Ipsilateral Carotid Endarterectomy Research Articles

Risk and outcome profile of carotid endarterectomy with proximal intervention is concerning in multi-institutional assessment

ObjectiveApproaching tandem bifurcation and brachiocephalic disease using carotid endarterectomy (CEA) with ipsilateral proximal endovascular intervention (IPE) has been promulgated as safe and durable. There have been recent concerns about neurologic risk with this technique. The goal of this study was to define stroke and perioperative risk with this uncommon procedure across multiple centers. MethodsBetween August 2002 and July 2016, patients who underwent CEA + IPE were identified by operative records at three institutions. Primary end points were perioperative stroke and death, restenosis, freedom from neurologic event, and need for reintervention. Factors related to these end points were analyzed. ResultsThere were 62 patients who underwent CEA + IPE. The average age was 69 ± 9 years. Most were female 34 (55%); 56 (90%) were taking a statin and at least one antiplatelet agent. Bilateral internal carotid stenosis (>50%) was present in 32 (52%); 26 (42%) patients were symptomatic and 12 (19%) had undergone prior ipsilateral CEA. Bifurcation operations included longitudinal CEA/patch (38 [61%]), eversion CEA (20 [32%]), bypass graft (3 [5%]), and CEA/primary repair (1 [2%]). CEA was performed first in 53 (85%). All IPEs included stenting, with a single stent used in 58 (94%). Balloon-expandable stents were placed in the majority of patients (51 [82%]). Proximal arteries treated included the innominate (20 [32%]), left common carotid (32 [52%]), right common carotid (8 [13%]) and both innominate and right common carotid (2 [3%]). IPE was protected by carotid cross-clamp in 48 (77%). Shunting occurred in 14 (23%). There were four (6.5%) perioperative ipsilateral strokes and two hyperperfusion events. There were three (4.8%) operative deaths, one from stroke and two cardiovascular. Combined stroke and death rate was 11.3% and was not different between centers. Mean clinical follow-up was 6 ± 4 years. Mean imaging follow-up was 3 ± 4 years. Restenosis ≥50% at either intervention occurred in 20 (34%). Reintervention was performed for five proximal and three bifurcation failures (14%). Symptomatic status, redo operation, carotid clamp protection, multiple stents, and procedural order were not associated with operative stroke. Carotid clamp protection was associated with less restenosis (P = .003). Redo operation (P = .04) and hyperlipidemia (P = .05) were associated with reintervention. The 5-year actuarial survival was 81%, whereas freedom from stroke and reintervention were 94% and 81%, respectively. ConclusionsPerioperative stroke and death with CEA + IPE are substantial and consistent across centers. It is strikingly different from isolated CEA or CEA added to open brachiocephalic reconstruction. Restenosis is frequent, and reintervention at either the proximal stent or bifurcation is common. This technical strategy should be used cautiously and selectively reserved for those who are symptomatic with hemodynamically relevant tandem lesions and unfit for open revascularization.

CAROTID ARTERY ENDARTERECTOMY VERSUS CAROTID ARTERY STENTING FOR RESTENOSIS AFTER CAROTID ARTERY ENDARTERECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis. This study was performed according to the PRISMA and MOOSE guidelines

CRT-200.29 Carotid Artery Endarterectomy vs. Carotid Artery Stenting For Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-analysis

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis. This study was performed according to the PRISMA and MOOSE guidelines

IP133. Carotid Reoperation and Carotid Artery Stenting Have Similar Early and Late Results in Patients With Carotid Restenosis

This study defined outcomes after carotid reoperation (CREOP) and stenting (CAS) for restenosis after ipsilateral carotid endarterectomy (CEA) and compared results between CREOP and primary CEA. All patients undergoing carotid procedure for restenosis (2003-2014) were retrospectively reviewed (CREOP, CAS). A 1:2 case-control match for age, gender, procedure side, symptom, surgical risk, and year was performed between CREOP and patients undergoing primary CEA for >70% carotid stenosis for high-risk (hCEA) and low-risk groups (lCEA). Primary end points were composite stroke and death and ipsilateral stroke; secondary end points were death, any stroke, and myocardial infarction (MI). A total of 166 carotid procedures in 164 patients (female: 40%; mean age: 69 ± 8.3 years) were included (CREOP: 29, CAS: 47, hCEA1: 58, lCEA2: 58). Symptomatic patients were more frequent in CREOP than CAS (41% vs 15%; P = .01). Median time from ipsilateral CEA to CREOP or CAS was 3.6 years (range, 33 days-19.1 years) and 1.7 years (range, 35 days-20.8 years), respectively (P = .71). There were no early deaths or strokes after CREOP. Thirty-day composite stroke and death rates were 0%, 4.3%, 3.5%, and 1.7 for CREOP, CAS, hCEA, and lCEA, respectively. Ipsilateral stroke was 0%, 4.3%, 1.9%, and 0% for the four groups. For the same four groups, mortality was 0%, 2.1%, 1.7%, and 1.7%; any stroke was 0%, 4.3%, 1.7%, and 0%; and MI was 6.9%, 0%, 3.5%, and 1.7% (P > .05). Results were similar between CREOP and the other three groups regardless of symptoms (Table). In asymptomatic patients, hospital stay was the longest for CREOP (P > .05). Early complications were higher in CREOP in both asymptomatic (29% vs 5.9%; P = .03) and symptomatic patients (67% vs 25%; P = .03) compared to lCEA, but similar to hCEA. Over an average follow-up of 5.2 ± 4.1 years, 5-year composite stroke and death was 31%, 20%, 40%, and 15% for CREOP, CAS, hCEA, and lCEA, respectively. Five-year ipsilateral stroke was 0%, 4.3%, 7.4%, and 0% (P > .05). However, composite stroke and death was higher in symptomatic CREOP patients compared to lCEA (P = .049, Table). There were no early or late differences in primary end points between CREOP and CAS. Composite stroke and death, and ipsilateral stroke, are similar between reoperative carotid surgery and CAS for recurrent carotid stenosis. However, redo carotid surgery can be performed safely in both asymptomatic and symptomatic patients, with similar early stroke or death as primary CEA. CAS carries low early stroke or death in asymptomatic patients. There were too few symptomatic patients to determine its risk.TableOutcomes after carotid procedure in asymptomatic and symptomatic patientsVariableAsymptomaticSymptomaticCREOPn = 17n (%)CASn = 40n (%)hCEAn = 34n (%)lCEAn = 34n (%)P valueaP valuebP valuecCREOPn = 12n (%)CAS n = 7n (%)hCEA n = 24n (%)lCEAn = 24n (%)P valueaP valuebP valuecProcedure time (min)199 ± 61202 (121-309)81 ± 2977 (45-205)177 ± 51175 (90-241)162 ± 54160 (62-323)<.001.18.03271 ± 86291 (112-418)110 ± 5092 (58-211)188 ± 36190 (127-250)172 ± 26170 (121-219)<.001<.001<.00130-day outcomes LOS (day)2.2 ± 1.72 (1-7)1.3 ± 0.71 (0-5)1.5 ± 0.81 (1-4)1.4 ± 0.61 (0-3).003.04.0082.3 ± 1.92 (1-8)3.6 ± 3.53 (1-11)2.9 ± 2.32 (1-8)1.9 ± 1.81 (1-8).32.48.49 Composite stroke and death0 (0)1 (2.5)0 (0)0 (0)1.00……0 (0)1 (14)2 (8.3)1 (4.2).37.541.00 Mortality0 (0)1 (2.5)0 (0)0 (0)1.00……0 (0)0 (0)1 (4.2)1 (4.2)…1.001.00 Any stroke0 (0)1 (2.5)0 (0)0 (0)1.00……0 (0)1 (14)1 (4.2)0 (0).371.00… Ipsilateral stroke0 (0)1 (2.5)0 (0)0 (0)1.00……0 (0)1 (14)1 (4.2)0 (0).371.00… MI0 (0)0 (0)0 (0)0 (0)………2 (17)0 (0)2 (8.3)1 (4.2).51.59.25 Complication5 (29)5 (13)7 (21)2 (5.9).15.50.038 (67)3 (43)12 (50)6 (25).38.48.03 Cranial nerve injury0 (0)0 (0)1 (2.9)0 (0)…1.00…3 (25)0 (0)1 (4.2)0 (0).26.10.03 Reintervention0 (0)0 (0)1 (2.9)0 (0)…1.00…1 (8.3)0 (0)3 (13)2 (8.3)1.001.001.005-year outcomes Composite stroke and death21213517.94.32.8346144613.49.83.049 Survival79796482.94.33.80731005887.54.53.36 Any stroke02.53.53.1.40.37.392214170.91.47.02 Ipsilateral stroke02.500.40……014170.16.18– Freedom from reintervention839697100.34.21.0376608791.55.71.40CAS, Carotid artery stenting for carotid restenosis; hCEA, all high-risk primary carotid endarterectomy; lCEA, primary carotid endarterectomy excluding prior ipsilateral CEA as a high-risk; CREOP, carotid reoperation for restenosis; LOS, length of stay; MI, myocardial infarction.aCREOP vs CAS.bCREOP vs hCEA.cCREOP vs lCEA. Open table in a new tab

Remote pre-procedural ischemic stroke as the greatest risk in carotid‑stenting‑associated stroke and death: a single center's experience.

The goal of carotid artery stenting (CAS) is to decrease the stroke risk in patients with carotid stenosis. This procedure carries an immediate risk of stroke and death and many patients do not benefit from it, especially asymptomatic patients. It is crucial to accurately select the patients who would benefit from carotid procedure, and to rule out those for whom the procedure might be hazardous. Remote ischemic stroke is a known risk factor for stroke recurrence during surgery. The aim of our study was to determine the periprocedural complication risk (within 30 days after CAS) associated with carotid stenting (stroke, death) in patients with and without remote pre-procedural ischemic stroke, to analyze periprocedural risk in other specific patient subgroups treated with CAS, and to determine the impact of observed variables on all-cause mortality during long-term follow-up. We conducted a retrospective review of prospectively collected data from all patients treated with protected CAS between June 20, 2008 and December 31, 2015. Patient age, gender, type of carotid stenosis (symptomatic versus asymptomatic), side of stenosis (right or left carotid artery), type of cerebral protection (proximal versus distal), presence of comorbidities (remote ischemic pre-procedural ischemic stroke, coronary artery disease, diabetes mellitus, peripheral artery disease), previous ipsilateral carotid endarterectomy (CEA), contralateral carotid occlusion (CCO) and previous contralateral CAS/CEA were analyzed to identify higher CAS risk and to determine the impact of these variables on all-cause mortality during follow-up. Survival data were obtained from the Health Care Surveillance Authority registry. Mean follow-up was 1054 days (interquartile range 547.3; 1454.8). Remote pre-procedural ischemic stroke was defined as any-territory ischemic stroke >6 months prior to CAS. Primary periprocedural endpoint incidence (stroke/death) in 502 patients was 3.8% (N.=19) of all patients, 5.4% (N.=10) of symptomatic patients and 2.8% (N.=9) of asymptomatic patients. The risk of periprocedural stroke/death was 3.4 times higher in patients with (N.=198) compared to patients without remote ischemic stroke (N.=304) (6.6% versus 2.0% of patients without remote ischemic stroke; P=0.008). Periprocedural stroke/death in symptomatic patients (N.=186) was non-significantly higher in patients with remote ischemic stroke (N.=76) compared with patients without remote ischemic stroke (N.=110) (7.9% versus 3.6%; P=0.206). Asymptomatic patients with remote ischemic stroke (N.=122) had a 5.6-time-higher periprocedural risk of stroke/death compared with asymptomatic patients without remote ischemic stroke (N.=194) (5.7% versus 1.0%; P=0.014). Patients ≥75 years (N.=83) had a 3.0-time-higher periprocedural risk of stroke/death compared with younger patients (N.=419) (8.4% versus 2.9%; P=0.015); a non-significant increase of periprocedural stroke/death was found in both symptomatic (N.=35) and asymptomatic (N.=48) elderly patients (11.4% versus 4.0%, P=0.078; and 6.3% versus 2.4%, P=0.124, respectively). Increased periprocedural risk of stroke/death was not documented in other analyzed patient subgroups. During long-term follow-up, a 1.5-time-higher mortality risk was found in patients with remote ischemic stroke compared with patients without remote ischemic stroke in multivariable analysis; other patient subgroups (except older versus younger patients) did not differ in long-term mortality following carotid stenting. In our experience, all patients with remote pre-procedural any-territory ischemic stroke belong to risky subgroup for periprocedural stroke death after CAS. All asymptomatic patients with remote ischemic stroke should not be treated with CAS. Remote ischemic stroke increases all-cause mortality in long-term follow-up after carotid stenting. Patients aged ≥75 years also have increased risk of periprocedural stroke and death after CAS. These factors should help us to be more selective when planning carotid procedures.

Staging bilateral CEA perioperative management of blood pressure

Objective To evaluate the perioperative management of blood pressure in patients with bilateral carotid artery severe stenosis underwent staging carotid endarterectomy (CEA). Methods This retrospective study included 31 patients with bilateral carotid stenosis who underwent bilateral revascularizations in our department from April 2012 to November 2015. Patients were recorded with general information, and the changes of blood pressure in preoperative, intraoperative and postoperative were observed, respectively. Regulation and control of blood pressure were performed according to individual patient's condition. Results Thirty one patients underwent a total of 62 consecutive procedures successfully. Postoperative symptoms disappeared or significantly reduced. Twenty three cases (74.2%) had high perfusion symptoms in the ipsilateral CEA, and 5 cases (16.1%) with high perfusion syndrome in the contralateral surgery. Patients were improved after strict control of blood pressure and dehydration reduced intracranial pressure. The high perfusion symptoms in patients were significantly improved or disappeared after 1 week. Doppler ultrasound was used to evaluate the carotid artery before discharge. Conclusions For patients with bilateral carotid stenosis, staging purposes CEA is safe and effective. However, perioperative blood pressure management is very important. Individual control of blood pressure can significantly reduce the risk of postoperative high perfusion and cerebral infarction. Blood pressure control is recommended after 1 week in about 85% of preoperative blood pressure. Key words: Endarterectomy, carotid; Intraoperative period; Blood pressure

Stenting versus endarterectomy after prior ipsilateral carotid endarterectomy

BackgroundRestenosis after carotid endarterectomy (CEA) is associated with an increased risk of stroke, and the management of critical or symptomatic restenotic lesions poses a treatment challenge. The superiority of CEA vs carotid angioplasty and stenting (CAS) for restenosis remains debatable because existing studies are few and limited by small sample size or the inability to align interventions with ipsilateral events beyond the periprocedural period. We performed a population-based evaluation of CEA vs CAS in a large contemporary cohort of patients with carotid artery restenosis. MethodsWe studied all patients in the Vascular Quality Initiative (VQI) database who underwent CEA or CAS after prior ipsilateral CEA between January 2003 and April 2015. Univariate methods (χ2 and t-test) were used to compare patients' characteristics and outcomes ≤30 days and up to 1 year. Multivariate logistic and Cox regression analyses, adjusting for patients' demographic and clinical characteristics, were used to compare the procedures with respect to ipsilateral stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI. ResultsThis cohort of patients with prior ipsilateral CEA underwent 2863 carotid interventions, 1047 (37%) CEA, and 1816 (63%) CAS. Characteristics were similar in both groups. The 30-day ipsilateral stroke rate comparing CEA vs CAS was 2.2% vs 1.3% (P = .09) for asymptomatic patients and 1.2% vs 1.6% (P = .604) for symptomatic patients. The 30-day mortality was 1.3% vs 0.6% (P = .04), and MI occurred in 1.4% of CEA vs 1.1% of CAS patients (P = .443). Cranial nerve injury occurred in 4.1% of the redo-CEA cases, and access site complications occurred in 5.3% of the CAS cases. CEA was associated with higher mortality at 30 days (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.13-7.14; P = .027) and at 1 year (adjusted hazard ratio, 2.17; 95% CI, 1.03-4.58; P = .042). However, there were no differences in postoperative stroke (aOR, 0.54; 95% CI, 0.20-1.45, P = .22), MI (aOR, 0.98; 95% CI, 0.31-3.10; P = .97), stroke/death (aOR, 1.38; 95% CI, 0.72-2.67; P = .22), and stroke/death/MI (aOR, 1.38; 95% CI, 0.80-2.37; P = .25) between CEA and CAS after adjusting for patient characteristics, and freedom from stroke at 1 year was also similar (CEA: 96.7% vs CAS: 96.4%; P = .78). ConclusionsIn this population-based study, we have shown higher mortality but similar stroke and MI associated with redo CEA compared with CAS after prior ipsilateral CEA. We recommend avoidance of redo CEA in very sick patients. Smoking cessation remains a potent target for improvement of outcomes of carotid revascularization in these patients.

Retrograde stenting of proximal lesions with carotid endarterectomy increases risk

Concomitant carotid bifurcation and proximal ipsilateral arch branch disease is uncommon. A combined approach using carotid endarterectomy (CEA) with ipsilateral proximal endovascular (IPE) intervention (CEA+IPE) has been proposed as safe and durable, with similar results to isolated CEA. This study was conducted to identify diagnostic modalities and outcomes of this uncommon procedure at our institution. Operative records were used to identify patients who underwent CEA+IPE between May 2003 and July 2014. Patients were excluded if they underwent open retrograde access for endovascular intervention only, without CEA. The primary end points were freedom from neurologic event and need for reintervention. Twenty-three patients (15 women [65%]) underwent CEA+IPE. Mean clinical follow-up was 44± 35months. Average age was 69± 9years. Most patients (22 [96%]) were taking a statin and at least one antiplatelet agent. Bilateral internal carotid stenosis (>50%) was present in 12 patients (52%), and eight (35%) were symptomatic. Seven patients (30%) had prior ipsilateral CEA. All patients underwent preoperative carotid duplex and axial imaging. Computed tomography angiography was the initial imaging assessment in 10 patients (43%). The proximal lesion was identified in 19 (83%) by blunted waveforms on carotid duplex. Most bifurcation operations were CEA with patch (20 [87%]), and 21 (91%) underwent the bifurcation procedure first, followed by IPE. All IPE included balloon-expandable stenting (22 of 23 [96%] bare-metal, 7 [30%] innominate artery, 16 [70%] left common carotid artery). Electroencephalographic changes occurred in two patients (9%). Shunting was used in three (13%). Three vessel dissections (13%) occurred at the IPE site; two required further stenting and one was complicated by stroke and death. There were two perioperative strokes(9%)and one death (4%). Mean imaging follow-up was 30.6.± 27.2months, with restenosis identified in five patients (23%; four bifurcation, one IPE in-stent). One patient required open reintervention with subclavian-carotid bypass at 13months for recurrent transient ischemic attack. The 4-year actuarial survival was 85%. Stroke-free survival and freedom from reintervention were 80% and 90% at 36months, respectively. The stroke and death rate for CEA+IPE is higher than that of isolated CEA at our institution. Duplex findings can suggest proximal stenosis; however, confirmation with physical examination in conjunction with axial imaging are integral. This combined treatment strategy should be reserved for those with evident hemodynamically significant proximal stenosis and approached with caution in asymptomatic patients.

Redo Carotid Endarterectomy Versus Stenting: Durability and Midterm Outcomes

s from the 2016 Southern Association for Vascular Surgery Annual Meeting Redo Carotid Endarterectomy Versus Stenting: Durability and Midterm Outcomes Isibor Arhuidese, Tammam Obeid, Besma Nejim, Mahmoud Malas. Johns Hopkins Medical Institution, Baltimore, Md; Johns Hopkins Medical Institutions, Baltimore, Md Background: Restenotic carotid artery lesions are biologically different from de novo lesions. Those lesions are less likely to cause a stroke, but when they are critical or symptomatic, they represent a treatment challenge. Studies in patients with restenosis are few and limited by small sample size or inability to align interventions with ipsilateral events and outcomes in the long-term. In this study, we performed a populationbased evaluation of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) outcomes in a large cohort of patients who underwent prior ipsilateral CEA. Methods: We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS after prior ipsilateral carotid revascularization between January 2003 and April, 2015. Univariate methods (c test) were used to compare patients’ characteristics and outcomes #30 days and in the midterm. Multivariate logistic and Cox regression adjusting for patient characteristics were used to compare the procedures and identify predictors of ipsilateral stroke, death, myocardial infarction, and restenosis. Log-rank and Wilcoxon tests were used to compare survival function between groups. Results: There were 2863 carotid interventions (CEA: 1047 [37%]; CAS: 1816 [63%]) performed in this cohort of patients with prior ipsilateral CEA. The patients who underwent CEA vs CAS had similar age (mean, 70 years), gender (female: 42% vs 45%), race (Caucasian: both 95%), symptomatic status (32% vs 34%), prevalence of hypertension (91% vs 93%), diabetes (35% vs 36%), CAD (32% vs 34%), CHF (10% vs 11%), and COPD (29% vs 25%). Perioperative ipsilateral stroke rate comparing CEA vs CAS was 2.2% vs 1.3% (P 1⁄4 .09) for asymptomatics and 1.2% vs 1.6% (P 1⁄4 .604) for symptomatic patients. Perioperative mortality and myocardial infarction after CEA vs CAS was 1.3% vs 0.6% (P 1⁄4 .04) and 1.4% vs 1.1% (P 1⁄4 .443), respectively. Cranial nerve injury occurred in 2.5% of the redo-CEA cases. CEA was associated with an increased risk of death at 30 days (OR; 2.84; 95% CI, 1.137.14; P 1⁄4 .027) and in the mid-term (HR, 1.97; 95% CI, 1.25-3.12; P 1⁄4 .004). However, there were no differences in stroke, MI, and restenosis between CEA and CAS after adjusting for patient characteristics (Table). Stroke-free survival was also similar between groups (Fig). The significant predictors of stroke or death were increasing age (OR, 1.06; 95% CI, 1.03-1.09; P < .001) and CHF (OR, 1.71; 95% CI, 1.022.86; P 1⁄4 .040). Conclusions: To our knowledge, this is the largest study to date to evaluate midterm outcomes of carotid revascularization in patients with prior ipsilateral CEA. Redo CEA is associated with increased mortality and cranial nerve injury compared with CAS. Although most restenotic lesions are benign, CAS is a safer revascularization approach when the need to intervene arises. Table. Outcomes after carotid endarterectomy (CEA) compared with coronary artery stenting (CAS) Variable Unadjusted Adjusted OR (95% CI) P value OR (95% CI) P value

Stenting Versus Endarterectomy for Restenosis Following Prior Ipsilateral Carotid Endarterectomy: An Individual Patients' Data Meta-Analysis

OBJECTIVE: To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis. BACKGROUND: The optimal treatment strategy for patients with restenosis after CEA remains unknown. METHODS: A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA. RESULTS: In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications. CONCLUSIONS: In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

Poststent ballooning is associated with increased periprocedural stroke and death rate in carotid artery stenting

Whereas carotid endarterectomy (CEA) remains the "gold standard" treatment, given its low complication rate, carotid artery stenting (CAS) has emerged as a valid alternative in patients with prohibitive surgical risks. However, the application of CAS has been scrutinized, given its increased perioperative risk in comparison to CEA. Operators follow general guidelines in intraoperative techniques in CAS. However, few of those are evidence based. We believe that a specific outcome-driven examination of the effect of pre- and poststent deployment ballooning is warranted. The objective of this study was to analyze the effect of prestent ballooning (pre-SB) and poststent ballooning (post-SB) on hemodynamic depression (HD) and perioperative stroke or death. We performed a retrospective analysis of all patients who had CAS between 2005 and 2014 in the Vascular Quality Initiative database. Logistic regression analyses of the effect of different pre-SB and post-SB combinations on HD and the 30-day stroke and death rate were performed. We excluded patients who had no protection device, those with isolated common carotid artery lesions, and those who had no ballooning at all. The models controlled for patient age, gender, comorbidities, smoking status, symptomatic status, history of previous ipsilateral CEA, preoperative medications, and ipsilateral degree of stenosis. A total of 3772 patients who underwent CAS were included for analysis. Average age of patients was 69.8 ± 9.6 years, with 63% being male. The overall perioperative stroke and death rate was 3.0%. Compared with pre-SB only technique, the combined pre-SB and post-SB technique had a 2.1-fold increase in HD (odds ratio, 2.13; 95% confidence interval, 1.51-3.01; P < .001) and 2.4-fold increase in perioperative stroke and death rate (odds ratio, 2.37; 95% confidence interval, 1.01-5.62; P < .050). Compared with pre-SB alone, the use of post-SB increases the chances of perioperative HD and stroke and death rate in patients undergoing CAS. Post-SB should be used only in those cases with severe residual stenosis.

Stenting versus endarterectomy for restenosis following prior ipsilateral carotid endarterectomy: an individual patient data meta-analysis.

To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis. The optimal treatment strategy for patients with restenosis after CEA remains unknown. A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA. In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications. In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

Role of Stent Selection in the Incidence of Persisting Hemodynamic Depression After Carotid Artery Stenting

Purpose: To investigate the possible role of stent selection and procedure-related vessel diameter changes in the development of persisting hemodynamic depression (PHD) and to demonstrate the effectiveness and safety of permanent pacemaker implantation in patients with refractory PHD. Methods: Data from 584 procedures performed in 542 patients (398 men; mean age 67.3 years) between 2008 and 2011 using Wallstent, Precise, and Xact stents in a nonrandomized fashion were analyzed retrospectively. Cardiovascular risk factors and lesion, stent, and balloon characteristics were collected, and the pre- and postprocedure diameters of the common carotid artery (CCA) and internal carotid artery were measured. PHD was defined as any episode of hypotension (systolic blood pressure <90 mm Hg) and/or bradycardia (heart rate <60/min) lasting >6 hours. Risk factors for PHD were sought using logistic regression analyses; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The incidence of PHD was 37.0% (216/584). Refractory PHD was encountered in 9 patients; among these, 6 were successfully treated with pacemaker implantation. A history of prior ipsilateral carotid endarterectomy (OR 0.44, 95% CI 0.22 to 0.87, p=0.019) and the presence of a contralateral high-grade stenosis (OR 0.12, 95% CI 0.02 to 0.95, p=0.045) were independent protective factors, while calcification (OR 1.5, 95% CI 1.03 to 2.18, p=0.034), involvement of the carotid bulb (OR 2.56, 95% 1.62 to 4.03, p<0.001), and implantation of a nitinol stent (adjusted OR 1.62, 95% CI 1.12 to 2.34, p=0.011) were independent risk factors for developing PHD after carotid artery stenting. The ratio of the post-/preprocedure CCA diameter (p=0.002), the stent to CCA diameter ratio (p=0.009), and the presence of residual stenosis (p=0.009) were significantly higher in the PHD group. Conclusion: Stent selection and procedure-related changes in vessel diameter may have an influence on the development of PHD. Permanent pacemaker implantation is an effective treatment option in patients with refractory PHD.

Transcatheter aortic valve implantation using the left transcarotid approach in patients with previous ipsilateral carotid endarterectomy.

To assess the feasibility and safety of transcatheter aortic valve implantation (TAVI) through a left transcarotid approach in patients previously operated on for ipsilateral carotid endarterectomy (CEA). The healthcare impact of extracranial carotid artery disease is essential as stroke is the third-leading cause of death in industrialized nations and CEA is often present in the history of patients awaiting TAVI. The primary endpoint was to evaluate 30-day mortality and freedom from major TAVI-related complications in an observational analysis. From December 2011 to February 2014, we performed 9 TAVI. The mean age was 84.6 years. The procedure was performed without any technical complication or vascular injury in every patient. There was neither intraoperative mortality nor intraoperative major complications. One (11.1%) patient experienced spatial-temporal disorientation but cerebral computed tomography did not show any sign of stroke. Two (22.2%) patients needed the implantation of a pacemaker due to third-degree atrioventricular block appearance. Three (33.3%) patients were transfused with packed red blood cells and 1 (11.1%) patient developed a groin hematoma. Only 1 (11.1%) patient showed a residual paravalvular regurgitation ≥ 2. At 30-day follow-up there was neither mortality nor other TAVI-related complications and echocardiography parameters remained stable. TAVI through a left transcarotid approach in patients previously operated on for ipsilateral CEA is feasible and safe. The presence of a previous ipsilateral CEA represents no more a limitation to the utilization of this promising access route. At short-term follow-up, mortality and major complications rates are low.

Poststent Ballooning Increases Postoperative Stroke and Death Rate in Carotid Artery Stenting

Stroke remains the fourth leading cause of death and the leading cause of disability in the United States. Carotid endarterectomy (CEA) has been proven superior to medical therapy alone in decreasing the risk of stroke in patients with high-grade stenosis of the internal carotid artery. Although CEA remains the gold standard, with low perioperative stroke risk, carotid artery stenting (CAS) has seen progressively improved outcomes. Operators follow general guidelines in intraoperative techniques in CAS. However, few of those are evidence based. We believe that an outcome-driven examination of the effect of prestent and poststent deployment ballooning is warranted. We performed a retrospective analysis of all patients who had CAS between 2005 and 2014 in the Vascular Quality Initiative (VQI) database. Logistic regression analyses of the effect of different prestent and poststent ballooning combinations on hemodynamic instability and the 30-day stroke and death rate were constructed. We excluded patients who had no protection device, those who received any ballooning prior to protection device deployment, and those who had no ballooning. The model(s) controlled for patient age, sex, comorbidities, smoking status, symptomatic status, history of previous ipsilateral CEA, preoperative medications (statin, aspirin, and β-blockers), lesion site (common carotid artery, internal carotid artery, or both), and ipsilateral degree of stenosis. A total of 5379 patients had undergone CAS between 2005 and 2015, and 4166 patients remained after applying the exclusion criteria mentioned above. Patients were a mean ± standard deviation age of 69.7 ± 9.6, men represented 63% of the data set. The overall perioperative stroke/death rate was 3.1%. Compared with only prestent ballooning technique, the combined prestent ballooning and poststent ballooning technique had a 2.2-fold increase in hemodynamic instability (odds ratio, 2.2; 95% confidence interval, 1.6-3.1; P < .000) and 2.5-fold increase in the perioperative stroke/death rate (odds ratio, 2.5; 95% confidence interval, 1.1-5.8; P < .038). Compared with prestent ballooning alone, the use of poststent deployment ballooning increases the chances of perioperative hemodynamic instability and stroke/death rate in patients undergoing carotid artery stenting. Poststent ballooning should be limited to select populations only.

Outcomes of carotid endarterectomy versus stenting in comparable medical risk patients

In medically high-risk patients the choice between carotid artery stenting (CAS) and carotid endarterectomy (CEA) can be difficult. The purpose of this study was to compare risk-stratified outcomes of CAS and CEA. Patients who underwent isolated primary CEA (n= 11,336) or primary CAS (n= 544) at 29 centers in the Vascular Study Group of New England were analyzed (2003-2013); patients with previous ipsilateral CEA or CAS, or concomitant coronary artery bypass graft were excluded. A medical risk score based on predicted 5-year mortality was developed for each patient using a Cox proportional hazards model. Patients in the highest risk score quartile were termed high-risk (vs normal-risk for the other three quartiles). Medically high-risk patients had a 5-year survival of 65% and comprised 23% of CEA and 25% of CAS patients. Risk-stratified outcomes were compared within neurologically symptomatic and asymptomatic patients. Among asymptomatic patients, rates of in-hospital stroke and/or death were not different between CAS and CEA in normal and high-risk cohorts, ranging from 0.7% in normal-risk CEA patients to 1.6% in high-risk CAS patients. In symptomatic patients, significantly worse outcomes were seen with CAS compared with CEA in normal-risk and high-risk patients. Normal-risk symptomatic patients had a stroke or death rate of 1.3% with CEA, but 5.2% with CAS (P< .01). In high-risk symptomatic patients, the stroke or death rate was 1.5% with CEA and 9.3% with CAS (P< .01). No significant differences were seen between asymptomatic CEA and CAS within risk strata across secondary outcome measures of stroke, death, or myocardial infarction, and ipsilateral stroke, major stroke, or death. However, symptomatic high-risk CAS patients had significantly greater rates of all secondary outcomes compared with CEA except death, and symptomatic normal-risk CAS patients had only significantly greater rates of death and stroke, death, or myocardial infarction. In the Vascular Study Group of New England, asymptomatic normal- and high-risk patients do equally well after CEA or CAS. However, normal- and high-risk symptomatic patients have substantially worse outcomes with CAS compared with CEA. High medical risk alone might be an insufficient indication for CAS in symptomatic patients.

Clinical and anatomic outcomes after carotid endarterectomy

The purpose of this study was to examine 30-day and long-term outcomes after carotid endarterectomy (CEA) in a contemporary series and to identify variables associated with stroke and death after CEA. This was a retrospective review of patients undergoing an isolated CEA at a single institution between January 1989 and December 2005. Primary study end points were 30-day and long-term overall stroke, ipsilateral stroke, and death. Secondary end points were recurrent stenosis (>70% stenosis) and reintervention. Kaplan-Meier analysis was used to create survival curves for the long-term study end points. Multivariate models were created to identify variables associated with the study end points. During the study period, 3014 CEAs were performed on 2644 patients (mean age, 71.0 ± 8.9 years; 60.9% male; 33.5% symptomatic; 37% primary closure), with mean follow-up of 7.0 years. The 30-day ipsilateral stroke, death, and combined ipsilateral stroke/death rates were 1.3%, 1.1%, and 2.2%, respectively. Previous ipsilateral CEA or neck dissection for cancer (hazard ratio [HR], 3.68; P = .0081) and symptomatic disease (HR, 2.45; P = .0071) were predictive of 30-day ipsilateral stroke. Stroke-free survival was 93.8% at 4 years and 86.9% at 10 years. Diabetes (HR, 1.94; P < .0001), symptomatic disease (HR, 1.75; P < .0001), female gender (HR, 1.34; P = .035), and increasing age (HR, 1.02; P < .0001) were predictors of long-term overall stroke. Ipsilateral stroke-free survival was 97.6% at 5 years and 94.6% at 10 years, respectively. Contralateral occlusion (HR, 2.06; P = .025) and symptomatic disease (HR, 1.87; P = .003) were predictors of ipsilateral stroke, whereas antilipid therapy was protective (HR, 0.65; P = .049). Overall survival was 70.1% at 5 years and 42.2% at 10 years, with no difference between symptomatic and asymptomatic patients. Although a variety of comorbidities were associated with inferior late survival, as anticipated, female gender (HR, 0.89; P = .016) and lipid-lowering therapy (HR, 0.69; P < .0001) were protective. Reintervention was 3.4% at 5 years and 6.6% at 10 years, with primary closure (vs patch angioplasty/eversion) increasing the risk of reintervention (HR, 1.72; P = .007). CEA has favorable perioperative and long-term clinical and anatomic outcomes with respect to its goal of stroke prevention for symptomatic and asymptomatic patients. Adjuvant medical therapy (antilipid) has increased overall and ipsilateral stroke-free survival.

Clinical Relevance of Cranial Nerve Injury following Carotid Endarterectomy

The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI. We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI. A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3-15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2-2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3-3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4-3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5-1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3-2.5, p = .80). As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.

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

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

Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy

The safety and durability of carotid endarterectomy (CEA) require attention to certain technical details that may evolve over time. The objective of this study was to determine whether routine patch angioplasty and precautions related to the common carotid cuff could reduce the risks for perioperative stroke, internal carotid artery (ICA) thrombosis, or recurrent carotid stenosis. The senior author (N.H.) performed 1959 consecutive isolated CEAs at the Cleveland Clinic from 1976 to 2004. This series can be divided into three distinct eras with respect to patching and management of the proximal common carotid cuff: (1) primary arteriotomy closure with selective patching in only 38 of 653 CEAs (5.8%) from 1976 to 1983 (group 1); (2) routine patching without any special precautions related to the common carotid cuff in 568 CEAs from 1983 to 1990 (group 2); and (3) routine patching with extended exposure and tacking sutures to secure the carotid cuff in 738 CEAs from 1990 to 2004 (group 3). Although vein patching alone seemed to have less risk for perioperative stroke (1.2% vs 2.4%) or ICA thrombosis (0.6% vs 1.8%) than primary closure, these differences did not attain statistical significance. There also were no significant differences in the perioperative stroke and ICA thrombosis rates among the three eras in which changes occurred in patch use and in the management of the carotid cuff. After adjusting for the various lengths of follow-up in the study groups, however, group 3 had a significantly lower risk for recurrent 60% to 99% stenosis or ICA occlusion at >5 years after CEA (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.04-0.22; P < .001). On multivariable analysis, group 3 (OR, 0.23; 95% CI, 0.09-0.60; P = .003) and advancing age (OR, 0.89 per year; 95% CI, 0.85-0.92 per year; P < .001) had less risk for late recurrent stenosis, whereas this risk was higher in women (OR, 2.23; 95% CI, 1.23-4.06; P = .009) and in patients who had undergone previous ipsilateral CEA (OR, 6.02; 95% CI, 1.63-22.2; P = .007). Routine patching plus extended exposure and tacking of the common carotid cuff appear to significantly reduce the long-term incidence of recurrent 60% to 99% stenosis or ICA occlusion after CEA.