Indications and Contraindications for Carotid Artery Stenting in Asymptomatic Patients: The case for Risk Stratification

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.

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Carotid Artery Stenting with Distal Protection Using the Carotid Wallstent and Filterwire Neuroprotection: Single-Center Experience of 380 Cases with Midterm Outcomes

Vascular ◽

10.2310/6670.2006.00054 ◽

2006 ◽

Vol 14 (5) ◽

pp. 237-244 ◽

Cited By ~ 13

Author(s):

Peter H. Lin ◽

Wei Zhou ◽

Marlon A. Guerrero ◽

Sally A. McCoy ◽

Deborah Felkai ◽

...

Keyword(s):

High Risk ◽

Carotid Artery ◽

Stent Placement ◽

Carotid Artery Stenting ◽

Multivariable Analysis ◽

Related Complication ◽

Asymptomatic Patients ◽

Distal Protection ◽

Carotid Wallstent

Emerging data have supported the clinical efficacy of carotid artery stenting (CAS) in stroke prevention in high-risk surgical patients. This study was performed to evaluate the midterm clinical outcome of CAS using the Carotid Wallstent and FilterWire distal protection (both Boston Scientific, Natick, MA) at an academic institution. Risk factors for in-stent restenosis (ISR) were also analyzed. Clinical variables and treatment outcome of high-risk patients who underwent Carotid Wallstent placement with FilterWire EX/EZ neuroprotection were analyzed during a recent 54-month period. Three hundred eighty CAS procedures were performed in 354 patients. Technical success was achieved in 372 cases (98%), and symptomatic lesions existed in 85 (24%) patients. No patient experienced periprocedural mortality or neuroprotective device–related complication. The 30-day stroke and death rate was 2.7%, and the overall complication rate was 6.9%. The overall major or fatal stroke rates in symptomatic and asymptomatic patients were 4.6% and 1.3%, respectively (not significant). The overall stroke and death rates between the symptomatic and asymptomatic groups were 5.8% and 2.4%, respectively (not significant). The median follow-up period was 29 months (range 1–53 months). With Kaplan-Meier analysis, the rates of freedom from 60% or greater ISR after CAS procedures at 12, 24, 36, and 48 months were 97%, 94%, 92%, and 90%, respectively. The rates of freedom from all fatal and nonfatal strokes at 12, 24, 36, and 48 months were 97%, 91%, 89%, and 85%, respectively. Multivariable analysis of significant univariate predictors identified that postendarterectomy stenosis (odds ratio [OR] 3.98, p = .02) and multiple stent placement (OR 3.68, p = .03) were independent predictors of ISR. Our study yielded favorable short-term and midterm clinical results using Carotid Wallstent with FilterWire neuroprotection. Late follow-up results showed low rates of fatal and nonfatal stroke and favorable ISR rates compared with other carotid stent trials. Postendarterectomy and multiple stent placement were associated with subsequent ISR.

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Early results of carotid endarterectomy versus carotid stenting: Outcomes from a Mediterranean country

Vascular ◽

10.1177/1708538119841451 ◽

2019 ◽

Vol 27 (5) ◽

pp. 468-474

Author(s):

Ricardo Castro-Ferreira ◽

Alberto Freitas ◽

Sérgio M Sampaio ◽

Paulo G Dias ◽

Armando Mansilha ◽

...

Keyword(s):

Carotid Artery ◽

Hospital Mortality ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenting ◽

Public Hospitals ◽

Hospital Length Of Stay ◽

Mediterranean Country ◽

Main Diagnosis ◽

Asymptomatic Patients

Introduction and objectives Which is the best carotid stenosis treatment remains a controversial issue. To present day, no study has compared the results of carotid artery stenting versus carotid endarterectomy in Portugal. We aim to provide real life numbers regarding the outcomes of both procedures in Portuguese public hospitals. Methods Every patient registered between 2005 and 2015 with the main diagnosis of carotid stenosis and submitted to carotid endarterectomy or carotid artery stenting was included. The information was obtained through the Central National Healthcare Administrative database, a mandatory registry for hospital refunding. Primary outcomes were hospital mortality and stroke. Patient demographics, comorbidities and hospital length of stay were also evaluated. Results The study included 6094 patients: 1399 were symptomatic (mention of prior stroke) and 4695 asymptomatic. Carotid artery stenting was performed on 22% of the symptomatic and 18% of the asymptomatic patients. In the symptomatic patients, the in-hospital mortality was significantly higher in those submitted to stenting (3.6% vs. 1.6% in carotid endarterectomy, p = 0.025). No significant differences in outcomes were observed in the asymptomatic group (mortality 0.9% vs. 0.8%, p = 0.852; stroke rate of 2.6% vs. 2.3%, p = 0.652 – carotid artery stenting vs. carotid endarterectomy). In both groups, there was an important increase in the proportion of stenting between 2005 and 2012, followed by a gradual decline until 2015. Conclusion Despite its increasing frequency, a higher early mortality was documented for CAS in symptomatic patients. No worse outcome was observed in asymptomatic patients.

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Three-year outcomes after carotid artery revascularization: Gender-related differences

Vascular ◽

10.1177/1708538119836312 ◽

2019 ◽

Vol 27 (5) ◽

pp. 459-467

Author(s):

Renato Casana ◽

Chiara Malloggi ◽

Valerio Stefano Tolva ◽

Andrea Odero Jr ◽

Richard Bulbulia ◽

...

Keyword(s):

Myocardial Infarction ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Long Term Outcomes ◽

Single Centre ◽

Men And Women ◽

Asymptomatic Patients ◽

Carotid Artery Endarterectomy

Objectives Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre. Methods From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up. Results Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors. Conclusions Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.

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Carotid artery plaque assessment using quantitative expansive remodeling evaluation and MRI plaque signal intensity

Journal of Neurosurgery ◽

10.3171/2015.2.jns142783 ◽

2016 ◽

Vol 124 (3) ◽

pp. 736-742 ◽

Cited By ~ 11

Author(s):

Yoshitaka Kurosaki ◽

Kazumichi Yoshida ◽

Ryu Fukumitsu ◽

Nobutake Sadamasa ◽

Akira Handa ◽

...

Keyword(s):

Carotid Artery ◽

Risk Stratification ◽

Signal Intensity ◽

Plaque Vulnerability ◽

Carotid Artery Plaque ◽

Asymptomatic Patients ◽

Group A ◽

Group B ◽

Group D ◽

Ischemic Events

OBJECT Plaque characteristics and morphology are important indicators of plaque vulnerability. MRI-detected intraplaque hemorrhage has a great effect on plaque vulnerability. Expansive remodeling, which has been considered compensatory enlargement of the arterial wall in the progression of atherosclerosis, is one of the criteria of vulnerable plaque in the coronary circulation. The purpose of this study was risk stratification of carotid artery plaque through the evaluation of quantitative expansive remodeling and MRI plaque signal intensity. METHODS Both preoperative carotid artery T1-weighted axial and long-axis MR images of 70 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were studied. The expansive remodeling ratio (ERR) was calculated from the ratio of the linear diameter of the artery at the thickest segment of the plaque to the diameter of the artery on the long-axis image. Relative plaque signal intensity (rSI) was also calculated from the axial image, and the patients were grouped as follows: Group A = rSI ≥ 1.40 and ERR ≥ 1.66; Group B = rSI< 1.40 and ERR ≥ 1.66; Group C = rSI ≥ 1.40 and ERR < 1.66; and Group D = rSI < 1.40 and ERR < 1.66. Ischemic events within 6 months were retrospectively evaluated in each group. RESULTS Of the 70 patients, 17 (74%) in Group A, 6 (43%) in Group B, 7 (44%) in Group C, and 6 (35%) in Group D had ischemic events. Ischemic events were significantly more common in Group A than in Group D (p = 0.01). CONCLUSIONS In the present series of patients with carotid artery stenosis scheduled for CEA or CAS, patients with plaque with a high degree of expansion of the vessel and T1 high signal intensity were at higher risk of ischemic events. The combined assessment of plaque characterization with MRI and morphological evaluation using ERR might be useful in risk stratification for carotid lesions, which should be validated by a prospective, randomized study of asymptomatic patients.

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Perioperative Complications After Carotid Artery Stenting

Neurosurgery ◽

10.1227/neu.0000000000000077 ◽

2013 ◽

Vol 73 (4) ◽

pp. 689-694 ◽

Cited By ~ 8

Author(s):

Travis M. Dumont ◽

Michael M. Wach ◽

Maxim Mokin ◽

Grant C. Sorkin ◽

Kenneth V. Snyder ◽

...

Keyword(s):

Carotid Artery ◽

Adverse Events ◽

Carotid Artery Stenting ◽

Perioperative Complications ◽

High Volume ◽

Perioperative Morbidity ◽

Asymptomatic Patients ◽

Technological Advances ◽

Trial Experience ◽

Symptomatic Intracranial Hemorrhage

Abstract BACKGROUND: Technological advances have resulted in diminishing perioperative complications reported during carotid artery stenting (CAS) trials. Because trial experience lags behind technological advances, an understanding of the incidence of perioperative complications after CAS remains in flux. OBJECTIVE: In this single-arm, observational study, a contemporary experience of CAS at a high-volume academic training center for neuroendovascular surgeons was reviewed to assess perioperative morbidity. METHODS: A prospectively maintained database of all neuroendovascular procedures was queried for all CAS procedures performed for stenotic atherosclerotic disease between 2009 and 2011. Each case was assessed for major perioperative (30 day) adverse events, including new acute ischemic stroke, postoperative symptomatic intracranial hemorrhage, myocardial infarction (MI), and mortality. RESULTS: A total of 474 patients were identified. Perioperative adverse events were noted in 13 patients (2.7%). These included 4 ischemic strokes, 4 intracranial hemorrhages, 3 MIs, and 5 deaths. Most perioperative events occurred in symptomatic patients (10 of 239 symptomatic patients with events, 4.2% event incidence), whereas these events occurred rarely in asymptomatic patients (3 of 235 asymptomatic patients with events, 1.3% event incidence). CONCLUSION: In this retrospective analysis of consecutive patients treated with CAS, the perioperative incidence of stroke (0.9%), MI (0.6%), and death (1.1%) was favorable.

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Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy: SPACE2 – a Three-Arm Randomised-Controlled Clinical Trial

International Journal of Stroke ◽

10.1111/j.1747-4949.2009.00290.x ◽

2009 ◽

Vol 4 (4) ◽

pp. 294-299 ◽

Cited By ~ 66

Author(s):

T. Reiff ◽

R. Stingele ◽

H. H. Eckstein ◽

G. Fraedrich ◽

O. Jansen ◽

...

Keyword(s):

Primary Prevention ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Carotid Artery Disease ◽

Controlled Clinical Trial ◽

Vascular Events ◽

Asymptomatic Carotid ◽

Symptomatic Carotid ◽

Asymptomatic Patients

Moderate to severe (≥70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4–7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; http://www.space-2.de ) with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017.

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