Stent Angioplasty for Cervical Carotid Artery Stenosis in High-Risk Symptomatic NASCET-Ineligible Patients

Abstract

Background and Purpose —Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) has shown carotid endarterectomy (CEA) to be protective compared with medical therapy alone, its stringent eligibility criteria excluded patients with severe medical, angiographic, and neurological risk factors. We sought to determine the safety and efficacy of stent angioplasty in this high-risk subset for whom the perioperative morbidity and mortality of surgery are elevated. Methods —Twenty-eight consecutive symptomatic NASCET-ineligible patients (10 female; median age, 72.2 years) underwent microcatheter-based carotid stent angioplasty. Half of the patients had sustained a previous stroke. Classification of surgical risk by Sundt criteria yielded no patients in grade 1, 3 patients in grade 2 (10.7%), 8 in grade 3 (28.6%), and 17 (60.7%) in grade 4. Stratification of stroke risk for medical therapy according to the European Carotid Surgery Trial (ECST) 5-point score showed 8 patients with a score of 3 (28.6%), 12 with 4 (42.8%), and 8 with 5 (28.6%). Follow-up was obtained in all patients at a median of 14 months. Results —The procedure was technically successful in all cases (100%), with immediate stenosis reduction from a mean of 80.3% to 2.7%. There were no periprocedural deaths, 1 major stroke (3.6%), no minor strokes, and 3 transient ischemic attacks (10.7%). In-hospital complications included 2 nonfatal myocardial infarctions, 1 case of acute renal failure, and 1 groin hematoma requiring transfusion. There were 5 deaths during the follow-up period, all beyond 30 days after the procedure: 3 from cardiac causes, 1 from lung cancer, and 1 following unrelated surgery. The patient with major stroke died at 7.8 months during rehabilitation. No surviving patients had further strokes, and all except 1 (95.5%) remained asymptomatic. Anatomic follow-up in 20 patients showed occlusion in 2 (10%) (1 symptomatic, 1 asymptomatic) and intimal hyperplasia in 3 asymptomatic patients (15%). Conclusions —The clinical results and sustained freedom from symptoms and stroke during the short available follow-up period suggest that stent angioplasty may be useful in the treatment of symptomatic cervical carotid stenosis in high-risk patients despite a notable incidence of restenosis.

Reporting Standards for Carotid Artery Angioplasty and Stent Placement

“…This excludes the other studies that represented very-high-risk cohorts. 98,99,[102][103][104][105] Similar favorable results were reported by Al-Mubarak et al, who reported on 51 consecutive patients undergoing simultaneous or staged carotid artery stenting and percutaneous coronary intervention. Technical success was achieved in all carotid arteries, with a minor stroke rate of 4% and no major strokes, myocardial infarctions, or deaths.…”

Long-Term Results of Elective Stenting for Severe Carotid Artery Stenosis in Taiwan

“…Surgical endarterectomy has been shown to be superior to medical treatment in severe stenosis, but carries a substantial peri-procedural death and stroke rate of 2–7% even in highly selected patients [1, 2, 3]. Transcatheter endovascular stenting may be a safe and effective alternative to endarterectomy [4], especially in patients at high surgical risk [5, 6]. In Taiwan, the incidence of carotid stenosis in patients with cortical infarction is reported to be 32% [7], and hereafter we report our series of consecutive endovascular carotid interventions in this pure ethnic Chinese population.…”

Early Outcome of Carotid Angioplasty and Stenting versus Carotid Endarterectomy in a Single Academic Center

“…While the heterogeneity of patient populations might hamper the comparability of data across various institutions, we classified patients with respect to their surgical risk on the basis of an established scoring system [12]. Since both surgical and non-surgical groups contained patients with multiple comorbid conditions and elevated periprocedural risks (modified Sundt grades 3–4) and no significant differences between the complication rates in these groups were found the common practice of preferentially submitting high-risk patients to CAS might not be justified [18, 19, 20]. In the group of surgical patients there were no instances of myocardial infarction or respiratory complications, suggesting that surgical patients do not have a higher rate of non-neurological complications than might be expected when undergoing anesthesia for a major operation.…”