Carotid artery stenting in elderly patients: Importance of case selection

Chiam, Paul T.L.; Roubin, Gary S.; Iyer, Sriram S.; Green, Richard M.; Soffer, Daniel; Brennan, Christina; Vitek, Jiri J.

doi:10.1002/ccd.21620

Cited by 64 publications

(45 citation statements)

References 42 publications

(56 reference statements)

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“…To reduce the risk of stroke after CAS, improvements in training and technique, embolic protection and stent design, and patient selection hold promise. 15 In our study, 2 patients (4.7%) with MRpositive IPH experienced a major stroke within 30 days after CAS, but no myocardial infarctions or deaths were observed. Therefore, the overall 30-day stroke rate was 2.1%.…”

Section: Discussionmentioning

confidence: 45%

“…14 MR-positive IPH was defined as the presence of hyperintense intraplaque of Ͼ200% of the signal intensity of the adjacent muscle for at least 2 consecutive sections on MPRAGE images. 13,15 For MPRAGE-positive IPH analysis, signal intensities were measured in a 6-to 8-mm 2 circular region of interest over the carotid plaque. Positive DWI for analysis of ipsilateral ischemic lesions was defined as the detection of a hyperintense signal on a DWI trace with an associated signal decrease on the apparent diffusion coefficient map by 2 experienced neuroradiologists through consensus interpretation.…”

Section: Definition and Outcomesmentioning

confidence: 99%

See 1 more Smart Citation

Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Chung

Jeong

Kwak

et al. 2015

AJNR Am J Neuroradiol

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Section: Discussionmentioning

confidence: 45%

Section: Definition and Outcomesmentioning

confidence: 99%

Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Chung

Jeong

Kwak

et al. 2015

AJNR Am J Neuroradiol

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“…Therefore, improvement in treatment methods is desperately needed in this population. Nonetheless, thanks to improvement in procedural equipment and techniques as well as appropriate case selection, CAS can be performed with lower periprocedural adverse events, falling within the American Heart Association guidelines (Chiam et al., 2008; Grant et al., 2010). Research demonstrates that 85% of the selected elderly patients survived 2 years and ≥75% survived 3 years after stenting.…”

Section: Discussionmentioning

confidence: 99%

Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

Duan

Dai

et al. 2017

Brain and Behavior

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BackgroundMultiple studies suggest that internal carotid artery stenting can be performed safely in octogenarians with low periprocedural complication rates. However, great concern still exists as to whether these patients will gain long‐term benefits from this procedure given their advanced age and uncertain life expectancy. We decided to conduct a retrospective study to determine short‐and long‐term clinical outcomes and to analyze survival duration in this population.Methods and ResultsSixty‐nine consecutive elderly patients with either symptomatic or asymptomatic stenosis ≥70% underwent 86 procedures. Immediate and late outcomes, as well as survival data, were analyzed retrospectively. Mean age was 83.1 ± 2.7 years. Mean survival was 49.3 ± 10.1 months. A complete neurological assessment was obtained at 1 and 2 years in 100% of patients, at 3 years in 90.7% of patients and at 5 years in 84.8% of patients. Two major and one minor ischemic strokes occurred during the periprocedural period. No death, myocardial infarction or intracranial hemorrhage was recorded. The mean follow‐up period was 55.4 ± 24.6 months. Four patients experienced a minimum of 1 year of follow‐up, and the longest is 8 years. Among the patients with the longest follow‐up time, 6 had ischemic strokes, of which 2 were fatal. In total, 17 deaths occurred. Four patients experienced dementia without stroke. Survival at 3 and 5 years was estimated to be 90% and 73%, respectively.ConclusionThis study demonstrated that stenting in octogenarians was safe and effective during the periprocedural period. Long‐term follow‐up showed a low rate of fatal and nonfatal stroke, and patients survived long enough to benefit from the procedure. However, it was associated with a relatively high rate of long‐term event. Though carotid artery stenting is a minimally invasive procedure, it should still be performed with great caution and only in carefully selected patients. The present study suggested that in this age population, carotid artery stenting might be considered as a revascularization option.

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“…However, the incidence of periprocedural stroke was lower in the CEA group than in the CAS group, whereas the incidence of periprocedural myocardial infarction was lower in the CAS group than in the CEA group (15). In order to reduce the risk of stroke after CAS, it is critical to improve training, technique, embolic protection, stent design, and patient selection (27). In our study, the composite rate of 30-day stroke (minor or major), myocardial infarction, and death was 3.9%, which is lower than that of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) trial.…”

Section: Outcome Based On Carotid Hr-mri Findingsmentioning

confidence: 99%

The Safety of Protected Carotid Artery Stenting in Patients with Unstable Plaque on Carotid High-Resolution MR Imaging

Jeong

Kwak

Hwang

et al. 2018

J Korean Soc Radiol

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Purpose:The aim of this study was to determine the safety of the carotid artery stenting (CAS) procedure, using an embolic protection device which is based on the presence of unstable plaques on carotid MR imaging in patients who presented with severe carotid artery stenosis. Materials and Methods: This prospective study assessed 102 consecutive patients who had been noted with severe carotid stenosis. These patients underwent a preprocedural carotid MR imaging, and a periprocedural diffusion-weighted imaging (DWI) after the CAS. The unstable plaque on the carotid MR imaging was defined as characterized as intraplaque hemorrhage (IPH), thin/ruptured fibrous caps, or ulcers. We analyzed the incidence of the noted periprocedural ipsilateral ischemic events on the DWI, and noted the primary outcomes within 30 days of the CAS. Results: In the study, it is noted that 50 patients (49.0%) had IPH, 84 patients (82.4%) had thin/ruptured fibrous caps, and 43 patients (42.2%) had ulcers as seen on the carotid plaque MR imaging. The IPH was more common in the symptomatic group than in the asymptomatic group (58.7% vs. 41.1%, p = 0.12). Overall, the DWI was positive after CAS in 25.5% of cases. Additionally, the combined rate of 30-day stroke, myocardial infarction, or death was recorded at 3.9%. The new periprocedural ischemic lesions on the DWI were characteristically more frequently observed in the symptomatic group (17/46, 37.0%) than in the asymptomatic group (9/56, 16.1%) (p = 0.03). There was no significant difference in the primary outcome of the CAS, based on the type of unstable plaque of IPH, thin/ruptured fibrous caps, or ulcers. Conclusion:The protected CAS appears to be safe, regardless of the noted unstable plaque findings as seen on the carotid MR imaging. In this case, because of the higher risk of periprocedural ipsilateral ischemic events, it is therefore recommended that the symptomatic patients should receive more careful treatment during the CAS placement going forward. Korea. Tel. 82-63-250-2582 Fax. 82-63-272-0481 E-mail: kwak8140@jbnu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Index terms

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Carotid artery stenting in elderly patients: Importance of case selection

Abstract: CS can be performed safely in anatomically suitable elderly patients with low adverse event rates. CS should remain a revascularization option in appropriately selected elderly patients.

Cited by 64 publications

References 42 publications

Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

The Safety of Protected Carotid Artery Stenting in Patients with Unstable Plaque on Carotid High-Resolution MR Imaging

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