Anatomical and technical predictors of perioperative clinical outcomes after carotid artery stenting

Abstract

Background A few other studies have reported the effects of anatomical and technical factors on clinical outcomes of carotid artery stenting (CAS). This study analyzed the effect of these factors on perioperative stroke/myocardial infarction/death after CAS. Methods This was a retrospective analysis of prospectively collected data of 409 of 456 patients who underwent CAS during the study period. A logistic regression analysis was used to determine the effects of anatomical and technical factors on perioperative stroke, death, and myocardial infarction (major adverse events [MAEs]). Results The MAE rate for the entire series was 4.7% (19 of 409), and the stroke rate was 2.2% (9 of 409). The stroke rate for asymptomatic patients was 0.46% (1 of 218; P = .01). The MAE rates for patients with transient ischemic attack (TIA) were 7% (11 of 158) vs 3.2% (8 of 251) for other indications (P = .077). The stroke rates for heavily calcified lesions were 6.3% (3 of 48) vs 1.2% (4 of 332) for mildly calcified/noncalcified lesions (P = .046). Differences in stroke and MAE rates regarding other anatomical features were not significant. The stroke rate for patients with percutaneous transluminal angioplasty (PTA) before embolic protection device (EPD) insertion was 9.1% (2 of 22) vs 1.8% (7 of 387) for patients without (P = .07) and 2.6% (9 of 341) for patients with poststenting PTA vs 0% (0 of 68) for patients without. The MAE rate for patients with poststenting PTA was 5.6% (19 of 341) vs 0% (0 of 68) for patients without (P = .0536). The MAE rate for patients with the ACCUNET (Abbott, Abbott Park, Ill) EPD was 1.9% (3 of 158) vs 6.7% (16 of 240) for others (P = .029). The differences between stroke and MAE rates for other technical features were not significant. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for PTA performed before EPD insertion, 1.7 for PTA performed before stenting, and 5.4 (P = .0315) for heavily calcified lesions. The MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 for PTAs performed before EPD insertion, 2.2 for poststent PTAs, and 2.2 (P = .1888) for heavily calcified lesions. A multivariate analysis showed that patients with TIA had an odds ratio of stroke of 11.05 (P = .029). Patients with PTAs performed before EPD insertion had an OR of 6.15 (P = .062). Patients with heavily calcified lesions had an odds ratio of stroke of 4.25 (P = .0871). The MAE odds ratio for ACCUNET vs others was 0.27 (P = .0389). Conclusions Calcific lesions and PTA before EPD insertion or after stenting were associated with higher stroke or MAE rates, or both. The ACCUNET EPD was associated with lower MAE rates. There was no correlation between other anatomical/technical variables and CAS outcome.

Predictors of Perioperative Stroke/Death after Carotid Artery Stenting: A Review Article

“…Notably, they found a stroke rate of 6.5% in patients with target site calcification compared with 2.3% in patients without target site calcification. Similar findings were also reported by AbuRahma et al 27 ) In their study, patients with heavily calcified lesions had a 30-day stroke rate of 6.3%, whereas those with non-calcified/mildly calcified lesions had a stroke rate of 1.2% (p=0.046).…”

“…In a recent study, 27 ) however, we could not demonstrate a correlation with lesion length, which may be attributed to the small sample size or to the fact that most of the treated lesions were <20–30 mm long ( Fig. 1 ).…”

“…The EVA-3S trial (Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis) reported that patients with a type III aortic arch had a higher incidence of 30-day perioperative stroke (17.2%) than those with type II and III aortic arches (8.1%). 26 ) We could not demonstrate significant differences between arch types from our experience, 27 ) which was, perhaps, secondary to the fact that most of our patients had type I and II aortic arches, with only 32 patients having type III aortic arch. It was also reported that aortic arch calcification was significantly higher in patients aged >80 years than in those aged <80 years (59% versus 30%), whereas a type III aortic arch is more common in patients aged >80 years than in those aged <80 years (82% versus 56%).…”

“…Our study confirmed these findings. 27 ) Theiss et al 12 ) also reported no statistical significance between perioperative outcomes and the side of CAS or the degree of carotid stenosis. However, in a single-center study, Mathur et al 8 ) showed that CAS performed for lesions with >90% stenosis was associated with higher 30-day perioperative stroke rates than CAS performed for lesions with <90% stenosis (14.9% versus 3.5%).…”

“…However, other studies did not report significant differences in stroke and death rates between patients undergoing right-sided CAS and those undergoing left-sided CAS. 2 , 5 ) In a recent study, AbuRahma et al 27 ) showed that the 30-day perioperative stroke rate was 2.6% for all left-sided carotid lesions compared with 1.7% for right carotid lesions and that the 30-day major adverse event (MAE) rate (stroke, death, and MI) was 6.1% for left carotid lesions compared with 2.8% for right carotid lesions (p=0.1164). Further, the 30-day stroke rate was 3.1% for left internal carotid artery (ICA) lesions compared with 1.5% for right ICA lesions, and the 30-day MAE rate was 6.2% for left ICA lesions compared with 2.9% for right ICA lesions (p=0.1808).…”