Complication Of Carotid Artery Stenting Research Articles

Uncommon Carotid Artery Stenting Complications: A Series by Images.

To describe through emblematic images rare but clinically relevant carotid artery stenting complications that occurred at two high-volume centres for carotid artery stenting (CAS). CAS is an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis in patients judged to be at high risk for CEA. CAS complications range between 1 and 9% and are higher in older patients complaining of neurological symptoms at the time of presentation. Besides periprocedural or early-after-procedure stroke, which remains the true Achilles' heel of CAS, other dramatic complications might compromise the clinical outcomes of this procedure. Five infrequent complications, out of more than 1000 CAS performed in the years 2016-2021, have been described. Among CAS complications, acute carotid stent thrombosis, rescue retrieval of a disconnected distal cerebral embolic protection device, plaque prolapse after carotid stenting, cerebral hyperperfusion syndrome (CHS), and radial artery long sheath entrapment requiring surgical intervention were found to account for 0.3% of the total number of procedures performed by operators with high CAS volume. Unusual CAS complications may infrequently occur, even in hands of expert operators. To know how to deal with such complications might help interventionalists to improve CAS performance.

Important Notes for Preventing Entrapment of Distal Filter-based Embolic Protection Device in Carotid Artery Stenting.

Failure to retrieve a distal filter-based embolic protection device (EPD) is a potential complication of carotid artery stenting. This may be caused by trapping of the proximal marker of the EPD within the stent tip marker. Maintaining an adequate distance between the two can prevent this. We examined the behavior of several stent-filter-based EPD combinations, focusing on their propensity to become trapped or disengage in vitro. Four physicians subjectively rated the force required to result in trapping using a 5-point scale. Moreover, the force required to disengage trapped devices was evaluated. The Casper stent-Spider FX EPD combination was difficult to disengage when entrapment occurred, which suggested that this phenomenon tended to occur with this combination. The stent tip marker of the closed-cell stents advanced as they shortened, which may be a unique feature of closed-cell stents. Although trapping is uncommon, it can cause serious complications. To prevent these complications, device characteristics should be well understood before they are used in patients.

Karotid Arter Darlık Oranı ile Perioperatif Stent Komplikasyonları İlişkisi

Objective: This study aimed to examine complications that may occur after carotid artery stenting (CAS) and their relationships with carotid artery stenosis rate.
 Materials and Methods: Complications, such as cerebral hyperperfusion, stroke, death, stent thrombosis or occlusion and restenosis, were evaluated on the 30th day after CAS and at the end of the first year. 
 Results: Of the 205 CAS procedures, complications developed in 12 patients. The complication rate for the first 30 days after the procedure was 4,87%, and at the end of the first year, it was 5,85%. Of the 12 patients with complications, 8 had carotid stenosis of ≥90%. Death occurred in 4 of 195 patients with carotid artery stenosis. The mortality rate within the first 30 days and during the 1-year follow-up period was 1,53% and 2,05%, respectively. Ischemic stroke occurred in 6 of 195 patients with carotid artery stenosis. After the first 30 days and one year follow-up, ischemic stroke had occurred in 3,07% of patients. Stent thrombosis and occlusion rate was 4,87% in 205 CAS procedures, and 7 of them occurred in the first 24 hours and another 3 occurred within the first 30 days. Restenosis rates were 0,48% and 0,97% at 6 months and the first year, respectively. 
 Conclusion: The complications of CAS have been associated with the urgency of treatment (emergency), symptom presence (symptomatic patients) and high degree of stenosis (≥90%); whereas bilateral stenosis is not associated with complications. In addition, stent thrombosis and occlusion were observed as the most common CAS complication.

The efficacy and safety of carotid stenting under dual antiplatelet therapy with ticagrelor and acetylsalicylic acid

Aim: To prevent thrombotic complications in carotid artery stenting (CAS), it is recommended to use acetylsalicylic acid (ASA) and clopidogrel for at least one month, followed by single antiplatelet therapy. The number of studies on the use of ticagrelor in CAS is very few. We aimed to evaluate the efficacy and safety of ticagrelor in CAS in this study.Methods: The records of the patients who underwent CAS between January 2020 and January 2022 were scanned and the patients who were treated with the ASA and ticagrelor therapy were included in this study. Demographic data of the patients, vascular risk factors, ipsilateral-contralateral stenosis rates, balloon angioplasty application status, residual stenosis rates, periprocedural ischemic and hemorrhagic events, and vascular events developed during three-month follow-up were noted.Results: Thirteen patients were included in the present study. Their mean age was 69.38±7.1 years. The mean carotid stenosis rate was 82.07±10.44%, and contralateral stenosis rate was 65.07±32.98%. Stent thrombosis was not observed in any patient. After the procedure, minor ischemic stroke that did not cause disability developed in one patient and puncture site bleeding that did not require transfusion in one patient. One patient had >50% restenosis at three months.Conclusion: The findings suggest that dual antiplatelet therapy with ticagrelor + ASA appears to be a safe and effective treatment for CAS. Given that clopidogrel resistance cannot be evaluated in many centers, it may be more accurate to prefer ticagrelor, especially in high-risk patients with bilateral stenosis.

Intolerance to occlusion during carotid artery stenting with proximal protection: causes, mechanisms, treatment and prevention.

Periprocedural cerebral microembolization is the most important complication of carotid artery stenting. Among several variables that play a role to reduce this risk, brain protection (proximal vs. distal) plays a pivot role. Data are accumulating in favor of a better performance of proximal vs. distal especially in symptomatic patients and high-risk carotid plaques. A prerequisite for the technique to be safe and effective is the presence of a valid intracranial collateral circulation to compensate for the target vessel hemisphere avoiding patient intolerance. This complication may occur either soon after the common carotid balloon occlusion or slowly developing during the procedure peaking at the stent post-dilation step. While Willis' circle anatomic variants are the most frequent cause of acute intolerance, a mix of anatomic, hemodynamic and patient cerebral condition play a role for the late developing form. Prevention is the best treatment of intolerance through a pre- and procedural imaging with different techniques (CT angiography, NMR angiography, transcranial Doppler assessment, digital subtraction angiography and back pressure monitoring).

Treatment results of carotid artery stenting in a developing country

The purpose of this study was to investigate the details of minor complications of carotid artery stenting in a developing country. This was a retrospective, single-center study conducted on the target group consisting of 65 symptomatic patients who underwent carotid artery stenting. We assessed technical success rate, periprocedural complication within 30 days (hypotension, bradycardia, acute kidney injury, vasospasm, a transient ischemic attack, stroke, myocardial infarction, and death), and the differences between groups with and without complications. Minor periprocedural complications occurred in 15 patients. In all, 8 (12.3%) had transient hypotension, 6 (9.2%) had bradycardia, 7 (10.7%) had acute kidney injury, 2 (3.1%) had vasospasm, and 1 (1.5%) had transient ischemic attack. A greater rate of minor complications was observed in women (p=0.051). The results of the carotid artery stenting procedures performed in a developing country were acceptable.

Diabetes Mellitus and Clinical Outcomes in Carotid Artery Revascularization Using Second-Generation, MicroNet-Covered Stents: Analysis from the PARADIGM Study.

Introduction Carotid artery stenting (CAS) using conventional (single-layer) stents is associated with worse clinical outcomes in diabetes mellitus (DM) vs. non-DM patients: an effect driven largely by lesion-related adverse events. CAS outcomes with MicroNet-covered stents (MCS) in diabetic patients have not been evaluated. Aim To compare short- and long-term clinical outcomes and restenosis rate in DM vs. non-DM patients with carotid stenosis treated using MCS. Materials and Methods In a prospective study in all-comer symptomatic and increased-stroke-risk asymptomatic carotid stenosis, 101 consecutive patients (age 51-86 years, 41% diabetics) underwent 106 MCS-CAS. Clinical outcomes and duplex ultrasound velocities were assessed periprocedurally and at 30 days/12 months. Results Baseline characteristics of DM vs. non-DM patients were similar except for a higher prevalence of recent cerebral symptoms in DM. Type 1 and type 1+2 plaques were more prevalent in DM patients (26.7% vs. 9.8%, p = 0.02; 62.2% vs. 37.7%, p = 0.01). Proximal embolic protection was more prevalent in DM (60% vs. 36%; p = 0.015). 30-day clinical complications were limited to a single periprocedural minor stroke in DM (2.4% vs. 0%, p = 0.22). 12-month in-stent velocities and clinical outcomes were not different (death rate 4.8% vs. 3.3%; p = 0.69; no new strokes). Restenosis rate was not different (0% vs. 1.7%, p = 0.22). Conclusions MCS may offset the adverse impact of DM on periprocedural, 30-day, and 12-month clinical complications of CAS and minimize the risk of in-stent restenosis. In this increased-stroke-risk cohort, adverse event rate was low both in DM and non-DM. Further larger-scale clinical datasets including extended follow-ups are warranted.

Vasoconstriction and hyperperfusion syndrome after carotid artery stenting

BackgroundCommon complications of carotid artery stenting (CAS) are cerebral ischemia and hyperperfusion syndrome. To date, only a few cases of late-onset cerebral vasoconstriction occurring several hours after CAS have been reported. However, there are no reports of developed vasoconstriction and hyperperfusion syndrome.Case presentationA 79-year-old man developed vasoconstriction 1 day after carotid artery stenting. Vasoconstriction improved immediately with glucocorticoid. However, a week later, the patient developed hyperperfusion syndrome.ConclusionsPostoperative vasoconstriction and hyperperfusion syndrome is an unrecognized complication and surgeons should be aware of it.

Predictive values of carotid high-resolution magnetic resonance imaging for large embolus shedding in carotid artery stenting.

Embolus shedding is one of the important complications in carotid artery stenting (CAS). Carotid high-resolution magnetic resonance imaging (HR-MRI) is often used to directly reflect important biological characteristics, such as plaque size and composition, as well as the structure of the carotid artery wall. The aim of this study was to investigate the predictive values of carotid HR-MRI for large embolus shedding in CAS. In total, 195 patients with carotid stenosis were enrolled. Preoperative carotid HR-MRI was performed to define the nature of the carotid plaques. CAS was performed in all patients, and intraoperative embolic protection devices were used to collect the shed emboli. According to the diameter and number of shed emboli, the patients were divided into the small-embolus group (group X) and largeembolus group (group Y). Logistic regression analysis was used to analyze the risk factors of large embolus shedding. Group Y included 58 patients, and group X included 137 patients. Age, stenosis length, smoking, and ≥3 transient cerebral ischemic attacks were risk factors for large embolusshedding. Two cases of shed large emboli developed from stable plaques, and 56 cases of large emboli developed from vulnerable plaques. When vulnerable plaques were associated with more risk factors, the incidences of large embolus shedding in cases with vulnerable plaques combined with 0, 1, 2, 3, and 4 risk factors were 44 % (4/9), 68.1% (15/22), 72.2% (13/18), 76.5% (13/17), and 84.6% (11/13), respectively. Carotid HR-MRI can predict the incidence of large embolus shedding in CAS.

A retrospective study on the preventive effect of statin after carotid artery stenting.

This retrospective study appraised the preventive effect of statin after carotid artery stenting (CAS).Records were extracted for 100 patients with CAS surgery indicator, aged between 20 and 75 years old, and treated for statin. The cohort study included treatment group (statin and routine treatment) and control group (routine treatment), each group 50 patients. Outcomes consisted of degree of nerve defect (as measured by National Institute of Health Stroke Scale), lipid profiles (mg/dL), and CAS complications within 30 days after surgery.After treatment, there were no significant differences in National Institute of Health Stroke Scale, lipid profiles, and mortality rate between 2 groups. However, significant differences in total cholesterol (mg/dL, P = .03), low-density lipoprotein (mg/dL, P = .01), transient ischemic attack (P = .03), ischemic stroke (P = .04), and cardiac complications (P = .03) were identified within 30 days after CAS between 2 groups.The results of this study showed that prior statin treatment may be effective for the prevention of CAS complications.

Efficacy of Carotid Artery Stenting Performed under General Anesthesia with Somatosensory Evoked Potential Monitoring

ObjectivesDuring carotid artery stenting (CAS), hemodynamics may be affected by the carotid sinus reflex in some cases. Although general anesthesia has been reported to stabilize intraoperative hemodynamics, the patient's neurological condition must be assessed indirectly. Therefore, we investigated the changes in intraoperative hemodynamics and perioperative complications of CAS under general anesthesia and evaluated the efficacy of somatosensory evoked potential (SEP) monitoring in detecting a reduction in perfusion during CAS. Materials and methodsFrom April 2011 to August 2016,57 consecutive patients who underwent CAS under general anesthesia were evaluated. The follow-up period ranged from 3 to 8 years. During CAS, anesthesiologists monitored and managed the hemodynamics. SEP monitoring was performed during the CAS procedure in all patients. ResultsIntraoperative hypotension (systolic blood pressure ≤ 100 mmHg) was evident in 16 patients (28.1%), and 13 patients (22.8%) experienced intraoperative bradycardia; however, all of these cases were promptly managed under general anesthesia. None of the patients showed systolic blood pressure < 50 mmHg from baseline. Regarding perioperative complications, none of the patients exhibited myocardial infarction or postoperative hyperperfusion symptoms, and there was no mortality. Among 21 patients (36.8%) with a decrease in the intraoperative SEP, 3 (5.3%) exhibited transient ischemic symptoms and 1 (1.8%) had postoperative infarction. ConclusionsCAS under general anesthesia is a safe and effective management option in terms of intraoperative hemodynamic stability. In addition, our findings indicate that SEP monitoring could be helpful in evaluating transient postoperative cerebral ischemia or cerebral infarction after CAS.

Isolated Intraventricular Hemorrhage after Carotid Artery Stenting

Cerebral intraventricular hemorrhage (IVH) is an extremely rare complication of carotid artery stenting (CAS). Fully dilated terminal arteries of a chronic, severely stenosed proximal artery could be ruptured by impaired autoregulation of cerebral blood flow. Hyperperfusion syndrome can occur even if there is no blood pressure fluctuation during the CAS. We report a case of an isolated IVH that occurred hours after CAS.

Predisposing Factors and Management of Hemodynamic Depression Following Carotid Artery Stenting.

Carotid artery stenting (CAS) involves dilatation of carotid bulb which can trigger a series of neuronal responses resulting in hemodynamic depression that might influence the outcome of the procedure. This is a frequent but underdiagnosed complication of CAS. Although it is mild, transient and self-limiting in majority of cases, it can result in significant morbidity and mortality if persistent. Neurologists should be aware of the predisposing factors and management of this common complication. In patients who present with stroke following carotid stenting, neurologists should be aware of hypoperfusion secondary to hemodynamic depression as a cause of stroke apart from the stent thrombosis and occlusion.

Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study

BackgroundCarotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis.MethodsBetween July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose.ResultsThe overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919).ConclusionsStatin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

Initiative to Prevent Perioperative Complications of Carotid Artery Stenting

Initiative to Prevent Perioperative Complications of Carotid Artery Stenting

Predictive values of carotid high-resolution magnetic resonance imaging for large embolus shedding in carotid artery stenting

Embolus shedding is one of the important complications in carotid artery stenting (CAS). Carotid high-resolution magnetic resonance imaging (HR-MRI) is often used to directly reflect important biological characteristics, such as plaque size and composition, as well as the structure of the carotid artery wall. The aim of this study was to investigate the predictive values of carotid HR-MRI for large embolus shedding in CAS. In total, 195 patients with carotid stenosis were enrolled. Preoperative carotid HR-MRI was performed to define the nature of the carotid plaques. CAS was performed in all patients, and intraoperative embolic protection devices were used to collect the shed emboli. According to the diameter and number of shed emboli, the patients were divided into the small-embolus group (group X) and large-embolus group (group Y). Logistic regression analysis was used to analyze the risk factors of large embolus shedding. Group Y included 58 patients, and group X included 137 patients. Age, stenosis length, smoking, and ?3 transient cerebral ischemic attacks were risk factors for large embolus shedding. Two cases of shed large emboli developed from stable plaques, and 56 cases of large emboli developed from vulnerable plaques. When vulnerable plaques were associated with more risk factors, the incidences of large embolus shedding in cases with vulnerable plaques combined with 0, 1, 2, 3, and 4 risk factors were 44 % (4/9), 68.1% (15/22), 72.2% (13/18), 76.5% (13/17), and 84.6% (11/13), respectively Conclusion: Carotid HR-MRI can predict the incidence of large embolus shedding in CAS.

Application of spectral CT in the diagnosis of contrast encephalopathy following carotid artery stenting: a case report

BackgroundContrast encephalopathy is a rare complication of carotid artery stenting (CAS). Contrast encephalopathy is a diagnosis of exclusion that often needs to be distinguished from high perfusion syndrome, cerebral haemorrhage, subarachnoid haemorrhage (SAH), cerebral infarction and so on.Case presentationIn this study, we report on a 70-year-old man who was admitted to the hospital with transient ischaemic attacks presenting paroxysmal weakness of limbs in the previous 2 years. He had severe stenosis of the left internal carotid artery diagnosed by digital subtraction angiography (DSA) and underwent CAS. Two hours after the operation, the patient developed paralysis of the right upper limb, unclear speech, fever and restlessness. Emergency skull computed tomography (CT) showed swelling and a linear high-density area in the left cerebral hemisphere. To clarify the components of this high-density area in the traditional CT, the patient had spectral CT, which made the diagnosis of the leakage of contrast clear. After 1 week of supportive treatment, the patient improved.ConclusionsSpectral CT can easily distinguish the components of high-density areas on traditional CT, which is haemorrhage, calcification or iodine contrast leakage. Therefore, spectral CT is worth consideration for the differential diagnosis of complications of vascular intervention.

Risk factors and impact of postoperative hypotension after carotid artery stenting in the Vascular Quality Initiative

ObjectiveHypotension is a frequent complication of carotid artery stenting (CAS). Although common, its occurrence is unpredictable, and association with adverse events has not been well defined. The aim of this study was to identify predictors of postoperative hypotension after CAS and the association with stroke/transient ischemic attack (TIA), major adverse cardiac events (MACEs), increased length of stay (LOS), and in-hospital mortality. MethodsThis is a retrospective analysis of all CAS procedures, including transfemoral CAS (TF-CAS) and transcarotid artery revascularization (TCAR), performed in the Vascular Quality Initiative between 2003 and 2018. The primary study end point was postoperative hypotension, defined as hypotension treated with continuous infusion of a vasoactive agent for ≥15 minutes. Secondary end points included any postoperative neurologic events (stroke/TIA), MACEs (myocardial infarction, congestive heart failure, and dysrhythmias), prolonged LOS (>1 day), and in-hospital mortality. Patients' demographics predictive of hypotension were determined by multivariable logistic regression, and a risk score was developed for correlation with outcomes. ResultsDuring the time period of study, 24,699 patients underwent CAS; 19,716 (80%) were TF-CAS, 3879 (16%) were TCAR, and 1104 (4%) were not defined. Fifty-six percent were for symptomatic disease, 75% were for a primary atherosclerotic lesion, and 72% were performed under local or regional anesthesia. Postoperative hypotension occurred in 15% of TF-CAS and 14% of TCAR patients (P = .50). Patients with hypotension (vs no hypotension) had higher rates of stroke/TIA (7.3% vs 2.6%; P < .001), MACEs (9.6% vs 2.1%; P < .001), prolonged LOS (65% vs 28%; P < .001), and in-hospital mortality (2.9% vs 0.7%; P < .001). By multivariable analysis, risk factors associated with hypotension included an atherosclerotic (vs restenotic) lesion (odds ratio, 2.2; 95% confidence interval, 2.0-2.4; P < .001), female sex (1.3 [1.2-1.4]; P < .001), positive stress test result (1.3 [1.2-1.4]; P < .001), age 70 to 79 years (1.1 [1.1-1.3]; P < .002), age >80 years (1.2 [1.1-1.4]; P < .001), history of myocardial infarction or angina (1.3 [1.2-1.4]; P < .001), and an urgent (vs elective) procedure (1.1 [1.0-1.2]; P < .01). A history of hypertension was protective (0.9 [0.8-0.9]; P < .02). A normalized risk score for hypotension was created from the multivariable model. Increasing risk scores correlated directly with rates of adverse events, including postoperative stroke/TIA, MACEs, increased LOS, and increased in-hospital mortality. ConclusionsHypotension after CAS is associated with adverse neurologic and cardiac events as well as with prolonged LOS and in-hospital mortality. A scoring tool may be valuable in stratifying patients at risk. Interventions aimed at preventing postoperative hypotension may improve outcomes with CAS.

Very Low Rate of New Brain Lesions After Vulnerable Carotid Artery Stenting Cases Using Only FilterWire EZ as Distal Embolic Protection

Although carotid artery stenting (CAS) has been widely acknowledged as an effective alternative option for patients at high risk of carotid endarterectomy, embolic stroke is a major complication of CAS. Several reports have emphasized that distal protection filter alone is associated with a high risk of embolic complications of CAS with vulnerable plaque. Thus, relatively complicated protection systems have recently been recommended to prevent distal embolic complications. However, those protection systems require many steps, which, themselves, can also cause complications. The FilterWire EZ embolic protection device (EPD) for use in CAS was approved for national health insurance coverage in Japan in 2010. Since then, we have been using it as an EPD in all CAS procedures, even those with vulnerable plaque. The medical records of 80 patients who had undergone CAS from February 2014 to September 2019 at Moriyama Memorial Hospital were retrospectively reviewed. Emergent cases with distal mechanical thrombectomy were not included. We enrolled patients whose target lesion was vulnerable as evaluated by magnetic resonance imaging and who had undergone diffusion-weighted imaging studies the next day. Of the 80 patients, 60 had met the inclusion criteria. No symptomatic embolic complications developed, and only 5 patients (8.3%) had shown new lesions on diffusion-weighted imaging after CAS. The rate of new lesions after CAS with vulnerable plaque was much lower than that in previous studies. We meticulously analyzed the data to determine the predictive factors. The FilterWire EZ as an EPD for CAS is quite safe, even for vulnerable carotid stenosis.

Carotid Artery Stenting and Its Impact on Cognitive Function: A Prospective Observational Study.

PurposeCarotid artery stenting (CAS) has evolved as a first-line therapeutic option for carotid revascularization in indicated patients for stroke prevention, but there is still a lack of data on its effect on cognitive function (CF), especially among Indian patients. To determine the effect of CAS on CF and to study the immediate and delayed complications of CAS in Indian patients.Materials and MethodsThis was a prospective, observational, single-center study. CF was assessed using Addenbrooke’s cognitive examination version III (ACE) before and 3 months after stenting. The demographic and clinical parameters were also assessed. A follow-up evaluation after 3 months was done to compare CF and to observe the occurrence of any complications.ResultsOut of 31 patients, 3 were lost to follow up. There were no immediate or delayed procedure-related complications. There was a statistically significant improvement in overall ACE score and memory before and after stenting. On subgroup analysis of those with and without strokes, there was a significant improvement in visuospatial function and mean ACE score. Those with left CAS had significant improvement in memory, visuospatial, language, and ACE scores than right CAS.ConclusionCAS was associated with significant improvement in CF in patients.