Evaluation of Carotid Angioplasty and Stenting for Radiation-Induced Carotid Stenosis

Abstract

[18][19][20][21][22][23][24] In the current study, we aimed to evaluate the procedural safety, clinical, and angiographic outcome of CAS for severe (≥70%) RIS using atherosclerotic stenosis (AS) as a control.Background and Purpose-We aimed to evaluate the procedural safety, clinical, and angiographic outcome of carotid angioplasty and stenting for high-grade (≥70%) radiation-induced carotid stenosis (RIS) using atherosclerotic stenosis (AS) as a control. Methods-In this 6-year prospective nonrandomized study, we compared the carotid angioplasty and stenting outcome of 65 consecutive patients (84 vessels) with RIS with that of a control group of 129 consecutive patients (150 vessels) with AS. Study end points were 30-day periprocedural stroke or death, ipsilateral ischemic stroke, technical success, procedural characteristics, instent restenosis (ISR; ≥50%) and symptomatic ISR. Results-The median follow-up was 47.3 months (95% confidence interval, 26.9-61.6). Imaging assessment was available in 74 vessels (RIS) and 120 vessels (AS) in 2 years. Comparing RIS group with AS group, the rates of periprocedural stroke or death were 1.5% (1/65) versus 1.6% (2/129; P=1); ipsilateral ischemic stroke rates were 4.6% (3/65) versus 4.7% (6/129; P=1); the annual risks of ipsilateral ischemic stroke were 1.2% (3 patient/254.7 patient year) versus 1.2% (6 patient/494.2 patient year; P=0.89); technical success rates were both 100%. Stenting of common carotid artery and the use of multiple stents was more common in the RIS group (P=0 in both cases); ISR rates were 25.7% (19/74) versus 4.2% (5/120; P<0.001); symptomatic ISR rates were 6.8% (5/74) versus 0.8% (1/120; P=0.031). Conclusions-The safety, effectiveness, and technical difficulty of carotid angioplasty and stenting for RIS are comparable with that for AS although it is associated with a higher rate of ISR.

Review of cranial radiotherapy-induced vasculopathy

“…However, a prospective evaluation of angioplasty and stenting for highgrade radiation-induced carotid stenosis demonstrated similar rates of efficacy and stroke risk compared to patients with non-radiation induced stenosis, but a higher rate of instent restenosis [50]. Available data demonstrates an instent restenosis rate of 21-26 % [48,50]. Strategies to decrease the risk of vasculopathies include delaying RT at the young age, using lower dose of RT, using more conformal radiotherapy [52], and perhaps long-term stroke prophylaxis after RT as suggested below.…”

“…The management of stroke in this patient population has been extrapolated from stroke therapy in adult patients without prior cranial radiotherapy such as the use of t-PA, aspirin, heparin, LMWH, surgery, embolisation, angioplasty, and stenting [48][49][50][51]. There is limited data describing interventional techniques specifically for radiation-induced cranial vasculopathies.…”

“…There is limited data describing interventional techniques specifically for radiation-induced cranial vasculopathies. However, a prospective evaluation of angioplasty and stenting for highgrade radiation-induced carotid stenosis demonstrated similar rates of efficacy and stroke risk compared to patients with non-radiation induced stenosis, but a higher rate of instent restenosis [50]. Available data demonstrates an instent restenosis rate of 21-26 % [48,50].…”

Cardiovascular Complications of Cranial and Neck Radiation

“…Therefore, in patients with suitable anatomy and no prior radical neck dissection, CEA should be considered, given the long-term outcome benefits. Comparison of outcomes with CAS in radiation-induced carotid stenosis versus atherosclerotic carotid disease shows that radiation patients have similar rates of peri-procedural stroke or death and postprocedural ipsilateral stroke as atherosclerotic patients [28]. However, radiation patients have a significantly higher rate of both asymptomatic and symptomatic in-stent restenosis at 2 years (27.5 vs. 4.2 %, p G 0.001) [28].…”

“…Comparison of outcomes with CAS in radiation-induced carotid stenosis versus atherosclerotic carotid disease shows that radiation patients have similar rates of peri-procedural stroke or death and postprocedural ipsilateral stroke as atherosclerotic patients [28]. However, radiation patients have a significantly higher rate of both asymptomatic and symptomatic in-stent restenosis at 2 years (27.5 vs. 4.2 %, p G 0.001) [28]. This highlights the aggressive nature of radiation-induced carotid disease and underscores the need for continued screening, even after revascularization.…”