Outcome Evaluation of Carotid Stenting in High-Risk Patients with Symptomatic Carotid near Occlusion

Abstract

<jats:p> Management of symptomatic carotid near occlusion especially in high-risk patients is different from outcome analysis of NASCET. We evaluated outcome in high-risk patients with symptomatic near occlusion. </jats:p><jats:p> For 48 patients with near occlusion out of 166 symptomatic high-risk patients who underwent carotid stenting, we assessed the procedural success defined as residual stenosis &lt;30%, modified Rankin Scale (mRS) at one and six months following stenting, and the 13 cerebrovascular factors related to the outcome. Initial National Institutes of Health Stroke Scale (NIHSS) ≥4, 1–3 and 0 were 13, 14 and 21 patients each. We compared the outcome with patients who underwent CAS (n=118) due to symptomatic stenosis without near occlusion during the same period. </jats:p><jats:p> Our procedural success rate was 98%. A good outcome (mRS ≤2) was achieved in 44 patients (92%) at six months. There were five events (10%) within six months, i.e. three minor strokes, one major stroke caused by hemorrhage, and one death excluding two deaths not related to stroke. Hyperperfusion (n=4) was the most common cause of events leading to two minor strokes and a major stroke. Although initial NIHSS (P = .012) was related to poor outcome (mRS &gt;2) compared to the CAS group, there was no statistical significance between two groups in the event rate of stroke, death or restenosis. </jats:p><jats:p> The outcome of carotid stenting in high-risk patients with symptomatic near occlusion did not reveal any difference compared with CAS. Poor outcome was related to the initial NIHSS (≥4). Hyperperfusion tended to be more commonly related to an event occurring after stenting. </jats:p>

Carotid Near-Occlusion: A Comprehensive Review, Part 1—Definition, Terminology, and Diagnosis

“…Those who recognized near-occlusion as with and without full collapse have often used with and without the "string sign" to describe this. 2,7,22,24,26 Near-Occlusion. "Nearly occluded" was used by Gabrielsen et al 31 in 1981 to describe a tight carotid stenoses with distal collapse.…”

Carotid Near-Occlusion: A Comprehensive Review, Part 2—Prognosis and Treatment, Pathophysiology, Confusions, and Areas for Improvement

“…15 Some studies included measurements of intracerebral hemodynamics, without analyzing them in detail. [16][17][18][19] • Near-occlusion with full collapse (diagnosed with low-flow velocities on sonography) and high-grade stenosis cause similar infarction patterns with approximately half of patients having infarctions in watershed areas, though occlusions often have large territorial infarctions. 20 • Some near-occlusions looked similar to conventional stenoses histologically, whereas some were actually recanalized thrombotic occlusions.…”

Carotid Baroreceptor Reaction after Stenting in 2 Locations of Carotid Bulb Lesions of Different Embryologic Origin

“…8 Therefore, our study suggests that different hemodynamics operate in each of the carotid bulb lesion locations, and we recommend careful consideration of the possible variations in hemodynamic responses after stent placement. 3,17,21,35 There are several limitations to our study. First, although we demonstrated carotid BR differences according to carotid body lesion location and a tendency of AE difference, a larger cohort may reveal a significant difference between event rate and the location of carotid bulb lesion.…”

“…The carotid stent placement procedure used in this study was the same as that previously described. 17,[21][22][23] Wallstents (Boston Scientific, Natick, Massachusetts) were used in 45 patients; Precise stents (Cordis, Miami Lakes, Florida), in 43; and Protégé stents (ev3, Irvine, California), in 7. Protection devices were used in 92 patients (97%).…”