High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection

Fanous, Andrew A.; Natarajan, Sabareesh K.; Jowdy, Patrick K.; Dumont, Travis M.; Mokin, Maxim; Yu, Jihnhee; Goldstein, Adam; Wach, Michael M.; Budny, James L.; Hopkins, L. Nelson; Snyder, Kenneth V.; Siddiqui, Adnan H.; Levy, Elad I.

doi:10.1227/neu.0000000000000871

Cited by 24 publications

(22 citation statements)

References 69 publications

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“… 14) In addition, some reports mentioned that plaque volumes, severe aortic valve stenosis, approach route, intraoperative hemodynamic instability, were associated with the treatment outcomes of CAS. 9 , 22 – 24) For these findings, it is reasonable to evaluate treatment risks and select the treatment. 7 , 16) Recently, CEA and CAS appear to be complementary treatments for ICAS with various risk factors.…”

Section: Discussionmentioning

confidence: 99%

“… 12 , 13 , 20) The treatment risks were compiled from previous reports. 2 , 9 , 10 , 21 , 22) Risk factors of CEA were listed high position (>C2), post-radiation therapy, restenosis, and general anesthesia high risk (cardio-pulmonary disease, dual antiplatelet therapy, contralateral occlusion, and post-Swan–Ganz catheter insertion). Risk factors of CAS were listed tortuous or elongated vessel, thoracic aortic aneurysm, abdominal aortic aneurysm, severe calcification, and severe aortic valve stenosis.…”

Section: Methodsmentioning

confidence: 99%

“…The current literature describes CEA and CAS not to be appropriate for all patients with ICAS. 2 , 9 , 10) A plaque image of ICAS is one of most attractive diagnostic methods. 11) Development of MRI enabled noninvasive assessment of plaque imaging.…”

Section: Introductionmentioning

confidence: 99%

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Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Ito

Tsuruta

Nakai

et al. 2018

Neurol. Med. Chir.(Tokyo)

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Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Ito

Tsuruta

Nakai

et al. 2018

Neurol. Med. Chir.(Tokyo)

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“…Carotid tortuosity was defined as carotid curvature of the stenting site <120°, and a difficult distal landing zone was determined as severe angulation or tortuosity for protective embolic devices, according to the Buffalo risk assessment scale (BRASS). [ 11 ]…”

Section: Methodsmentioning

confidence: 99%

Calcification in original plaque and restenosis following carotid artery stenting

Katano¹,

Nishikawa²,

Yamada³

et al. 2017

Surg Neurol Int

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Background:The relationship between calcification in primary plaque and recurrent stenosis after carotid artery stenting (CAS) is not established, but an inverse association with restenosis following carotid endarterectomy (CEA) has been suggested.Methods:We retrospectively analyzed 75 plaques of 109 consecutive CAS with regard to calcification, using the calcium score and shape, location, and other characteristics of original plaques together with stenting-related factors. CAS was performed in a standard fashion with an embolic protection device. Greater-than-moderate restenosis (≥50%) was assessed by peak systolic velocity (PSV) with duplex ultrasonography (≥130 cm/s, internal/common carotid or distal/proximal PSV ratio ≥2.0).Results:Univariate analysis revealed percentages of dyslipidemia treated with statins (P = 0.03), calcification in distal ICA (P = 0.02), and immediate residual stenosis (P = 0.02) were significantly higher in patients with greater-than-moderate restenosis, whereas calcification in carotid bulb and usage of open-cell stent were rather less frequent (P < 0.001 and P = 0.02, respectively). Multivariate logistic regression analysis showed that rarity of calcification in carotid bulb was a sole independent predictor for greater-than-moderate recurrent carotid stenosis 1 year after CAS (OR = 0.21, CI = 0.06–0.77, P = 0.02).Conclusions:Calcium score was not significantly related to restenosis at 1 year after CAS, as was previously found following CEA, though scarcity of calcification in carotid bulb was suggested as a predictor of in-stent restenosis. Compared to post-CEA restenosis, carotid plaque calcification may be inversely but tenuously associated with recurrent stenosis 1 year post-CAS. No other stenting factors (e.g., stent design, pre-/post-dilation, or protection devices) showed a significant association with recurrent stenosis post-CAS.

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“…However, difficult vascular anatomy such as type III or diseased aortic arch, carotid tortuosity, difficult peripheral access, and difficult distal landing may lead to complications. Fanous et al developed a scoring system using demographics and vascular anatomy that predicts complications, 35) whereby patients with a high score should avoid CAS. Furthermore, improved imaging techniques such as CT, magnetic resonance imaging, and ultrasonography have enabled us to understand not only the degree of carotid artery stenosis but also the vulnerability of the plaque, which stratify the risk of patients or treatments.…”

Section: Introductionmentioning

confidence: 99%

Recent Trends in Neuro-endovascular Treatment for Acute Ischemic Stroke, Cerebral Aneurysms, Carotid Stenosis, and Brain Arteriovenous Malformations

Matsumaru

Ishikawa

Yamamoto

et al. 2017

Neurol. Med. Chir.(Tokyo)

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The efficacy of mechanical thrombectomy with stent retrievers for emergent large vessel occlusion has been proved by randomized trials. Mechanical thrombectomy is increasingly being adopted in Japan since stent retrievers were first approved in 2014. An urgent clinical task is to offer structured systems of care to provide this treatment in a timely fashion to all patients with emergent large vessel occlusion. Treatment with flow-diverting stents is currently a preferred treatment option worldwide for large and giant unruptured aneurysms. Initial studies reported high rates of complete aneurysm occlusion, even in large and giant aneurysms, without delayed aneurysmal recanalization and/or growth. The Pipeline Embolic Device is a flow diverter recently approved in Japan for the treatment of large and giant wide-neck unruptured aneurysms in the internal carotid artery, from the petrous to superior hypophyseal segments. Carotid artery stenting is the preferred treatment approach for carotid stenosis in Japan, whereas it remains an alternative for carotid endarterectomy in Europe and the United States. Carotid artery stenting with embolic protection and plaque imaging is effective in achieving favorable outcomes. The design and conclusions of a randomized trial of unruptured brain arteriovenous malformations (ARUBA) trial, which compared medical management alone and medical management with interventional therapy in patients with an unruptured arteriovenous brain malformation, are controversial. However, the annual bleeding rate (2.2%) of the medical management group obtained from this study is worthy of consideration when deciding treatment strategy.

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High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection

Cited by 24 publications

References 69 publications

Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Calcification in original plaque and restenosis following carotid artery stenting

Recent Trends in Neuro-endovascular Treatment for Acute Ischemic Stroke, Cerebral Aneurysms, Carotid Stenosis, and Brain Arteriovenous Malformations

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