Efficacy Of Carotid Artery Stenting Research Articles

Navigating complexity with low-crossing profile dual-layer micromesh carotid stent: implications for contemporary carotid artery stenting outcomes (ROADSAVER study insights).

The safety and efficacy of carotid artery stenting (CAS) can be affected by certain technical and anatomical factors. However, it is not known whether the use of a dual-layer micromesh stent (DLMS) with a low-crossing profile could reduce the risks associated with complex vascular anatomies during CAS. This study involved 1965 asymptomatic or symptomatic carotid artery stenosis patients who received the Roadsaver DLMS during CAS, as part of a prospective, multicenter observational ROADSAVER study, conducted from January 2018 to February 2021. The primary outcome was the 30-day rate of major adverse events (MAE; i.e. any death or stroke) after CAS. Procedural details and outcomes were compared between patients with complex anatomical features and those without. One or more complex anatomical characteristics were identified in 1639 (83.4%) patents. Patients with complex anatomies were older and had a higher prevalence of arterial hypertension, cardiovascular disease, and prior stroke. Between patients with or without complex anatomical features, no significant differences were found either in procedural techniques, or in 30-day MAE (age-adjusted odds ratio (95% CI) for complexities vs. no complexities: 0.76 (0.35, 1.66); p=0.4905) and any stroke (age-adjusted odds ratio (95% CI) for complexities vs. no complexities: 0.89 (0.37, 2.17); p=0.8032) incidence. Furthermore, neither the presence of specific types of anatomic complexity nor their number (per patient) markedly influenced the 30-day MAE and any stroke incidence. In this real-world cohort of patients undergoing CAS with the Roadsaver DLMS, no significant difference in the occurrence of 30-day MAE and any stroke was observed between patients with or without high-risk anatomical features.

Evaluation of the efficacy of Wall Shear Stress in Carotid Artery Stenting

To characterize the value of carotid wall shear stress (WSS) following carotid artery stenting (CAS) in patients with carotid stenosis. Twenty-eight patients with carotid stenosis treated with CAS between March 2021 to May 2022 in the eighth medical center of the PLA General Hospital were selected for our study. Carotid ultrasound was performed before the operation, one week post-operation, and six months post-operation. Carotid artery WSS was detected by blood flow vector imaging, and the changes in WSS before and after the operation were collected. Genetic testing of drugs was detected for patients with restenosis. Pre-operative WSS of the proximal, narrowest region, and distal carotid arteries in patients with ischemic carotid artery stenosis was 7.88±3.18Pa, 14.36±6.66Pa, and 1.55±1.15Pa, respectively. Comparatively, pre-operative WSS of the proximal, narrowest region and distal carotid arteries in patients without ischemic symptoms was 5.02±1.99Pa, 9.68±4.23Pa, and 1.10±0.68Pa, respectively, with a significant difference between the two groups (p<0.001). Overall WSS of the proximal, narrowest region, and distal carotid arteries in patients before CAS was 6.68±3.0Pa, 12.47±5.98Pa, and 1.39±0. 96Pa. WSS of the proximal, narrowest region, and distal carotid was 4.15±1.42Pa, 6.71±2.64Pa, and1.86±1.13Pa one week after CAS, compared to 4.44±1.91Pa, 7.90±4.38Pa, and 2. 36±1.09Pa six months after CAS. WSS of the proximal and narrowest region of the carotid artery was reduced after carotid stenting, and the difference was statistically significant (p<0.001). There was no statistically significant difference in WSS between one week and six months after stenting (P>0.05). We employed early carotid WSS as a means of evaluating the efficacy of carotid artery stenting. Changes in carotid WSS are closely associated with carotid artery stenosis, providing valuable hemodynamic information for CAS treatment. This technique holds great application value in pre-operative evaluation and long-term follow-up.

Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis.

Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

The Safety and Long-Term Efficacy of Carotid Artery Stenting: An All-Comers Registry.

Background Carotid artery stenting (CAS) has emerged as a less invasive alternative to carotid endarterectomy (CEA) for the prevention of future cerebrovascular events in patients with carotid artery stenosis. Despite multiple randomized controlled trials (RCTs) comparing CAS and CEA for carotid disease, real-world data outside the rigorous environment of trials is scarce. Methods The present study is a prospectiveobservational study conducted at a tertiary care center, wherein all patients who underwent CAS between January 2007 and December 2019 were included. All patients were followed up for one year of the last enrolled patient at an interval of one, six, and 12 months and then yearly thereafter. The primary composite outcome was defined as a combination of periprocedural (until 30 days of procedure) major adverse cardiac and cerebrovascular events (MACCEs) and the long-term incidence of ipsilateralstroke. The secondary outcome included the rate of restenosis. Results A total of 115 patients (86 males and 29females) (147 lesions) who underwent CAS between 2007 and 2019 were followed up for a median of 80.5 months. Seventy-seven (67.27%) patients were symptomatic, and 38/115 (33%) were asymptomatic. PeriproceduralMACCEs were noted in six patients, and four patients had ipsilateral stroke on long-term follow-up; hence, the primary composite outcome was observed in 10 (8.7%) patients. Higher age was found to be significantly associated with the primary composite outcome (p-value = 0.005). Five (4.34%) patients were lost to follow-up, while four (3.48%) patients developed restenosis. Conclusion CAS is a safe and less invasive intervention in patients with significant carotid artery stenosis and is equally effective in preventing future strokes. The incidence of primary outcome rises with an increase in age.

Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke

BackgroundDouble-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion.MethodsWe retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months.ResultsIn 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0–2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%.ConclusionThe CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting.

Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting. We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up. We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p < 0.001) and use of general anesthesia (19% vs. 4%, p = 0.001) than elective CAS. There were no significant differences between emergency and elective CAS in the primary (5.7% vs. 1%, p = 0.161) and secondary (9% vs. 4.8%, p = 0.232) outcomes. We did not find differences in the rate of restenosis/occlusion (7% vs. 11.6%; log-rank test p = 0.3) at a median of 13 months follow-up. In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

The CRP/albumin ratio: a novel predictor of in-stent restenosis after carotid artery stenting

Abstract Background In-stent restenosis (ISR) remains a potential problem and raises concerns about the long-term safety and efficacy of carotid artery stenting (CAS). As inflammation has a pivotal role in the pathogenesis of ISR, a novel and more sensitive inflammatory marker, CRP/albumin ratio (CAR) may be used to predict ISR in patients undergoing CAS. Purpose The present study aimed to assess the predictive value of preprocedural C-reactive protein/albumin ratio (CAR) for ISR after CAS. Method In this retrospective study, 206 patients who underwent successful CAS procedure in a tertiary heart centre were included. For each patient, both C-reactive protein (CRP) and serum albumin were determined before the index procedure. The CAR was calculated by dividing serum CRP by serum albumin level. The main end-point of the study was ISR during long-term follow-up. Results ISR developed in 34 (16.5%) out of 206 patients after a mean follow-up of 24.2±1.5 months. The CAR was significantly elevated in patients with ISR compared to those who were not (0.99 [1.3] vs. 0.15 [0.2], p&amp;lt;0.01, respectively). In a multivariate Cox regression analysis, the CAR was an independent predictor of ISR (HR: 1.85, 95% CI: 1.29–2.64, p&amp;lt;0.01). A ROC curve analysis revealed that the optimal value of CAR in predicting ISR was &amp;gt;0.53 with a sensitivity of 100% and a specificity of 97.1% [area under curve (AUC) 0.98, p&amp;lt;0.001]. Conclusion The present study demonstrated that CAR, a new inflammatory-based index, is a strong independent predictor of ISR after CAS. As a simple and easily accessible parameter, this index may be used for the assessment of ISR in patients who are treated with CAS. Funding Acknowledgement Type of funding source: None

Efficacy and safety of carotid artery stenting: Experience of a single center.

Moderate and severe carotid artery stenosis in the internal carotid artery causes 10% to 15% of all strokes. The aim of this study was to evaluate the safety and short-term efficacy of carotid artery stenting (CAS) performed at a tertiary referral center. The records of patients who underwent CAS between January 2017 and May 2018 at a tertiary care center were analyzed retrospectively and a total of 145 patients were included in the study. The mean age of the patients was 70.1±8.6 years, 75.2% of the study group was male, and 37.9% had hypertension. Of the patients evaluated, 81 (55.9%) were classified as symptomatic and 64 (44.1%) were classified as asymptomatic. A percutaneous coronary intervention was performed after CAS more often in symptomatic patients (38.9%), while it was observed at the same rate both before (25.9%) and after (25.9%) CAS in the asymptomatic group, but the difference between the groups was not statistically significant. A distal embolic protection device (EPD) was used in symptomatic patients (59.2%) and in the asymptomatic group (78.7%); however, a proximal EPD was used significantly more often in symptomatic patients (45.6%) compared with asymptomatic patients. No patient death was recorded while in hospital, and stroke/transient ischemic attack (TIA) development was observed in 5 (3.4%) patients. Stroke was seen in 2 patients (2.4%) and TIA in 3 patients (3.7%) in the symptomatic group; TIA or stroke was not seen in the asymptomatic group. The results of this study revealed that CAS was a safe and practical procedure with an acceptable complication rate. In the appropriate patients, experienced interventionists can achieve good results when aggressive risk modification is applied and an EPD and optimal medical therapy are used.

Long-term Outcomes of Carotid Artery Stenting: A Single-center Experience.

The long-term prophylactic effect of carotid artery stenting (CAS) remains incompletely elucidated. We evaluated outcomes of CAS at our institution to determine the safety and efficacy of CAS in real-world settings. We retrospectively analyzed 73 patients who underwent CAS from 2006 to 2013. Periprocedural results were compared between asymptomatic and symptomatic carotid stenosis groups. The primary endpoint was a composite of ipsilateral stroke, death, and carotid artery restenosis beyond 30 days and within 5 years after the first procedure. The average age was 72.2 years with a majority of male subjects (84.9%). Twenty-seven patients (37%) were asymptomatic. Incidence of periprocedural adverse events and mRS ≤2 at 30 days after CAS were not significantly different between groups (P = 0.14 and 0.07, respectively). CAS was unsuccessful in three patients and one post-procedural minor stroke occurred. Therefore, 69 patients were included in the long-term study. The rate of occurrence of the primary endpoint was 21.7%. Ipsilateral ischemic stroke occurred in one patient, which was due to cardiogenic embolus. Nine patients died, and cancer was the most frequent cause. Five in-stent restenoses were observed. All patients with restenosis underwent additional CAS without any occurrence of stroke. This study revealed the safety and long-term efficacy of CAS in a real-world setting. Routine follow-up is also important for detecting carotid artery restenosis.

Clinical efficacy and safety of statin treatment after carotid artery stenting

Objective The randomized controlled trail was carried out to investigate the influence of statin pre-treatment on clinical efficacy of carotid artery stenting (CAS). Methods 160 eligible patients were randomly divided into statin group (n = 82) and control group (n = 78). The patients in statin group received 40 mg atorvastatin daily 7 days before operation. Major endpoints included transient ischemic attack (TIA), stroke, death, myocardial infarction (MI), and other cardiac adverse events within 30 days after CAS. Results Preoperative baseline information was similar between the statin and control groups (p > 0.05 for all). Within 48 h after operation, the occurrence rate of CIN (3.66% vs 8.97%, p = .019) and new infarction (4.88% vs. 14.10%, p = .045) were significantly lower in statin group than in control group. 30 days after CAS, the incidences of TIA (12.20% vs. 26.92%, p = .018), ischemic stroke (6.10% vs. 16.67%, p = .034), and other cardiac complications (7.32% vs. 19.23%, p = .026) were also significantly lower in statin group, than in the control group. Multiple analysis demonstrated that statin use exerted protective effect against ischemic stroke (OR = 0.038, 95% CI = 0.003–0.543, p = .016) and other cardiac complications (OR = 0.208, 95%CI = 0.063–0.694, p = .011). Conclusion Pre-treatment with statin is an effective and safe strategy to prevent from perioperative complications and to improve postoperative outcomes in patients undergoing CAS.

Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data

The risk of periprocedural stroke or death is higher after carotid artery stenting (CAS) than carotid endarterectomy (CEA) for the treatment of symptomatic carotid stenosis. However, long-term outcomes have not been sufficiently assessed. We sought to combine individual patient-level data from the four major randomised controlled trials of CAS versus CEA for the treatment of symptomatic carotid stenosis to assess long-term outcomes. We did a pooled analysis of individual patient-level data, acquired from the four largest randomised controlled trials assessing the relative efficacy of CAS and CEA for treatment of symptomatic carotid stenosis (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial, Stent-Protected Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy trial, International Carotid Stenting Study, and Carotid Revascularization Endarterectomy versus Stenting Trial). The risk of ipsilateral stroke was assessed between 121 days and 1, 3, 5, 7, 9, and 10 years after randomisation. The primary outcome was the composite risk of stroke or death within 120 days after randomisation (periprocedural risk) or subsequent ipsilateral stroke up to 10 years after randomisation (postprocedural risk). Analyses were intention-to-treat, with the risk of events calculated using Kaplan-Meier methods and Cox proportional hazards analysis with adjustment for trial. In the four trials included, 4775 patients were randomly assigned, of whom a total of 4754 (99·6%) patients were followed up for a maximum of 12·4 years. 21 (0·4%) patients immediately withdrew consent after randomisation and were excluded. Median length of follow-up across the studies ranged from 2·0 to 6·9 years. 129 periprocedural and 55 postprocedural outcome events occurred in patients allocated CEA, and 206 and 57 for those allocated CAS. After the periprocedural period, the annual rates of ipsilateral stroke per person-year were similar for the two treatments: 0·60% (95% CI 0·46-0·79) for CEA and 0·64% (0·49-0·83) for CAS. Nonetheless, the periprocedural and postprocedural risks combined favoured CEA, with treatment differences at 1, 3, 5, 7, and 9 years all ranging between 2·8% (1·1-4·4) and 4·1% (2·0-6·3). Outcomes in the postprocedural period after CAS and CEA were similar, suggesting robust clinical durability for both treatments. Although long-term outcomes (periprocedural and postprocedural risks combined) continue to favour CEA, the similarity of the postprocedural rates suggest that improvements in the periprocedural safety of CAS could provide similar outcomes of the two procedures in the future. None.

Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience

Purpose: To evaluate the safety and efficacy of carotid artery stenting (CAS) performed without an embolic protection device (EPD) in a selected group of asymptomatic patients with primary internal carotid artery (ICA) stenosis or restenosis after carotid endarterectomy (CEA). Materials and Methods: Between May 2015 and May 2018, 77 patients (mean age 77 years; 60 men) underwent CAS without any embolic protection device. Forty-seven (61%) patients had primary ICA stenosis and were excluded from CEA because of high surgical risk; the other 30 (39%) patients had post-CEA restenosis (n=26) or a distal ICA flap after eversion CEA (n=4). The mean ICA stenosis was 82%. All procedures were performed from a femoral artery access. Pre- and/or postdilation were used in 64 patients. The primary outcome was the incidence of major complications (death, stroke, or myocardial infarction) during the procedure and within 30 days; the secondary outcome was the incidence of restenosis in follow-up. Results: No relevant bradycardia was encountered during CAS. The combined rate of stroke, death, or myocardial infarction at 30 days was 1.3%. The single stroke patient recovered fully after 2 months. Over a follow-up that ranged to 3 years (mean 24±18 months), no further neurological events were recorded. One (1.3%) patient had a >70% restenosis after 6 months; the lesion was dilated, successfully restoring the lumen contour. Conclusion: In our series, endovascular treatment of carotid stenosis without the use of protection devices in patients with primary stenosis or postsurgical restenosis can achieve satisfactory safety and efficacy outcomes. The choice of performing CAS without using EPDs should follow a tailored approach based on the appropriate patient anatomy and specific clinical parameters to minimize neurological complications.

The Long-Term Efficacy and Safety of Carotid Artery Stenting among the Elderly: A Single-Center Study in China

Compared to carotid endarterectomy, carotid artery stenting (CAS) is reportedly associated with higher perioperative risks in elderly patients. To verify the long-term safety and efficacy of CAS with embolic protection in elderly patients, we retrospectively reviewed the medical records of patients with carotid stenosis treated between January 2003 and March 2010 at the Department of Neurology of a large university hospital in China. We included patients with symptomatic, moderate, or severe carotid stenosis of atherosclerotic etiology (other etiologies were excluded), with a disability score ≤ 3 on the modified Rankin Scale, and who received CAS instead of carotid endarterectomy. The clinical endpoints studied were stroke recurrence and all-cause death. The 84 patients included in this study (median follow-up, 8.08 years) were stratified according to age at surgery (<70 vs. ≥70 years), and no significant between-group difference was found regarding baseline characteristics. Of the 14 patients (16.67%) who experienced a defined clinical endpoint, 4 (7.14%) were aged <70 years and 10 (35.71%) were aged ≥70 years (P = 0.002). Overall mortality was 14.29% (12/84), with 3 (5.36%) and 9 (32.14%) deaths among patients aged <70 and ≥ 70 years, respectively (P = 0.002). Heart disease and cancer accounted for most deaths. The two groups did not differ regarding stroke recurrence, disability score, or rate of in-stent restenosis (blockage ≥ 50%), but patients aged ≥70 years had a higher risk of mortality (odds ratio, 8.3684; 95% confidence interval, 2.048–34.202; P = 0.003), and age was an independent risk factor for death (odds ratio, 20.054; 95% confidence interval, 3.094–129.987, P = 0.002). Among elderly patients in Southwest China, CAS can effectively prevent stroke recurrence without increasing the risk of stroke-related death, but the risk of all-cause death is higher, with age as an independent risk factor. Careful patient selection is of key importance in the treatment of symptomatic carotid artery stenosis.

Efficacy of Carotid Artery Stenting by the Universal Protection Method

To avoid distal plaques embolization during carotid artery stenting, we developed Universal Protection Method that combined the use of a proximal common carotid artery balloon, an external carotid artery balloon, and a distal internal carotid artery filter, with continuous flow reversal to the femoral vein. Herein, we assessed the efficacy of the Universal Protection Method by comparing stenting outcomes before and after its introduction. We assessed outcomes for 115 cases before and 41 cases after the Universal Protection Method was adopted (non-Universal Protection Method and Universal Protection Method groups, respectively). We then compared procedure details, magnetic resonance imaging (within 48 hours after the procedure), intraprocedural complications, and postoperative stroke rates. Ischemic stroke was not observed in the Universal Protection Method group, but 1 major stroke and 2 minor strokes were observed in the non-Universal Protection Method group. High-intensity areas were seen in 6 (15.0%) and 49 (42.6%) cases in the Universal Protection Method and non-Universal Protection Method groups, respectively (P = .001). Contrastingly, intraprocedural complications were observed in 9 (22.5%) and 21 (18.3%) cases in the Universal Protection Method and non-Universal Protection Method groups, respectively. Among these intraprocedural complication cases, high-intensity areas were observed in 1 case (11.1%) in the Universal Protection Method group and in 15 cases (71.4%) in the non-Universal Protection Method group. Universal Protection Method is a safe technique that is applicable to all patients undergoing carotid artery stenting, irrespective of individual risk factors. Notably, the incidence rates of both distal embolization and unexpected intraprocedural complications are low.

The Safety of Carotid Artery Stenting for Patients in the Acute Poststroke Phase

The efficacy of carotid artery stenting (CAS) for patients in the acute poststroke phase has not been established. We investigated the outcome of CAS for patients with symptomatic internal carotid artery (ICA) stenosis in the acute poststroke phase. We performed a retrospective analysis of all patients who underwent CAS for symptomatic ICA stenosis in our institution. Patients in whom the time interval between neurological deterioration and the CAS procedure was less than 3 days were included in the early group, and the other patients were included in the delayed group. Perioperative complications including major adverse events (MAEs) were compared between the early and the delayed groups. One hundred five patients were included in the study. Forty patients were assigned to the early group and 65 patients were assigned to the delayed group. The overall MAE rate was 4.8%. There was no significant increase in the perioperative MAE in the early group compared with the delayed group (early group 2.5% versus delayed group 6.5%, P = .65). In the early group, 25 of 40 patients (62.5%) were functionally independent (modified Rankin scale [mRS] score of 0-2) at discharge. Significant differences between the independent patients and the disabled patients (mRS score of 3-6) included age (independent 72 versus disabled 79, P < .01) and prevalence of transient ischemic attack (36.0% versus .0%, P = .02). CAS performed within 3 days from the last ischemic event did not increase the risk of perioperative complication. Early CAS may be a useful option for the treatment of symptomatic carotid artery stenosis.

Carotid Stenting in Neuroradiology : AShort Journey from the Past to Current Debates.

After aperiod of stagnation due to negative results of randomized trials for patients with symptomatic stenosis, the relevance of carotid artery stenting (CAS) is increasing again. CAS has become an important and evidence-based part of interventional stroke treatment. Our ability to manage acute recanalization of carotid occlusions and other niche indications properly led some skeptical neurologists to trust in carotid intervention for elective cases as well. The evolution of CAS from initial euphoria to more realistic views under consideration of trial results and guidelines is reviewed. Quality assurance in Germany proves that CAS complication rates within the carotid endarterectomy (CEA) quality criteria are feasible even with higher proportions of high-risk patients. Recent trial results showed that long-term efficacy of CAS or CEA are not significantly different. Other than in symptomatic stenoses, acute complication rates of both means treatment does not differ in asymptomatic patients, where medical therapy becomes increasingly competitive. Technical issues of CAS like the cell design of stents or the usefulness of embolic protection are still under discussion. We will see whether CAS results will further improve over time. Standardized techniques, proper training, and patient selection are important for acute and elective cases.

Potential of New-Generation Double-Layer Micromesh Stent for Carotid Artery Stenting in Patients with Unstable Plaque: A Preliminary Result Using OFDI Analysis.

One disadvantage of carotid artery stenting (CAS) is a high incidence of distal embolism (DE) during or after the procedure. Patients with unstable plaque are considered at high risk for DE and plaque protrusion (PP) after stent placement, which can cause postprocedural ischemic complications. This study was conducted to compare the rate and size of PP between the CASPER stent, a new-generation double-layer micromesh stent, and conventional stents as assessed by optical frequency domain imaging (OFDI), and also to evaluate the efficacy of CAS with the CASPER stent in cases with unstable plaque. The study group comprised 46 consecutive patients with unstable plaque, identified on magnetic resonance imaging, undergoing CAS with OFDI image acquisition. Cross-sectional OFDI images within the stented segments were evaluated at 0.125-mm intervals, and the rate and size of PP were compared between the CASPER stent and conventional stents. The CASPER stent was used in 9 patients. No procedural complications occurred. On OFDI analysis, the presence of PP was apparently lower in CASPER stent group compared with the conventional stent group (44% vs. 88%; P= 0.022). In addition, mean PP area was significantly smaller in the CASPER stent group (mean PP area, 0.013 ± 0.034 mm2 vs. 0.057 ± 0.09 mm2; P= 0.006). On OFDI evaluation after CAS, the degree of PP was significantly smaller in the CASPER stent group compared with the conventional stent group. This result provides new insight into the use of CAS to treat carotid artery stenosis with unstable plaque.

An Observational Registry of Carotid Endarterectomy and Carotid Artery Stenting in Brazil: Study Protocol

BackgroundCarotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. CEA has been considered the first-line treatment for carotid stenosis worldwide, and the safety and efficacy of CAS compared to CEA remains in question.ObjectiveThe purpose of this study is to compare the practice and outcomes of CAS and CEA in a real-world setting within public university hospitals in Brazil.MethodsThis study will be a prospective 5-year analysis of treatment for atherosclerotic carotid stenosis with CEA and CAS performed at 5 centers affiliated with the Vascular Study Group at public university hospitals in Brazil. The indications for the procedures will be determined by each surgeon’s individual discretion, in accordance with preoperative risk evaluation. The primary outcome measures will be (1) any in-hospital stroke or death, and (2) any per-procedural stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery will be excluded from the study. Multivariate logistic regression will be performed to identify predictors of stroke or death in patients undergoing CEA and CAS. All tests of significance will be performed at the .05 level. This study was approved by the Committee of Ethics in Research at the University Hospital of Ribeirao Preto Medical School, and in all other participating institutions linked to National Research System and National Board of Health in Brazil (Process 15695/2011).ResultsThis study is currently in the recruitment phase, and the final patient is expected to be enrolled by the end of 2018. We hope to recruit approximately 800 patients to the study. Analyses will focus on primary end points for patients that are allocated to each treatment group. During the per-procedural period, the occurrence of the primary end point components (stroke, MI, or death) for CAS and CEA will be analyzed for symptomatic or asymptomatic subjects.ConclusionsThe analyses of the primary endpoints (and all others variables of the study) are expected to be published in 2019 in a peer reviewed journal, and results will be presented at scientific meetings, with summary results published online. This study will obtain new data related to the quality of treatment for carotid disease in Brazil at the primary training centers of future vascular surgeons, but the initial data that will be obtained and published (with the outcomes and complications) are restricted to the first 30 days postprocedure. This time restriction limits the comparison of the results that relate to the main goal of treatment, which is to decrease the risk of stroke over 5 years. The purpose of the study group is to continue the monitoring of patient records, and evaluate the follow-up data in the 5 years following the initial evaluation. This study protocol will contribute very significantly to improving the care of patients with carotid disease, in addition to qualifying the level of assistance provided in public university hospitals in the state of São Paulo, Brazil.Trial RegistrationClinicaltrials.gov NCT02538276; https://www.clinicaltrials.gov/ct2/show/NCT02538276 (Archived by WebCite at http://www.webcitation.org/6m7APnFLD)

Anatomical and Technical Factors Influence the Rate of In-Stent Restenosis following Carotid Artery Stenting for the Treatment of Post-Carotid Endarterectomy Stenosis.

BackgroundCarotid artery stenting (CAS) has been advocated as an alternative to redo surgery for the treatment of post-carotid endarterectomy (CEA) stenosis. This study analyzed the efficacy of CAS for post-CEA restenosis, focusing on an analysis of technical and anatomical predictive factors for in-stent restenosis.MethodsWe performed a retrospective monocentric study. We included all patients who underwent CAS for post-CEA restenosis at our institution from July 1997 to November 2013. The primary endpoints were the technical success, the presence of in-stent restenosis >50% or occlusion, either symptomatic or asymptomatic, during the follow-up period, and risk factors for restenosis. The secondary endpoints were early and late morbidity and mortality (TIA, stroke, myocardial infarction, or death).ResultsA total of 153 CAS procedures were performed for post-CEA restenosis, primarily because of asymptomatic lesions (137/153). The technical success rate was 98%. The 30-day perioperative stroke and death rate was 2.6% (two TIAs and two minor strokes), and rates of 2.2% (3/137) and 6.2% (1/16) were recorded for asymptomatic and symptomatic patients, respectively. The average follow-up time was 36 months (range, 6–171 months). In-stent restenosis or occlusion was observed in 16 patients (10.6%). Symptomatic restenosis was observed in only one patient. We found that young age (P = 0.002), stenosis > 85% (P = 0.018), and a lack of stent coverage of the common carotid artery (P = 0.006) were independent predictors of in-stent restenosis.ConclusionWe identified new risk factors for in-stent restenosis that were specific to this population, and we propose a technical approach that may reduce this risk.