A systematic review and meta-analysis of predilation and postdilation in transfemoral carotid artery stenting
Behrad Ziapour1, Marc L Schermerhorn2, Mark D Iafrati1
1Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, Mass.
Insights
Avoiding postdilation in carotid artery stenting reduces hemodynamic instability and neurologic events. This strategy may offer a safer approach for patients, though long-term effects require further investigation.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Carotid artery stenting (CAS) is a procedure to prevent stroke.
- Hemodynamic instability and neurologic events are potential complications.
- The role of postdilation in CAS outcomes is debated.
Purpose of the Study:
- To evaluate the short-term impact of different ballooning combinations on CAS outcomes.
- To assess effects on hemodynamic instability, neurologic events, and mortality.
Main Methods:
- Systematic review and meta-analysis of cohort studies up to May 2019.
- Searched Cochrane Library, PubMed, EMBASE, Google Scholar, and clinical trial databases.
- Used fixed and random models to summarize data on hemodynamic instability, neurologic events, and mortality.
Main Results:
- Patients without postdilation showed significantly less hemodynamic instability (RR, 0.53; P = .001).
- Fewer dilations, regardless of type, significantly decreased short-term neurologic events (RR, 0.67; P = .03).
- No significant effect on mortality was observed with or without postdilation.
Conclusions:
- Avoiding postdilation reduces perioperative hemodynamic instability for up to 30 days.
- Fewer dilations during CAS may decrease short-term neurologic events.
- Higher residual stenosis thresholds might safely prompt postdilation; long-term effects need more study.
Objective:
In this review, we evaluate the short-term impact of different ballooning combinations on hemodynamic instability neurologic events, and mortality associated with carotid artery stenting.
Methods:
We used a search strategy to identify studies in the Cochrane Library trials register, PubMed, EMBASE, Google Scholar, and the US National Library of Medicine clinical trial databases up to May 2019. Studies reporting either hemodynamic instability, neurologic events, or mortality were included according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-analysis. Fixed and random models were used to summarize the effects.
Results:
Of seven included cohort studies for qualitative review, six were selected for meta-analysis. Patients without postdilation had significantly less hemodynamic instability in the random effects model (risk ratio, 0.53; 95% confidence interval, 0.37-0.77; P = .001). Regardless of the dilation type, the overall summary effect in the fixed model showed a significant decrease in the risk of developing short-term neurologic events (risk ratio, 0.67; 95% confidence interval, 0.47-0.97; P = .03). Last, the exclusion of either of the two dilation techniques had no significant effect on mortality.
Conclusions:
Avoiding postdilation reduces perioperative hemodynamic instability and this benefit lasts at least up to 30 days. Regardless of the type, fewer dilations during carotid artery stenting possibly decreases the neurologic events during and 30 days after the procedure. The data also suggest that the residual stenoses above current practiced standard may provide a safer threshold to prompt postdilation. Statements about the long-term effects of dilation techniques requires more study.
