Outcomes Of Carotid Artery Stenting Research Articles

Midterm outcomes of simultaneous carotid revascularization combined with coronary artery bypass grafting.

Simultaneous carotid endarterectomy (CEA) combined with coronary artery bypass grafting (CABG) has been widely used in patients with coronary heart disease complicated with severe carotid stenosis to reduce the risk of stroke and death. Carotid artery stenting (CAS) has been proven to be an alternative to CEA in recent years. We investigated the early and mid-term outcomes of simultaneous CEA or CAS combined with CABG in these patients. From January 2011 to January 2021, 88 patients who underwent simultaneous carotid revascularization combined with CABG under the same anesthesia in Beijing Anzhen Hospital were retrospectively analyzed, and this study included 25 patients who underwent CAS-CABG and 63 patients who underwent CEA-CABG. The main outcomes included all-cause death, stroke, myocardial infarction and combined adverse events. The main outcomes of the two groups were compared at 30days after the operation and the mid-term follow-up. Univariate and multivariate Cox proportional hazards regression analyses were performed to determine the independent risk factors affecting mid-term mortality. Within 30days after the operation, there was no significant difference in combined adverse events between the two groups (P = 0.88). During the median follow-up period of 6.69years (IQR, 5.82-7.57years), 9 patients (14.30%) in the combined CEA-CABG group died, while 1 patient (4.00%) in the combined CAS-CABG group died. There were no significant differences in mid-term death (P = 0.20), stroke (P = 0.78), myocardial infarction (P = 0.88), or combined adverse events (P = 0.62) between the two groups. Univariate and multivariate Cox proportional hazards regression showed that NYHA grade IV (HR 5.01, 95% CI 1.16-21.64, P = 0.03) and previous myocardial infarction (HR 5.43, 95% CI 1.01-29.29, p = 0.04) were independent risk factors for mid-term mortality. We also found that combined CEA-CABG surgery may be associated with a higher risk of death (HR, 13.15; 95% CI 1.10-157.69, p = 0.04). Combined CAS-CABG is a safe and effective treatment for patients with coronary heart disease complicated with severe carotid stenosis. NYHA grade IV and previous MI were independent risk factors for mid-term mortality.

Age and Five-Year Outcomes After Carotid Artery Stenting in Symptomatic Carotid Stenosis: A Retrospective Cohort Study.

Several clinical trials have reported that periprocedural risk of carotid artery stenting (CAS) increase with age. China is experiencing one of the most rapid transitions to an aging society, while the clinical outcomes of CAS in real-world China are still limited. The study aimed to compare the periprocedural and an extending 5-year event rates between younger and older patients treated by CAS to testify the safety of CAS in older patients in China. This is a single center, retrospective cohort study. Symptomatic patients who underwent CAS from Nov 2011 to June 2014 were retrospectively included in this study, The population was divided into two age groups: <70 and ≥70. The main primary endpoint was stroke, myocardial infarction or death occurring at 30 days, or ipsilateral stroke over 5-year after stenting. A total of 103 symptomatic patients (<70: 68%; ≥70: 32%) with CAS included in the study. During the 30-day period, the rate of primary outcome was 1.0% with only one stroke in patients younger than 70years old (P = 1.000). After five years, the rate of primary outcome was low (10.9%, 10/92) despite some of the patients had major stroke or underwent bilateral C1 stenting. There was no significant difference in the 5-year rates of the primary outcome between the young and old groups (12.3% vs 7.4%, P = .718). Kaplan-Meier estimates of the proportion of study participants with a primary endpoint showed that there was no significant age-dependent difference of the stroke and death outcome in symptomatic patients. Age (<70 vs ≥ 70) had no influence on the risk of stroke or death in symptomatic patients either in the short or long term. CAS is an optimal treatment for older patients with cervical carotid artery stenosis, and CAS was safe for those with major stroke or bilateral C1 stenting.

Embolic protection devices for carotid artery stenting: A network meta-analysis.

Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

Outcomes of carotid stenting in patients with fibromuscular dysplasia

ObjectiveFibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD. MethodsA retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay. ResultsAfter matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m2). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up. ConclusionsCAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.

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.

Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment

Purpose: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution’s treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. Materials and Methods: Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. Results: A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601–5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061–16.418, p=1.00) were not significantly associated with either institution group. Conclusions: The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Carotid Endarterectomy Versus Carotid Artery Stenting for Carotid Disease in Octogenarians: A Nationwide Analysis of 6-Month Outcomes

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are widely performed revascularization procedures for the prevention of neurological sequences of atherosclerotic carotid artery disease. The optimal revascularization approach for older adults (>80 years) is still unknown. The aim of our study was to evaluate the outcomes of CAS versus CEA in octogenarians.

Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis

A retrospective review of 11 French academic institutions (University Association for Research in Vascular Surgery—AURC) from 2005 to 2017. One hundred and twenty-one transfemoral carotid artery stent (TF-CAS) procedures were performed in 112 patients (31% symptomatic). The mean interval between irradiation and TF-CAS was 15 years. Duplex ultrasound examination was performed at 1, 6, and 12 months, and annually thereafter. The combined 30-day perioperative stroke and mortality rate was 6.5%. After 5 years, the neurologic event-free survival rate was 88% and in-stent restenosis rate was 39%. Diabetes mellitus and single postoperative antiplatelet therapy were significant predictors of in-stent restenosis. TF-CAS is an effective option for radiation-induced stenosis. CAS was associated with low rates of neurological events and reinterventions at a mean follow-up of 3.5 years.

Outcomes of carotid artery stenting in patients with radiation arteritis compared with those with atherosclerotic disease: Presented at the Carotid Scientific Session at the Society for Clinical Vascular Surgery 48th Annual Symposium, Miami, Fla, March 13-17, 2021.

Objective Head and neck malignancies are often treated with radiotherapy (RT). Nearly 80% of patients who have undergone RT will develop carotid radiation arteritis to some degree and 29% will develop stenosis >50%. Surgery in a radiated neck has higher rates of complications, and carotid artery stenting (CAS) has become the primary therapy. The outcomes for CAS in patients with radiation arteritis have not been rigorously evaluated. The objective of the present study was to evaluate the differences in perioperative outcomes, restenosis rates, the need for reintervention, and freedom from mortality between RT patients and patients with atherosclerotic disease who had undergone CAS.

Outcomes Of Carotid Artery Stenting In Patients With Carotid Tandem Lesions

INTRODUCTION AND OBJECTIVES Management of tandem lesions of the common carotid artery and the ipsilateral carotid bifurcation is challenging. Endovascular techniques have been helpful in managing these complex lesions; either combined with endarterectomy or with stenting alone. However, data on outcomes of total carotid artery stenting for tandem lesions is scarce. We aim to describe the impact of tandem lesions on outcomes of transcarotid (TCAR) and transfemoral (TFCAS) carotid stenting. METHODS We reviewed the VQI database for carotid artery stenting. Multivariable logistic regression analysis was used to assess the association between tandem lesions and in-hospital outcomes. RESULTS A total of 15,775 underwent TFCAS and 20,673 underwent TCAR. In each procedure, 3.6% of patients had tandem lesion. Patients with tandem lesion were younger, more likely to have high grade stenosis, and to be operated on under general anesthesia. After adjusting for potential confounders, there was no difference in the risk of stroke, death, stroke/TIA, stroke/death, and extended length of stay (ELOS) between tandem vs non-tandem lesion in patients undergoing TCAR. On the other hand, the presence of tandem lesion was associated with higher risk of stroke/TIA (OR: 1.5, 95%CI (1.002-2.3) P=.049) and ELOS (OR: 1.3, 95%CI(1.04-1.6), P=.022)(Table). CONCLUSIONS The presence of tandem lesions did not seem to impact the risk of adverse events in patients undergoing TCAR. However, tandem lesions were associated with 50% increased risk of stroke/TIA and 30% increased risk of ELOS in patients undergoing TFCAS. These results support the advantage of flow reversal over distal embolic protection devices (DEP) as it may be difficult deploying DEP in distal lesions. Studies comparing outcomes of TCAR vs TFCAS in patients with tandem lesions are warranted. Management of tandem lesions of the common carotid artery and the ipsilateral carotid bifurcation is challenging. Endovascular techniques have been helpful in managing these complex lesions; either combined with endarterectomy or with stenting alone. However, data on outcomes of total carotid artery stenting for tandem lesions is scarce. We aim to describe the impact of tandem lesions on outcomes of transcarotid (TCAR) and transfemoral (TFCAS) carotid stenting. We reviewed the VQI database for carotid artery stenting. Multivariable logistic regression analysis was used to assess the association between tandem lesions and in-hospital outcomes. A total of 15,775 underwent TFCAS and 20,673 underwent TCAR. In each procedure, 3.6% of patients had tandem lesion. Patients with tandem lesion were younger, more likely to have high grade stenosis, and to be operated on under general anesthesia. After adjusting for potential confounders, there was no difference in the risk of stroke, death, stroke/TIA, stroke/death, and extended length of stay (ELOS) between tandem vs non-tandem lesion in patients undergoing TCAR. On the other hand, the presence of tandem lesion was associated with higher risk of stroke/TIA (OR: 1.5, 95%CI (1.002-2.3) P=.049) and ELOS (OR: 1.3, 95%CI(1.04-1.6), P=.022)(Table). The presence of tandem lesions did not seem to impact the risk of adverse events in patients undergoing TCAR. However, tandem lesions were associated with 50% increased risk of stroke/TIA and 30% increased risk of ELOS in patients undergoing TFCAS. These results support the advantage of flow reversal over distal embolic protection devices (DEP) as it may be difficult deploying DEP in distal lesions. Studies comparing outcomes of TCAR vs TFCAS in patients with tandem lesions are warranted.

Comparison of Transcarotid Artery Revascularization And Transfemoral Carotid Artery Stenting Outcomes Among Symptomatic And Asymptomatic Patients Based On Lesion Calcification

INTRODUCTION AND OBJECTIVES Anatomic details affecting adverse outcomes following transcarotid artery stenting are not well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification. METHODS Data from patients in the Society for Vascular Surgery Vascular Quality Initiative database undergoing TCAR (Jan 2017 to Apr 2020) or TFCAS (May 2005 to Apr 2020) and had carotid artery calcification grading was analyzed. Degree of calcification was stratified into three groups: none, <=50% calcification, and >50% calcification. RESULTS A total of 9,868 patients (TCAR:4,224; TFCAS:5,644) were included. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among symptomatic patients, there was no difference in rates of stroke, stroke/TIA, and MI by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all three events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR:0.9% vs TFCAS:2.8%, P=0.013), stroke/death (TCAR:2.7% vs TFCAS:5.8%, P=0.006), stroke/death/MI (TCAR:3.3% vs TFCAS:6.5%, P=0.007), and postop complications (TCAR:6.0% vs TFCAS:12.4%, P<0.001) compared to TFCAS. Furthermore, TCAR had lower risk of death at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR:0.4% vs TFCAS:1.1%, P=0.080) and stroke/death (TCAR:1.5% vs TFCAS:3.1%, P=0.029) were reduced. CONCLUSIONS While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR. Furthermore, TCAR had lower rates of death than TFCAS across all degrees of calcification and lower rates of stroke/death among patients with severe calcification. These findings suggesting that TCAR is protective against death despite anatomic differences and may be particularly beneficial over TFCAS in patients with calcified lesions. Anatomic details affecting adverse outcomes following transcarotid artery stenting are not well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification. Data from patients in the Society for Vascular Surgery Vascular Quality Initiative database undergoing TCAR (Jan 2017 to Apr 2020) or TFCAS (May 2005 to Apr 2020) and had carotid artery calcification grading was analyzed. Degree of calcification was stratified into three groups: none, <=50% calcification, and >50% calcification. A total of 9,868 patients (TCAR:4,224; TFCAS:5,644) were included. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among symptomatic patients, there was no difference in rates of stroke, stroke/TIA, and MI by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all three events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR:0.9% vs TFCAS:2.8%, P=0.013), stroke/death (TCAR:2.7% vs TFCAS:5.8%, P=0.006), stroke/death/MI (TCAR:3.3% vs TFCAS:6.5%, P=0.007), and postop complications (TCAR:6.0% vs TFCAS:12.4%, P<0.001) compared to TFCAS. Furthermore, TCAR had lower risk of death at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR:0.4% vs TFCAS:1.1%, P=0.080) and stroke/death (TCAR:1.5% vs TFCAS:3.1%, P=0.029) were reduced. While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR. Furthermore, TCAR had lower rates of death than TFCAS across all degrees of calcification and lower rates of stroke/death among patients with severe calcification. These findings suggesting that TCAR is protective against death despite anatomic differences and may be particularly beneficial over TFCAS in patients with calcified lesions.

Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis

Purpose: Carotid artery stenting (CAS) appears as a promising alternative treatment to carotid endarterectomy for radiation therapy (RT)-induced carotid stenosis. However, this is based on a poor level of evidence studies (small sample size, primarily single institution reports, few long-term data). The purpose of this study was to report the long-term outcomes of a multicentric series of CAS for RT-induced stenosis. Methods: All CAS for RT-induced stenosis performed in 11 French academic institutions from 2005 to 2017 were collected in this retrospective study. Patient demographics, clinical risk factors, elapsed time from RT, clinical presentation and imaging parameters of carotid stenosis were preoperatively gathered. Long-term outcomes were determined by clinical follow-up and duplex ultrasound. The primary endpoint was the occurrence of cerebrovascular events during follow-up. Secondary endpoints included perioperative morbidity and mortality rate, long-term mortality rate, primary patency, and target lesion revascularization. Results: One hundred and twenty-one CAS procedures were performed in 112 patients. The mean interval between irradiation and CAS was 15 ± 12 years. In 31.4% of cases, the lesion was symptomatic. Mean follow-up was 42.5 ± 32.6 months (range 1–141 months). The mortality rate at 5 years was 23%. The neurologic event-free survival and the in-stent restenosis rates at 5 years were 87.8% and 38.9%, respectively. Diabetes mellitus (p=0.02) and single postoperative antiplatelet therapy (p=0.001) were found to be significant predictors of in-stent restenosis. Freedom from target lesion revascularization was 91.9% at 5 years. Conclusion: This study showed that CAS is an effective option for RT-induced stenosis in patients not favorable to carotid endarterectomy. The CAS was associated with a low rate of neurological events and reinterventions at long-term follow-up.

A systematic review supporting the Society for Vascular Surgery Guidelines on the management of carotid artery disease.

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. We searched multiple data bases for studies addressing five questions: medical management vs carotid revascularization (CEA) in asymptomatic patients, CEA vs carotid artery stenting (CAS) in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high-risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. Medical management compared with carotid interventions in asymptomatic patients was associated with better early outcome during the first 30days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5years. In symptomatic low-risk surgical patients, CEA was associated with a lower risk of stroke, but a significant increase in myocardial infarction compared with CAS during the first 30days. When the long-term outcome of transfemoral CAS vs CEA in symptomatic patients were examined using preplanned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that, over the long term, CEA has a superior outcome compared with transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48hours to that between day 2 and day 14 did not reveal a statistically significant difference on outcomes during the first 30days. Registry data show good results with CEA performed in the first week, but not within the first 48hours. A single risk factor, aside from peripheral artery disease, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared with a combined carotid intervention and coronary artery bypass grafting, had better outcomes. This updated evidence summary supports the Society for Vascular Surgery clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in the long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2 and 14days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

Outcomes of carotid artery stenting in patients with radiation arteritis compared with those with atherosclerotic disease

ObjectiveHead and neck malignancies are often treated with radiotherapy (RT). Nearly 80% of patients who have undergone RT will develop carotid radiation arteritis to some degree and 29% will develop stenosis >50%. Surgery in a radiated neck has higher rates of complications, and carotid artery stenting (CAS) has become the primary therapy. The outcomes for CAS in patients with radiation arteritis have not been rigorously evaluated. The objective of the present study was to evaluate the differences in perioperative outcomes, restenosis rates, the need for reintervention, and freedom from mortality between RT patients and patients with atherosclerotic disease who had undergone CAS. MethodsThe national Vascular Quality Initiative CAS dataset from 2016 to 2019 comprised the sample for analyses (n = 7343). The primary independent variable was previous head and/or neck RT. The primary endpoint was the interval to mortality. The secondary endpoints were the cumulative incidence of restenosis (>50% and >70% by duplex ultrasound) and reintervention. We also examined the following secondary perioperative endpoints: myocardial infarction, in-hospital mortality (death before discharge), neurologic events, ipsilateral stroke, and contralateral stroke. Kaplan-Meier and multivariable Cox proportional hazard models were used to assess for mortality, and cumulative incidence function estimates were used for the nonfatal endpoints. ResultsOf the 7218 patients, 1199 (17%) had undergone prior RT. We found a significant difference in the 3-year estimates of mortality for those with and without prior RT (9.4% and 7.5%, respectively; P = .03). Furthermore, on adjusted analysis, we observed a 58% increase in the risk of mortality for those with prior RT (adjusted hazard ratio, 1.58; 95% confidence interval, 1.13-2.21). We did not observe any differences in the risk of perioperative complications (myocardial infarction, in-hospital mortality, ipsilateral or contralateral stroke), restenosis (>50% or >70%), or reintervention for the prior RT group compared with those without RT. ConclusionsThe CAS patients with RT had significantly greater mortality at all time points compared with those without RT, even after adjusting for other covariates. No significant difference was found in the incidence of perioperative complications, reintervention, or restenosis between the two groups. The present study is unique because of the large sample size and length of follow-up. The results suggest that for this high-risk group, CAS provides the same patency as it does for atherosclerotic carotid stenosis and avoids potentially morbid cranial nerve injury and wound healing complications.

The impact of carotid lesion calcification on outcomes of carotid artery stenting

ObjectiveThe impact of carotid artery lesion calcification on adverse events following carotid artery stenting is not well-studied. Few reports associated heavily calcified lesions with high risk of perioperative stroke following transfemoral carotid artery stenting (TFCAS). With the advent of transcarotid artery revascularization (TCAR), we aimed to compare the outcomes of these two procedures stratified by the degree of lesion calcification. MethodsOur cohort was derived from the Vascular Quality Initiative database for carotid artery stenting. Patients with missing information on the degree of carotid artery calcification were excluded. Patients were stratified into two groups: >50% (heavy) calcification and ≤50% (no/mild) calcification. The Student t test and the χ2 test were used to compare patients' baseline characteristics and crude outcomes, as appropriate. Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. ResultsA total of 11,342 patients were included. Patients with >50% calcification were older, had more comorbidities, and more contralateral occlusion. There were more patients with prior ipsilateral carotid endarterectomy in the ≤50% calcification group. In patients who underwent TCAR, there were no significant differences between those who had >50% vs ≤50% carotid calcification in the odds of in-hospital adverse outcomes. However, in patients with heavy calcification who underwent TFCAS, there was a 50% to 60% increase in the odds of stroke (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.04-2.5; P = .03), stroke/transient ischemic attack (TIA) (OR, 1.6; 95% CI, 1.1-2.3; P = .013), and stroke/death (OR, 1.5; 95% CI, 1.02-2.08; P = .039). Compared with TFCAS in patients with heavy calcification, TCAR was associated with a 40% to 90% reduction in the odds of contralateral stroke (OR, 0.13; 95% CI, 0.04-0.4; P = .001), contralateral stroke/TIA (OR, 0.3; 95% CI, 0.1-0.87; P = .024), any stroke/TIA (OR, 0.6; 95% CI, 0.38-0.91; P = .02), death (OR, 0.3; 95% CI, 0.13-0.72; P = .006), stroke/death (OR, 0.5; 95% CI, 0.32-0.8; P = .004), and stroke/death/myocardial infarction (OR, 0.58; 95% CI, 0.39-0.87; P = .008). There were no significant differences in the odds of stroke and myocardial infarction. ConclusionsIn this retrospective analysis of patients undergoing TFCAS vs TCAR in the Vascular Quality Initiative database, TCAR demonstrated favorable outcomes compared with TFCAS among patients with calcification greater than 50% of the carotid circumference. Advance burden of carotid artery calcification was associated with worse outcomes in patients undergoing TFCAS but not TCAR. These results are consistent with previously demonstrated superiority of flow reversal compared with distal embolic protection devices. Further research is needed to assess long-term outcomes and confirm the durability of TCAR in heavily calcified lesions.

Carotid artery angioplasty versus stenting for management of acute tandem occlusions

BackgroundThe optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions.MethodsIn this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016–2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions.ResultsWe identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05–2.12, P 0.025].ConclusionThe emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Preoperative Dependent Functional Status Is Associated With Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients

BackgroundBoth Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most common procedures to treat patients with symptomatic, and asymptomatic high-grade carotid stenosis. Poor preoperative functional status (FS) is increasingly being recognized as predictor for postoperative outcomes. The purpose of this study is to determine the impact of preoperative functional status on the outcomes of patients who undergo CEA or CAS. MethodsData was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2011–2018. All patients in the database who underwent CEA or CAS during this time period were identified. Patients were then further divided into 2 subgroups: FS-Independent and FS-dependent. Bivariate and multivariate analyses was performed for pre, intra and post-operative variables with functional status. Outcomes for treatment of symptomatic carotid disease were compared to those with asymptomatic disease among the cohort of functionally dependent patients. ResultsA total of 27,163 patients (61.2% Males, 38.8% Females) underwent CEA (n = 26,043) or CAS (n = 1,120) from 2011–2018. Overall, primary outcomes were as follows: mortality 0.77% (n = 210) and stroke 1.87% (n = 507).Risk adjusted multivariate analysis showed that FS-D patients undergoing CEA had higher mortality (AOR 3.06, CI 1.90–4.92, P < 0.001), longer operative times (AOR 1.36, CI 1.17–1.58, P< 0.001) higher incidence of unplanned reoperation (AOR 1.68, CI 1.19–2.37, P = 0.003), postoperative pneumonia (AOR 5.43, CI 1.62 – 18.11, P = 0.006) and ≥3 day LOS (AOR 3.05, CI 2.62–3.56, P < 0.001) as compared to FS-I patients. FS-D patients undergoing CAS had higher incidence of postoperative pneumonia (AOR 20.81, CI 1.66–261.54, P = 0.019) and higher incidence of LOS ≥3 days (AOR 2.18, CI 1.21–3.93, P < .01) as compared to FS-I patients. Survival analysis showed that the best 30-day survival was observed in FS-I patients undergoing CEA, followed by FS-I patients undergoing CAS, followed by FS-D patients undergoing CEA, followed by FS-D patients undergoing CAS. FS-D status increased mortality after CEA by 2.11%. When the outcomes of CAS and CEA were compared to each other for the cohort of FS-D patients, CAS was associated with higher incidence of stroke (AOR 3.46, CI 0.32–1.97, P= 0.046), shorter operative times (AOR 0.25, CI 0.12–0.52, P < 0.001) and higher incidence of pneumonia (AOR 11.29, CI 1.32–96.74, P = 0.027). Symptomatic patientsundergoing CEA had higher LOS as compared to symptomatic patients undergoing CAS, and asymptomatic patients undergoing CEA or CAS. ConclusionsFS-D patients, undergoing CEA have higher mortality as compared to FS-I patients undergoing CAS. FS-D patients undergoing CAS have higher incidence of postoperative pneumonia and longer LOS as compared to FS-I patients. For the cohort of FS-D patients undergoing either CEA or CAS, CAS was associated with higher risk of stroke and reduced operative times. Risk benefit ratio for any carotid intervention should be carefully assessed before offering it to FS-D patients.Preoperative Dependent Functional Status Is Associated with Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients

Could Gender Impact on Immediate and Long-term Carotid Artery Stenting Outcome? Insight from an Italian Single Center Experience

Carotid artery stenting (CAS) has become a valid alternative to carotid endarterectomy in stroke prevention. However, female gender is still considered as an independent risk factor for CAS procedures, potentially limiting immediate and long-term benefits. Aim of present study was to evaluate gender differences in CAS submitted patients from an Italian high-volume center. a retrospective monocentric study has been conducted on 568 patients (366 males and 202 females), submitted to CAS, between January 2000 and December 2019. Besides gender sex, clinical anatomical, and procedural data were collected as possible factors determining the outcome, when associated to sex gender itself. Primary endpoint of this study consisted in evaluating the technical and procedural success ratio, and the incidence of major and minor stroke, transient ischemic attack, acute myocardial infarction (AMI) peri-procedurally and at medium and long term, between the male and the female population. Secondary endpoint of this study consisted in evaluating the percentage ratio of minor complications happening peri-procedurally in both genders. Male patients were more likely to be octogenarians, clinical history of coronary artery disease, and smokers, while diabetes was more frequent in female patients. Anatomical and plaque morphology features were not different between the two groups. Technical success was obtained in all but two patients (99,6%), while procedural success was 95% (538/566 patients). During the peri-procedural time, no major stroke, 16 minor strokes (2,81%, 2,45% males vs. 3,45% females, P= 0,48), and 11 transient ischemic attack (2,18% males vs. 1,48% females, P= 0,56) were recorded. At a medium follow-up 57 months, 32 stroke (8 major strokes, 24 minor strokes) episodes (5,6%, males 5,7% vs. females 5,4%, P= 0,88), 24 AMIs (4,2%, males 4,6% vs. females 3,46%, P= 0,5;), 13 restenosis (2,8%, males 2,4% vs. females 1,9%, P= 0,71) and 223 deaths (39,2%, males 34,9% vs. females 47%, P= 0,0048) were noted. Our results showed no differences in immediate, and long-term CAS outcomes between gender. Larger, prospective studies are required to assess the real importance and significance of gender in determining CAS procedures' benefit and outcome.

Long-term cognitive and multimodal imaging outcomes after carotid artery stenting vs intensive medication alone for severe asymptomatic carotid stenosis

Severe carotid stenosis is associated with cognitive impairment, which may be attributed to asymptomatic microembolism and/or chronic hypoperfusion. We aim to evaluate the long-term cognitive and brain connectivity outcomes of carotid artery stenting (CAS) for asymptomatic ≥70% stenosis of the extracranial internal carotid artery (ICA). We conducted a non-randomized controlled study to compare intensive medical therapy alone (Med) or in combination with carotid artery stenting for the composite vascular events, neuropsychological, and multimodal magnetic resonance perfusion imaging and diffusion tensor imaging outcomes. Sixty-nine patients were followed for a mean of 2.3 years (31 Med, 38 CAS) and 11 patients had composite vascular events of all-cause death, ischemic stroke, or myocardial infarction (6 Med vs 5 CAS). Forty-six asymptomatic subjects completed neuropsychological and multimodality imaging follow-ups (23 Med, 23 CAS). Compared to the Med group, the CAS group had a modest improvement of 12-item delayed verbal memory (8.9±2.4 to 9.8±2.7 vs 9.0±2.1 to 8.9±2.3, p=0.04), but not in global cognition, attention or executive function, which was associated with increased structural connectivity of fractional anisotropy at the ipsilateral deep white matter. Importantly, the memory improvement was correlated with the perfusion increment at the ipsilateral middle cerebral artery territory. For asymptomatic extracranial carotid steno-occlusion, successful carotid revascularization in addition to intensive medical treatment may potentially benefit cognitive reserve and connectivity strength which are partly attributed to restoration of non-critical hypoperfusion.

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature

Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature