Treatment Of Carotid Artery Stenosis Research Articles

Carotid Endarterectomy Under Regional Anesthesia

Background Carotid endarterectomy (CEA) has been shown to be a safe and effective treatment for carotid artery stenosis. This procedure can be performed under regional or general anesthesia. This study describes our initial experience of performing CEA under regional anesthesia and the development of specific patient selection criteria for the use of regional versus general anesthesia. Methods A consecutive series of 100 CEAs performed under regional anesthesia over a 5-year period was reviewed. Results The mean age was 69.9 years (±9.0). The mean stenosis by North American Symptomatic Carotid Endarterectomy Trial criteria was 73.9%. The stenosis was asymptomatic in 57 patients; 14 experienced transient hemispheric ischemic attacks; 10, transient monocular blindness; and 25, preoperative strokes. All patients were evaluated with carotid duplex and magnetic resonance angiography; some had digital subtraction angiography or computed tomographic angiography. Electroencephalography monitoring was used for all cases. A shunt was needed in only 5 cases. No patient deaths occurred; 2 patients experienced a postoperative stroke (1 was moderately disabling for 3 months, with a good functional recovery and 1 was a retinal infarct). Five patients experienced a minor non-neurologic, nonfatal complication. Conversion from regional to general anesthesia was required in 2 cases owing to changes in clinical status, without complication. Conclusions CEAs can be performed by experienced neurosurgeons under regional anesthesia with an acceptably low rate of complications and provide certain operative advantages. Careful patient selection can aid the neurosurgeon in making the transition from general to regional anesthesia.

Endovascular treatment for carotid artery stenosis after neck irradiation

To lower the risk of complications, carotid angioplasty and stenting (CAS) has been proposed as an alternative to open surgery for carotid artery stenosis after neck irradiation. However, there are little postoperative data to support the benefits of this strategy. This study evaluated the outcome of CAS in patients who had undergone neck irradiation. This retrospective study was conducted at 15 vascular surgery or interventional radiology centers in France between January 1998 and July 2006. A total of 135 patients (115 men) with a mean age of 67 +/- 8 years (range, 43-88) underwent CAS for 149 irradiation-induced lesions. The interval between irradiation and discovery of the lesions was 12 +/- 8 years. Mean diameter reduction was 81% (range, 50%-95%), and stenosis was symptomatic in 34%. Contralateral carotid lesions were observed in 48% of patients, including thrombosis in 18 and stenosis >50% in 53. Technical failure occurred during CAS in three cases. The overall technical success rate was 98%. A cerebral protection device was used in 59%. No death, one transient ischemic attack, and two strokes occurred during the first postoperative month. Mean follow-up was 30 months. Six patients were lost to follow-up. Survival rates were 93.9% at 1 year and 75.3% at 3 years. Complications after the first postoperative month included neurologic events in six, carotid thrombosis in nine, and restenosis in 18. The rates of freedom from neurologic and anatomic events were, respectively, 96.2% and 93.2% at 1 year and 93.1% and 85.9% at 3 years. The immediate outcome of CAS for irradiation-induced carotid artery stenosis was satisfactory. Medium-term neurologic outcome was acceptable, but the incidence of anatomic events such as thrombosis and restenosis was high. A randomized study is needed to confirm that the outcome of the endovascular and surgical therapy is comparable in this indication.

Clinical selection of endovascular stenting and carotid endarterectomy in treatment of carotid artery stenosis

To explore reasonable clinical decision in treating carotid artery stenosis under different conditions. The data of 133 carotid artery stenosis patients were retrospectively analyzed. Of the patients, 46 cases were treated with carotid angioplasty and stenting (CAS), 87 patients received carotid endarterectomy (CEA). The length of hospital stay and National Institutes of Health Stroke Scale (NIHSS) grade before and after treatment in both groups were observed; the forward flow were assessed by digital subtraction angiography (DSA) before and after treatment; the degree of carotid artery stenosis were determined by using ultrasound during 3 to 24 months after treatment in both groups; the cumulative incidence of major cardiovascular events was concentrated, including appearance of death, stroke or myocardial infarction during 30 days after CAS and CEA and death or homonymy stroke during 31 days to 2 years. Significant difference was found in hospital stay and when NIHSS exceed 20 after treatment between the two groups (P < 0.05); there was no significant difference in the forward flow before and after treatment in both groups; the carotid artery stenosis had been improved significantly after the operation in both groups; the cumulative incidence of major cardiovascular events in CEA group was significantly higher than in CAS group in 30 days after the operation (P < 0.05), but no statistical difference in 31 days to 2 years after the operation. CAS and CEA has equivalent effects in treating carotid artery stenosis, and should be selected according to the location of stenosis, etiological factors and the condition of opposite carotid artery.

Carotid Artery Stenting Compared to Carotid Endarterectomy Performed Exclusively in a Veteran Population

To evaluate a single center's experience with carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed by vascular surgeons in an entirely veteran population. Data from the Lakeside and Jesse Brown Veterans Affairs Medical Centers (VAMC) from September 1997 to December 2006 were retrospectively reviewed. Indications for CAS or CEA included asymptomatic carotid stenosis >70% or symptomatic stenosis >50%. Demographic data, procedural details, and clinical outcomes are reported. A cohort of 104 patients (98% men) underwent 113 CAS procedures with 100% technical success. Cerebral protection was used in 98% of the procedures. Average age was 70 years (15 patients >or=80 years old); 30% were symptomatic. Previous ipsilateral CEA, neck dissection or irradiation was present in 10.6% of procedures. The 30-day transient ischemic attack, stroke, and death rates were 2.7%, 3.5%, and 0.0% respectively. The 1-year all cause death rate was 6.2%. During the same time period, 79 patients (98% male) underwent 91 CEA procedures. Average age was 67 years (9 patients >or=80 years old); 45% were symptomatic. The 30-day transient ischemic attack, stroke, and death rates were 1%, 2.2%, and 1% respectively. The 1-year all cause death rate was 5.5%. There were no statistically significant differences in outcome within asymptomatic and symptomatic patient groups between CAS and CEA, respectively. CAS is a safe and efficacious alternative for the treatment of carotid artery stenosis in a veteran population and outcomes compare favorably to contemporary CAS and CEA trials. Veterans should be offered CAS as a treatment option for carotid artery stenosis by vascular surgeons or interventionalists who are trained to perform this procedure and have the appropriate resources.

Initial experience of using the filter protection device during carotid artery stenting in Japan

No filter protection devices for carotid artery stenting (CAS) have been formally approved for use in Japan; however, as of April 2008, the Angioguard XP (AGXP) was approved. This article describes our initial results using the AGXP during CAS for the treatment of carotid artery stenosis. A group of 15 patients (14 men) with a mean age of 72.3 years (range 53-81 years) were treated by CAS using the AGXP. Among them, 10 were symptomatic with >50% stenosis of the common or internal carotid artery (ICA), and 5 were asymptomatic with >70% stenosis. The rates of technical success, periprocedural stroke, ICA flow impairment, filter movement, and development of new ischemic lesions on diffusion-weighted imaging (DWI) were assessed. CAS using the AGXP was successful in all cases. There was one minor stroke, and flow impairment occurred in six patients. Filter movement averaged 1.9 vertebral bodies. DWI showed new ipsilateral ischemic lesions in eight of the patients. Initial clinical experience using the AGXP for CAS has been generally sufficient. However, attention must be paid to three problems when using the AGXP: the filter may move after placement; the filter may disturb blood flow in the ICA; and debris may pass around the filter.

Fractured Internal Carotid Artery Stent

Carotid artery stenting is gaining wider acceptance as an alternative option in the treatment of carotid artery stenosis. Conventional complications such as stroke and recurrent in-stent restenosis are well documented in the literature. However, we believe that carotid stent complications are underreported. The carotid artery segment has features that are relatively smilar to the femoropopliteal segment with respect to forces affecting the stented segment, which can contribute to stent complications such as fracture. In this article, we present a case of internal carotid artery stent fracture and thrombus formation after the patient was exposed to direct trauma to the chest and neck.

Stenting for carotid artery stenosis: Fractures, proposed etiology and the need for surveillance

Carotid artery stenting is a relatively new intervention for the treatment of carotid artery stenosis, and the long-term outcomes and complications are therefore yet to be determined. In one surgeon's practice, it was found that a stent fracture was the etiological factor for recurrent stenosis. A retrospective study was therefore performed with the hypothesis that carotid stent fractures are common. The aims were to determine prevalence of fractures in this surgeon's series, risk factors, and most importantly, clinical relevance. Patients from one surgeon's private practice who had carotid stenosis deemed suitable for intervention (>80% asymptomatic, >70% symptomatic, 50% to 70% if an ulcerated lesion) and had suitable aortic and carotid morphology for carotid stenting between March 2004 and December 2006 were included. To enhance the quality of the measurement, two vascular surgeons and one radiologist examined the films independently to determine if there was a fracture present. Given that this was a retrospective study, there was no preconceived sample size determined. Fracture prevalence was found to be 29.2% or 14 out of 48 stents. Restenosis occurred in 21% of those stents with a detected fracture, after an average follow-up of 15 months. Several anetiological factors are proposed, with a finding in this series, of a strong and significant association between the presence of calcified vessels and the presence of fractures (odds ratio 7.7; standard error 5.6; 95% confidence interval 1.9-32.0, P =.003). Although this is a small study, it demonstrates that carotid stent fractures do exist, and importantly, not all of them are benign. Therefore, the authors recommend regular surveillance with plain radiography in addition to duplex ultrasonography to enable early detection of fracturing. Following detection, institution of increased surveillance frequency and/or any appropriate intervention can be implemented, to aid in the prevention of complications resulting from restenosis should it become apparent.

Safety of endovascular treatment of carotid artery stenosis compared with surgical treatment: A meta-analysis

Since publication of previous meta-analyses comparing endovascular and surgical treatment of patients with carotid artery stenosis, two further large-scale trials have been conducted, almost doubling the number of patients available for analysis. Therefore, it is justified to update these meta-analyses. Relevant trials were identified by a search of the literature using an electronic database. Trials with a nonrandomized patient allocation were not included. We focused on events within 30 days after intervention and made two sets of analysis: one with all trials and one with large trials exclusively including symptomatic patients. Only Endartérectomie Versus Angioplastie chez les patients ayant une Sténose carotide Symptomatique Serrée (EVA3S) and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) were identified to be included in the updated meta-analysis. In total, 2985 patients were included in eight trials of which 89% were symptomatic. In contrast to previous analyses, this meta-analysis found a significant difference between the odds ratios of any stroke or death within 30 days after treatment with a disadvantage of endovascular treatment when analysing all trials (odds ratio [OR], 1.38; 95% confidence interval [CI] 1.04-1.83; P = .024). Significant heterogeneity was found for this analysis (P = .03). The increase of the odds of suffering from disabling stroke or death in the endovascular compared with the surgical group was not significant in the analysis of all trials (OR, 1.37; 95% CI, 0.92-2.04; P = .12); no heterogeneity was found for this analysis (P = .27). In the analysis of the large trials with symptomatic patients, the OR for the endpoint any stroke or death was 1.29 (95% CI 0.94-1.76; P = .11); with a hint for heterogeneity (P = .10). For the endpoint disabling stroke or death, the OR was 1.33 (95% CI 0.89-1.93; P =.17) without any heterogeneity (P = .58). The expressiveness of this meta-analysis is limited by the heterogeneity of some tests. The main result is that surgical treatment still remains the gold standard for treatment of patients with symptomatic carotid artery stenosis, who do not have an increased surgical risk. Carotid artery stenting is neither safer than nor as safe as carotid endarterectomy in large clinical trials when short-term stroke and death rates are taken into account. Further recruitment into ongoing randomized trials is strongly recommended.

Angiographic lesion characteristics can predict adverse outcomes after carotid artery stenting

Carotid artery angioplasty and stenting (CAS) is an evolving and increasingly common endovascular treatment for carotid artery stenosis. Risk factors associated with an increased incidence of adverse periprocedural neurologic outcomes are being recognized. The goal of this study was to determine if certain angiographic lesion characteristics were predictive of higher risks of adverse outcomes. A total of 421 patients who underwent 429 carotid artery stenting procedures between June 1996 and June 2005 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Demographic data and procedural variables were recorded, including the presence or absence of the use of a cerebral protection device. Angiograms were reviewed for the following carotid lesion characteristics: length of lesion, percentage of stenosis, ostial involvement, lesion ulceration, calcification, and presence of contralateral carotid occlusion. Periprocedural stroke and 30-day adverse event rates (stroke, myocardial infarction, and death) were recorded for each patient. The periprocedural all-stroke rate was 3.7%. Octogenarians had a higher incidence of 30-day adverse events at 10.0% vs 3.8% (P = .029). The incidence of periprocedural stroke was increased in lesions > or =15 mm long, at 17.0% (8 of 47) vs 2.1% (8 of 382; P < .001), and in ostial centered lesions, 7.1% (11 of 154) vs 1.8% (5 of 275; P = .007). Multivariate regression also identified these two variables as independently associated with 30-day stroke rate: lesion length > or =15 mm (odds ratio [OR], 6.38; 95% confidence interval [CI], 35 to 17.29) or ostial involvement (OR, 3.12; 95% CI, 3.12 to 8.36). Other variables, including lesion calcification, ulceration, degree of stenosis, or presence of contralateral occlusion, were not associated with adverse outcomes. When studied separately, the use of cerebral protection devices in 241 patients (56%) did not change our observed correlations between angiographic characteristics and adverse procedural events. Certain lesion characteristics on angiography, such as length and ostial location, can predict adverse outcomes. The indication for CAS should be carefully evaluated in these cases.

Current status of carotid artery angioplasty and stent placement: Impact of recent clinical studies

Carotid angioplasty with stent placement has emerged as an alternative treatment for carotid artery stenosis. Because it is a less invasive procedure and does not require general anesthesia, this intervention is a good choice for patients at high surgical risk. Additional advantages include easier access to anatomically challenging lesions and shorter length of hospital stay with reduced costs. Its major disadvantage is the possibility of debris dislodgement in the aortic arch and supra-aortic vessels during device manipulation, which can lead to cerebral embolism. This concern led to the development of distal protection devices. Several randomized trials have been published without actual proof of superiority of endovascular intervention over the standard treatment except for high-risk patients. In recent years, technical developments, cumulative experience, and new standards for training have reduced the complication rates. Ongoing trials will provide the evidence to demonstrate whether this intervention is superior to carotid endarterectomy, and if so, in which subgroup of patients.

頸部内頸動脈狭窄症に対するステント留置術の長期成績―自己拡張型ステントの再狭窄について―

Carotid artery stenting has emerged as an acceptable treatment alternative in patients with carotid artery stenosis. Although early clinical results of carotid artery stenting have shown promise, long, term clinical results remain less certain. We report the frequency, management, and clinical results of in-stent restenosis after carotid artery stenting using a self-expandable stent. Between August 1998 and September 2004, 80 carotid artery stenting procedures in 78 patients were performed. We evaluated 76 of the 80 procedures in 75 of the 78 patients treated during this period who had a minimum 6-month clinical and imaging (ultrasound and/or magnetic resonance angiography) follow-up. Recurrent stenosis (≧50%) after carotid artery stenting occurred in 3 (3.9%) patients. The recurrent stenosis occurred within one year after the procedure in all cases. The low rate of in-stent restenosis using self-expandable stent suggested that carotid artery stenting may be an effective alternative treatment for carotid artery stenosis, but more data of long-term follow-up are required.

Screening for Carotid Artery Stenosis: An Update of the Evidence for the U.S. Preventive Services Task Force

Cerebrovascular disease is the third leading cause of death in the United States. The proportion of all strokes attributable to previously asymptomatic carotid artery stenosis (CAS) is low. In 1996, the U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening of asymptomatic persons for CAS by using physical examination or carotid ultrasonography. To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasonography and treatment with carotid endarterectomy for CAS. MEDLINE and Cochrane Library (search dates January 1994 to April 2007), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts. English-language randomized, controlled trials (RCTs) of screening for CAS; RCTs of carotid endarterectomy versus medical treatment; systematic reviews of screening tests; and observational studies of harms from carotid endarterectomy were selected to answer the following questions: Is there direct evidence that screening with ultrasonography for asymptomatic CAS reduces strokes? What is the accuracy of ultrasonography to detect CAS? Does intervention with carotid endarterectomy reduce morbidity or mortality? Does screening or carotid endarterectomy result in harm? All studies were reviewed, abstracted, and rated for quality by using predefined Task Force criteria. No RCTs of screening for CAS have been done. According to systematic reviews, the sensitivity of ultrasonography is approximately 94% and the specificity is approximately 92%. Treatment of CAS in selected patients by selected surgeons could lead to an approximately 5-percentage point absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from carotid endarterectomy vary from 2.7% to 4.7% in RCTs; higher rates have been reported in observational studies (up to 6.7%). Evidence is inadequate to stratify people into categories of risk for clinically important CAS. The RCTs of carotid endarterectomy versus medical treatment were conducted in selected populations with selected surgeons. The actual stroke reduction from screening asymptomatic patients and treatment with carotid endarterectomy is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.

Screening for Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement

Update of the 1996 U.S. Preventive Services Task Force statement about screening for asymptomatic carotid artery stenosis (CAS) in the general population. The U.S. Preventive Services Task Force examined the evidence on the natural history of CAS; systematic reviews of the accuracy of screening tests; observational studies of the harms of screening and treatment of asymptomatic CAS; and randomized, controlled trials of the benefits of treatment for CAS with carotid endarterectomy. Do not screen for asymptomatic CAS in the general adult population. (Grade D recommendation).

Embolic Protection Devices for Carotid Artery Stenting: Have They Made a Significant Difference in Outcomes?

Carotid angioplasty and stenting (CAS) is a valid alternative to conventional carotid endarterectomy for treatment of carotid artery stenosis in a select group of patients. Distal embolization of atherosclerotic debris and air causing neurologic deficits during CAS has been one of the most significant concerns limiting widespread application of CAS technology. A variety of distal embolic protection devices have been designed to minimize the risk of major embolization causing stroke. This review will examine the types of available devices, including strengths and weaknesses of each, and present the available evidence and rationale for their routine use during CAS.

Carotid endarterectomy was performed with lower stroke and death rates than carotid artery stenting in the United States in 2003 and 2004

Although carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis, the recent United States Food and Drug Administration approval of carotid artery stenting (CAS) may have led to its widespread use outside of clinical trials and registries. This study compared in-hospital postoperative stroke and mortality rates after CAS and CEA at the national level. The Nationwide Inpatient Sample (NIS) was queried to identify all patient-discharges that occurred for revascularization of carotid artery stenosis. The International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for CEA (38.12), CAS (00.63), and insertion of noncoronary stents (39.50, 39.90) were used in conjunction with the diagnostic codes for carotid artery stenosis, with (433.11) and without (433.10) stroke. Primary outcome measures included in-hospital postoperative stroke and death rates. Multivariate logistic regressions were performed to evaluate independent predictors of postoperative stroke and mortality. Adjustment was made for age, sex, medical comorbidities, admission diagnosis, procedure type, year, and hospital type. During the calendar years 2003 and 2004, an estimated 259,080 carotid revascularization procedures were performed in the United States. CAS had a higher rate of in-hospital postoperative stroke (2.1% vs 0.88%, P < .0001) and higher postoperative mortality (1.3% vs 0.39%) than CEA. For asymptomatic patients (92%), the postoperative stroke rate was significantly higher for CAS than CEA (1.8% vs 0.86%, P < .0001), but the mortality rate was similar (0.44% vs 0.36%, P = .36). For symptomatic patients (8%), the rates for postoperative stroke (4.2% vs 1.1%, P < .0001) and mortality (7.5% vs 1.0%, P < .0001) were significantly higher after CAS. By multivariate regression, CAS was independently predictive of postoperative stroke (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.91 to 3.25). CAS was also associated with in-hospital postoperative mortality for asymptomatic (OR, 2.37; 95% CI, 1.46 to 3.84) and symptomatic (OR, 2.64; 95% CI, 1.89 to 3.69) patients. As determined from a large representative national sample including the years 2003 and 2004, the in-hospital stroke rate after CAS for asymptomatic patients was twofold higher than after CEA. For symptomatic patients, the respective in-hospital stroke and mortality rates were fourfold and sevenfold higher. These unexpected results indicate that further randomized controlled trials with homogenous symptomatic and asymptomatic patient groups should be performed.

Economic impact of endarterectomy vs carotid artery stenting: a one year, single centre study

Carotid artery stenting (CAS) has been suggested by some clinicians as an alternative to endarterectomy (CEA), especially in some specific subgroups of the population. The aim of this study is to evaluate the costs of these two procedures. A review of costs was performed on all patients who underwent elective treatment of carotid artery stenosis between January and December 2006 (184 CAS vs 97 CEA). Clinical data had been prospectively gathered from both the CAS and the CEA groups, while financial data was obtained retrospectively to match hospital admissions with the generated charge from the hospital business office. In this series there was one major event in CEA and one transient ischaemic attacks (TIA) in CAS. One death procedure-related event occurred in CEA. The mean total cost associated with a single CEA was slashed integral 3,897.86, whereas the cost associated with CAS was slashed integral 3,806.66. It was apparent that the increasing costs involved in purchasing material for CAS, were balanced by the lower spending for hospital stay. Costs for CAS and CEA are comparable. In our experience, the choice between CAS and CEA is based on the comorbidity of the patient, the type of the lesion and the preferences of the patient, without economic criteria being important.

Carotid Artery Stenting Will Replace Carotid Endarterectomy

Stroke is the third leading cause of death in the United States. Carotid artery stenosis represents one of the most common etiologies of stroke. The current treatment modalities available for the treatment of carotid artery stenosis are carotid endarterectomy (CEA) and carotid artery stenting (CAS). Several clinical trials comparing CEA with medical management showed superiority of the surgical arm; however, the applicability of these results to the general population is limited by the fact that the patients and surgeons enrolled in these trials were carefully selected, and the optimal medical therapy used does not meet the current treatment standards. Carotid artery stenting has emerged as a treatment alternative to CEA, as shown in randomized trials comparing the 2 treatment modalities. Recent data from large-volume CAS registries indicate that percutaneous treatment of carotid artery stenosis compares favorably to CEA. Furthermore, the CAS trial designs make these results more applicable to the community standards. These data suggest that CAS will become the treatment of choice in patients with carotid artery stenosis.

Contemporary Management of Carotid Stenosis: Carotid Endarterectomy Is Here to Stay

Thromboembolic complications from atherosclerotic disease of the carotid bifurcation are a common etiology of ischemic stroke, which has a significant morbidity and mortality. Carotid artery angioplasty and stenting (CAS) has been proposed as an alternative therapy for patients requiring treatment of carotid artery stenosis as opposed to the "gold standard" surgical intervention, carotid endarterectomy (CEA). Intense debate regarding these 2 therapeutic approaches has centered on their respective safety profiles. To date, despite multiple studies, no convincing evidence demonstrates the superiority or even equality of CAS to the proven safety, efficacy, and durability of CEA. This chapter reviews in detail the available evidence for CAS and CEA and provides a rationale that, given the available data, CEA remains the preferred therapy for the majority of patients who require treatment of carotid artery stenosis.

Short- and long-term outcome after carotid artery stenting with neuroprotection: single-center experience within a prospective registry

Carotid artery stenting is an alternative method to surgical endarterectomy for treatment of carotid artery stenosis. Three hundred and seventy-one consecutive patients (71+/-9 years) undergoing 405 carotid artery interventions at a single cardiologic center were studied prospectively within a therapy registry. In general, the interventional procedure was performed using neuroprotective devices to prevent distal embolization. Stents were used routinely whenever possible. Independent neurological assessment took place prior to and after carotid stenting. The neurological event rate was assessed in the early (<30 days) and late post interventional period. In asymptomatic patients, 286 interventions were done with a 30-day stroke rate of 1.3% (ipsilateral 1.0%). In symptomatic patients, strokes occurred in a significantly (p<0.005) higher rate of 5.0% after 119 interventions (all ipsilateral). At long-term follow-up (mean 728+/-548 days) additional strokes occurred ipsilateral to the side of carotid intervention in 0.4% of asymptomatic patients (1.7% of symptomatic patients); contralateral strokes were seen at long-term follow-up in 1.1% of asymptomatic (1.7% of symptomatic) patients. Due to their comorbidities, 1.6% of patients died early, and an additional 11.1% late after carotid stenting. Carotid artery stenting with the general use of neuroprotective devices yields acceptable shortterm results with respect to neurological events. Asymptomatic patients have significantly less periprocedural strokes than symptomatic patients. Neurological events during long-term follow-up are rare, in particular ipsilateral to the side of carotid stenting. Thus, carotid artery stenting with neuroprotection is a safe method for carotid revascularization, with acceptable periprocedural events, particularly in asymptomatic patients, and a good long-term neurologic outcome.

Economic Evaluation of Carotid Artery Stenting Versus Carotid Endarterectomy for the Treatment of Carotid Artery Stenosis

The clinical effectiveness of carotid endarterectomy (CEA) is well established. But the economic impact of CEA and carotid artery stenting (CAS) is still uncertain. The objective of this study was to compare hospital costs and reimbursement for CAS and CEA. We performed a retrospective database analysis on pair-matched patients who underwent CEA (n = 31) and CAS (n = 31) at the Richard M Ross Heart Hospital in Columbus, OH. The hospital's clinical and financial databases were used to obtain patient-specific information and procedural charges. Cost data were generated by applying the hospital's ratio of cost to charges for all DRG charges. The Wilcoxon signed-rank test was used to examine the differences between costs of these procedures. Data are reported as mean +/- SD. The mean age of patients in CAS group was 70.14 years (+/- 1.60 years) versus 68.64 years (+/- 1.75 years) for CEA patients (p < 0.05). The total direct cost associated with CEA ($3,765.12+/-$2,170.82) was significantly lower than the CAS cost ($8,219.71+/-$2,958.55, p < 0.001). The mean procedural cost for CAS ($7,543.61+/-$2,886.54) was significantly higher than that for CEA ($2,720.00+/-$926.38, p < 0.001). The hospital experienced cost savings of $9,690.87 for CEA versus $4,804.79 for CAS from private insurance. Similarly, savings obtained by Medicare-enrolled CEA patients were higher than those for CAS patients ($1,497.79). CAS is significantly more expensive than CEA, with a major portion of cost attributed to the total procedural cost. The hospital experienced significant savings from CEA procedures compared with CAS under all DRG classifications and insurers. Hospitals must develop new financial strategies and improve the efficiency of infrastructure to make CAS financially viable.