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Predictors of difficult carotid stenting as determined by aortic arch angiography
Surabhi Madhwal1, Vivek Rajagopal, Deepak L Bhatt
1Cleveland Clinic, F25, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
Insights
Quantitative analysis of aortic arch anatomy can predict the difficulty of carotid artery stenting (CAS). Longer distance from the treated artery origin to the descending aorta (D1) and severe tortuosity (T) independently predict prolonged fluoroscopy time during CAS.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Medical Imaging
Background:
- Existing aortic arch classifications lack validation for predicting carotid artery stenting (CAS) difficulty.
- Objective assessment of aortic arch anatomy is needed to anticipate procedural complexity.
Purpose of the Study:
- To compare quantitative angiographic characteristics of the aortic arch between easy and difficult CAS procedures.
- To identify anatomical predictors of prolonged fluoroscopy time during CAS.
Main Methods:
- Defined difficult CAS by the 90th percentile of fluoroscopy time (FT) and easy CAS by the 10th percentile.
- Excluded patients with additional procedures, complications, or difficult vascular access.
- Analyzed quantitative angiographic features including distance (D1) and tortuosity (T).
Main Results:
- Difficult CAS cases (n=24) had significantly longer FT (58 min) than easy cases (n=24, 19 min).
- Independent predictors of procedural difficulty were increased D1 (OR 1.04/mm) and severe tortuosity (T) (OR 4.77).
- Patients with difficult CAS showed a longer D1 (50 vs. 40 mm) and higher prevalence of severe T (50% vs. 16.7%).
Conclusions:
- Quantitative measurements of aortic arch anatomy, specifically D1 and T, are crucial for predicting CAS difficulty.
- These findings can aid in pre-procedural planning and patient selection for carotid artery stenting.
Objective:
Although different aortic arch classifications exist to help determine carotid artery stenting (CAS) difficulty, they are not validated. We compared quantitative angiographic characteristics of aortic arch between easy and difficult CAS.
Methods:
We defined difficult procedures as requiring the longest fluoroscopy time (FT) (90th percentile) and easy procedures as the shortest FT (10th percentile) from our CAS database. We excluded patients undergoing additional procedures, intraprocedural complications or those with difficult vascular access.
Results:
We analyzed 24 patients with difficult CAS (median fluoroscopy time of 58 minutes) and 24 with easy CAS (median fluoroscopy time of 19 minutes). The two groups were similar with respect to demographics, comorbidities and clinical presentation at the time of CAS. Patients with difficult procedures had a longer distance from the origin of treated artery to the beginning of the descending aorta (D1; 50 +/- 17 mm vs. 40 +/- 16 mm; p = 0.04), severe tortuosity (T) of the common carotid and internal carotid vessels (T; 50.0% vs. 16.7%; p = 0.03) and a trend in the presence of a Type 3 arch (33.3% vs. 25.0%; p = 0.18) and angulated takeoff (20.8% vs. 4.3%; p = 0.19). There was no difference in the severity of stenosis or index lesion calcification, ulceration and eccentricity between the two groups. On multivariate analysis, independent predictors of procedural difficulty were D1 (odds ratio 1.04 per mm; 95% CI, 1.01-1.09; p = 0.04), and T (odds ratio 4.77; 95% CI 1.3-42.9; p = 0.03).
Conclusions:
Distance from the origin of the treated artery to the beginning of the D1 and target vessel T determine prolonged fluoroscopy time during CAS.
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