Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis

Roubin, Gary S.; New, Gishel; Iyer, Sriram S.; Vitek, Jiri J.; Al-Mubarak, Nadim; Liu, Ming W.; Yadav, Jay S.; Gomez, Camilo R.; Kuntz, Richard E.

doi:10.1161/01.cir.103.4.532

Cited by 626 publications

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“…Os benefícios da endarterectomia em pacientes sintomáticos com estenose entre 50 e 69% no NASCET, ECST e outros foram claramente menores do que naqueles com estenose maior [32][33][34][35] . Assim, nesse grupo, a endarterectomia tem maior valor para aqueles com alto risco de acidente vascular cerebral, como nos homens com 75 anos ou mais, sintomas hemisféricos e acidente vascular cerebral há 3 meses ou menos 1 .…”

Section: E Tab Iii)unclassified

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Estenose de carótida extracraniana

Campos¹,

Filho²

2004

Arq. Bras. Cardiol.

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A estenose de carótida extracraniana é uma importante causa de ataque isquêmico transitório 1 , estando relacionada em 90% dos casos à afecção da bifurcação da carótida comum 2 . Atinge 2 milhões de pessoas nos Estados Unidos 3 e a sua incidência, acima dos 65 anos, segundo o Cardiovascular Health Study, é de 4,2% nos homens e 1,8% nas mulheres 3 . Sua prevalência, conforme dados do estudo Framingham, é de 9% para homens e 7% para mulheres 4 .A aterosclerose da carótida representa ainda, 10 a 20% dos casos de acidente vascular cerebral 1 , que constitui a terceira causa de mortalidade nos Estados Unidos 4,5 , com uma incidência de 700.000 casos por ano e responsável por quatro dos 50 milhões de óbitos anuais no mundo 5 .Portanto, como o ataque isquêmico transitório, muitas vezes, precede o acidente vascular cerebral 2 e a estenose de carótida extracraniana está intimamente relacionada ao ataque isquêmico transitório, é necessária uma abordagem criteriosa e responsável desta entidade a fim de serem evitados graves prejuízos à saúde do paciente.Veja, por exemplo, o caso de um homem branco, de 66 anos com longa história de tabagismo, hipertensão arterial sistêmica não controlada, diabetes mellitus e hiperlipidemia há vários anos, que procurou assistência médica por alguns episódios de paresia em membro superior direito de, aproximadamente, 15 min. Durante o exame físico, o médico percebeu um sopro sobre a carótida esquerda, acrescido da confirmação de seu relato de hipertensão.Como conduzir o caso? -No paciente em questão, fatores de risco cerebrocardiovasculares eram óbvios e exigiam atenção imediata. Incluída na abordagem inicial onde uma investigação neurológica e cardiológica básica é imprescindível, nos deparamos com uma entidade, muito negligenciada na prática clínica, a afecção de carótida.Principais questões na estenose de carótida extracranianaPor quê a estenose de carótida extracraniana é tema tão controverso? Existe relação com a doença arterial coronariana? Como sua fisiopatologia pode explicar as principais complicações? Quando pensar e como diagnosticar a estenose de carótida? Qual o significado de um sopro carotídeo? Em se diagnosticando uma estenose de carótida, qual a conduta terapêutica que obtém melhores resultados?Estenose de carótida é um tema controverso, seria de se esperar? -Um dos grandes problemas na abordagem do paciente com estenose de carótida extracraniana é a existência de muitas controvérsias na sua terapêutica, já que é uma doença que afeta o território arterial macrovascular, tendo relação íntima com a doença arterial coronariana e, como esta, sua etiopatogenia não está totalmente compreendida.Estenose de carótida extracraniana e doença arterial coronariana -Kallikazaros e cols. 6 avaliaram 225 pacientes referidos ao hospital para investigação de dor precordial, sugestivamente isquêmica, submetidos a ultra-sonografia de carótidas e angiografia quantitativa de coronárias, buscando correlacionar a estenose de carótida à doença arterial coronariana e observaram que desses pacientes, 8...

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Section: E Tab Iii)unclassified

“…34 acompanharam 528 pacientes submetidos a angioplastia com stent por cinco anos e seus resultados sugeriram que o procedimento pode ser comparável à endarterectomia.…”

Section: E Tab Iii)unclassified

Estenose de carótida extracraniana

Campos¹,

Filho²

2004

Arq. Bras. Cardiol.

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“…9 Of special note are the success and complication rates of carotid artery stenting that have been observed with the development of the technique. As reported by Roubin et al, 10 success rates of 98% are now achievable, and the incidence of minor strokes seems to be declining. What does not seem to be declining, however, is the incidence of procedure-related major stroke.…”

Section: See P 12mentioning

confidence: 72%

Carotid Filters

Williams

2001

Circulation

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A lthough percutaneous, catheter-based treatment for atherosclerotic arterial obstruction began in the peripheral circulation, usage became widespread only after coronary application. The procedure's abilities to relieve angina and either spontaneous or provoked myocardial ischemia and to achieve prompt reperfusion in myocardial infarction are well-documented. 1 Even selected patients with advanced, multivessel coronary disease can expect outcomes similar to those provided by the more invasive bypass surgery. [2][3][4] Now, enthusiasm for catheter revascularization is circling back to arteries beyond the coronary circulation. See p 12Among these new targets are the carotid arteries, which are well recognized as sources for cerebral emboli, a major cause of stroke. Surgical endarterectomy is performed for severe, symptom-related carotid atherosclerosis and, in selected asymptomatic patients, it seems superior to medical treatment alone in preventing stroke. [5][6][7] Using approaches and techniques developed from coronary intervention, clinicianinvestigators have demonstrated that balloon angioplasty and stent deployment are feasible for narrowings involving the internal and external carotid and its bifurcation. Initial observational results are encouraging to the point where a direct comparison of catheter-based therapy to carotid endarterectomy has begun in the form of a large, multicenter, randomized, clinical trial. 8 Distal embolization of atherosclerotic debris as a consequence of balloon angioplasty has been an issue of concern since the inception of the procedure. Fearful of emboli, Andreas Gruentzig drained, filtered, and examined blood from the coronary sinus when he first performed coronary balloon angioplasty in man (Andreas Gruentzig, MD, personal communication, August 1978). With the exception of degenerated saphenous aortocoronary vein grafts and native arteries with substantial intracoronary thrombus, however, clinically significant embolization resulting from balloon angioplasty alone or with stent deployment is not a major concern in the coronary circulation.Such may not be the case with carotid intervention. Strokes, both major and minor, are acknowledged complications of carotid stenting, and the mechanism now seems to be embolic, rather than the acute occlusion or dissection that was observed during the early balloon angioplasty experience. 9 Of special note are the success and complication rates of carotid artery stenting that have been observed with the development of the technique. As reported by Roubin et al, 10 success rates of 98% are now achievable, and the incidence of minor strokes seems to be declining. What does not seem to be declining, however, is the incidence of procedure-related major stroke. Thus, in the first year of their experience, the major stroke rate was 1%; the rate was 1.2% in their fifth year. This issue is one of substantial concern given the grave consequences of major stroke, the low rate observed with alternative therapy, and recognition that avoidance of stroke...

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“…found that patients ≥80 years old had a 16% stroke rate in comparison to 5.4% in young patients, and thought that old age (≥80)had a negative influence on periprocedural adverse events Roubin et al. (2001). The lead‐in phase of the CREST trial showed that the periprocedural risk of stroke and death after CAS increased with age and was 12.1% in patients aged over 80, significantly above the rates for patients aged 70–79 (5.3%), 60–69 (1.3%), and less than 60 (1.7%) (Hobson et al., 2004).…”

Section: Discussionmentioning

confidence: 99%

“…These results suggest that after the periprocedural period, the majority of elderly patients are free from cerebrovascular complications. These results are also concordant with a previous large registry data, which demonstrated that, in patients who survive the periprocedural period, freedom from fatal and nonfatal ipsilateral stroke was 99% at 3 years (Roubin et al., 2001). In our study, we explain the lower rates of stroke and death by the fact that we excluded patients with significant medical comorbidities such as abnormal creatine clearance, hemoglobin level and cancer, and by the frequent follow‐ups we conducted to ensure no new conditions arose.…”

Section: Discussionmentioning

confidence: 99%

Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

Duan

Dai

et al. 2017

Brain and Behavior

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BackgroundMultiple studies suggest that internal carotid artery stenting can be performed safely in octogenarians with low periprocedural complication rates. However, great concern still exists as to whether these patients will gain long‐term benefits from this procedure given their advanced age and uncertain life expectancy. We decided to conduct a retrospective study to determine short‐and long‐term clinical outcomes and to analyze survival duration in this population.Methods and ResultsSixty‐nine consecutive elderly patients with either symptomatic or asymptomatic stenosis ≥70% underwent 86 procedures. Immediate and late outcomes, as well as survival data, were analyzed retrospectively. Mean age was 83.1 ± 2.7 years. Mean survival was 49.3 ± 10.1 months. A complete neurological assessment was obtained at 1 and 2 years in 100% of patients, at 3 years in 90.7% of patients and at 5 years in 84.8% of patients. Two major and one minor ischemic strokes occurred during the periprocedural period. No death, myocardial infarction or intracranial hemorrhage was recorded. The mean follow‐up period was 55.4 ± 24.6 months. Four patients experienced a minimum of 1 year of follow‐up, and the longest is 8 years. Among the patients with the longest follow‐up time, 6 had ischemic strokes, of which 2 were fatal. In total, 17 deaths occurred. Four patients experienced dementia without stroke. Survival at 3 and 5 years was estimated to be 90% and 73%, respectively.ConclusionThis study demonstrated that stenting in octogenarians was safe and effective during the periprocedural period. Long‐term follow‐up showed a low rate of fatal and nonfatal stroke, and patients survived long enough to benefit from the procedure. However, it was associated with a relatively high rate of long‐term event. Though carotid artery stenting is a minimally invasive procedure, it should still be performed with great caution and only in carefully selected patients. The present study suggested that in this age population, carotid artery stenting might be considered as a revascularization option.

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Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis

Cited by 626 publications

References 29 publications

Estenose de carótida extracraniana

Estenose de carótida extracraniana

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Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

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