Does a Contralateral Carotid Occlusion Adversely Impact Carotid Artery Stenting Outcomes?

Abstract

Background Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A pre-existing contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes following carotid endarterectomy (CEA), yet its impact on CAS outcomes is less understood. Methods Retrospective review of 417 CAS procedures from May 2001 through July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices. Patients were divided into those with a pre-existing contralateral carotid occlusion (Group A, n=39) versus those without a contralateral occlusion (Group B, n=378). Patient demographics and co-morbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4.0 years (range 0–9.4 years). Results Overall mean age of the 314 men and 103 women was 70.5 years. In Group A there were 2 (5.1%) octogenarians and 9 patients (23.1%) with symptomatic disease as compared to Group B with 53 (14.0%) octogenarians and 121 (32.0%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%. When comparing Group A to 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 not significantly different: death (25.6% vs 22.2%), stroke (5.3% vs 3.4%), and MI (15.4% vs 14.0%) (p=NS). Conclusion A pre-existing contralateral carotid artery occlusion does not appear to adversely impact CAS outcomes.

Treatment Strategy for Bilateral Carotid Stenosis: 2 Cases of Carotid Endarterectomy for the Symptomatic Side Followed by Carotid Stenting

“…Although several reports have confirmed that contralateral carotid occlusion does not adversely affect CAS [22][23][24] , previous studies have shown conflicting results regarding the perioperative risk of the patients with contralateral ICA occlusion undergoing CEA 22,24,[27][28][29][30][31] . Antoniou et al conducted a systematic review, and showed contralateral occlusion increases the incidence of perioperative strokes 27 .…”

“…One of the problems of this strategy is the higher incidence of post procedural hemodynamic complications. Although contralateral carotid occlusion does not adversely impact CAS [22][23][24] , there have been no reports indicating that CAS is safer in patients with contralateral severe ICA stenosis than is CEA. Rather, we think that hypotension after CAS for the asymptomatic side may be dangerous for the symptomatic hemisphere, because CAS for the asymptomatic side usually does not improve hemodynamics in the symptomatic cerebral hemisphere.…”

A Validated Risk Score to Predict Outcomes after Carotid Stenting

“…PAD was associated with a 1.6-to 2-fold increased risk of mortality and was found in up to 44% of patients. Finally, with regard to contralateral carotid occlusion, we extended data from Keldahl et al 7 who found a slight but not significant increase of mortality during a mean follow-up of 4 years in patients undergoing CAS with contralateral carotid occlusion. In our derivation but not in our validation cohort, contralateral occlusion was associated with a 1.7-fold increased risk of mortality.…”

“…So far, single risk factors such as medical high risk, diffuse proliferative hyperplasia after CAS, diabetes mellitus, low high-density lipoprotein cholesterol levels, low body mass index, and contralateral carotid occlusion have been described but no comprehensive risk assessment has been performed. [3][4][5][6][7] The identification of a comprehensive risk profile determining mortality in this high-risk population with advanced age and high probability of generalized atherosclerotic disease is of particular clinical interest, specifically if reversible risk factors are included in the risk profile and late outcome may be improved by their treatment. A comprehensive risk management may be of particular relevance for patients with asymptomatic carotid stenosis in whom competing risks are more likely to impact late outcome.…”

Surgical Outcomes for Cervical Carotid Artery Stenosis: Treatment Strategy for Bilateral Cervical Carotid Artery Stenosis

“…On the other hand, they thought that CAS would be better for the first revascularization procedure than CEA because CCS would adversely affect CEA. 17,18 Although CCO does not adversely impact CAS, [29][30][31] there have been no reports indicating that CAS is safer in patients with contralateral severe ICA stenosis than is CEA. In fact, contralateral occlusion is one of the risk factors in Protected…”