A meta-analysis of the effect of stent design on clinical and radiologic outcomes of carotid artery stenting

Abstract

Objective: Procedural characteristics, including stent design, may influence the outcome of carotid artery stenting (CAS). A thorough comparison of the effect of stent design on outcome of CAS is thus warranted to allow for optimal evidence-based clinical decision making. This study sought to evaluate the effect of stent design on clinical and radiological outcomes of CAS.Methods: A systematic search was conducted in MEDLINE, Embase, and Cochrane databases in May 2018. Included were articles reporting on the occurrence of clinical short-and long-term major adverse events (MAE, any stroke or death) or radiological adverse events (new ischemic lesions on postprocedural magnetic resonance diffusion-weighted imaging (MR-DWI), restenosis or stent fracture) in different stent designs used to treat carotid artery stenosis.Random effects models were used to calculate combined overall effect sizes. Meta-regression was performed to identify the effect of specific stents on MAE rates. Results: From 2,654 unique identified articles, two randomized controlled trials and 66 cohort studies were eligible for analysis (including 46,728 procedures). Short-term clinical MAE rates were similar for patients treated with open cell versus closed cell or hybrid stents. Use of Acculink stent was associated with a higher risk of MAE compared to Wallstent (RR: 1.51, p=0.03), as was true for use of Precise stent versus Xact stent (RR: 1.55, p<0.001). Long-term clinical MAE rates were similar for open versus closed cell stents. Use of open cell stents predisposed to a 25% higher chance (RR: 1.25; p=0.03) of developing postprocedural new ischemic lesions on MR-DWI. No differences were observed in incidence of restenosis, stent fracture, or intraprocedural hemodynamic depression with respect to different stent design. [Type here] Conclusions: Stent design does not affect short-or long-term clinical MAE rates in patients undergoing CAS. Furthermore, the division in open and closed cell stent design might conceal true differences in single stent efficacy. Nevertheless, open cell stenting resulted in a significantly higher number of MR-DWI-detected subclinical postprocedural new ischemic lesions compared with closed cell stenting. An individualized patient data meta-analysis,including future studies with prospective homogenous study design, is required to adequately correct for known risk factors and provide definite conclusions with respect to carotid stent design for specific subgroups.

Mid-term and late results of endovascular treatment for symptomatic carotid artery stenosis under proximal protection.

“…The use of closed-cell stents could also account for the low stroke rate in our study. Superiority of the closed-cell stents in comparison with the opencell ones has already been demonstrated in several trials [23][24][25]. In 29 patients we implanted modern dual-layered stents (the RoadSaver stents).…”

Editor's Choice – Predictors of New Ischaemic Brain Lesions on Diffusion Weighted Imaging After Carotid Stenting and Endarterectomy: A Systematic Review

“…34 A meta-analysis investigating stent design found no differences in terms of major adverse events but found an increased risk of development of peri-procedural DWI lesions in patients treated with open cell stenting. 40 Administration of additional pre-procedural anticoagulants and additional lipid lowering therapy may be protective for development of new DWI lesions. 35,36,41 Another topic of interest is procedural timing in symptomatic patients.…”

Carotid Revascularization: Current Practice and Future Directions

“…40 Interventionalists realized earlyon that open-cell stent design doubled the risk of postprocedural stroke in the SPACE and ICSS trials, and so modern stents used for carotid revascularization are closedcell in design. 41,42 Techniques that have a high risk of causing stroke during the CAS procedure, such as dilating after stent deployment, have been identified so that interventionalists can make informed decisions regarding use of these techniques. 43 CAS is safest when performed in a multidisciplinary environment with an experienced team.…”