Restenosis and risk of stroke after stenting or endarterectomy for symptomatic carotid stenosis in the International Carotid Stenting Study (ICSS): secondary analysis of a randomised trial

Carotid stenting (CAS) has been shown to be equivalent to carotid endarterectomy in symptomatic patients; however its optimal timing remains unclear. In this study, we aim to evaluate the safety of CAS when performed within the first 48 hours of symptom onset. We performed a retrospective analysis of a prospectively collected database of consecutive CAS patients admitted to our comprehensive stroke center with TIA/stroke and ipsilateral symptomatic carotid stenosis >50% from 2014 to 2019. Medical records were retrospectively reviewed for demographic, clinical and procedural data and outcomes. Acute and delayed treatment were defined as ≤48 and >48 hours from last known well (LKW) respectively. The primary endpoint was procedure-related major complications (stroke with NIHSS increase of ≥4, myocardial infarction, parenchymal hemorrhage type 2 or death) ≤30 days after CAS. Secondary endpoints were procedure-related minor neurological (stroke with NIHSS increase of <4 and reperfusion injury) and non-neurological (groin puncture hematoma, acute anemia and arrhythmia) complications. Functional outcome was assessed by discharge and 90 days mRS, dichotomized as good (0-2) and bad (3-6). A total of 72 patients were included in the analysis, 36 in each group. There was no difference in age, NIHSS at presentation, gender, incidence of TIA as presentation or percentage of TPA received. The acute group differed significantly from the delayed group in number of thrombectomies (36.1% vs. 5.6%, p=0.001) and median time from LKW to CAS (15.9 hours vs. 88.0 hours, p<0.001). There were significantly more carotid occlusions in the acute group when compared to the delayed group (37.8% vs. 2.2, p<0.0001). Overall, the acute group did not show significant difference from the delayed group in major (2.8% vs. 5.6%, p=1.0), minor neurological (13.9% vs. 2.8%, p=0.09) and minor non-neurological complication rates (13.9% vs. 8.3%, p=0.7). Rates of good outcomes were not significantly different between the two groups at discharge (52.8% vs. 50%) or 90 days (75% vs. 63%). CAS can be performed safely in acute symptomatic carotid stenosis patients within the first 48 hours from symptom onset.

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Abstract TP135: Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke Protocol

Stroke ◽

10.1161/str.51.suppl_1.tp135 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Daniel Tonetti ◽

Brian Jankowitz ◽

Kenmuir Cynthia ◽

Benjamin Zussman ◽

Rahul Rao ◽

...

Keyword(s):

Carotid Stenosis ◽

Primary Outcome ◽

Recurrent Stroke ◽

Carotid Stenting ◽

Clinical Equipoise ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Recorded Data ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. The aim of this report is to analyze prospectively-recorded data from an institutional protocol that standardized the urgent (<48 hours) treatment of patients presenting with symptomatic carotid stenosis and underwent either carotid stenting (CAS) or carotid endarterectomy (CEA). Methods: All patients presenting over 28 months to a comprehensive stroke center with symptomatic carotid stenosis within 48 hours of index event were screened for inclusion. All patients were given dual antiplatelet therapy. If there was clinical equipoise between CEA and CAS, patients underwent angiography and subsequently revascularization if DSA demonstrated ≥50% stenosis. The primary outcome was a composite of stroke or death within 30 days. Results: 178 patients with a diagnosis of recently symptomatic carotid stenosis were included; 120 patients (67%) met criteria. 59 patients underwent CEA and 61 patients underwent CAS. There were not significant differences in the primary outcome; 3 patients (5.1%) in the CEA arm and 3 patients (4.9%) in the CAS arm met the primary outcome. Conclusion: In this prospective analysis, urgent revascularization for symptomatic carotid stenosis can be done with equivalently low rates of stroke or death, regardless of revascularization strategy.

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Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial

The Lancet ◽

10.1016/s0140-6736(10)60239-5 ◽

2010 ◽

Vol 375 (9719) ◽

pp. 985-997 ◽

Cited By ~ 827

Keyword(s):

Randomised Controlled Trial ◽

Carotid Artery ◽

Carotid Stenosis ◽

Carotid Artery Stenting ◽

Interim Analysis ◽

Controlled Trial ◽

Carotid Stenting ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Randomised Controlled

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Obstructed Flow

10.1093/med/9780190495541.003.0011 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Early Period ◽

Carotid Stenting ◽

Symptomatic Carotid ◽

Symptomatic Carotid Stenosis ◽

Ischemic Attack

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

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