. During the course of 212 admissions, 198 patients underwent 215 procedures. Patient age, comorbidities, and admission status were analyzed as independent (predictor) variables. Complication rate, discharge disposition, and length of hospital stay were considered dependent (outcome) variables. Logistic regression and Fisher exact test or Student t test were performed, as appropriate. Complications included major and minor stroke, myocardial infarction, femoral artery pseudoaneurysm, and death. The rates of perioperative major and minor stroke were 0.5% and 2.8%, respectively. Chronic renal insufficiency was a predictor of perioperative complications, including stroke: patients with serum creatinine greater than 1.3 mg/dL had a 37% complication rate and a 11.1% stroke rate, while those with normal renal function had a 13% complication rate (P = .003) and a 0.6% stroke rate (P =.001). Similar association was seen between creatinine clearance and both stroke and complications. Obesity was a risk factor for complications, but not stroke: obese patients had a complication rate of 28%, while others had a 16% complication rate (P = .024). Emergency admission predicted both extended hospital stay (P < .001) and requirement for further inpatient care in a rehabilitation or nursing facility (P = .007). There was no significant difference in complication rate or stroke rate between octogenarians and others. This experience demonstrates that chronic renal insufficiency, obesity, and emergent clinical setting are risk factors for patients undergoing CAS.

COMPLICATIONS OF CAROTID ARTERY STENTING AT A HIGH-VOLUME TEACHING CENTER

Among neurosurgeons, cardiologists, neuroradiologists, vascular surgeons, and peripheral vascular radiologists, the metric of clinical competency in carotid artery angioplasty and stenting (CAS) continues to be debated. This review of fellowship experience with more than 200 CAS cases was undertaken to ascertain the 30-day morbidity and mortality rates at a high-volume endovascular training center with a well-established system for teaching CAS. A prospectively collected database of more than 8000 endovascular cases was culled for all patients undergoing CAS from July 2004 through February 2006, in which the primary operator was one of the current senior fellows (RDE, ES). The operative reports, hospital charts, and office notes were then reviewed for morbidity and mortality within 30 days. At 30 days, the combined rates of morbidity and mortality for each fellow were nearly identical at 4.9 and 5.9%, respectively. There were two deaths, one of which resulted from reperfusion hemorrhage and one after cardiac surgery. During the study period, six strokes and two myocardial infarctions occurred; one of the patients who had a myocardial infarction underwent coronary stenting on an emergency basis. One patient had a femoral artery occlusion requiring operative repair. At a high-volume endovascular training center with a well-established teaching pathway for CAS, morbidity and mortality rates comparable to those reported in previously published series of carotid endarterectomy were obtained.

Angiographic lesion characteristics can predict adverse outcomes after carotid artery stenting

Carotid artery angioplasty and stenting (CAS) is an evolving and increasingly common endovascular treatment for carotid artery stenosis. Risk factors associated with an increased incidence of adverse periprocedural neurologic outcomes are being recognized. The goal of this study was to determine if certain angiographic lesion characteristics were predictive of higher risks of adverse outcomes. A total of 421 patients who underwent 429 carotid artery stenting procedures between June 1996 and June 2005 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Demographic data and procedural variables were recorded, including the presence or absence of the use of a cerebral protection device. Angiograms were reviewed for the following carotid lesion characteristics: length of lesion, percentage of stenosis, ostial involvement, lesion ulceration, calcification, and presence of contralateral carotid occlusion. Periprocedural stroke and 30-day adverse event rates (stroke, myocardial infarction, and death) were recorded for each patient. The periprocedural all-stroke rate was 3.7%. Octogenarians had a higher incidence of 30-day adverse events at 10.0% vs 3.8% (P = .029). The incidence of periprocedural stroke was increased in lesions > or =15 mm long, at 17.0% (8 of 47) vs 2.1% (8 of 382; P < .001), and in ostial centered lesions, 7.1% (11 of 154) vs 1.8% (5 of 275; P = .007). Multivariate regression also identified these two variables as independently associated with 30-day stroke rate: lesion length > or =15 mm (odds ratio [OR], 6.38; 95% confidence interval [CI], 35 to 17.29) or ostial involvement (OR, 3.12; 95% CI, 3.12 to 8.36). Other variables, including lesion calcification, ulceration, degree of stenosis, or presence of contralateral occlusion, were not associated with adverse outcomes. When studied separately, the use of cerebral protection devices in 241 patients (56%) did not change our observed correlations between angiographic characteristics and adverse procedural events. Certain lesion characteristics on angiography, such as length and ostial location, can predict adverse outcomes. The indication for CAS should be carefully evaluated in these cases.