Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study

Abstract

Background and Purpose— Open-cell carotid artery stents are associated with a higher peri-procedural stroke risk than closed-cell stents. However, the effect of stent design on long-term durability of carotid artery stenting (CAS) is unknown. We compared the medium- to long-term risk of restenosis and ipsilateral stroke between patients treated with open-cell stents versus closed-cell stents in the ICSS (International Carotid Stenting Study). Methods— Patients with symptomatic carotid stenosis were randomized to CAS or endarterectomy and followed with duplex ultrasound for a median of 4.0 years. We analyzed data from patients with completed CAS procedures, known stent design, and available ultrasound follow-up. The primary outcome, moderate or higher restenosis (≥50%) was defined as a peak systolic velocity of >1.3 m/s on ultrasound or occlusion of the treated internal carotid artery and analyzed with interval-censored models. Results— Eight hundred fifty-five patients were allocated to CAS. Seven hundred fourteen patients with completed CAS and known stent design were included in the current analysis. Of these, 352 were treated with open-cell and 362 with closed-cell stents. Moderate or higher restenosis occurred significantly less frequently in patients treated with open-cell (n=113) than closed-cell stents (n=154; 5-year risks were 35.5% versus 46.0%; unadjusted hazard ratio, 0.68; 95% CI, 0.53–0.88). There was no significant difference in the risk of severe restenosis (≥70%) after open-cell stenting (n=27) versus closed-cell stenting (n=43; 5-year risks, 8.6% versus 12.7%; unadjusted hazard ratio, 0.63; 95% CI, 0.37–1.05). The risk of ipsilateral stroke beyond 30 days after treatment was similar with open-cell and closed-cell stents (hazard ratio, 0.78; 95% CI, 0.35–1.75). Conclusions— Moderate or higher restenosis after CAS occurred less frequently in patients treated with open-cell stents than closed-cell stents. However, both stent designs were equally effective at preventing recurrent stroke during follow-up. Clinical Trial Registration— URL: http://www.isrctn.com/ . Unique identifier: ISRCTN25337470.

Risk Factors for Residual Stenosis After Carotid Artery Stenting

“…On the contrary, closed-cell stents have tighter meshes, which may provide better coverage of the atheromatous lesion but are consequently more rigid. A recent study found that, compared with open-cell stents, the more rigid and more densely packed material in closed-cell stents might lead to greater irritation of the vessel wall, which in turn might stimulate neointima hyperplasia and result in a higher occurrence of restenosis (18). In this study, we found that the incidence of residual stenosis was higher for closed-cell stents than for open-cell stents, and different stent lengths did not influence residual stenosis.…”

“…CDU was performed within 1 week before and after CAS, and patients were followed-up for different periods (3,6,12,18,24, and 36 months) after CAS. The evaluation and detection of CDU was based on the vascular ultrasonography guidelines published by the Chinese Medical Doctor Association of Ultrasonography (9).…”

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

“…In the literature, anatomical and technical risk factors for restenosis include the number of stents deployed, the presence of large and calcified plaques, and the existence of residual stenosis after the procedure or even the stent design used, to the detriment of stiffer stents with small cell sizes, but moderate radial force, such as WALLSTENT (Boston Scientific Corporation, Natick, MA, USA) [ 29 , 30 ]. Dyslipidemia, statin therapy, female sex, and smoking were associated with CAS restenosis as well [ 31 , 32 ].…”

Carotid endarterectomy with stent removal for recurring in-stent restenosis: A case report and literature review

“…[ 5 ] Reported risk factors for ISR after CAS include aging,[ 1 , 6 , 8 , 12 ] smoking,[ 2 , 23 ] diabetes mellitus and dyslipidemia,[ 14 , 23 ] women,[ 12 , 14 , 23 ] hostile neck,[ 5 ] and prior neck cancer. [ 22 ] Stent-related factors, such as the diameter,[ 24 ] length,[ 16 ] type of stents (closed or open cell stent),[ 16 - 18 ] and multiple stent use,[ 12 ] are also possible risk factors for ISR after CAS.…”