Use Of Carotid Artery Stenting Research Articles

Urgent Carotid Artery Stenting for Carotid-Related Stroke-in-Evolution.

Stroke-in-evolution (SIE) is a major outcome determinant in patients with acute ischemic stroke. The benefit of surgery for treatment of carotid artery-related SIE remains controversial. To retrospectively evaluate the use of carotid artery stenting (CAS) as a possible alternative treatment in patients with carotid-related SIE. Ten patients with carotid-related SIE were treated with CAS from May 2005 to December 2014. The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 5.4 ± 4.4. Two patients had total occlusion of the internal carotid artery, and 8 had severe stenosis. The mean interval from symptom onset to clinical deterioration was 2.9 ± 2.9 d. The mean NIHSS score after deterioration was 14.3 ± 4.5. In the hemodynamic assessment using perfusion imaging, the ipsilateral cerebral hemodynamics was impaired in 7 of 8 patients. All patients underwent urgent CAS in the acute phase of SIE. Seven patients underwent CAS using flow reversal with or without distal protection. No procedure-related complications occurred in any patients, although 1 patient developed aspiration pneumonia. The mean NIHSS score 7 d after CAS was 4.8 ± 2.3. Six patients (60%) had a modified Rankin scale score of 0 to 2 at discharge. Urgent CAS for carotid-related SIE with hemodynamic impairment appears to be an effective method for achieving good clinical outcomes.

The Use of Endarterectomy or Stenting for Cervical Internal Carotid Artery Stenosis in Neurosurgical Facilities that Lack Full-time Neuroendovascular Specialists

The aim of the present study was to clarify the current practices related to the use of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA) for cervical internal carotid artery stenosis (CICAS) in neurosurgical facilities without full-time neuroendovascular specialists. A total of 82 patients (68 men and 14 women; mean age of 72.4 years) with CICAS treated surgically at Kanmon Medical Center during a 13-year period from April 2002 to March 2015 were identified, and their medical records were reviewed. Seventy-six CEAs (47 for symptomatic lesions and 29 for asymptomatic lesions) and 16 CASs (9 for symptomatic lesions and 7 for asymptomatic lesions) were performed in 68 and 15 patients, respectively. CAS has been performed since 2009, and 30 CEAs (21 for symptomatic lesions and 9 for asymptomatic lesions) were performed during the same period. Both sets of clinical data were compared and analyzed. No apparent difference in the characteristics of the stenotic lesion were observed. The main reasons for performing CAS were a high location of the stenotic lesion and serious previous disease. Cerebral ischemia occurred as a complication in 4 patients who had undergone CAS, but had no adverse influence on outcome; however it adversely influenced the outcome in 1 of 4 patients who had undergone CEA. Although currently few patients undergo CAS for CICAS, these results support its validity and safety in neurosurgical facilities that lack full-time neuroendovascular specialists. Accordingly the proportion of CAS procedures performed relative to CEA will likely increase in the future, also in such neurosurgical facilities.

Surgical treatment for complicated carotid artery stenting

Introduction The increasing use of carotid artery stenting has inevitably resulted in more carotid artery stenting-related complications. Report This report describes serious complications that developed in two patients after carotid artery stenting and were successfully treated by operative reconstruction. One patient presented with an unstable, symptomatic, emboligenic lesion without significant in-stent restenosis. The other presented with active bleeding and pseudoaneurysm formation due to an infected carotid stent. Discussion Surgical treatment for carotid artery stenting-related complications appears to be feasible, but studies on larger cohorts are warranted.

Selecting an appropriate surgical treatment instead of carotid artery stenting alone according to the patient's risk factors contributes to reduced perioperative complications in patients with internal carotid stenosis: a single institutional retrospective analysis.

This retrospective study was aimed to compare the perioperative complications for internal carotid artery stenosis (ICS) in a Japanese single institute between the use of carotid artery stenting (CAS) alone or the use of an appropriate individualized treatment method allowing either carotid endarterectomy (CEA) or CAS based on patient risk factors. Based on the policy at our hospital, only CAS was performed on patients (n = 33) between January 2005 and November 2009. From December 2009 to December 2012, either CEA or CAS (tailored treatment) was selected for patients (n = 61) based on individual patient risk factors. CEA was considered the first-line treatment in all cases. In high-risk CEA cases, CAS was performed instead (n = 11), whereas in low-risk CEA cases, CEA was performed (n = 19). Further, in moderate-risk CEA cases based on own criteria, CAS was considered first, whereas for high-risk CAS cases, CEA was performed (n = 17). For low-risk CAS cases, CAS was performed (n = 9). Perioperative clinical complications (any stroke, myocardial infarction, or death within 30 days) were compared between both periods. Significantly reduced perioperative complications were observed during the tailored period (4/61 sites, 6.6%) as compared with the CAS period (8/33 sites, 24.2%) [Fisher’s exact test p = 0.022; odds ratio, 4.56 (CAS/tailored); 95% confidence interval, 1.26–16.5]. Selecting an appropriate individualized treatment method according to patient risk factors, as opposed to adhering to a single treatment approach such as CAS, may contribute to improved overall outcomes in patients with ICS.

Abstract W P304: Variation in Use of Carotid Revascularization Procedures and In-Hospital Mortality Among Large, Urban Teaching Hospitals in the United States

Background: Guidelines and quality improvement efforts seek to minimize variation in care and outcomes across hospitals. We assessed hospital-level variation in procedure rates and in-hospital mortality for patients hospitalized with ischemic stroke at similar hospitals in the US. The use of procedures and in-hospital mortality were not expected to vary significantly among comparable, high-volume facilities after adjusting for patient case-mix. Methods: We selected urban teaching hospitals with ≥100 annual ischemic stroke discharges (ICD-9 433, 434, 436) from the Nationwide Inpatient Sample 2010-2011. Generalized linear mixed models were used to quantify between-hospital variation in the use of carotid artery stenting (CAS) and endarterectomy (CEA), as well as in-hospital mortality, adjusting for patient characteristics. Adjusted odds ratios were calculated to reflect the odds that patients would have the procedure/outcome when treated at hospitals 1 SD above relative to hospitals 1 SD below the overall rate for that procedure/outcome (an odds ratio of 1.0 would reflect no hospital variation in the procedure/outcome). Results: A total of 105 urban teaching hospitals were selected, with a median annual volume of 453 ischemic stroke discharges (IQR 351-600). Among a total of 52,090 ischemic stroke discharges (mean age 68±14.8 yrs), the overall rates were 3.7% (SD 3.1) for CAS and 15.6% (SD 8.0) for CEA; in-hospital mortality was 4.3% (SD 1.7). The odds of receiving CAS and CEA were almost 7 and 4 times as high, respectively, for a patient treated at a hospital 1 SD above versus 1 SD below the overall rate for that procedure (CAS: 6.68, 95% CI 4.97-8.98; CEA: 3.62, 95% CI 3.17-4.13). The odds of dying for those treated at a hospital 1 SD above relative to 1 SD below the overall mortality rate were 2.09 (95% CI 1.98-2.21). Conclusions: There was marked between-hospital heterogeneity in the use of carotid revascularization procedures and in-hospital mortality among large, urban US teaching hospitals. Future research needs to identify system-level factors contributing to these variations in care and outcomes.

Incidence and Risk Factors for Medical Complications and 30-Day End points After Carotid Artery Stenting

With the extensive use of carotid artery stenting (CAS) surgeries, scholars are paying more attention to the safety and efficiency of CAS. Our study aims to analyze the clinical efficiency, safety, and technical feasibility of CAS surgery in the treatment of carotid artery stenosis. A total of 379 cases of CAS were collected and retrospectively analyzed. The outcomes were summarized according to decrease in stenosis extent, incidence of early complications after procedure, 30-day end point events, and the follow-up data. Logistic regression was employed to analyze the correlations between risk factors and complications within 30 days and 30-day end points of stroke, myocardial infarctions (MIs), and mortality. The average extent of stenosis reduced from preoperative (81% ± 17%) to postoperative (26% ± 17%). In all, 53 patients had 72 medical complications, including 6 (1.58%) cerebral hemorrhage, 7 (1.85%) cerebral infarction, 5 (1.32%) transient ischemic attack (TIA), 5 (1.32%) heart failure, 10 (2.63%) symptomatic hypertension, 21 (5.54%) symptomatic hypotension, 10 (2.63%) symptomatic bradycardia, and 8 other complications; 15 patients had at least 2 complications. Advanced age, diabetes, and heart failure were associated with the high incidence of early complications (P < .05). Asymptomatic stenosis (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.131-1.131, P = .0426) and diabetes (OR = 3.38, 95% CI: 1.340-8.574, P = .0099) were correlated with the incidence of 30-day end point events. Diabetes and symptomatic stenosis are independent risk factors for 30-day end point events of CAS. Advanced age, hypertension, and vascular unstable plaque will increase the risk of postoperative complications.

Surgical Treatment of Carotid In-Stent-Restenosis: Novel Strategy and Current Management

Associated with increasing use of carotid artery stenting (CAS), the occurrence of late complications is likely to rise. The surgical strategies of CAS complications like in-stent-restenosis (ISR) are not yet to be determined. Thus different situations require individual operative techniques. This study contains our experience in the operative management for significant recurrent carotid stenosis following angioplasty and stent placement. As a novel strategy, we report successful stent removal and endarterectomy with eversion technique (ECEA). Four complete stent removals were performed in three patients with three different techniques and anesthesiological protocols (general anesthesia n = 1, regional anesthesia n = 3). First stent removal with excision of common carotid artery (CCA) and internal carotid artery (ICA) following interposition of CCA-ICA with Dacron graft (n = 1). Second carotid endarterectomy with stent removal followed by patch angioplasty (n = 2). Third stent removal and ECEA and thus biological reconstruction without synthetic material (n = 1). Mean operative time was 131 minutes (±19.25). Mean follow-up was 11.5 months (±7.7). As postoperative complications, one major bleeding, one transient neurologic deficit and one postoperative neck hematoma, requiring operative revision, occurred. During a 30-day follow-up, all patients made an uneventful recovery. There was no evidence of restenosis or neurological deficit during the following postoperative controls. A review and comparison of the current surgical management and strategies in the treatment of ISR was also performed (Pubmed). Surgical treatment of ISR after CAS is beneficial but in literature infrequently reported. We could demonstrate in this study that even stent removal and ECEA is feasible and safe with durable outcome. The current strategies are therefore extended as well as the reported performance under regional anesthesia. However, surgical treatment in ISR remains a challenging option and larger series are highly recommended.

Periprocedural outcome for patients with carotid stenosis treated with endovascular therapy: a single center evaluation

Endovascular procedures are a less invasive revascularization strategies than endoarterectomy for carotid stenosis, but to date Guidelines recommend surgery for a major periprocedural safety. Evidences come from randomized studies where operator's experience in endovascular group was not considered. We retrospectively evaluated 524 endovascular procedures (carotid angioplasty ± stenting, CAS) performed between 1996 and 2010 on 486 patients (mean age 71.3 ± 7.8 years) with symptomatic or asymptomatic carotid stenosis from a single center. We evaluated efficacy (residual stenosis ≤30 % after postprocedural angiography) and safety [minor (TIAs or myocardial infarcts) and major (stroke or death) complications in the first 30 days] of procedures and correlated them with the increasing experience of the operator. CAS was successful in 504/524 cases (96.2 %); unsuccessful procedures occurred more frequently in case of angioplasty alone rather than angioplasty and stenting (13/61, 21.3 % vs. 7/463, 1.5 %, OR 17.64, 95 % CI 6.69-46.06). 17/524 (3.2 %) CAS met the combined safety endpoint: stroke in 2.4 % and death in 0.8 %; the rate of disabling stroke/death was 1.6 %. Center experience was inversely related to the rate of stroke/death (R (2) = 0.9375), passing from 5.0 % after 100 CAS to 2.8 % after 500 CAS; for disabling stroke/death (R(2) = 0.9386), the rate was 4 % after 100 CAS and 1.6 % after 500 CAS. CAS is an effective and safe revascularization procedure in both symptomatic and asymptomatic patients, if effected in experienced centers. The use of carotid artery stenting than angioplasty alone and emboli protection devices can much more improve the previous considerations.

Increased Hospital Use of Carotid Artery Stenting (CAS) Over Carotid Endarterectomy (CEA) is Associated With Inferior Outcomes in Asymptomatic Patients

Increased Hospital Use of Carotid Artery Stenting (CAS) Over Carotid Endarterectomy (CEA) is Associated With Inferior Outcomes in Asymptomatic Patients

Successful interdisciplinary management of the misdeployment of two self-expanding stents into the internal carotid artery: a case report

IntroductionWith the widespread use of carotid artery stenting, previously unknown technical mistakes of this treatment modality are now being encountered. There are multiple strategies for the treatment of in-stent restenosis. With regard to surgical management, endarterectomy and patch plasty are favored. To the best of our knowledge, this report is the first description of a complete stent removal by the eversion technique.Case presentationWe report the case of a 63-year-old Caucasian man with misdeployment of two stents into his stenotic proximal internal carotid artery, resulting in a high-grade mechanical obstruction of the internal carotid artery lumen. With the contralateral internal carotid artery already occluded and associated stenoses of both proximal and distal vertebral arteries, an interdisciplinary therapeutic concept was applied. Bilateral balloon angioplasty and stenting of the proximal and distal stenotic vertebral arteries were carried out to provide sufficient posterior collateral blood flow, followed by successful surgical stentectomy and carotid endarterectomy using the eversion technique. Duplex scanning and neurological assessments were normal over a 12-month follow-up period.ConclusionsInterdisciplinary treatment is a recommended option to protect patients from further impairment. Further evaluation in larger studies is highly recommended.

Changes in the Use of Carotid Revascularization Among the Medicare Population

It remains unknown if the increasing use of carotid artery stenting (CAS) has caused a change in the population-based use of carotid endarterectomy (CEA). We sought to examine national trends in carotid revascularization. Retrospective cohort study. Academic research. All Medicare beneficiaries (MCBEs) between January 1, 1998, through December 31, 2004. We examined the frequency of CEA and CAS using Current Procedural Terminology codes for CEA, peripheral stent insertion, and cerebrovascular disease. To exclude patients who underwent stenting of a peripheral artery other than the carotid artery, we excluded all patients with a primary diagnostic code for peripheral vascular disease. We identified 134 194 claims for carotid revascularization (9386 claims for CAS and 124 808 claims for CEA). The overall incidence of carotid revascularization procedures decreased slightly between 1998 and 2004, from 388.1 to 345.8 procedures per 100 000 MCBEs (11% decrease, P < .02). Between 1998 and 2004, the incidence of CEA decreased from 373.4 to 309.3 procedures per 100 000 MCBEs (17% decrease, P < .01), while the incidence of CAS increased from 14.6 to 36.4 procedures per 100 000 MCBEs (149% increase, P < .01). While rates of carotid revascularization in the Medicare population slightly decreased between 1998 and 2004, the use of CAS dramatically increased. Whether this represents a substitution of CAS for CEA vs a broadening of indications for carotid revascularization using CAS is unknown but is of interest to patients and third-party payers and requires future investigation.

Assessment of short-term outcomes for protected carotid angioplasty with stents using recent evidence

Carotid artery stenosis is an important risk factor and etiology of stroke. Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis; however, there are potential benefits to adopting the use of carotid artery stenting (CAS) with protection devices. A number of large protected CAS (PCAS) trials are underway, but final results are still several years away. In the interim, numerous PCAS studies have recently been published, and the aim of this study was to combine the published results and examine the outcomes and safety of PCAS. Electronic, manual, and bibliographic searches of PubMed and PreMedline were conducted. Proportion differences were calculated for the periprocedural (30-day) outcomes of any stroke and any stroke or death. More than 400 articles were identified. Only 26 studies met the inclusion criteria, resulting in the inclusion of 2,992 patients treated with PCAS. Within this patient group, the pooled perioperative PCAS rate of any type of stroke was 2.4% +/- 0.3% (95% confidence interval [CI]). The 30-day minor stroke rate was 1.1% +/- 0.2% (95% CI), and the 30-day major stroke rate was 0.6% +/- 0.2% (95% CI). The 30-day mortality rate was 0.9% +/- 0.4% (95% CI). This study demonstrates relatively low rates of reported perioperative adverse events in PCAS. Selective use of PCAS to treat carotid artery stenosis in those at highest risk for surgical complications is appropriate until the randomized trials of CEA vs PCAS provide concurrent short- and long-term outcome data.

Current status in cervical carotid artery stent placement

Carotid artery stenting has become a recommended alternative to carotid endarterectomy at many clinical centers in this country and aboard. Results of randomized clinical trials that established the efficacy of carotid endarterectomy are described and compared with retrospective analyses of results from investigative groups in this country and aboard. Introduction of cerebral protection devices appears to have decreased the 30-day stroke and death rate. These data suggest comparability with the results of carotid endarterectomy and support the value of currently on-going trials and registries. Increasing use of carotid artery stenting is predicted.