Target lesion ulceration and arch calcification are associated with increased incidence of carotid stenting-associated ischemic lesions in octogenarians

Chisci

et al. 2010

Stroke

103

Background and Purpose-Carotid artery stenting (CAS) still entails a considerable peri-interventional risk of serious neurological adverse events. The aim of this study was to generate a score to grade this risk for CAS in individual patients. Methods-This is a 9-year prospective study. Consecutive patients with Ն70% carotid artery stenosis were treated with a standardized CAS procedure. All patients included underwent independent neurological evaluation before and after the procedure and at 30 days. The rates of transient ischemic attack and minor, major, and fatal stroke were recorded. Stroke predictors were analyzed and a score system was generated using Arabic numerals for all variables to preoperatively grade the individual patient risk of stroke. Results-Two thousand one-hundred twenty-four successful CAS procedures were performed. The transient ischemic attack and minor, major, and fatal stroke rates at 30 days were, respectively, 2.72% (nϭ60), 1.55% (nϭ33), 1.18% (nϭ25), and 0.61% (nϭ13). Multiple regression analysis showed that the following significantly predicted the 30-day risk of treatment-related stroke: cardiac disease, symptomatic patient, diabetes, calcification or ulceration at the level of the lesion, native and ostial lesion, lesion length Ͼ15 mm, the need for predilatation, type III arch, bovine arch, arch calcification, procedure time Ͼ30 minutes, and the operator's experience of Ͻ50 CAS procedures. The operator's experience of Ͼ100 CAS procedures was the only protective factor against the development of stroke at 30 days (odds ratio, 0.81; confidence interval, 0.67-0.95). The Siena CAS score was developed from these variables and predicted the risk of CAS within the 3 categories of low risk (Ͻ1%; CAS I), medium risk (1% to 3%; CAS II), and high risk (Ͼ3%; CAS III), with a sensitivity of 0.82 and specificity of 0.79. Conclusions-The Siena CAS risk score seems to be a useful tool to help predict stroke after CAS but needs to be validated in independent cohorts at a variety of centers before it can be recommended for application, preferably in a randomized comparison with carotid endarterectomy. (Stroke. 2010;41:1259-1265.)

Section: Discussioncontrasting

confidence: 71%

Siena Carotid Artery Stenting Score

Chisci

et al. 2010

Stroke

103

Circ: Cardiovascular Quality and Outcomes

“…This finding is consistent with that of a recent meta-analysis of outcomes after stenting and endarterectomy in elderly patients 34 and may be explained by the increased calcification and tortuosity of the supra-aortic branches in older patients. [35][36][37] Although the results of CREST suggest a possible benefit with stenting in patients aged <70 years old, 10 no difference in stroke rate was observed in younger patients when data were pooled across trials. 3 Some trials have also suggested that treatment effects may differ in men and women, 11,38,39 and there is currently no consensus for management of carotid stenosis in women.…”

Section: Discussionmentioning

confidence: 99%

Meta-Analysis of Randomized Controlled Trials Comparing the Long-Term Outcomes of Carotid Artery Stenting Versus Endarterectomy

Vincent

Eberg

Eisenberg

et al. 2015

Carotid artery stenting was developed as an alternative to endarterectomy for the management of patients with carotid stenosis in the 1990s. With the assumption that an endovascular approach would offer a more favorable safety profile than an open surgical procedure, the use of stenting increased significantly 1 after its entry into the market. In the United States, the use of stenting increased from 3% of patients undergoing carotid artery revascularization procedures in 1998 to 13% in 2008. 2 Despite this observed increase in utilization, the long-term safety and efficacy of stenting relative to endarterectomy remain unclear. Current guidelines recommend endarterectomy as first-line treatment for most patients with symptomatic carotid stenosis of 50% to 99%, and a perioperative risk of stroke or death that is <6%.3 With long-term results from randomized controlled trials (RCTs) now available, we addressed this issue via a meta-analysis of RCTs that compared the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes. MethodsOur meta-analysis followed a prespecified protocol and is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 4 Search StrategyWe performed a systematic search of PubMed, EMBASE, MEDLINE, and the Cochrane Library Register of Controlled Trials online databases, from inception to October 22, 2014, for all RCTs that compared stenting with endarterectomy and reported periprocedural or long-term outcomes. We used Medical Subject Heading (MeSH) terms in PubMed and MEDLINE, EMTREE terms in EMBASE, and keyword search terms for carotid stenosis, stenting, carotid, and carotid endarterectomy in all 4 databases (Appendices I-IV in the Data Supplement). In PubMed, MEDLINE, and EMBASE, we then Background-Stenting is an endovascular alternative to endarterectomy for the management of carotid stenosis, but its long-term safety and efficacy relative to endarterectomy remain unclear. Our objective was to compare the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes, via meta-analysis of randomized controlled trials (RCTs). Methods and Results-We systematically searched PubMed, EMBASE, MEDLINE, and the Cochrane Library for RCTs with ≥50 patients that compared stenting with endarterectomy in patients with carotid stenosis. Periprocedural and longterm outcomes were assessed, with data pooled across RCTs using random-effects models. Eight RCTs were included in our meta-analysis (n=7091), with follow-up ranging from 2.0 to 10.0 years. When compared with endarterectomy, stenting was associated with an increased risk of periprocedural stroke (relative risk, 1.49, 95% confidence interval [CI], 1.11 to 2.01; risk difference, 1.7%; 95% CI, 0.3 to 3.0) but a decreased risk of periprocedural myocardial infarction (relative risk, 0.47; 95% CI, 0.29 to 0.78; risk difference, −0.4%; 95% CI, −0.8% to 0.1%). During long-term follow-up, stenting was associa...

Journal of Endovascular Therapy

“…Moreover, the aging population has presented new treatment challenges. [18][19][20][21][22][23][24] In particular, recent data suggest that octogenarians are at particularly high risk for CAS, 20,23,24 though various single-center experiences have reported the safety of CAS in this subgroup. 19,21,21,25,26 In this report of the 4-year outcomes of the CaRESS trial, we examine the CMS coverage guidelines for CAS in a series of subgroup analyses that stratify this large, broad-risk patient cohort by risk status, symptomatology, stenosis grade, and age .80 years.…”

Section: ¤ ¤mentioning

confidence: 99%

Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS):4-Year Outcomes

Zarins

White

Diethrich

et al. 2009

¤ ¤Purpose: To examine the 4-year outcomes from Carotid Revascularization using Endarterectomy or Stenting Systems (CaRESS) in light of the current reimbursement guidelines for carotid artery stenting (CAS) from the Centers for Medicare and Medicaid Services (CMS).Methods: CaRESS was designed as a prospective, nonrandomized comparative cohort study of a broad-risk population of symptomatic and asymptomatic patients with carotid stenosis. In all, 397 patients (247 men; mean age 71 years, range 43-89) were enrolled and underwent carotid endarterectomy (CEA; n5254) or protected CAS (n5143). More than 90% of patients had .75% stenosis; two thirds were asymptomatic. The primary endpoints included (1) all-cause mortality, (2) any stroke, and (3) myocardial infarction (MI), as well as the composite endpoints of (4) death and any nonfatal stroke and (5) death, nonfatal stroke, and MI. The secondary endpoints were restenosis, repeat angiography, and carotid revascularization. All patients were classified with respect to surgical risk, symptom status, and stenosis grade based on criteria published by the CMS. In addition, separate analyses were performed comparing genders and octogenarians to those ,80 years old.Results: No significant differences in the primary outcome measures were found between the CEA and CAS groups in the 4-year analysis. The incidences of any stroke at 4 years were 9.6% for CEA and 8.6% for CAS (p50.444); when combined with death, the composite death/nonfatal stroke rates were 26.5% for CEA versus 21.8% for CAS (p50.361). The composite endpoint of death, nonfatal stroke, and MI at 4 years was 27.0% in CEA versus 21.7% in CAS (p50.273) patients. The secondary endpoints of restenosis (p50.014) and repeat angiography (p50.052) were higher in the CAS arm. There were no differences in any of the subgroups stratified according the CMS guidelines or in the gender comparison. Four-year incidences of death/nonfatal stroke and death/nonfatal stroke/MI were higher in the CEA arm among patients ,80 years of age (p50.049 and p50.030, respectively). There were no significant differences between these incidences in the octogenarian subgroup.