Eight-year institutional review of carotid artery stenting

Vascular surgeons have increasingly become proficient in carotid artery stenting (CAS) as an alternative treatment modality for cervical carotid artery occlusive disease. We analyzed our early and late outcomes of CAS over the last 8 years.

We report a single-center retrospective review of 388 carotid bifurcation lesions treated with CAS using cerebral embolic protection from May 2001 to July 2009. Data analysis includes demographics, procedural records, duplex exams, arteriograms, and two-view plain radiographs over a mean follow-up time of 23.0 months (interquartile range, 10.9-35.4).

At the time of treatment, the mean age of the entire cohort (76% men and 24% women) is 71 years; 13% were >/=80 years of age, and 31% had a prior history of either carotid endarterectomy (CEA) and/or external beam neck irradiation (XRT). The mean carotid stenosis is 80%, and asymptomatic lesions represent 69% of the group. Overall 30-day rates of death, stroke, and myocardial infarction are 0.5%, 1.8%, and 0.8%, respectively. The combined death/stroke rate at 30 days is 2.3%. The 30-day major/minor stroke rates for analyzed subgroups are statistically significant only for XRT/recurrent stenosis vs de novo lesions, 0% and 2.6% (P = .03), but not for asymptomatic vs symptomatic patients, 1.9% and 1.7% (P = .91) and age <80 vs >/=80, 2.0% and 1.8% (P = .52), respectively. At long-term, the freedom from all strokes at 12, 24, 36, and 48 months was 99.2%, 97.6%, 96.7%, and 96.7%, respectively. At late follow-up, the restenosis rate is 3.5%. Restenosis rates for recurrent stenosis/XRT vs de novo lesions are 2.7% and 3.4% (P = .39). Among the restenotic lesions were two associated type III stent fractures in de novo lesions, both of which were closed-cell stents. An additional two other type I fractures have been identified, yielding a stent fracture rate of 5.5%. The late death rate for the entire group is 16.8%, with one stent-related death secondary to ipsilateral stroke at 20 months (0.3% death rate).

Vascular surgeons performing CAS with embolic protection can achieve good early and late outcomes that are comparable to CEA benchmarks. Late stent failures (stroke, restenosis, and/or stent fatigue), while uncommon, are a recognized delayed problem.