An evidence‐based review of the impact of periprocedural myocardial infarction in carotid revascularization

Abstract

Landmark trials comparing carotid endarterectomy (CEA) with medical therapy in patients with symptomatic or asymptomatic atherosclerotic stenosis of extracranial carotid arteries have favored carotid revascularization. Carotid artery stenting (CAS) has emerged as a minimally invasive option for revascularization of carotid artery stenoses and has been shown to be noninferior to CEA, regardless of patient symptom status. Debate continues regarding the importance of periprocedural myocardial infarction (PMI) as an endpoint in carotid revascularization trials. Recent randomized comparisons of CEA and CAS pre-specify PMI as an endpoint. Understanding PMI in CEA and CAS, the need for routine biomarker assessment surrounding both revascularization strategies, the effect of PMI on long-term morbidity and mortality, and the groups most at risk for PMI are of critical importance when choosing a carotid revascularization strategy for symptomatic and asymptomatic patients, since decreasing the incidence of PMI will make revascularization safer. This review examines available data regarding the relevance of PMI in vascular and carotid-specific outcomes.

One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field

“…The risk of death at 4 years was higher after peri-procedural stroke, hazard ratio 2.78; 95% CI: 1.63–4.76 [ 26 ]. Similarly, patients with MI showed a significantly higher 4-year mortality, hazard ratio 3.40, 95% CI: 1.67–6.92; an effect that remained significant after adjustment for baseline risk factors [ 27 , 28 ]. In addition, using different data-sets, arguments have been raised that “real-life” outcomes may be worse-than-CREST for CAS [ 29 ] as well as for CEA [ 30 ].…”

Long term durability and outcomes of carotid stenting and carotid endarterectomy

“…Additionally, CAS had a lower risk of PMI than CEA in both a previous meta-analysis6 and in the present study. PMI could affect long term morbidity and mortality; therefore, it should be considered as important when we choose the proper revascularization procedure, despite debate regarding its importance as an endpoint of a randomized controlled trial 30. The use of embolic protection devices decreased the difference in risk between the two treatments and finally eliminated it, although this result could not be extended to patients with asymptomatic stenosis.…”

Carotid stenting versus endarterectomy for the treatment of carotid artery stenosis: Contemporary results from a large single center study

“…CAS is a minimally invasive procedure and can even be performed on an outpatient basis, requiring only a small incision in the arm or groin region. This safe and effective alternative to CEA emerged in the 1980s and has increased in frequency in the US from 3% to 13% of all carotid revascularization procedures .…”