Percutaneous Carotid Artery Stenting Research Articles

English

Recent concerns have been raised about the potential for proton pump inhibitors (PPIs) to blunt the efficacy of clopidogrel. We observed the effect of clopidogrel plus aspirin with or without omeprazole in patients with carotid stenoses after they received placement of carotid stents. Sixty-four consecutive patients treated with percutaneous carotid artery stenting (CAS) comprised the sample. All enrolled patients underwent the C13 urea breath test (C13 UBT) before CAS. Patients with Helicobacter pylori infection and a history of peptic ulcer were assigned dual antiplatelet combination with omeprazole. Others received dual antiplatelet without omeprazole. Transcranial Doppler and ultrasonography were performed to assess the middle cerebral artery and carotid artery in follow-up at three months and six months. Eight patients had gastrointestinal bleeding; the event rate was 22.6% without omeprazole and 3.8% with omeprazole. The rate of gastrointestinal bleeding was reduced with omeprazole as compared without omeprazole (p = 0.026, p < 0.05). The two groups did not differ significantly in the rate of in-stent restenosis and thrombus through transcranial Doppler and ultrasonography. Among patients receiving dual antiplatelet therapy, prophylactic use of omeprazole reduced the rate of upper gastrointestinal bleeding. There was no apparent interaction between clopidogrel and omeprazole in patients with carotid artery stenting.

Dysautonomic responses during percutaneous carotid intervention: principles of physiology and management.

Percutaneous carotid artery stenting (CAS) has emerged as a less invasive alternative to carotid endarterectomy for the treatment of carotid atherosclerotic disease. The main risk of CAS is the occurrence of neuro-vascular complications; however, carotid artery stenting-related dysautonomia (CAS-D) (hypertension, hypotension, and bradycardia) is the most frequently reported problem occurring in the periprocedural period. Alterations in autonomic homeostasis result from baroreceptor stimulation, which occurs particularly at the time of balloon inflation in the region of the carotid sinus. The response can be profound enough to induce asystole or even complete cessation of postganglionic sympathetic nerve activity. Frequency and factors predisposing a patient to CAS-D have been investigated in several studies; however, there are significant discrepancies in results among reports. Lack of consistent findings may arise from using different methods and definitions, as well as other factors discussed in detail in this review. Furthermore, a correlation of CAS-D with short and long-term outcomes has been investigated only in small and mostly retrospective studies, explaining why its prognostic significance remains uncertain. In this manuscript, we have focused on risk factors, pathophysiology and management of periprocedural autonomic dysfunction. As there is no standardized approach to the treatment of CAS-D, we present an algorithm for the periprocedural management of patients undergoing CAS. The proposed algorithm was developed based on our procedural experience as well as data from the available literature. The Yale Algorithm was successfully implemented at our institution and we are currently collecting data for short- and long-term safety. © 2014 Wiley Periodicals, Inc.

Direct Percutaneous Carotid Artery Stenting for a Patient with Absence of the Common Carotid Artery

A 54-year-old man with symptomatic internal carotid artery stenosis with absence of the common carotid artery (CCA), who had been treated with surgery and postoperative radiotherapy for tonsillar carcinoma, underwent direct percutaneous carotid artery stenting (CAS). To our knowledge, this is the first report of direct percutaneous carotid artery stenting (CAS) for a patient with absent CCA.

Carotid Artery Stenting: A Single Center “Real World” Experience

BackgroundPercutaneous carotid artery stenting (CAS) became a widely used procedure in patients with symptomatic and asymptomatic carotid artery stenosis. However its role compared to carotid endarterectomy (CAD) remains questioned. We analysed the safety of carotid artery stenting program of a prospective CAS register program of a tertiary teaching hospital.MethodBetween July 2003 and December 2010, 208 patients underwent CAS procedure. Baseline, procedural and follow-up data were prospectively collected. Primary peri-interventional outcome was defined as 30-day major adverse events (MAE), including death, stroke or myocardial infarction, and mid- to long-term follow-up outcome included ipsilateral stroke, myocardial infarction or death. Secondary outcome was restenosis rate ≥50% per lesion.ResultsUnilateral carotid artery interventions were performed in 186 patients. In 22 patients CAS was performed bilaterally as stages procedures. The 30-day MAE rate was 1.9% consisting of two contralateral strokes and two ipsilateral stroke. Mean clinically follow-up was 22 months. Mid- to long-term MAE was 8.1% with 6.3% (n = 13) deaths, 1.9% (n = 4) myocardial infarctions and 0.9% (n = 2) ipsilateral stroke. The restenosis rate ≥50% per lesion was 4.3% at a mean follow-up of 22 months. Target lesion revascularization was performed in one patient, because of restenosis at 9 months follow-up after first CAS.ConclusionImplementation of a carotid artery stenting program at a tertiary, teaching hospital is a safe method for treatment of carotid artery stenosis. The adverse event rate during mid-to-long-term follow-up suggests an appropriate patient selection.

Percutaneous interventions combined with carotid artery stenting

Although the value of interventional treatment of arterial stenosis has not been confirmed for all sites by randomized studies, these methods are used more and more, often for several arteries simultaneously. This study reports results of percutaneous carotid artery stenting combined with simultaneous interventions in other central arteries. Among 90 patients who had undergone percutaneous carotid artery stenting, 13 had simultaneous intervention in other arteries: contralateral carotid artery (n = 4), ipsilateral common carotid artery near its aortic origin (n = 1), left subclavian artery (n = 1), coronary artery (n = 6) and one of both carotid arteries and a coronary artery. Primary success (restenosis < 30%) was achieved in all cases. Additional carotid artery stenting was done in 18. Stents were also implanted in eight coronary arteries, angioplasty without stenting in two. Mean stenosis of the carotid arteries was reduced from 85 +/- 10% to 3 +/- 6%, that of the coronary arteries from 90 +/- 10% to 9 +/- 10%. Serious complications, a major stroke, occurred in one of the 13 patients (7.7%). Minor complications were seen in two patients: transitory ischaemic attack in one, small myocardial infarction in the other. Carotid artery stenting combined with simultaneous intervention in other central arteries can be done with a high rate of success and relatively few complications. This form of treatment should be considered in selected patients.

Cerebral embolic protection devices and percutaneous carotid artery stenting

Cerebral embolic protection devices and percutaneous carotid artery stenting

Percutaneous carotid artery stenting: a strategy in evolution

Carotid stenting was initially proposed as an alternative to surgical endarterectomy for selected high-risk patients. More recently, patients of standard surgical risk are being considered for percutaneous treatment of their carotid disease. To describe the clinical outcomes of an initial consecutive cohort of patients treated by carotid stenting at one institution. Between December 1997 and July 2003, 111 patients underwent stenting of 118 carotid arteries. Peri-procedural and long-term outcome data were collected. Most patients (>70%) were high-risk candidates for endarterectomy. Stents were successfully placed in 117/118 carotid arteries (99.2%). Distal protection devices were used in 43/118 (36.4%). The peri-procedural rate of death or disabling stroke was 3/118 (2.5%). Death or any stroke occurred in 11/118 (9.3%). However, only 7/118 (5.9%) procedures resulted in death or any persistent stroke (neurological deficit >1 week post-procedure). No myocardial infarction occurred. Median length of post-procedure hospitalization was 1 day. Long-term follow up was possible for 101 patients (91.0%) over a mean period of 27.1 months. The Kaplan-Meier estimate of survival free of ipsilateral stroke 36 and 66 months after carotid stenting was 77.0 +/- 9.5% and 68.2 +/- 15.1%, respectively. The estimated survival free of any stroke or stent failure was 70.9 +/- 10.7% and 60.7 +/- 17.4%, respectively. The majority of late deaths (7/11) were due to cardiac disease. We conclude that stenting of carotid stenoses is feasible, with a high procedural success rate and low complication rate. Carotid stenting should be considered the procedure of choice for high-risk patients.

Direct percutaneous carotid artery stenting with distal protection: technical case report

We describe the technique of percutaneous carotid artery stent placement with distal protection in a patient in whom marked innominate artery ectasia prevented transfemoral access to the right common carotid artery. After induction of general anesthesia, ultrasound was used to guide direct puncture of the common carotid artery followed by the introduction of a 5 French sheath. A GuardWire distal protection balloon (Medtronic, Santa Rosa, CA) was placed distal to the lesion and deployed at nominal diameter. A balloon-expandable stent was deployed without difficulty. Following stent placement, angiography demonstrated improved flow in the entire right carotid artery territory. There were no complications related to cervical soft tissue damage or clinical embolism. The patient tolerated the procedure well and was discharged in 24 hours. Direct carotid access is acceptable in select patients in whom a transfemoral, brachial, or transradial approach is technically difficult. The use of distal cerebral protection devices may reduce cerebral embolism associated with these procedures.

Is Combined Percutaneous Carotid Artery Stenting and Coronary or Extra-Coronary Artery Angioplasty a Safe Procedure?

Is Combined Percutaneous Carotid Artery Stenting and Coronary or Extra-Coronary Artery Angioplasty a Safe Procedure?