Safety and security of carotid artery stenting for severe stenosis with contralateral occlusion
Alejandro González1, Jose Ramón González-Marcos, Eva Martínez
1Department of Radiology, Interventional Neuroradiology, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain.
Insights
Carotid angioplasty and stenting (CA/CAS) is a safe and effective treatment for severe internal carotid artery stenosis with contralateral occlusion. This procedure offers comparable outcomes to carotid endarterectomy, making it a potential treatment of choice for this patient subgroup.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Severe internal carotid stenosis (ICA) poses a surgical risk for some patients, particularly those with contralateral occlusion.
- Carotid angioplasty (CA) and stenting (CAS) present an alternative therapeutic option for these select patients.
- Limited data exists on the efficacy and safety of CA/CAS in patients with ICA stenosis and contralateral occlusion.
Observation:
- A prospective analysis of 96 patients (18.5% of 519) with severe ICA stenosis and contralateral occlusion undergoing CA or CAS between 1991 and 2004.
- The majority of patients (63.5%) were symptomatic, and 33.3% did not meet NASCET criteria for surgery.
- Carotid stenting (CAS) was performed in 74% of cases, with distal protection used in 39.6%.
Findings:
- Transient hemodynamic effects were common, including hypotension (54.5%) and bradycardia (61.5%).
- The study reported a 1% rate of transient ischemic attack (TIA), 1% minor stroke, and 2.1% disabling stroke.
- Zero mortality and 0% morbidity were observed in cases utilizing distal protection.
Implications:
- CA/CAS demonstrates favorable safety and efficacy in patients with severe ICA stenosis and contralateral occlusion.
- The procedure shows comparable results to carotid endarterectomy (CEA).
- CA/CAS may be considered the preferred treatment for this specific patient subgroup, warranting further randomized trials.
Background:
Despite advances in the surgical treatment of patients with severe internal carotid stenosis (ICA), there are selective groups of patients who, due to several reasons, are not good candidates for surgery. Patients with contralateral occlusion are one of these subgroups. Thereby, other therapeutic alternatives, such as angioplasty may be of value. So far, there has been little published data about carotid angioplasty (CA) or stenting (CAS) in those patients. The objective of this study was to evaluate the efficacy and safety of angioplasty and stenting in patients with severe internal carotid stenosis and contralateral occlusion.
Methods:
Between 1991 and June 2004, 519 consecutive patients who underwent CA or CAS for severe stenosis of the ICA were registered in our prospective CA Data Bank. Of them, we identified 96 with contralateral occlusion (18.5%), who formed the basis of the present analysis.
Results:
Mean age was 64 +/- 9 (range 40-80), 85 (88.5%) were men, and 61 (63.5%) were symptomatic. Thirty-two patients (33.3%) did not meet the criteria to be included in the NASCET. CA was done in 25 patients (26%) and CAS in 71 (74%). Distal protection was used in 38 patients (39.6%). Asymptomatic stenosis was treated in cases of progression (>85%), exhausted vasoreactivity, positive microemboli detection in transcranial Doppler, and/or asymptomatic lesions in CT/MRI. Transient hemodynamic effects were frequent: hypotension (54.5%), bradycardia (61.5%), asystole (33.3%), and syncope (33.3%). TIA occurred in 1 patient (1%), minor stroke in 1 (1%), and disabling stroke in 2 patients (2.1%). Mortality was 0%. Morbidity was 0% in cases done with distal protection.
Conclusion:
In our experience, CA/CAS performed in patients with severe carotid stenosis and contralateral occlusion compared favorably with the results obtained with carotid endarterectomy (CEA), to the extent that if randomized series comparing CEA and CA/CAS are done, CA/CAS might be considered as the treatment of choice in this subgroup of patients.