Outcomes Of Carotid Artery Stenting Research Articles

Trials and Frontiers in Carotid Endarterectomy and Stenting.

Based on the strength of randomized trials from the 1990s, major societal guidelines recommend carotid endarterectomy (CEA) for severe (≥70%), symptomatic carotid stenosis if an operative stroke/death rate of <6% can be maintained (history and major trials in carotid revascularization are summarized in the online-only Data Supplement).1–4 Though the benefit is less evident, most guidelines also recommend consideration of CEA for 50% to 69% symptomatic stenosis.2–4 There are subtle differences in recommendations regarding carotid artery stenting (CAS) in symptomatic patients. Some guidelines stipulate that CEA should be preferred over CAS in patients with severe (≥70%) symptomatic carotid stenosis,2,5 especially if >70 years old,4 whereas others position CAS as an alternative.1,3 Though the risk of operative stroke/death is higher with CAS, major randomized clinical trials (RCTs) report event rates under the recommended 6% cutoff for both treatment modalities. Regarding asymptomatic disease, CEA is recommended for patients with stenosis ≥60% to 70% in highly selected patients as long as operative stroke/death rates <3% can be maintained.1 A predicted life expectancy of at least 3 to 5 years has also been suggested.2 The 3% threshold has been easily met by CEA cohorts in the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial; 1.4%)6 and the ACT1 (Asymptomatic Carotid Trial; 1.7%),7 suggesting that an even lower threshold may be appropriate. Controversially, some guidelines have recommended that CAS can be considered in highly selected patients with asymptomatic carotid stenosis ≥60% to 70%,1,4,8 whereas others argue that the evidence remains insufficient.2 The lack of consensus in the management of asymptomatic carotid stenosis is reflective of an ongoing need for high-quality RCT data to guide practice. ### CEA Operative Stroke Risk and High Risk Designation Most clinical trials in carotid revascularization have focused …

PC072. The Impact of Stent Geometry on Outcomes of Carotid Artery Stenting

PC072. The Impact of Stent Geometry on Outcomes of Carotid Artery Stenting

Influence of stent design and use of protection devices on outcome of carotid artery stenting: a pooled analysis of individual patient data

Background and purposeCarotid artery stenting is an alternative to endarterectomy for the treatment of symptomatic carotid stenosis but was associated with a higher risk of procedural stroke or death in...

TCTAP A-053 Outcome of Carotid Artery Stenting in Patient with Combined Carotid and Coronary Artery Disease

Myocardial infarction (MI) remains the most common cause of mortality in the world, while stroke is the second leading cause of death and most common cause of disability. Atherosclerosis is a diffuse process that affects multiple vascular beds. Severe carotid, vertebral or subclavian stenosis is

Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis.

Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis. From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study.All patients had suggestive evidence of unstable plaque or plaque ulceration. Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years. This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.

Predictors of Perioperative Stroke/Death after Carotid Artery Stenting: A Review Article.

Carotid artery stenting (CAS) has been recommended as an alternative treatment to carotid endarterectomy for patients with significant carotid stenosis. Only a few studies have analyzed clinical/anatomical and technical variables that affect perioperative outcomes of CAS. Following a comprehensive Medline search, it was reported that clinical factors, including age of >80 years, chronic renal failure, diabetes mellitus, symptomatic indications, and procedures performed within 2 weeks of transient ischemic attack symptoms, are associated with high perioperative stroke and death rates. They also highlighted that angiographic variables, e.g., ulcerated and calcified plaques, left carotid intervention, >90% stenosis, >10-mm target lesion length, ostial involvement, type III aortic arch, and >60°-angulated internal carotid and common carotid arteries, are predictors of increased stroke rates. Technical factors associated with increased perioperative risk of stroke include percutaneous transluminal angioplasty (PTA) without embolic protection devices, PTA before stent placement, and the use of multiple stents. This review describes the most widely quoted data in defining various predictors of perioperative stroke and death after CAS. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)

Periprocedural Outcomes of Carotid Artery Stenting in Elderly Patients

Carotid artery stenting has emerged as an alternative to carotid endarterectomy especially in patients with high risk of carotid endarterectomy. Older age (≥80 years old) was recognized as one of the high risk factors of carotid endarterectomy. However, the association between older age and increased risk of adverse events for carotid artery stenting has been reported. The purpose of this study was to evaluate the association between age and periprocedural outcomes after carotid artery stenting. A total of 126 symptomatic and asymptomatic cases of carotid artery stenosis were treated with tailored carotid artery stenting. The type of stents and embolic protection devices were chosen according to clinical and morphologic characteristics of the patients. Procedural, imaging, and clinical outcomes were retrospectively assessed and compared between the elderly patients group (≥80 years old) and the non-elderly patients group (<80 years old). Clinical and morphologic characteristics except for dyslipidemia were not significantly different between the 2 groups. Periprocedural neurologic complications were not significantly different between the 2 groups (P = .095). Minor stroke occurred more frequently in the elderly patients group (P = .021). However, the frequency of major stroke was not significantly different between the 2 groups (P = 1). Presence of new ischemic lesions on postprocedural examination was not significantly different between the 2 groups (P = .84). Myocardial infarction and death did not occur in either group. Carotid artery stenting can be performed safely in elderly patients, comparable with non-elderly patients.

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

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

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease.

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Long-term Results of Tapered Stents in Endovascular Treatment of Carotid Stenosis

Recent technological developments allowed significant improvements in interventional approach to carotid artery stenosis. Tapered stents were specifically designed for extracranial carotid artery stenting (CAS) to deal with vessels mismatch with the objective of decreasing the risk of thrombosis. Nevertheless, whether the stent geometry may affect the outcomes of CAS is uncertain. This study aims to investigate the impact of stent configuration on perioperative and long-term results of this procedure. All CAS procedures performed between 2005 and 2012 at a single high-volume center were reviewed. Primary end points of the study were 30-day mortality and any ipsilateral neurological event. Secondary end points were any late (>30days) neurological event and restenosis >50%. About 1,368 procedures were performed in the period 2005-2012. 9.1% of the patients were symptomatic for recent focal neurological event. 883 patients were treated with a cylindrical stent while the others underwent a tapered design device implantation. Technical success was achieved in 96% of the procedures. No perioperative mortality was recorded; perioperative stroke occurred in 1.2% vs. 1.6% (P=not significant) in tapered and straight stent group respectively. Stent design did not predict perioperative ipsilateral neurological events neither at bivariate nor at multivariate analysis. At a mean follow-up of 30months, late neurological events occurred in 26 cases (1.9%); conic stents resulted protective at Kaplan-Meier analysis (P=0.027). The use of conic stents appears to be associated with similar perioperative results when compared with straight stents. Late outcomes suggest a lower risk of restenosis and late neurological events in patients with conical shape stents.

Systematic review of carotid artery procedures and the volume-outcome relationship in Europe.

Hospitals that conduct more procedures on the carotid arteries may achieve better outcomes. In the context of ongoing reconfiguration of UK vascular services, this systematic review was conducted to evaluate the relationship between the volume of carotid procedures and outcomes, including mortality and stroke. Searches of electronic databases identified studies that reported the effect of hospital or clinician volume on outcomes. Reference and citation searches were also performed. Inclusion was restricted to European populations on the basis that the model of healthcare delivery is similar across Europe, but differs from that in the USA and elsewhere. Analyses of hospital and clinician volume, and carotid endarterectomy (CEA) and carotid artery stenting (CAS) were conducted separately. Eleven eligible studies were identified (233 411 participants), five from the UK, two from Sweden, one each from Germany, Finland and Italy, and a combined German, Austrian and Swiss population. All studies were observational. Two large studies (179 736 patients) suggested an inverse relationship between hospital volume and mortality (number needed to treat (NNT) as low as 165), and combined mortality and stroke (NNT as low as 93), following CEA. The evidence was less clear for CAS; multiple analyses in three studies did not identify convincing evidence of an association. Limited data are available on the relationship between clinician volume and outcome in CAS; in CEA, an inverse relationship was identified by two of three small studies. The evidence from the largest and highest-quality studies included in this review support the centralization of CEA.

Outcome of carotid artery stenting in the hands of vascular surgeons.

To analyze the procedural and clinical outcomes of carotid artery stenting (CAS) in the hands of endovascular trained vascular surgeons. Between April 2008 to May 2013, 1197 patients were treated for extracranial internal carotid artery (ICA) stenosis. The proportion of endovascular treated patients was 5.0% (CAS n=60 vs. carotid endarterectomy (CEA) n=1137). All patients in the CAS group (44 males, median age 70years) were treated by two senior vascular surgeons experienced in endovascular methods. Restenosis was the indication for CAS in 32 out of 60 patients (53.3%). Further indications were contralateral ICA occlusion (n=14, 23.3%), radiogenic ICA stenosis (n=5, 8.3%), high-risk candidates for CEA (n=4, 6.6%), and the presence of contralateral recurrent paresis (n=2, 3.3%). High-risk patients for CEA were defined as patients with history of severe cardiac disease and patients with impaired general condition. 84.4% (n=27) of the restenosis were asymptomatic with a mean degree of stenosis of 83.7%, and 12.9% (n=4) were symptomatic (degree of stenosis of 90%). Mean procedural and fluoroscopy time were 61 and 14min. Study endpoints were periprocedural stroke-related mortality and morbidity, restenosis rate, and overall survival. Follow-up was performed by duplex ultrasound with a median follow-up period of 12 months (range 1-55). The periprocedural stroke rate of CAS within 30 days was 3.3% (one ischemic stroke, one intracranial hemorrhage); two additional patients suffered TIA (3.3%). None of the patients had a myocardial infarction perioperatively. The mortality rate was 0. CAS procedures were completed in 90.0% (n=54) of cases. Dropout rate was 8.3% (n=5) for morphological reasons (e.g., carotid kinking). Intraoperative complication rate was 1.7% (n=1) including one patient who suffered intraoperative rupture of access vessels. The conversion rate with subsequent CEA procedure was 6.6% (n=4 of 5). The restenosis rate during follow-up was 3.3% after CAS. The reintervention rate during the median follow-up period of 12 months (1-55 months) was 5.5% (n=3/54). Two patients received a reintervention with successful balloon angioplasty; in one case, a diagnostic angiography was performed excluding the presence of a relevant restenosis. No additional stent was implanted. The survival rate was 100% at 1 year, 90.4% at 2 years, and 77.7% at 3 years. CAS, in the hands of vascular surgeons, is feasible with a moderate perioperative risk in a highly selected patient cohort. A procedure termination rate of approximately 10% shows that the complementary therapy using CAS procedure is not overused by surgeons.

Anatomical and technical predictors of perioperative clinical outcomes after carotid artery stenting

BackgroundA few other studies have reported the effects of anatomical and technical factors on clinical outcomes of carotid artery stenting (CAS). This study analyzed the effect of these factors on perioperative stroke/myocardial infarction/death after CAS. MethodsThis was a retrospective analysis of prospectively collected data of 409 of 456 patients who underwent CAS during the study period. A logistic regression analysis was used to determine the effects of anatomical and technical factors on perioperative stroke, death, and myocardial infarction (major adverse events [MAEs]). ResultsThe MAE rate for the entire series was 4.7% (19 of 409), and the stroke rate was 2.2% (9 of 409). The stroke rate for asymptomatic patients was 0.46% (1 of 218; P = .01). The MAE rates for patients with transient ischemic attack (TIA) were 7% (11 of 158) vs 3.2% (8 of 251) for other indications (P = .077). The stroke rates for heavily calcified lesions were 6.3% (3 of 48) vs 1.2% (4 of 332) for mildly calcified/noncalcified lesions (P = .046). Differences in stroke and MAE rates regarding other anatomical features were not significant. The stroke rate for patients with percutaneous transluminal angioplasty (PTA) before embolic protection device (EPD) insertion was 9.1% (2 of 22) vs 1.8% (7 of 387) for patients without (P = .07) and 2.6% (9 of 341) for patients with poststenting PTA vs 0% (0 of 68) for patients without. The MAE rate for patients with poststenting PTA was 5.6% (19 of 341) vs 0% (0 of 68) for patients without (P = .0536). The MAE rate for patients with the ACCUNET (Abbott, Abbott Park, Ill) EPD was 1.9% (3 of 158) vs 6.7% (16 of 240) for others (P = .029). The differences between stroke and MAE rates for other technical features were not significant. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for PTA performed before EPD insertion, 1.7 for PTA performed before stenting, and 5.4 (P = .0315) for heavily calcified lesions. The MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 for PTAs performed before EPD insertion, 2.2 for poststent PTAs, and 2.2 (P = .1888) for heavily calcified lesions. A multivariate analysis showed that patients with TIA had an odds ratio of stroke of 11.05 (P = .029). Patients with PTAs performed before EPD insertion had an OR of 6.15 (P = .062). Patients with heavily calcified lesions had an odds ratio of stroke of 4.25 (P = .0871). The MAE odds ratio for ACCUNET vs others was 0.27 (P = .0389). ConclusionsCalcific lesions and PTA before EPD insertion or after stenting were associated with higher stroke or MAE rates, or both. The ACCUNET EPD was associated with lower MAE rates. There was no correlation between other anatomical/technical variables and CAS outcome.

Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume

Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year). Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P=0.3121; 6.3% for VS and 3.8% for others combined, P=0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P=0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P=0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P=0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P=0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P=0.5969). Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.

Abstract 323: Utilization and Outcomes of Carotid Artery Stenting vs. Carotid Endarterectomy

Introduction: Carotid artery stenting is an alternative to carotid endarterectomy in average surgical-risk symptomatic patients and asymptomatic patients with ≥60% stenosis. We wanted to compare utilization and peri-procedural mortality between these procedures. Methods: The 2000-2013 National Inpatient Sample (NIS) was analyzed for admissions when procedures for carotid artery stenting (CAS) or carotid endarterectomy (CEA) were performed. Admissions when both procedures were performed were excluded. Trend of procedures and death during index admission was compared depending on prior cerebrovascular symptoms. Results: During the study period, 1991941 patients underwent CEA of which 9.12% were symptomatic and 343,741 patients underwent CAS of which 10.8% were symptomatic. Mean age for CAS vs CEA group was lower among both symptomatic (68.6 vs 69.6 yrs, p&lt;0.001) and asymptomatic patients (70.7 vs 71.2 yrs, p&lt;0.001). More males than females underwent CAS (57% vs 43%) and CEA (58% vs 42%). Both CAS and CEA during same admission was carried out in 20,875 (0.89%) patients. There was a rising trend of both CEA and CAS procedures in symptomatic and asymptomatic patients (ptrend &lt; 0.001)(Figure A1 &amp; B1). Trend of mortality has not changed significantly in all groups except for CEA in asymptomatic patients wherein mortality rate has decreased (ptrend &lt;0.001)(Figure A2 &amp; B2). On multivariable logistic regression analysis, associated conditions significant for mortality in symptomatic patients were atrial fibrillation (OR 2.05, p&lt;0.001), myocardial infarction (OR 1.61, p=0.001) heart failure (OR 1.39, p=0.021) and malnutrition (OR 3.58, p&lt;0.001). Adjusted likelihood of mortality after CAS vs CEA was higher in symptomatic (OR 3.78, p&lt;0.001, C statistic 0.74) and asymptomatic patients (OR 2.00, p&lt;0.001, C statistic 0.80). Conclusion: Utilization of CAS and CEA has increased over time. Mortality after CAS vs. CEA during index admission, remains high.

Safety Outcome of Carotid Artery Stenting in Long Carotid Lesion with Proximal versus Distal Embolic Protection Devices (P3.077)

Safety Outcome of Carotid Artery Stenting in Long Carotid Lesion with Proximal versus Distal Embolic Protection Devices (P3.077)

Abstract WP309: Effects of Comprehensive Stroke Care Capabilities on Outcome of Carotid Endarterectomy and Carotid Artery Stenting (from the J-ASPECT Study [2013 to 2015

Background: The effectiveness of comprehensive stroke center (CSC) capabilities on outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital outcome of CEA and CAS. Methods: We analyzed 12,943 carotid artery stenosis patients treated with CEA or CAS in 350 certified training hospitals in Japan. Data between April 1, 2013 and May 31, 2015 was obtained from Japanese Diagnosis Procedure Combination Database. Among the institutions that responded, outcome was assessed by in-hospital mortality, ischemic stroke and myocardial infarction. CSC capabilities were evaluated from the 749 certified training institutions in Japan, which responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Total CSC scores of the participating hospitals were classified into quartiles (Q1: 0-15, Q2: 16-17, Q3: 18-19, Q4: 20-24). Results: The proportion of CEA and CAS were 5068 and 7875 (2013: 1685 and 2590, 2014: 1668 and 2564, 2015: 1715 and 2721). Between CEA and CAS, mortality rates were 0.24% and 0.75%, ischemic stroke were 8.41% and 7.56% and myocardial infarction were 0.76% and 0.17%. These outcomes had no differences among the years. There was tendency that mortality rates were lower with high total CSC scores in patients with CEA (Q1: 0.42%, Q2: 0.26%, Q3: 0.12%, Q4: 0%, P=0.16), but there were no differences with CAS (Q1: 1.0%, Q2: 0.74%, Q3: 0.63%, Q4: 0.83%, P=0.73). Ischemic stroke were significantly lower with high CSC scores in CEA (Q1: 9.76%, Q2: 10.77%, Q3: 9.14%, Q4: 6.59%, P&lt;0.05) and CAS (Q1: 9.86%, Q2: 8.76%, Q3: 7.14%, Q4: 6.98%, P&lt;0.05). Myocardial infarction had no correlation with CSC scores in CEA (Q1: 0.21%, Q2: 0.35%, Q3: 0%, Q4: 0.36%, P=0.37) and CAS (Q1: 0.3%, Q2: 0%, Q3: 0.31%, Q4: 0.16%, P=0.19). Conclusion: It is reported using the data of Nationwide Inpatient Sample that operator volume was an important predictor of postprocedural outcomes in CAS. We demonstrated that CSC capabilities were associated with reduced in-hospital ischemic stroke in patients with CEA and CAS.

Treatment Outcome of Carotid Artery Stenting Underwent within 14 Days of Stroke Onset - Consideration of Safety and Efficacy of Urgent Carotid Artery Stenting for Neurologically Progressing Patients.

As the safety and effectiveness of urgent carotid artery stenting (CAS) for neurologically progressing patients remain controversial, we retrospectively analyzed the outcome of urgent CAS based on the patients’ pathophysiological condition and neuroimaging findings. We divided 71 patients who underwent CAS within 14 days of stroke onset into two groups. Group 1 (n = 35) was comprised of patients with progressing neurologic signs and a reversible ischemic penumbra on magnetic resonance images (MRI). They were treated by urgent CAS. Group 2 (n = 36) was neurologically stable and underwent prophylactic CAS. In all patients we recorded the National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin scale (mRS). Urgent CAS resulted in significant improvement in the NIHSS score, when compared before and after CAS in group 1 (5.3 ± 4.3, P < 0.01). The rate of good outcomes (mRS 0–2 at 3 months post-CAS) was 48.6% in group 1, and 75% in group 2. The cumulative incidence of ipsilateral stroke between 31 days and 1 year was 5.9% in group 1, and 0% in group 2. The procedural complication rate was similar in both groups (group 1: 5.7%, n = 2; group 2: 5.6%, n = 2). No patient suffered a symptomatic intracerebral hemorrhage. When the pathophysiological status and neuroimaging findings are used to determine patient eligibility for urgent CAS, this treatment improve neurologic outcome and can be performed as safely as prophylactic CAS in our cohort of patients with acute ischemic stroke.

Transcervical access, reversal of flow and mesh-covered stents: New options in the armamentarium of carotid artery stenting.

In the last 25 years, the very existence of carotid artery stenting (CAS) has been threatened on a number of occasions. The initial disappointing results that even lead to the discontinuation of an early randomized controlled trial have improved considerably with time. Novel devices, advanced stent and equipment technology, alternative types of access and several types of filters/emboli protecting devices have been reported to reduce stroke/death rates during/after CAS and improve CAS outcomes. The present review will provide a description of the various technology advances in the field that aim to reduce stroke and death rates associated with CAS. Transcervical access, reversal of flow and mesh-covered stents are currently the most promising tools in the armamentarium of CAS.

Anatomic/Technical Predictors of Perioperative Clinical Outcomes after Carotid Artery Stenting

Only a few studies have reported on the impact of anatomic/technical factors on clinical outcomes of carotid artery stenting (CAS). This study will analyze the effect of these factors on perioperative stroke/death after CAS. This is a retrospective analysis of prospectively collected data on 456 patients with CAS. A logistic regression analysis was used to determine the impact of anatomic factors (lesion length, location, severity, calcification, and arch type) and technical factors (stent type, number, diameter, and length; filter type, filter insertion to recovery time, and pre- and poststent percutaneous transluminal angioplasty [PTA]) on perioperative stroke, death, and myocardial infarction (major adverse events [MAE]). The MAE and stroke rates for the whole series were 4.7% and 2.2%. The stroke rate for asymptomatic patients was 0.46% (P = .01). The MAE rates for patients with transient ischemic attacks (TIAs) were 7% vs 3.2% for other indications (P = .077). The stroke rates for calcific lesions were 6.3% vs 1.2% for noncalcific lesions (P = .046). There were no significant differences in stroke and MAE rates regarding other anatomic features. The stroke rate for patients with dilatation prior to filter insertion with prestent and/or poststent PTA was 9.1% vs 1.8% for patients without (P = .07) and 2.6% for patients with poststenting dilatation vs 0% for patients without (P = .36). MAE rates for patients with poststenting dilatation were 5.6% vs 0% for patients without (P = .0536). MAE rates for patients with Accunet filters (Abbott, Abbott Park, Ill) were 1.9% vs 6.7% for other filters (P = .029). There were no significant differences between stroke and MAE rates regarding stent type, number, diameter, length of stent, and time from filter insertion to recovery time. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for dilatation performed prior to filter insertion, and 1.7 (P = .4413) for PTA performed prior to stenting. It also showed that the MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 (P = .35) for predilatations performed prior to filter insertion, and 2.2 (P = .22) for poststent dilatations. A multivariate analysis showed that patients with TIA indications had an odds ratio of stroke of 15.26 (P = .0113); and patients with dilations performed prior to filter insertion with prestent and/or poststent PTA had an odds ratio of 7.98 (P = .0193). The MAE odds ratio for Accunet vs other filters was 0.27 (P = .0389, Tables I and II). PTA prior to filter insertion had higher stroke rates and poststenting PTA was associated with higher MAE rates. The Accunet filter was associated with lower stroke and MAE rates. There was no correlation between other anatomical/technical variables.Table IPercutaneous transluminal angioplasty (PTA) combination and perioperative stroke and major adverse events (MAEs)DilationStroke, No. (%)MAE, No. (%)None0/260/26Pre-EPD only0/10/1Prestent only0/390/39Poststent only2/130 (1.5)6/130 (4.6)Pre-EPD and present0/20/2Pre-EPD and poststent1/8 (12.5)1/8 (12.5)Prestent and poststent5/192 (2.6)11/192 (5.7)Pre-EPD, prestent and post stent1/11 (9.1)1/11 (9.1)EPD, Embolic protection device. Open table in a new tab Table IILogistic regression analysisUnivariate–early strokeOR95% CIP valueVariablesAge1.03(0.96,1.11).4058Sex (male vs female)0.86(0.23,3.24).8223Hypertension1.04(0.13,8.52).9683Coronary artery disease1.33(0.27,6.51).7215Congestive heart failure1.63(0.4,6.61).4977Hypercholesterolemia1.10(0.23,5.4).9026Renal failure1.00(0.21,4.91).9971Asymptomatic indication0.10(0.01,0.81).031TIA indication13.69(1.7,110.47).014Stroke indication1.10(0.14,9.02).9273Preprocedure stenosis (70-99 vs 50-69)0.56(0.07,4.6).5852Lesion length (≥15 mm)0.96(0.25,3.62).9501Predilatation performed prior to EPD6.09(1.19,31.2).0303Predilatation performed prior to stent1.73(0.43,7.01).4413Univariate–early MI/stroke/deathOR95% UCLP valueVariablesAge1.02(0.97,1.06).5127Sex (male vs female)1.00(0.42,2.38).9913Hypertension0.42(0.15,1.19).101Coronary artery disease1.01(0.39,2.65).981Congestive heart failure0.94(0.34,2.62).9102Hypercholesterolemia0.66(0.26,1.66).3781Renal failure1.34(0.51,3.51).5558Asymptomatic indication0.46(0.19,1.12).0858TIA indication2.04(0.86,4.82).1055Stroke indication0.88(0.2,3.87).8603Preprocedure stenosis (70-99 vs 50-69)0.58(0.13,2.66).4833Lesion length (≥15 mm)0.43(0.17,1.12).0831EPD (Accunet vs other)0.27(0.08,0.95).0413Predilatation performed prior to EPD2.07(0.45,9.45).35Predilatation performed prior to stent1.03(0.44,2.43).9463Poststent dilatation performed2.16(0.63,7.43).2232Multivariate– early strokeOR95% CIP valueVariableTIA indication15.26(1.85,125.66).0113Predilatation performed prior to EPD7.98(1.4,45.43).0193Multivariate– early MI/stroke/deathOR95% LCLP valueVariablesEPD (Accunet vs other)0.27(0.08,0.94).0389CI, Confidence interval; EPD, embolic protection device; LCL, lower confidence interval; MI, myocardial infarction; OR, odds ratio: TIA, transient ischemic attack; UCL, upper confidence interval. 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