Remote pre-procedural ischemic stroke as the greatest risk in carotid‑stenting‑associated stroke and death: a single
Mária Rašiová1,2, Ľubomír Špak3, Ľudmila Farkašová3
1Department of Cardiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia - rasiova@unlp.sk.
Insights
Patients with a history of remote ischemic stroke face higher risks of stroke and death after carotid artery stenting (CAS). Asymptomatic patients with remote stroke should avoid CAS, as it increases long-term mortality.
Area of Science:
- Vascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Carotid artery stenting (CAS) aims to reduce stroke risk in patients with carotid stenosis.
- CAS carries inherent risks of stroke and death, particularly for asymptomatic individuals.
- Accurate patient selection is crucial to maximize benefits and minimize hazards of CAS.
Purpose of the Study:
- To determine the periprocedural complication risk (stroke, death) associated with CAS in patients with and without remote pre-procedural ischemic stroke.
- To analyze periprocedural risk in specific patient subgroups undergoing CAS.
- To assess the impact of various factors on long-term all-cause mortality after CAS.
Main Methods:
- Retrospective review of prospectively collected data from patients treated with protected CAS (June 2008 - December 2015).
- Analysis of patient demographics, stenosis characteristics, comorbidities (including remote ischemic stroke), and previous interventions.
- Long-term survival data obtained from the Health Care Surveillance Authority registry.
Main Results:
- Overall periprocedural stroke/death incidence was 3.8%.
- Patients with remote ischemic stroke had a 3.4-fold higher risk of periprocedural stroke/death (6.6% vs. 2.0%).
- Asymptomatic patients with remote stroke showed a 5.6-fold increased risk (5.7% vs. 1.0%), and patients ≥75 years had a 3.0-fold increased risk (8.4% vs. 2.9%).
- Remote ischemic stroke was associated with a 1.5-fold higher long-term mortality risk.
Conclusions:
- Remote pre-procedural ischemic stroke identifies a high-risk subgroup for periprocedural complications after CAS.
- CAS should be avoided in asymptomatic patients with a history of remote ischemic stroke.
- Remote ischemic stroke increases long-term all-cause mortality post-CAS, and older age (≥75 years) also elevates periprocedural risk.
Background:
The goal of carotid artery stenting (CAS) is to decrease the stroke risk in patients with carotid stenosis. This procedure carries an immediate risk of stroke and death and many patients do not benefit from it, especially asymptomatic patients. It is crucial to accurately select the patients who would benefit from carotid procedure, and to rule out those for whom the procedure might be hazardous. Remote ischemic stroke is a known risk factor for stroke recurrence during surgery. The aim of our study was to determine the periprocedural complication risk (within 30 days after CAS) associated with carotid stenting (stroke, death) in patients with and without remote pre-procedural ischemic stroke, to analyze periprocedural risk in other specific patient subgroups treated with CAS, and to determine the impact of observed variables on all-cause mortality during long-term follow-up.
Methods:
We conducted a retrospective review of prospectively collected data from all patients treated with protected CAS between June 20, 2008 and December 31, 2015. Patient age, gender, type of carotid stenosis (symptomatic versus asymptomatic), side of stenosis (right or left carotid artery), type of cerebral protection (proximal versus distal), presence of comorbidities (remote ischemic pre-procedural ischemic stroke, coronary artery disease, diabetes mellitus, peripheral artery disease), previous ipsilateral carotid endarterectomy (CEA), contralateral carotid occlusion (CCO) and previous contralateral CAS/CEA were analyzed to identify higher CAS risk and to determine the impact of these variables on all-cause mortality during follow-up. Survival data were obtained from the Health Care Surveillance Authority registry. Mean follow-up was 1054 days (interquartile range 547.3; 1454.8). Remote pre-procedural ischemic stroke was defined as any-territory ischemic stroke >6 months prior to CAS.
Results:
Primary periprocedural endpoint incidence (stroke/death) in 502 patients was 3.8% (N.=19) of all patients, 5.4% (N.=10) of symptomatic patients and 2.8% (N.=9) of asymptomatic patients. The risk of periprocedural stroke/death was 3.4 times higher in patients with (N.=198) compared to patients without remote ischemic stroke (N.=304) (6.6% versus 2.0% of patients without remote ischemic stroke; P=0.008). Periprocedural stroke/death in symptomatic patients (N.=186) was non-significantly higher in patients with remote ischemic stroke (N.=76) compared with patients without remote ischemic stroke (N.=110) (7.9% versus 3.6%; P=0.206). Asymptomatic patients with remote ischemic stroke (N.=122) had a 5.6-time-higher periprocedural risk of stroke/death compared with asymptomatic patients without remote ischemic stroke (N.=194) (5.7% versus 1.0%; P=0.014). Patients ≥75 years (N.=83) had a 3.0-time-higher periprocedural risk of stroke/death compared with younger patients (N.=419) (8.4% versus 2.9%; P=0.015); a non-significant increase of periprocedural stroke/death was found in both symptomatic (N.=35) and asymptomatic (N.=48) elderly patients (11.4% versus 4.0%, P=0.078; and 6.3% versus 2.4%, P=0.124, respectively). Increased periprocedural risk of stroke/death was not documented in other analyzed patient subgroups. During long-term follow-up, a 1.5-time-higher mortality risk was found in patients with remote ischemic stroke compared with patients without remote ischemic stroke in multivariable analysis; other patient subgroups (except older versus younger patients) did not differ in long-term mortality following carotid stenting.
Conclusions:
In our experience, all patients with remote pre-procedural any-territory ischemic stroke belong to risky subgroup for periprocedural stroke death after CAS. All asymptomatic patients with remote ischemic stroke should not be treated with CAS. Remote ischemic stroke increases all-cause mortality in long-term follow-up after carotid stenting. Patients aged ≥75 years also have increased risk of periprocedural stroke and death after CAS. These factors should help us to be more selective when planning carotid procedures.
More Related Videos
09:36A Magnetic Resonance Imaging-based Computational Protocol for Analysis of Plaque Morphology and Hemodynamics in Patients with Carotid Artery Stenosis
Published on: August 12, 2025
04:30A Murine Model of Stent Implantation in the Carotid Artery for the Study of Restenosis
Published on: May 14, 2013