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Carotid artery stenting: analysis of data for 105 patients at high risk
Robert W Hobson1, Brajesh K Lal, Elie Chakhtoura
1Division of Vascular Surgery, Department of Surgery, UMDNJ-NJMS, 30 Bergen St, ADMC Bldg 6, Rm 620, Newark, NJ 07103, USA. hobsonrw@umdnj.edu
Insights
Carotid artery stenting (CAS) is a safe alternative to carotid endarterectomy (CEA) for high-risk patients, showing a low 30-day stroke and death rate of 2.85%. Further clinical investigation is recommended.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA).
- Recent trials show high 30-day stroke and death rates (10-12%) for CAS.
- This study reviews CAS experience in high-risk patients.
Purpose of the Study:
- To evaluate the safety and efficacy of CAS in high-risk patients.
- To document outcomes and guide future CAS use.
- To assess CAS as an alternative to CEA in specific patient groups.
Main Methods:
- 114 consecutive CAS procedures performed in 105 high-risk patients (mean age 70).
- Indications included restenosis post-CEA (65%), high-risk primary lesions (28%), and post-radiation stenosis (7%).
- Patients had asymptomatic (>80%) or symptomatic (>50%) stenosis.
Main Results:
- CAS was technically successful in all patients.
- Mean stenosis reduced from 87% to 9%.
- The 30-day stroke and death rate was 2.85% (2 deaths, 1 stroke). No neurologic complications in the last 27 patients.
Conclusions:
- CAS demonstrates an acceptable 30-day stroke and death rate of 2.85% in high-risk patients.
- CAS is a viable alternative to repeat operation or primary CEA in select high-risk patients.
- Further clinical investigation and surgeon participation in trials are recommended.
Objectives:
Carotid artery stenting (CAS) has been recommended as an alternative to carotid endarterectomy (CEA) by some clinicians. However, recently published clinical trials have reported 30-day stroke and death rates of 10% to 12%. This prompted review of our experience with CAS in patients at high risk, to document our results and guide further use of CAS.
Methods:
From September 1996 to the present, we performed 114 consecutive CAS procedures in 105 patients. Sixty-three patients were men (60%) and 42 patients were women (40%), with mean age of 70 years (range, 45-93 years). Indications for CAS included recurrent stenosis after previous CEA in 74 patients (65%), primary lesions in 32 patients at high risk (28%), and carotid stenosis with previous ipsilateral radiation therapy in 8 patients (7%). Asymptomatic stenosis (>80%) was managed in 70 patients (61%), and symptomatic lesions (>50%) were treated in 44 patients (39%).
Results:
CAS was technically successful in all patients. Mean severity of stenosis before CAS was 87% +/- 6%, compared with 9% +/- 4% after CAS. Two patients (1.9%) died, 1 of reperfusion-intracerebral hemorrhage and 1 of myocardial infarction 10 days after discharge; and 1 patient (0.95%) had a stroke (retinal infarction), for a 30-day stroke and death rate of 2.85%. Two patients (1.9%) had transient neurologic events. No cranial nerve deficits were noted. No neurologic complications have been noted in the last 27 patients (26%).
Conclusions:
A 30-day stroke and death rate of 2.85% in our experience demonstrates acceptability of CAS as an alternative to repeat operation or primary CEA in patients at high risk or in patients with radiation-induced stenosis. We recommend further clinical investigation of CAS and participation in clinical trials by vascular surgeons.