Does Free Cell Area Influence the Outcome in Carotid Artery Stenting?

Bosiers, Marc; Donato, Gianmarco de; Deloose, Koen; Verbist, Jürgen; Peeters, Patrick; Castriota, Fausto; Cremonesi, Alberto; Setacci, Carlo

doi:10.1016/j.ejvs.2006.09.019

Cited by 289 publications

(109 citation statements)

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“…A multicenter study of 3179 patients concluded that a free-cell area of >7.5 mm was associated with a higher 30-day stroke rate of 1.3% vs 3.4%, suggesting that closed-cell designed stents may be associated with a lower rate of stroke 20 ; however, in contrast, data from the Society for Vascular Surgery Registry did not show any significant difference in CAS outcome, whether using open-cell or closed-cell stent designs. 21 Timaran et al, 22 in a recent randomized controlled trial of 40 CAS patients treated by closed-cell or open-cell design, found no significant difference in embolic events, as documented by diffusion-weighted magnetic resonance imaging and transcranial Doppler.…”

Section: Discussionmentioning

confidence: 99%

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

AbuRahma

DerDerian

Hariri

et al. 2017

Journal of Vascular Surgery

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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.

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Section: Discussionmentioning

confidence: 99%

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

AbuRahma

DerDerian

Hariri

et al. 2017

Journal of Vascular Surgery

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“…The complication rate of symptomatic patients treated with stents by closed-cell stenting was significantly lower than in patients treated with open-cell stenting [21,22]. Jansen et al [22] speculated that closed-cell stents do not benefit from the additional use of EPDs because the protective effect of the stent is sufficient, but in open-cell stents the use of EPDs may help to reduce the periprocedural embolic rate.…”

Section: Discussionmentioning

confidence: 99%

Fibro-Fatty Volume of Culprit Lesions in Virtual Histology™ Intravascular Ultrasound Is Associated with the Amount of Debris during Carotid Artery Stenting

et al. 2010

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Objectives: This study aimed to evaluate the relationship between the amount of aspirated debris during distal balloon-protected carotid artery stenting (CAS) and the pre-intervention plaque composition, as assessed by Virtual Histology™ (VH) intravascular ultrasound (IVUS). Methods: The study subjects were 25 consecutive patients (mean age, 73.0 ± 5.2 years; 20 males and 5 females) who underwent CAS under distal balloon protection. The average rate of carotid stenosis was 74.6 ± 12.9% by North American Symptomatic Carotid Endarterectomy Trial criteria. We assessed culprit plaque components by VH-IVUS before CAS. Aspirated debris was filtered, stained with HE and mounted onto glass slides. The quantity of debris was evaluated by measuring its surface area. We evaluated the relationship between the quantity of aspirated debris and VH-IVUS measurements before CAS. Results: The amount of debris during CAS was positively correlated with the total plaque volume in grayscale IVUS (Rs = 0.480, p = 0.015) and fibro-fatty volumes over the entire lesion length in VH-IVUS (Rs = 0.561, p = 0.001). Conclusions: Culprit lesions with large plaque volumes, especially larger fibro-fatty volumes, as imaged by VH-IVUS, are associated with large amounts of debris during balloon-protected CAS.

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“…Although this was not a randomised comparison, the findings are in keeping with results from the SPACE study and large observational studies. 60,61 This effect of stent design may reflect the benefit of closed-cell stents providing greater coverage of the atheromatous lesion and implies that, in general, closed-cell stents should be preferred to open-cell stents.…”

Section: Implications For Health Carementioning

confidence: 99%

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Featherstone

Dobson

Ederle

et al. 2016

Health Technol Assess

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BackgroundCarotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain.ObjectiveTo compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis.DesignInternational, multicentre, randomised controlled, open, prospective clinical trial.SettingHospitals at 50 centres worldwide.ParticipantsPatients older than 40 years of age with symptomatic atheromatous carotid artery stenosis.InterventionsPatients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years.Main outcome measuresThe primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost–utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon.ResultsA total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45;p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93;p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57;p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300;p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75;p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments.LimitationsPatients and investigators were not blinded to treatment allocation. Interventionists’ experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected.ConclusionsThe functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation.Trial registrationCurrent Controlled Trials ISRCTN25337470.FundingThis project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.

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Does Free Cell Area Influence the Outcome in Carotid Artery Stenting?

Abstract: After carotid stenting, complication rates vary according to stent type, free cell area and cell design. In the symptomatic population (and also in the total population), post-procedural complication rates are highest for the open cell types and increase with larger free cell area.

Cited by 289 publications

References 24 publications

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

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

Fibro-Fatty Volume of Culprit Lesions in Virtual Histology™ Intravascular Ultrasound Is Associated with the Amount of Debris during Carotid Artery Stenting

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

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