Lesion-Related Carotid Angioplasty and Stenting with Closed-Cell Design without Embolic Protection Devices in High-Risk Elderly Patients—Can This Concept Work Out? A Single Center Experience Focusing on Stent Design

Abstract

Approximately 200,000 patients per year suffer from ischemic insult in Germany. Of those, approximately 30,000 originate from carotid stenosis. 1 Carotid artery stenting (CAS) has emerged as an alternative revascularization technique for extracranial carotid stenotic disease. 2 Nevertheless, one of the limitations of CAS is the potential for embolic stroke caused by plaque dislodgement of atheromatous material. 2 AbstractTo compare the performance differences of three carotid artery stents in high-risk elderly patients without embolic protection devices (EPDs) on the basis of stent design, procedure-related complications, conveniences in handling, in-stent restenosis, 30-day outcome, and long-term follow-up. A total of 101 symptomatic internal carotid stenoses of 94 patients were prospectively treated with stent-protected angioplasty to 94 patients. Three closed-cell stents, one of those being hybrid cell design, were chosen depending on vascular anatomy: curved vessel, lesion length > 1 cm: 64 Carotid Wallstent (Boston Scientific, Natick, MA); curved vessel, lesion length < 1 cm: 21 Cristallo Ideale (Invatec, Roncadelle, Italy); straight vessel, lesion length > 1 cm: 16 Xact (Vascular Abbott, Santa Clara, CA). Comparisons of demographics, procedures, and outcomes were performed. The mean age of patients was 73.1 years (standard deviation [SD], AE 7.9; range, 58-87 years), 71% of the patients were older than 70 years and 20% were octogenarians. Male/female ratio was 3.1:1. About 13.9% (14/101) had contralateral internal carotid artery occlusion. Overall peri-interventional complication rate was 2.9% and 30-day mortality rate was 1%. During the long-term follow-up (34 months, range 1-59) no ipsilateral stroke was documented. Ten deaths (three after MI) were recognized. Two in-stent restenosis were detected (> 70% North American Symptomatic Carotid Endarterectomy Trial) during follow-up, one patient was detected with previous carotid endarterectomy. Especially, if individual anatomical variance is considered, lesion-related stent-protected carotid angioplasty with lesion-adapted closed-cell design is an effective, reliable, safe, and comprehensible treatment option in symptomatic patients. Even without EPDs, the rate of complications is low, when compared with symptomatic carotid artery stenosis described in the literature. In-stent restenosis seems to play no significant role in follow-up.

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…We conducted a systematic literature review without meta-analysis per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [8]. Nineteen studies were identified that discussed perioperative risk in the context of relevant anatomy [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] (Table 1) in addition to fourteen studies [28][29][30][31][32][33][34][35][36][37][38][39][40][41] (Table 2) and fifteen case reports/series [42][43][44][45][46][47][48][49][50][51][52][53][54]…”

“…The predominant feared risk in CAS is AIS or TIA [62]. Available literature by way of retrospective case series and reports describes a variety of techniques to safely account for anatomy including unfavorable great vessel variants and angulations [28][29][30][31][32][33][34][35][36]38,39,41], near-total ICA stenosis [33,36,40], tortuosity [28,34,35,37,39], and vulnerable plaque morphology [38] in the context of carotid intervention. Modalities range from anchoring techniques [28], the use of dedicated guide catheters [55], and alternative access sites [30].…”

“…TRA is associated with decreased strain on catheter systems and facilitates navigation of tortuous vessels and effective treatment and EPD system placement in stenotic or vulnerable lesions in appropriate patients [32,34,38]. Reviewed case series showed a rate of stroke of 2.0% across 495 patients in TFA [28,29,31,33,[35][36][37]40] and 1.6% across 443 patients in TRA or TBA [30,32,34,38,41]. Univariate comparison of proportions found no significant differences in associated AIS (p = 0.6142), suggesting TRA and TBA routes to be viable considerations.…”

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

“…There are pros [25,26,27,28] and cons [29,30] of using EPD in CAS. Proponents advocate EPD use because of its ability to eliminate emboli detected by transcranial Doppler sonography [31].…”