Elective Carotid Artery Stenting in the Presence of Contralateral Occlusion

doi:10.1016/S0002-9149(98)00161-1

The American Journal of Cardiology

Volume 81, Issue 11, 1 June 1998, Pages 1315-1317

https://doi.org/10.1016/S0002-9149(98)00161-1 Get rights and content

Abstract

Significant carotid stenosis in the presence of an occluded contralateral artery has a poor prognosis with medical therapy alone. Carotid cross clamping during surgical endarterectomy results in critical flow reductions in patients with inadequate collateral flow, and represents a significant risk for procedural strokes. Carotid stenting is being evaluated as an alternative to endarterectomy. We describe the immediate and late outcome of a series of 26 patients treated with carotid stenting in the presence of contralateral carotid occlusion. The mean age of the patients in this group was 65 ± 9 years, 23 (89%) were men and 10 (39%) were symptomatic from the vessel treated. The procedural success of carotid stenting in this group of patients was 96%. The mean diameter stenosis was reduced from 76 ± 15% to 2.8 ± 5%. There was 1 (3.8%) minor stroke in a patient who developed air embolism during baseline angiography. At late follow-up there was no neurologic event in any patient at a mean of 16 ± 9.5 months after the procedure. Thus, carotid stenting of lesions with contralateral occlusion can be performed successfully with a low incidence of procedural neurologic complications and late stroke.

Section snippets

Patient population

Between September 1994 and January 1997, 231 patients underwent elective stenting of the extracranial carotid arteries at the University of Alabama at Birmingham Hospital. Symptomatic and asymptomatic patients with >60% stenosis involving the extracranial carotid arteries were included in a protocol approved by the institutional review board. Of these, a subgroup of 26 patients who had occlusion of the contralateral carotid artery at the time of procedure form the basis of the present analysis.

Carotid stenting protocol

Results

The 26 patients who underwent carotid stenting in the presence of contralateral carotid artery occlusion had a mean age of 64.5 ± 8.6 years: 23 (89%) were men, 21 (81%) had significant coronary artery disease, 20 (77%) were hypertensive, 10 (39%) had diabetes mellitus, and 19 (73%) had hyperlipidemia. Eleven lesions (42%) were restenotic after prior carotid endarterectomy and 10 (39%) lesions had been symptomatic within the last 120 days.

The angiographic characteristics and procedural results

Discussion

Patients with bilateral carotid artery disease in which 1 artery is totally occluded have a poor prognosis with medical therapy alone.1., 2. The increased long-term stroke risk in medically treated patients with an occluded artery is related to the inadequacy of collateral circulation, from both the circle of Willis and the leptomeningeal vessels.15 Surgical revascularization of the carotid arteries is an accepted modality for treating atherosclerotic obstructive disease.7., 16., 17., 18.

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There are more references available in the full text version of this article.

Cited by (60)

Three-Year Clinical Results of Carotid Artery Stenting in Treating Patients with Contralateral Carotid Artery Occlusion
2018, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Mercado et al reviewed the data from Carotid Artery Revascularization and Endarterectomy (CARE) registry, and found that the rate of composite in-hospital events, including death, nonfatal myocardial infarction, and nonfatal stroke, did not differ between patients with and without a CCO after CAS.12 Some other studies reported similar results, stating that the safety and clinical efficacy of CAS in patients with CCO have been evaluated.13-16 To our knowledge, these previous studies only involved in-hospital or short-term results, and in contrast, our work represents the longest follow-up period to date appraising outcomes of patients with CCO receiving CAS.
Patients presenting a carotid stenosis and contralateral carotid occlusion (CCO) have been historically considered at high risk of carotid surgical treatment, and there are few data regarding short-term recovery after stenting therapy in patients with CCO. The aim of this study is to evaluate the short-term recovery and safety of stenting for patients with CCO and different subgroup population.
We retrospectively reviewed the records of consecutive patients with CCO who were treated with stenting endovascular methods between 2008 and 2014. The postoperative outcomes were analyzed according to age, ischemic symptom, cerebral infarction history, and collateral situation subgroups, respectively.
Fifty-eight consecutive patients with CCO were treated and 49 (84.5%) completed a 3-year follow-up. There were significant higher stroke, myocardial infarction, or death events in the aged (≥75 years old) group and poor collateral group (P = .007 and .0024, respectively). There was no difference in the 3-year primary endpoint incidence between the cerebral ischemia symptom subgroups and cerebral infarction history subgroups. Event-free survival, aged group, and poor collateral group were lower (P = .007 and P = .0024, respectively).
Carotid artery stenting (CAS) for patients with common carotid artery is a safe and effective therapy. Factors such as age 75 years or older and poor collateral are associated with a higher 3-year rate of postprocedural stroke, myocardial infarction and death, and lower event-free survival in patients with CCO treated by CAS. Meanwhile, our data do not show a significant impact of cerebral ischemic symptom and cerebral infarction history on clinical outcome of patients with CCO undergoing CAS.
Contralateral carotid occlusion in endovascular and surgical carotid revascularization: A single centre experience with literature review and meta-analysis
2013, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
The inter-study bias evaluation of patients who have undergone CEA with and with CCO was performed by the funnel plot analysis, which showed a good level of symmetry. Six studies met the inclusion criteria.15,16,38–41 All of these studies were retrospective studies, with one being a national (German) registry38 and five being single-centre experiences.15,16,31–41
The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO.
All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect.
Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs (p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7–14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57–2.11]; OR: 1.22 [0.60–2.49], respectively).
CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.
Carotid artery stenting of a contralateral occlusion and in-hospital outcomes: Results from the CARE (Carotid Artery Revascularization and Endarterectomy) registry
2013, JACC: Cardiovascular Interventions
The authors sought to study the characteristics and outcomes of patients with contralateral carotid artery occlusions (CCOs) undergoing elective carotid artery stenting (CAS).
CCOs are associated with adverse neurological events following carotid endarterectomy.
In-hospital outcomes were examined in patients with and without CCO undergoing elective CAS in the Carotid Artery Revascularization and Endarterectomy (CARE) registry. A CCO was defined as a 100% occlusion of the contralateral internal carotid artery. To minimize differences in measured comorbidities, a 3:1 propensity matching analysis was performed comparing 42 clinical and demographic variables between CCO and non-CCO patients from the CARE registry. The primary endpoint was a composite of in-hospital death, nonfatal myocardial infarction, and nonfatal stroke.
Between April 2005 and January 2012, 13,993 eligible patients underwent elective CAS, of whom 1,450 (10%) had CCO. There were 5,500 CAS procedures (1,375 CCO and 4,125 non-CCO) identified in the propensity analysis. The primary composite endpoint occurred in 29 (2.1%) and 107 (2.6%) patients with and without CCO, respectively (adjusted odds ratio: 0.81, 95% confidence interval: 0.53 to 1.23, p = 0.316).
In the CARE registry, there was no evidence that the presence of a CCO was associated with an increased risk of in-hospital death, nonfatal myocardial infarction, or nonfatal stroke in patients undergoing elective CAS. These findings may have implications on the selection of carotid revascularization procedures for such patients.
Influence of the contralateral carotid artery on carotid surgery outcome
2012, Annals of Vascular Surgery
Any obstacle in the contralateral artery has long been considered a high risk for carotid surgery. Here, we report the results of a monocentric, continuous, consecutive, prospective series and present a review of the literature.
All carotid endarterectomies performed under locoregional anesthesia in our department between 2003 and 2010 were recorded in a prospective database (n = 1,212). Different statuses of the contralateral carotid artery—occlusion (group O, n = 81) and stenosis of >60% (group S, n = 173)—were compared with a control group (group C, n = 958). A shunt was used in cases of clinical intolerance to clamping. The assessment criteria concerned the need for a shunt and the combined 30-day nonfatal stroke and death rate. A stepwise logistic regression was performed.
Overall, a shunt was necessary in 7.3% of cases. The proportion was greater in group O (25.9%, P < 0.001). Severe renal insufficiency (odds ratio [OR] = 1.94) and contralateral carotid occlusion (OR = 5.53) were the sole factors predicting the need for shunting. The overall 30-day nonfatal stroke and death rate was 2.5%, with no difference between groups (P = 0.738), and severe renal insufficiency was the single predictor of a poor outcome (OR = 3.11; 95% confidence interval: 1.21–7.97; P = 0.18).
In this series, and in a large review of literature, occlusion of the contralateral internal carotid artery increased the incidence of intolerance to clamping and thus the use of shunts but did not worsen postoperative morbidity and mortality. The presence of a stenosed contralateral carotid was not predictive of postoperative events. In our experience, the status of the contralateral carotid artery cannot be considered a high risk for carotid surgery.
Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes?
2012, Annals of Vascular Surgery
Citation Excerpt :
Interestingly, a preexisting contralateral carotid occlusion has been designated a “high-risk” inclusion criterion for many CAS trials and registries. In 1998, Mathur et al. reported their series of 26 patients presenting with a contralateral occlusion who underwent CAS with low incidence of procedural neurologic complications and late stroke.8 Although a small series, this report initiated a more thorough investigation of the impact of a contralateral occlusion on CAS outcomes.
Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood.
A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years).
Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant).
A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.
Effectiveness and Safety of Carotid Artery Stenting for Significant Carotid Stenosis in Patients With Contralateral Occlusion (from the German ALKK-CAS Registry Experience)
2009, American Journal of Cardiology
Citation Excerpt :
Few studies have evaluated the role of CAS in patients with contralateral carotid occlusion.16–20 The studies that included >10 patients are summarized in Table 6.16–20 However, the designs of these studies varied widely, all were retrospective, almost all were a single-center analysis, with the exception of 1,19 and most had no comparison group.
Data on the safety of carotid artery stenting (CAS) in a large number of unselected patients with contralateral occlusion and significant ipsilateral stenosis are less known. Accordingly, we evaluated 3,137 patients undergoing CAS who were enrolled in a German Registry from 2000 to 2008 and compared the clinical features and in-hospital outcomes of those with and without contralateral carotid occlusion. Contralateral carotid occlusion was present in 191 patients (6.1%) undergoing CAS. Despite the similar age of the patients with and without contralateral carotid occlusion, those with contralateral occlusion had a greater prevalence of co-morbidities, complex carotid stenosis, and greater number of focal neurologic lesions on the contralateral side. The incidence of in-hospital events, including death (1.0% vs 0.5%), ipsilateral major stroke (1.1% vs 1.1%), death or major ipsilateral stroke (1.6% vs 1.4%), ipsilateral transient ischemic attack (2.7% vs 2.5%), myocardial infarction (0.0% vs 0.1%), and reintervention (0.5% vs 1.1%), was low and was not significantly different between those with and without contralateral occlusion (p >0.05 for all comparisons). Among patients with carotid occlusion, major ipsilateral stroke (2.2%), death (2.2%), and a combination of these 2 events (3.3%) were observed exclusively in symptomatic patients with no event in asymptomatic patients. In conclusion, our data from a large number of patients undergoing CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events among patients with contralateral carotid occlusion supporting CAS as an attractive option for the treatment of these patients.

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MiscellaneousElective Carotid Artery Stenting in the Presence of Contralateral Occlusion

Abstract

Section snippets

Patient population

Carotid stenting protocol

Results

Discussion

Mayo Clin Proc

J Vasc Surg

J Vasc Surg

Joint study of extracranial arterial occlusion X Internal carotid artery occlusion

JAMA

Unilateral internal carotid artery occlusionspecial considerations

Stroke

Beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis

N Engl J Med

Stent placement in supra-aortic artery disease

Percutaneous transluminal angioplasty of supra-aortic arteries especially the internal carotid artery

Neuroradiology

Miscellaneous
Elective Carotid Artery Stenting in the Presence of Contralateral Occlusion