Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study

Abstract

BACKGROUND AND PURPOSE:The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis. MATERIALS AND METHODS:We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-fourmonth clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared. RESULTS:One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P ¼ .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement ¼ 2.3%; carotid endarterectomy ¼ 13%; P ¼ .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P ¼ .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P ¼ .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P ¼ .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P ¼ .009; 21.4% versus 2.9%, P ¼ .032, respectively).CONCLUSIONS: Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment. ABBREVIATIONS: CAS ¼ carotid artery stent placement; CEA ¼ carotid endarterectomy; CHS ¼ cerebral hyperperfusion syndrome; CNO ¼ carotid nearocclusion; IQR ¼ interquartile range T he treatment of symptomatic carotid near-occlusion (CNO) is controversial. Post hoc analyses of the NASCET and the European Carotid Surgery Trial (ECST) conducted in the 1990s revealed that the risk of recurrent stroke could be lower in

Cartoid Near Occlusion: Time to Re-think Endarectomy?

“…In their current study, which included 141 CNO patients, Garcia-Pastor et al 6 reported that they performed CEA on 23 patients. And they reported the CEA procedure success rate at 83.6% and also reported the rate of periprocedural ischemic stroke or death at 13%.…”

“…Consistent with these findings, they reported that revascularization is associated with high technical failure and perioperative complications in patients with CNO. 6 On the contrary, in their meta-analysis, Meershoek et al 13 evaluated 17 CNO patients undergoing CEA, and the 30-day stroke or death rate was reported to be 1.8% in these patients. When the results were compared with the results of non-CNO patients 14 undergoing CEA in the literature, it was reported that the CNO patients were not at high risk for surgery.…”

“…In fact, high rates of technical failure and periprocedural complications in the revascularization of CNO patients are reported in the literature. 6 …”

“…In addition to the guideline recommendations, other studies have also reported that surgical treatment in CNO is a high-risk procedure. In a recent multicenter registry study on this topic, Garcia-Pastor et al 6 reported that revascularization is associated with high technical failure and periprocedural complications in patients with CNO. 6 Based on these data, CEA is typically not performed in patients with CNO in current practice.…”

Update on Management of Symptomatic Carotid Stenosis

“…[63] Both CAS and CEA are associated with high rates of failure and periprocedural stroke.51 When the carotid artery is nearly completely occluded, revascularization has not been shown to reduce the risk of stroke as compared to just medical treatment. [30] It has also been shown that long-term complications are less for CAS than for CEA. [46] CEAs also come with operative complications to consider.…”