Dual-layer vs. closed-cell devices in carotid artery stenting: The role of plaque morphology on short-term outcomes

Carotid artery stenting (CAS) is an alternative revascularization method for patients with internal carotid stenosis in whom an endovascular approach is selected instead of carotid endarterectomy. In recent years, dual-layer stents have increasingly been employed due to their better plaque coverage compared to closed-cell stents. The aim of this study was to report the outcomes of these two stent types in a real-world clinical setting.

Patients with internal carotid artery stenosis who underwent CAS between 2004 and 2023 at two high-volume centers were retrospectively analyzed. Plaques were classified as: type 1(lipid-rich), type 2(fibro lipid) and type 3(calcified). Primary endpoints included technical success (defined as residual stenosis <30% on completion angiography), and the incidence of stroke/death and TIA/stroke within 30 days comparing period of procedures and clinical manifestation (symptomatic and asymptomatic) comparing type of stent and type of plaque.

A total of 944 CAS procedures were performed. Most of patients were male (68%) and younger than 80 years (72%). Symptomatic stenosis was present in 236(25%) patients, while 708(75%) were asymptomatic, with calcified plaques being most common (60%). Technical success was achieved in 94% procedures. In 6%, CAS procedure was abandoned due to excessive arch/carotid tortuosity. Before and after 2014 technical success rates were 9.7% and 3.6% (p < 0.001). The overall 30-day TIA/stroke and stroke/death rates were 6.4% and 2.4%, 10% and 4% in symptomatic and 5% and 2% in asymptomatic. Closed-cell stents (Wallstent, Boston Scientific Corporation, Massachusetts, USA) and dual-layer stents (Roadsaver, Terumo Corporation, Tokyo, Japan) were used in 64% and 36% of cases. Stroke/death and TIA/stroke occurred in 2.8%vs.0.8% (p = 0.20) in asymptomatic, and in 14.2%vs.5.4%(p = 0.05) in symptomatic. The 30-day stroke/death rate was 0.7%vs.0.8% (p = 0.80) in asymptomatic, while the 30-day TIA/stroke rate was higher, but not statistically significant, in the Wallstent group (5.9% vs.4.2%p = 0.30) in symptomatic. Patients with type 0-2 plaques treated with dual-layer stents had a significantly lower 30-day TIA/stroke rate (10% vs.3.7%, p = 0.02). Asymptomatic status (OR:0.4,95%CI:0.2-0.8, p = 0.008) and use of dual-layer stents (OR:0.5,95%CI:0.3-1, p = 0.05) are independent protective factors for 30-day TIA/stroke.

Dual layer devices are associated with a significantly lower 30-day TIA/stroke rate in patients with vulnerable plaque types (1-2). Symptomatic status and stent design both influenced periprocedural outcomes, underscoring the value of tailoring device choice to plaque morphology.