Long-Term Results of Carotid Artery Stents to Manage Symptomatic Carotid Artery Stenosis and Factors That Affect Outcome

Abstract

Background-Limited data are available about the long-term outcomes of the use of carotid artery stents in symptomatic patients and the impact of patient variables on the durability of endovascular carotid procedures. Outcome data previously reported from registry series mix symptomatic and asymptomatic patients. We present analysis of long-term follow-up, with independent neurological assessment, for patients with symptomatic high-grade carotid lesions undergoing stenting to identify patients at risk of recurrence. Methods and Results-Prospectively collected data on 563 carotid stenting procedures in a single center were analyzed.Univariate and multivariate techniques were used to identify risk groups and beneficial technical adaptations. Ipsilateral stroke rates for all patients were 4.8%, 7.0%, and 9.5% at 30 days, 1 year, and 4 years, respectively. The rates improved to 2.7%, 4.1%, and 4.5% when patients were treated with optimal therapy. Retinal events had a lower risk of long-term recurrent ipsilateral stroke (hazard ratioϭ0.228, CIϭ0.082 to 0.632, Pϭ0.004) than cerebral events. A recurrent or residual stenosis of Ͼ50% had a statistically significant effect on long-term stroke recurrence in multivariate analysis (hazard ratioϭ2.187, CIϭ1.173 to 4.078, Pϭ0.014). Conclusions-Patients with retinal presentations are a lower risk group to treat. Residual stenosis or restenosis Ͼ50%has a statistically significant trend to an increased risk of recurrence for ipsilateral stroke in the long term in this population. In our patients, a combination of procedural modifications and pharmacological changes seems to improve outcomes. (Circ Cardiovasc Interv. 2010;3:50-56.)

Clinical impact and predictors of carotid artery in-stent restenosis

“…This is in line with previous studies and may be due to heavily calcified plaques, which made it difficult to establish an appropriate stent positioning without residual narrowing [13, 14]. Interestingly, in a study with 563 patients, Randall et al found that a residual stenosis of >50% after CAS is associated with an increased risk of ipsilateral stroke in the long run [15]. Therefore, pursuing an optimal stent deployment during CAS seems to be a worthwhile aim, although it is known that an aggressive postdilation bears the risk of distal embolization.…”

Outcomes After Carotid Artery Stenting in Medicare Beneficiaries, 2005 to 2009

“…We selected subgroups based on factors shown to affect CAS performance in the literature or based on clinical knowledge. These factors included the following: sex (male or female), symptomatic status, [15][16][17][18][19][20] race (white or not white), type of CAS procedure (elective or nonelective), 14 age (66-69, 70-74, 75-79, or ≥80 years), 12,14,15,17,19,33 clinical trial enrollment status (enrolled or not enrolled), 16 and National Coverage Determination indication (high surgical risk with symptomatic carotid Median (IQR) 11 (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) No. of past-year nursing home visits…”

“…To our knowledge, outcomes during and beyond the periprocedural period have not been described in real-world, contemporary Medicare populations. Also, little is known about the significance of patient characteristics, clinical indications, carotid stenosis characteristics, and center characteristics outside of the RCT setting 4,[7][8][9][10][11][12] or small prospective registry or single-center or dual-center studies [13][14][15][16] or how these characteristics affect CAS performance beyond the periprocedural period. 8, 10,[13][14][15][17][18][19][20] The objective of this study was to describe the incidence of outcomes overall and among subgroups of Medicare beneficiaries undergoing CAS.…”

Relationship Between Physician and Hospital Procedure Volume and Mortality After Carotid Artery Stenting Among Medicare Beneficiaries

“…One of the major strengths of this study is that we were able to evaluate and adjust for important clinical and procedural factors, such as high surgical risk status 31 and symptomatic status, 32 which have been associated with poor outcomes after CAS. In using mortality as the outcome, we selected the hardest and most reliable end point.…”