Related Experiment Videos
Carotid artery stenting according to the tailored-CAS algorithm is associated with a low complication rate at 30
Piotr Pieniążek1, Lukasz Tekieli, Piotr Musiałek
1Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland. kardio@kki.krakow.pl
Insights
Carotid artery stenting (CAS) using a tailored approach with specific embolic protection devices (EPD) and stent types is safe, achieving a 2.38% 30-day complication rate. Advanced age and prior neurological symptoms predict adverse outcomes.
Area of Science:
- Cardiovascular Interventions
- Neurology
- Vascular Surgery
Background:
- Carotid artery stenting (CAS) complication rates are debated, with some studies failing to meet established safety thresholds.
- The optimal strategy for CAS, particularly regarding embolic protection devices (EPD) and stent types, remains an area of investigation.
- A tailored approach to CAS aims to improve safety and efficacy in patients with carotid artery stenosis.
Purpose of the Study:
- To evaluate the 30-day safety of CAS using various EPDs and stent types within the tailored-CAS algorithm.
- To identify patient and lesion-specific risk factors associated with CAS complications.
- To assess the effectiveness of the tailored-CAS algorithm in managing high-risk carotid artery lesions.
Main Methods:
- A retrospective analysis of 1176 CAS procedures performed between 2002 and 2010 in 1081 patients.
- Utilized the tailored-CAS algorithm, incorporating extracranial ultrasound and CT angiography for EPD and stent selection.
- Preferential use of proximal EPD and closed-cell stents for high-risk lesions and symptomatic patients.
Main Results:
- Achieved a procedural success rate of 99.8% with a 30-day complication rate of 2.38% (death/stroke/MI).
- In-hospital complications included 0.55% deaths, 0.08% major stroke, and 1.61% minor strokes; no myocardial infarctions occurred.
- Advanced age (>75 years) predicted death, and prior neurological symptoms predicted death/stroke. Hyperperfusion syndrome occurred in 0.59% of cases, with 2 fatal outcomes.
Conclusions:
- The tailored-CAS approach, selecting EPD and stent types based on non-invasive diagnostics, is a safe method for carotid artery stenting.
- Advanced age and prior neurological symptoms are significant predictors of adverse outcomes following CAS.
- The tailored-CAS strategy effectively mitigates risks associated with high-risk lesion features, and hyperperfusion syndrome, though severe, can be managed.
Background:
The rate of early complications of carotid artery stenting (CAS) should not exceed 3% in asymptomatic and 6% in symptomatic patients. However, some recent studies/registries failed to reach this threshold, fueling a debate on the role of CAS in the treatment of patients with carotid artery stenosis.
Aim:
To evaluate 30-day safety of CAS using different embolic protection devices and different stent types according to the tailored-CAS algorithm and to identify risk factors for complications.
Methods:
Between 2002 and 2010, we performed 1176 CAS procedures in 1081 patients (age 38-86 years, mean 66.3 ± 8.4 years, 51.5% symptomatic) according to the tailored-CAS algorithm that included extracranial ultrasound and computed tomography angiography to select the most appropriate embolic protection device (EPD) and stent type. Proximal EPD and closed-cell (CC) stents were preferentially used for high-risk lesions (HR - soft/thrombus-containing/tight/ulcerated, 36.14% of all lesions) and in symptomatic patients.
Results:
Procedural success rate was 99.8%. In symptomatic patients, proportion of HR lesions was higher (41.1%) than in the asymptomatic group (30.8%, p = 0.001) and the usage of CC stents (76.2% vs 71.7%, p = 0.103) and proximal EPD (P-EPD, 34.8% vs 27.7% among asymptomatic patients, p = 0.010) was more frequent. CC stents were used in 82.4% of CAS procedures involving HR lesions (vs 69.1% for non-HR lesions, p < 0.01), and P-EPD were used in 83.1% of procedures involving HR lesions (vs 2.5% for non-HR lesions, p < 0.001). In-hospital complications included 6 (0.55%) deaths, 1 (0.08%) major stroke and 19 (1.61%) minor strokes. No myocardial infarctions (MI) were noted. Among 7 (0.59%) cases of hyperperfusion syndrome, 2 were fatal. Thirty-day complication rate (death/any stroke/MI) was 2.38%. Age > 75 years was a predictor of death (p = 0.015), and prior neurological symptoms were a predictor of death/stroke (p = 0.030). There were 4 cases of periprocedural embolic cerebral artery occlusion, all treated with combined intracranial mechanical and local thrombolytic therapy.
Conclusions:
CAS with EPD and stent type selection on the basis of thorough non-invasive diagnostic work-up (tailored- -CAS) is safe. Advanced age was associated with an increased risk of death and the presence of prior neurological symptoms was a predictor of death/stroke at 30 days. With the tailored-CAS approach, high-risk lesion features (soft/thrombus- -containing/tight/ulcerated) are eliminated as a risk factor. Hyperperfusion syndrome is a severe CAS complication which may lead to intracranial bleeding and death. Acute, iatrogenic embolic cerebral artery occlusion is rare and may be managed by combined intracranial mechanical and local thrombolytic therapy.
