Outcomes Of Carotid Artery Stenting Research Articles

Procedural and Short-Term Outcomes of Carotid Artery Stenting: A Single-Center Experience.

Background Carotid artery stenting is a well-established alternative treatment to carotid endarterectomy for carotid artery stenosis for preventing stroke. This study assessed the procedural and clinical outcomes in patients undergoing carotid artery stenting in a tertiary care center in India. Methods A total of 39 patients underwent carotid artery stenting from January 2022 to December 2023, with different embolic protection devices and carotid stents. All the patients had symptomatic carotid artery stenosis with at least 50% stenosis as per the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Procedural and technical success was assessed, and patients were followed for 20 ± 7 months for survival, new-onset stroke, and quality of life. Results The mean age was 64.8 ± 9.1 years and 25 (64.1%) of the patients were males. A total of 26 (66.7%) patients were hypertensive and 21 (53.9%) patients had a history of diabetes mellitus. Out of 39 patients, 2 (5.1%) had recurrent transient ischemic attacks while the rest (37; 94.9%) had a subacute and chronic ischemic stroke. A total of 37 (94.9%) patients had carotid artery stenosis of more than 70%. In this study, 9 (23.1%) patients had a history of sub-acute ischemic stroke of a 1 to 3-week duration. Two patients underwent bilateral staged stenting over a gap of one month. The overall procedural success rate was 39 (100%) and none of the patients had access site-related major complications. Out of the total 41 implants, 21 (51.2%) were self-expanding carotid WALLSTENT (Boston Scientific, Marlborough, Massachusetts, US) and 20 (48.8%) implants were Protégé RX tapered self-expanding carotid stent (Medtronic, Dublin, Ireland). A FilterWire EZ (Boston Scientific) embolic protection device was used in 23 (56.1%) cases and Spider FX (Medtronic) in 18 (43.9%) cases. None of our patients had an intraprocedural death. One patient had postprocedural ipsilateral third nerve palsy, which was resolved partially on the next day of carotid angioplasty. We used dual-antiplatelet drug therapy post-procedure for a month followed by a single antiplatelet drug lifelong. All patients were followed for a minimum of six months and a maximum of 30 months. A total of three (7.7%) patients have died, and 2 (5.1%) patients had a new-onset ischemic stroke with one on the same side of the carotid stenting. A total of 31 (79.5%) patients were doing well and in the recovery phase while those two patients who had a recurrent stroke were bedridden. None of the patients had clinically significant restenosis that needed revascularization of the carotid artery over a mean follow-up period. Conclusion Carotid artery stenting is an effective method to reduce the recurrence of ischemic stroke in significant symptomatic carotid stenosis patients. Experience in neuro-interventional procedures at our center leads to an acceptable rate of peri-procedural stroke, recurrence, and mortality in carotid artery stenting procedures.

Robotic versus manual diagnostic and stenting procedures: a systematic review and meta-analysis.

Endovascular procedures are associated with improved outcomes and patient satisfaction compared to open surgery in selected cases. However, this is at the cost of increased radiation exposure. Robotic procedures are thought to minimize radiation exposure and may confer procedural efficacy due to the lack of operator fatigue. Our systematic review and meta-analysis compares procedural efficacy of robotic versus manual diagnostic and stenting procedures. PubMed, Embase and Scopus were searched in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Articles reporting comparative outcomes between robotic and manual diagnostic and stenting procedures were included. Articles related to stereotactic radiosurgery and open surgical procedures were excluded. The Newcastle Ottawa Scale was used to assess risk of bias. Effect sizes (mean difference for robotic and manual procedures) and variances were calculated for procedure time. The random effects model was used to calculate pooled estimates for technical success using the "metafor" package in R (R software v4.2.1, Vienna, Austria). 6465 articles were identified through our search strategy. After 4683 articles were excluded through a title and abstract screen and 30 articles were excluded through a full text review, 3 articles reporting outcomes in 175 patients undergoing robotic procedures and 185 patients undergoing manual procedures were included. These studies reported comparative outcomes for carotid artery stenting, diagnostic cerebral angiograms and transverse sinus stenting. There was no significant difference in procedure time (mean difference: 0.14min [95% confidence interval (CI): -0.58, 0.86, p = 0.64, I2 = 68%]. Technical success was 0.05-fold lower for robotic procedures compared to manual procedures [95% CI: 0.00- 0.84), P = 0.04]. One study was considered high quality using the NOS. Robotic procedures confer significantly lower rates of technical success with no significant difference in procedure time. Further studies are necessary to draw conclusions about potential benefits of robotic procedures including lower radiation exposure.

Robotic carotid artery stenting: a multicenter, propensity score–matched analysis of clinical outcomes and cost-effectiveness

OBJECTIVE Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exist for patients who have undergone robotic versus manual CAS. In addition, no data exist comparing the costs of manual and robotic CAS. METHODS All robotic CAS cases at two academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration by using time-driven activity-based cost analysis. RESULTS A total of 24 robotic CAS operations were performed between 2019 and 2023. Comorbidities and baseline procedural characteristics were well matched between robotic and manual cases. Unplanned manual conversion was observed in only 1 robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs 19.2 minutes; p < 0.001). Robotic procedure time (88.9 ± 18.2 minutes) was significantly (p = 0.003) longer than manual time (68.72 ± 22.4 minutes). Health personnel costs ($1589.71 ± $176.92 vs $1375.99 ± $233.39, p = 0.005); supply costs ($3918.25 ± $421.20 vs $2152.74 ± $1030.26, p < 0.001); and total procedure costs ($5306.11 ± $608.95 vs $3437.56 ± $1165.67, p < 0.001) were greater for robotic CAS. CONCLUSIONS In the first multicenter study and largest sample to date, the authors show that robotic CAS, with a low rate of procedural failure and postoperative complications, is safe and feasible. In addition, robotic CAS achieves comparable clinical outcomes to manual CAS. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX system. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Robotic CAS failed to show superiority to manual CAS. These findings set a foundation for randomized controlled trials of robotic CAS, and also highlight the need for further studies to optimize robotic CAS and reduce its associated costs.

Carotid Artery Stenting Outcomes by Neurointerventional Surgeons (CASONI)

Carotid Artery Stenting Outcomes by Neurointerventional Surgeons (CASONI)

Abstract 059: 2023 Highlights from the Prospective CASSH Registry

Background Multiple studies have highlighted the importance of carotid artery stenting (CAS) operator's experiences. However, fellowship‐trained neurointerventionalists (NIRs) remain an under‐represented specialty in the literature. The CASSH (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) registry aims to provide comprehensive insights into CAS outcomes, particularly when performed by NIR at comprehensive stroke centers (CSCs). Methods CASSH is a multicenter, prospective, observational study regarding CAS performed by neurointerventional physicians for patients with carotid stenosis that was collected at multiple CSCs. The primary outcome included a composite of the 30‐day periprocedural mortality, symptomatic ischemic stroke, symptomatic intracranial hemorrhage (sICH), and myocardial infarction (MI). The secondary outcomes included other complications. All data were analyzed using R statistical software (Version 4.4.1). Categorical variables were summarized as proportions and continuous variables were summarized as medians and inter‐quartile ranges. Associations between categorical outcomes and other considered categorical variables were examined using Chi‐square tests of independence with Yates continuity correction. Associations between categorical variables of two categories and continuous variables were explored using Wilcoxon rank sum tests. Associations between categorical variables of more than two categories and continuous variables were examined using Kruskal Wallis tests and when appropriate, subsequent pair‐wise comparisons were performed using Wilcoxon rank sum tests using Holm Bonferroni corrections to adjust the threshold for statistical significance. Associations between continuous variables were examined using Spearman correlations. Results In 2023, 389 CAS procedures were performed in 12 CSCs across the United States. The primary outcomes occurred in 6 (1.5%) cases, with 1 (0.25%) 30‐day periprocedural mortality, 2 (0.5 %) symptomatic ischemic stroke, 2 (0.5%) sICH, and 1(0.25%) MI. The secondary outcome occurred in 18 patients (4.62%) with 6 (1.5) non‐periprocedural mortality, 9 (2.3%) access site complications, 1 (0.25%) TIA, 1 (0.25%) dissection secondary to CAS, and 1(0.25%) other complication. One patient had both a primary outcome of symptomatic ischemic stroke in addition to non‐periprocedural mortality. History of cerebrovascular accident (P=0.003), symptomatic carotid disease (P<0.011), and aortic arch type (P=0.038) were predictors of post‐procedure complications. Increased fluoroscopy time with a median= 21.7 minutes (interquartile range, 15.075 ‐ 34), and obesity (BMI= 27.14, interquartile range, 24.20 ‐ 31.70) were also associated with post‐procedure complications. Conclusion CAS, demonstrates favorable outcomes when performed by fellowship‐trained NIR physicians CSCs, with a complication rate of 1.5% of 30‐day periprocedural mortality, symptomatic ischemic stroke, symptomatic intracranial hemorrhage (sICH), and MI. This underscores the effectiveness and safety of CAS in this specialized setting.

Abstract 273: Evaluating Clinical Outcomes and Cost‐Effectiveness of Robotic Carotid Artery Stenting: A Multi‐Center, Propensity Score Matched Study

Objective Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exists comparing robotic and manual CAS patients. In addition, no data exists comparing the costs of manual and robotic CAS. Methods All robotic CAS cases at 2 academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration using time‐driven activity‐based cost‐analysis (TDABC). Results 24 robotic CAS cases were performed between 2019 and 2023. Co‐morbidities and baseline procedural characteristics were well‐matched between robotic and manual cases. Unplanned manual conversion was observed in only one robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs. 19.2 min.; p<0.001). Robotic procedure time (88.9±18.2 min.) was significantly (p=0.003) higher than manual (68.72±22.4 min.). Health professional costs ($1,589.71±176.92, $1,375.99±233.39, p<0.005), supply cost ($3,918.25±421.20, $2,152.74±1,030.26, p<0.001) and total procedure costs ($5,306.11±608.95, $3,437.56±1,165.67, p<0.001) were greater for robotic CAS. Conclusions With a low rate of technical failure and post‐operative complications, we show robotic carotid artery stenting is safe and feasible in the first multi‐center and largest sample to date. In addition, robotic CAS achieves comparable clinical outcomes. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Our findings highlight the need for further studies to optimize robotic CAS and reduce its associated costs.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization. We conducted a retrospective review of the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into four groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA (CEA-CEA); 2) patients who had a prior unilateral CAS followed by a contralateral CEA (CAS-CEA); 3) patients had a prior unilateral CAS followed by a contralateral CAS (CAS-CAS); and 4) patients had a prior unilateral CEA followed by a contralateral CAS (CEA-CAS). Univariate analysis (Pearson χ 2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality. A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the CAS-CAS group, patients who underwent CEA followed by contralateral CAS (CEA-CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P=0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (OR 0.42; 95% confidence interval [CI] 0.29 - 0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% CI 0.49 - 0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for CEA-CEA and CAS-CEA groups. Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

CASSH Registry: Rationale and Study Design

Background Carotid artery disease, a major cause of strokes, often results from carotid atherosclerotic stenosis. Although carotid endarterectomy has long been the standard treatment, carotid artery stenting (CAS) emerged as an alternative for high‐risk surgical patients. Operator experience plays a crucial role in reducing complications, with neurointerventional specialists demonstrating proficiency in CAS. However, they are often underrepresented in CAS studies. The CASSH (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) registry aims to provide comprehensive insights into CAS outcomes, particularly when performed by neurointerventionalists at comprehensive stroke centers. Methods The CASSH is a multicenter, prospective, observational study currently enrolling patients with carotid artery stenosis undergoing CAS performed by neurointerventional physicians. All the participating sites will screen and report cases that meet inclusion criteria, on a monthly basis. The decision of whether to use CAS is at the discretion of the interventionalist. Results We will collect patients’ baseline clinical, demographic, and radiographic data. In addition, we plan to collect procedure variables and postoperative clinical and imaging data. Outcomes include the rate of postoperative symptomatic stroke (hemorrhagic/ischemic), access site complications, in‐stent thrombosis, and mortality. Conclusion Current literature underrepresents neurointerventionalists in CAS studies, especially as it pertains to procedural expertise and outcomes. CASSH is a prospective observational study that will enhance our understanding of CAS management and outcomes, emphasizing the benefits of neurointerventional expertise within comprehensive stroke centers.

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

ObjectiveThe outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive. MethodsUsing Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. ResultsWe identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). ConclusionsIn asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Optimizing Treatment of Significant Carotid Artery Stenosis in Times of Logistic Restraints as a Result of COVID-19 Pandemic

BackgroundCOVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints. PurposeTo evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach. MethodsRetrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post COVID (patient tailored approach). Primary outcome was the composite endpoint of stroke, TIA or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis or occlusion. ResultsA total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (p = .27; p = 1.00; p = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (p = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs CAS, 12.7% vs 7.9% and 23.9% vs 4.8% with a p-value of .03 and .03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic. ConclusionOutcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.

Clinical characteristics and imaging patterns of cerebral infarction with outcomes of carotid artery stenting in symptomatic carotid stenosis: An eight-year journey

Objectives: Carotid artery stenting (CAS) for symptomatic carotid stenosis (SCS) has emerged as an attractive option in recent times. CAS and topographical patterns of stroke in symptomatic stenosis have been inadequately addressed. With this objective, we conducted a study to analyze infarct patterns and complications of carotid stenting and determine outcome predictors after stenting. Materials and Methods: A single-center retrospective study from January 01, 2015, to December 31, 2022, on patients with SCS, who underwent carotid stenting with at least six months of follow-up was conducted. Infarct patterns, angiographic findings, procedural complications, and outcomes (favorable [modified Rankin scale (mRS) ≤2] or unfavorable [mRS &gt;2]) were recorded. Chi-square, analysis of variance for qualitative and quantitative variables was employed. Significant variables on univariate analysis were entered into regression and outcome predictors were determined. Results: Ninety-six records were included in the study. Forty-six (47.91%), 12 (12.50%), and 38 (39.58%) patients had territorial infarcts (TIs), border-zone infarcts (BZIs), and mixed infarcts (MIs). National Institutes of Health Stroke Scale (NIHSS) &lt;5 and transient ischemic attack (TIA) were significant (P &lt; 0.05) while the circle of Willis anomalies were comparable in TI versus BZI versus MI. Bradycardia (54.16%) and vessel spasm (19.79%) were noted during stenting. Successful revascularization (residual stenosis &lt;20%) was achieved in 97.87%. Procedural complications were comparable in TI versus BZI versus MI. Minor cerebral hyperperfusion syndrome (CHS) with headache (9.57%), seizure (2.12%) peaking between 6 and 12 h, and severe with basal ganglia hemorrhage and death occurred. There were no major strokes. 64.13% and 75.28% achieved a favorable mRS at one and six months, respectively. NIHSS ≤10, early intervention (≤ 2 weeks), absence of diabetes, hypertension, or ischemic heart disease were significant (P &lt; 0.05) for a favorable outcome. NIHSS ≤10, absence of hypertension at one month and NIHSS ≤10, absence of diabetes at six months were predictors of a favorable outcome. Conclusion: Severe carotid disease predisposed to CHS. Overall, CAS was a safe and effective procedure with 74.15% achieving favorable outcomes at six months.

Clinical and radiological outcomes of extracranial carotid artery stent placement: A single-center study

Objectives: Carotid artery stenting (CAS) and carotid endarterectomy are established treatments for carotid artery stenosis. We evaluated the early and mid- to late-term clinical and radiological outcomes of patients who underwent CAS. Materials and Methods: This retrospective study included 98 patients (112 arteries), who underwent CAS. Baseline demographics, stent types, embolic protection devices, and procedural complication rates within 30-day and 3-year post-CAS, including transient ischemic attack (TIA), stroke, death, and stent restenosis, were analyzed. Results: The 30-day complication rates included TIA (5.1%), ipsilateral stroke (4.1%), and death (4.1%). At three-year follow-up, TIA (8.5%), ipsilateral stroke (2.1%), restenosis (1.1%), and death (6.4%) were observed. Contralateral carotid artery angiography revealed neointimal hyperplasia in two vessels (1.9%) and 70–99% restenosis 1 (1%). Notably, a significant association was observed between neointimal hyperplasia and stent geometry, with a higher incidence observed in open-cell stents compared to closed-cell stents (P = 0.03). Conclusion: Our study demonstrated comparable early-term and lower mid- to late-term complication rates compared to prior studies. A multidisciplinary approach with meticulous technique, appropriate materials, and careful patient selection can optimize CAS outcomes.

Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center

In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P<0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P=0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System.

Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

Clinical Outcomes of Carotid Artery Stenting for Carotid Artery Stenosis in Maintenance Hemodialysis Patients.

Most previous large studies of carotid artery stenting (CAS) in maintenance hemodialysis patients are old-era, do not describe the types of stents and method of protection, and their effectiveness is unknown. CAS has progressed remarkably, and tailor-made CAS is now possible in hemodialysis patients according to the lesion. We aimed to analyze the outcomes of CAS in maintenance hemodialysis patients treated in our institution.We retrospectively investigated the data of patients who underwent elective CAS in our institution between January 2012 and April 2023. Firstly, we verified the outcomes of CAS in maintenance hemodialysis patients. Secondly, the outcomes of CAS in maintenance hemodialysis patients were compared with CAS in nondialysis patients during the same period.During the study period, 212 patients with carotid stenosis underwent CAS. Among these, 18 patients undergoing maintenance hemodialysis were identified for analysis. All 18 patients underwent lesion-specific tailor-made CAS. All 18 patients were technically successfully stented with good vasodilation and improvement in stenosis. No symptomatic cerebral infarction occurred within 30 days after CAS. There was no difference between dialysis and nondialysis patients in the risk of symptomatic complications and death occurring within 30 days after surgery. There was a higher risk of hemorrhagic complications not associated with prognosis in the dialysis group (23.1% vs 1.0%, P = 0.0047). No in-stent restenosis (>50% stenosis) and ipsilateral cerebral infarction at 1 year occurred during follow-up.CAS in hemodialysis patients may be safe and effective.

Socioeconomic status as a predictor of post-operative mortality and outcomes in carotid artery stenting vs. carotid endarterectomy.

The association between low socioeconomic status (SES) and worse surgical outcomes has become an emerging area of interest. Literature has demonstrated that carotid artery stenting (CAS) poses greater risk of postoperative complications, particularly stroke, than carotid endarterectomy (CEA). This study aims to compare the impact of low SES on patients undergoing CAS vs. CEA. The National Inpatient Sample (NIS) was queried for patients undergoing CAS and CEA from 2010 to 2015. Patients were stratified by highest and lowest median income quartiles by zip code and compared through demographics, hospital characteristics, and comorbidities defined by the Charlson Comorbidity Index (CCI). Primary outcome was in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), post-operative stroke, sepsis, and bleeding requiring reoperation.Multivariable logistic regression was used to determine the effect of SES on outcomes. Five thousand four hundred twenty-five patients underwent CAS (Low SES: 3,516 (64.8%); High SES: 1,909 (35.2%) and 38,399 patients underwent CEA (Low SES: 22,852 (59.5%); High SES: 15,547 (40.5%). Low SES was a significant independent predictor of mortality [OR = 2.07 (1.25-3.53); p = 0.005] for CEA patients, but not for CAS patients [OR = 1.21 (CI 0.51-2.30); p = 0.68]. Stroke was strongly associated with low SES, CEA patients (Low SES = 1.5% vs. High SES = 1.2%; p = 0.03), while bleeding was with high SES, CAS patients (Low SES = 5.3% vs. High SES = 7.1%; p = 0.01). CCI was a strong predictor of mortality for both procedures [CAS: OR1.45 (1.17-1.80); p < 0.001. CEA: OR1.60 (1.45-1.77); p < 0.001]. Advanced age was a predictor of mortality post-CEA [OR = 1.03 (1.01-1.06); p = 0.01]. While not statistically significant, advanced age and increased mortality trended towards a positive association in CAS [OR = 1.05 (1.00-1.10); p = 0.05]. Low SES is a significant independent predictor of post-operative mortality in patients who underwent CEA, but not CAS. CEA is also associated with higher incidence of stroke in low SES patients. Findings demonstrate the impact of SES on outcomes for patients undergoing carotid revascularization procedures. Prospective studies are warranted to further evaluate this disparity.

12-Month Outcomes of Carotid Artery Stenting With CGuard MicroNET-Covered Stent: A Single-Center Study in 113 Patients.

Dual layer mesh stents constitute a novel treatment option for patients who undergo carotid artery stenting (CAS). The aim of this prospective study is to report 12month outcomes of patients who underwent CAS with CGuard (Inspire MD, Tel Aviv, Israel) microNET self-expanding stent with embolic protection system in a tertiary center from October 2018 to March 2022. Primary endpoints included in-stent restenosis >70% verified by ultrasound (DUS), ipsilateral transient ischemic attack (TIA), and stroke at 12months. Secondary endpoints included cardiovascular-related mortality (stroke, myocardial infarction, heart failure) and all-cause mortality during follow-up. One hundred thirteen patients were included in the study (male 72.5%), symptomatic 47.8%. Median follow-up was 25months (2-48). By 12months, there was one in-stent occlusion that manifested as stroke (1/113, 0.8%) but no other forms of in-stent restenosis. Two patients experienced contralateral TIA (1.7%). CVRM was 3.5% (4 MI) and all-cause mortality was 6% at follow-up. This prospective study shows that CAS with CGuard MicroNET-covered stent is safe with minimal neurological adverse events at 12months follow-up. Larger, and longer-term studies are necessary to define CGuard long-term safety and protection against carotid-related stroke.

Abstract 234: Antithrombotic use in Emergent Cervical Carotid Artery Stenting in Thrombectomy

Introduction Current literature suggests a benefit in functional outcomes and reperfusion rates when carotid artery stenting (CAS) and mechanical thrombectomy (MT) are performed emergently. However, rates of symptomatic intracranial hemorrhages have been inconclusive. Antithrombotic protocols used in CAS and MT tend to be heterogenous among physicians. There is no standardized data on antithrombotic therapy use during CAS and MT procedures with less associated rates of symptomatic hemorrhagic transformation. We aimed to compare the efficacy and safety of antithrombotic use in patients requiring CAS and MT. Additionally, we sought to analyze clinical and mortality outcomes in CAS and MT retrospectively at our institution. Methods We searched for patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent‐retriever and/or aspiration devices in our institution between 2019‐2023. Clinicoangiographic and antithrombotic data were analyzed. Good clinical outcomes were a &lt; 4 points of NIHSS at 24 hours, mRS (0‐3) at 90 days, and disposition to home or inpatient rehabilitation. Characteristics of hemorrhagic transformation (HT) according to the European Cooperative Acute Stroke Study (ECASS). Clinical, radiographic, and mortality outcomes were described. Results Twenty‐seven patients were treated. The mean age was 64 years, nine females: mean occlusion time 400 minutes, mean fluoro time 32 minutes. Fourteen patients received IV tissue‐type plasminogen (tPA) activator. The admission NIHSS score mean was 16. Stent placement was feasible in all cases. Thrombolysis in Cerebral Infarction score of 2B was achieved in 18 patients (66.7%); the rest had a TICI 3 score. Twelve patients had improved 4 NIHSS points between admission and 24 hours. Dual antiplatelet therapy with aspirin and clopidogrel was used in 15 patients before stenting. While six patients received aspirin and ticagrelor, and the rest received eptifibatide drip. Seven (26%) patients had symptomatic intracranial hemorrhages. Antithrombotic type of treatment had no significant association with bad outcomes (p‐value: 0.872), neither did IV tPA use (p‐value: 0.853). Fourteen patients had good clinical outcomes (mRS 0‐3) at discharge, while eight died. At 90 days follow‐up, the median mRS was 3. Conclusion Our analysis suggests no significant association between symptomatic hemorrhagic transformation with IV tPA or heterogenous antithrombotic use. Our retrospective study has several limitations, including sample size and heterogeneous pathology. Larger studies are needed to stratify symptomatic hemorrhages' high‐risk profile in CAS and MT.

Patients with Prior Exposure to a Combination of Statins & Angiotensin-Converting Enzyme Inhibitors (ACE-Is)/Angiotensin Receptor Blockers (ARBs) Have Better Outcomes after Carotid Revascularization than Patients with Prior Exposure to Statins Alone: A MultiCenter Analysis

Statin use has been studied and confirmed to have a beneficial impact on perioperative carotid endarterectomy (CEA) and carotid artery stenting (CAS) outcomes. The benefits of Angiotensin-converting enzyme inhibitors (ACE-I) in hypertension, ischemic heart disease, heart failure, diabetes mellitus, and renal disease are well-known; however, the impact of continuing or withholding ACE-Is/angiotensin receptor blockers (ARBs) on CEA and CAS outcomes is not addressed well in the literature. This study aimed to evaluate the impact of preoperative statin use combined with ACE-Is/ARBs in patients undergoing CEA or CAS on mortality and morbidity using a multi-institutional database. Using the data of all patients who underwent carotid artery revascularization, including CEA, transcarotid artery revascularization, and transfemoral carotid artery stenting from 2016 to 2021 in the Vascular Quality Initiative data, we determined as our primary outcome 30-day mortality/stroke after carotid revascularization based on periop exposure to statins alone, or the combination of statins and ACE-Is/ARBs. Secondary outcomes were postop myocardial infarction and postop congestive heart failure. Poisson regression with robust variance was used to determine postop outcomes comparing the combination of statin and ACE-Is/ARBs group with statins alone group. A total of 131,285 patients were included in the study, with 59,860 (46%) patients receiving statin only, and 71,425 (54%) receiving both statin and ACE-Is/ARBs preoperatively. Both patient groups differed significantly in preop clinical and demographic characteristics. After adjusting for potential confounders, the statins plus ACE-I/ARB group had a 12% lower risk of postop mortality/stroke (Incident Rate Ratio comparing Statin/ACE group to Statins Only group [IRR] 0.88, 95% confidence interval 0.81-0.95, P=0.001), 18% lower risk of postop congestive heart failure (IRR 0.82, 95% CI 0.68-0.98, P=0.029), and similar risk of postop myocardial infarction (IRR 1.05 95% confidence interval 0.91-1.20, P=0.54) compared to the statin-only group. Statins combined with ACE-Is/ARBs perioperatively offer better protection compared to statins alone in patients undergoing carotid revascularization surgery. We recommend the continuation of ACE-Is/ARBs use in patients undergoing carotid revascularization, especially if they have concurrent hypertension. Further prospective studies are needed to evaluate the benefit of adding ACE-Is/ARBs.

Perioperative Outcomes in Transcarotid Artery Revascularization Versus Carotid Endarterectomy or Stenting Nationwide.

Transcarotid artery revascularization (TCAR) is a newer treatment for carotid stenosis where the carotid artery is accessed directly in the neck for stenting. It is less invasive than carotid endarterectomy (CEA) and has less embolic potential than carotid artery stenting (CAS), but population-level utilization of TCAR and outcomes are currently unknown. Our study compares outcomes of TCAR with those of CEA and CAS. The National Inpatient Database was used for years 2015 to 2019. A multivariate logistic regression model was used to compare CEA, CAS, and TCAR outcomes with age, sex, race, hospital teaching status, symptomatic carotid disease status, side of procedure, intraoperative monitoring, and the weighted Elixhauser comorbidity score as covariates. TCAR comprised 0.69% of these procedures in 2016, rising to 1.35% in 2019. The inpatient rates of death, stroke, and myocardial infarction for TCAR were 0.63% (95% confidence interval: 0.36%, 1.06%), 0.42% (0.21%, 0.80%), and 1.46% (1.04%, 2.05%), respectively. Compared with CEA, TCAR had statistically insignificant difference odds of death, odds ratio (95% CI) for stroke was 0.47 (0.25, 0.87), and for myocardial infarction, it was 0.66 (0.37, 0.94). Compared with CAS, for TCAR, the odds ratio for death was 0.41 (0.24, 0.71), and for stroke, it was 0.48 (0.26, 0.91). TCAR is underutilized relative to other revascularization techniques yet has favorable outcomes compared with CEA and CAS. TCAR may be preferred to CAS in patients not surgical candidates for CEA and has a less invasive possibility for those eligible for CEA.