Evolving indications for and early results of carotid artery stenting

doi:10.1016/S0002-9610(97)90065-9

The American Journal of Surgery

Volume 174, Issue 2, August 1997, Pages 111-114

https://doi.org/10.1016/S0002-9610(97)90065-9 Get rights and content

Background: While carotid endarterectomy continues to be the gold standard of treatment for most patients with significant carotid artery disease, there are cases where lesion or anatomy-related factors create situations less than ideal for conventional surgery. Other therapeutic modalities, such as endoluminal stenting, may represent reasonable options for such patients.

Methods: Thirty-three patients with 70% or greater internal carotid artery lesions were treated by endovascular stent placement from July 1994 through June 1996. Indications included transient ischemic attacks in 20 and previous stroke in 4; and 9 were asymptomatic.

Result: Stents were placed successfully in all instances. Mortality and stroke rates were zero. All patients remained asymptomatic during follow-up (mean 8 months), and stent patency by duplex ultrasound has been 100%. A single instance of intrastent restenosis has been observed.

Conclusions: Endoluminal stenting is an investigational technique of unproven efficacy and longterm durability. Yet it appears technically feasible, and possibly reasonable, as an alternate option for cases unfavorable for standard surgery.

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Reporting Standards for Carotid Artery Angioplasty and Stent Placement
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Despite the fact that it is unknown whether these benefits apply to the carotid circulation, endovascular carotid revascularization is now most commonly performed with stents. Since 1996, there have been 11 large carotid stent series published in which the total number of patients is 1311 (71,91–101) (Table 3). Comparative analysis of these reports is made difficult by inconsistencies in the sample populations, lesion characteristics, endovascular techniques, and outcome data.
Endarterectomy or carotid artery stenting: the quest continues
2008, American Journal of Surgery
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The first balloon angioplasty for carotid stenosis was performed in 1979, and reports in the 1980s included balloon occlusion to decrease embolic complications [41–43]. Meanwhile, carotid artery stenting has been presented in an increasing variety of publications as a viable alternative to CEA in the treatment of patients with extracranial carotid stenosis [43–50]. Several arguments have been brought forward to advocate its use.
Carotid endarterectomy (CEA) is still considered the “gold-standard” of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS.
A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS.
Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects–such as evolving best medical treatment, timely intervention, interventionalists’ experience, and analysis of plaque composition–may have important influences on the future treatment of patients with carotid artery stenosis.
CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.
Angiographic lesion characteristics can predict adverse outcomes after carotid artery stenting
2008, Journal of Vascular Surgery
Carotid artery angioplasty and stenting (CAS) is an evolving and increasingly common endovascular treatment for carotid artery stenosis. Risk factors associated with an increased incidence of adverse periprocedural neurologic outcomes are being recognized. The goal of this study was to determine if certain angiographic lesion characteristics were predictive of higher risks of adverse outcomes.
A total of 421 patients who underwent 429 carotid artery stenting procedures between June 1996 and June 2005 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Demographic data and procedural variables were recorded, including the presence or absence of the use of a cerebral protection device. Angiograms were reviewed for the following carotid lesion characteristics: length of lesion, percentage of stenosis, ostial involvement, lesion ulceration, calcification, and presence of contralateral carotid occlusion. Periprocedural stroke and 30-day adverse event rates (stroke, myocardial infarction, and death) were recorded for each patient.
The periprocedural all-stroke rate was 3.7%. Octogenarians had a higher incidence of 30-day adverse events at 10.0% vs 3.8% (P = .029). The incidence of periprocedural stroke was increased in lesions ≥15 mm long, at 17.0% (8 of 47) vs 2.1% (8 of 382; P < .001), and in ostial centered lesions, 7.1% (11 of 154) vs 1.8% (5 of 275; P = .007). Multivariate regression also identified these two variables as independently associated with 30-day stroke rate: lesion length ≥15 mm (odds ratio [OR], 6.38; 95% confidence interval [CI], 35 to 17.29) or ostial involvement (OR, 3.12; 95% CI, 3.12 to 8.36). Other variables, including lesion calcification, ulceration, degree of stenosis, or presence of contralateral occlusion, were not associated with adverse outcomes. When studied separately, the use of cerebral protection devices in 241 patients (56%) did not change our observed correlations between angiographic characteristics and adverse procedural events.
Certain lesion characteristics on angiography, such as length and ostial location, can predict adverse outcomes. The indication for CAS should be carefully evaluated in these cases.
Pro: Carotid angioplasty and stenting will be the first-line interventional therapy for stroke prevention in patients with extracranial carotid occlusive disease
2005, Journal of Cardiothoracic and Vascular Anesthesia
Operative intervention for recurrent stenosis after carotid stent angioplasty: A report
2002, Annals of Vascular Surgery
Carotid artery angioplasty and stenting is gaining popularity, yet the natural history and optimal treatment for recurrent stenoses within stents are not known. Recurrent stenosis rates are not well characterized, with rates between 0 and 33% reported within the first year. Treatment of these lesions with repeat angioplasty may not be feasible or desirable, leading to operative interventions. We present two cases of asymptomatic high-grade in-stent restenosis treated successfully with carotid artery bypass using PTFE.
Carotid artery stenting in a vascular surgery practice
2002, Journal of Vascular Surgery
Citation Excerpt :
Percutaneous CAS has emerged as an appealing therapeutic alternative in these cases, with the potential to achieve results equal or possibly superior to those of CEA in the same clinical setting. With this in mind, the senior author (F.J.C.) began to offer endovascular intervention to selected patients in 1994.4 This initial effort involved a direct cervical approach to the carotid artery and the use of balloon-expandable stents.
Purpose: We tested the clinical applicability, technical results, and morbidity of carotid angioplasty-stenting (CAS) in the treatment of severe stenosis of the internal carotid artery (ICA) in patients deemed to be high-risk candidates for carotid endarterectomy (CEA). Method: After an initial series (1994-1997) of 52 interventions, we adopted the use of a transfemoral access technique and self-expanding stents in late 1997. From Dec 1, 1997, to Mar 31, 2001, 135 CAS procedures were performed on 132 patients with more than 70% (symptomatic) or more than 80% (asymptomatic) stenoses of the ICA. Sixty percent of the patients had no symptoms, and 40% of patients had symptoms. The interventional technique was standardized with the use of a 7F long interventional sheath, balloon pre-dilatation of the stenotic lesion, placement of a self-expanding stent (Wallstent in 12 patients and a SMART stent in 120 patients), and post-balloon dilatation when necessary. Brain protection devices were not used. Patients were given clopidogrel and aspirin before and after the procedure and heparin during the intervention. Results: All procedures except two were completed as planned, with access failure in three patients (2.2%). Residual in-stent stenosis of less than 20% was detected in 14 of 132 stented vessels (11%) and accepted as a satisfactory angiographic outcome. Neurologic complications included one patient with a single-episode transient ischemic attack (TIA; motor-sensory deficit of the hand) occurring 2 hours after CAS. One patient sustained a major stroke after thrombosis of the stented ICA, which occurred 3 days after the CAS procedure and 24 hours after open-heart surgery. A third patient sustained a minor stroke that began intraprocedurally after post-balloon dilatation of the stent, and a fourth patient had another minor stroke with transient aphasia (beginning during the procedure and resolving after 4 hours) and monoparesis of the hand, which resolved after 1 week. All stented vessels remained patent during the follow-up period (range, 2-41 months; mean, 16 ± 9 months), with four instances of hemodynamically significant in-stent restenosis. Re-intervention with balloon angioplasty was undertaken successfully at 4 months in one patient with restenosis. The periprocedural mortality rate was 0. Conclusion: Carotid stenting can be performed with acceptable safety on carefully selected patients by using meticulous, standardized interventional techniques. It may offer a possibly superior therapeutic alternative for non-CEA candidates. Evolving technological improvements and brain protection devices are likely to enhance its role in the treatment of carotid artery disease in the future. Surgical endarterectomy remains the standard of care for most patients at the present time. (J Vasc Surg 2002;35:430-4.)

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^†: Presented at the 25th Annual Meeting of The Society for Clinical Vascular Surgery, Naples, Florida, March 12–16, 1997.

¹: From the Division of Vascular Surgery, Union Memorial Hospital, Baltimore, Maryland

View full text

Evolving indications for and early results of carotid artery stenting†

J Vasc Surg.

Am J Cardiol.

Beneficial effect of carotid endarterectomy in symp- tomatic patients with high-grade carotid stenosis

NEJM

Clinical advisory: carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis

Stroke.

Concern about safety of carotid angioplasty

Stroke.

Carotid angioplasty and stenting: is endovascular treatment for cerebrovascular disease justified?

J Endovasc Surg.

Stenting in the carotid artery: initial experience in 110 patients

J Endovasc Surg.

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

Neuroradiology.