Long-term results of carotid artery stenting

Abstract

Objective: Data regarding the long-term efficacy of carotid artery stenting (CAS) are still scarce. As demonstrated by several major randomized controlled trials (RCT) comparing the efficacy of carotid endarterectomy (CEA) vs medical therapy, even after successful carotid revascularization late ipsilateral stroke occurs in 5-13% at 5 years. Therefore, major concerns also remain about the durability of the CAS procedure in terms of stroke prevention. The purpose of this study was to review long-term results after carotid stent implantation in a large cohort of patients. Methods: This retrospective investigation involved 3179 CAS procedures performed at four European carotid highvolume centers. Echo-duplex scan using modified velocity criteria to recognize in-stent restenosis (ISR) and neurological examinations of all patients were carried out every 6 months after the procedure. Life-table analysis was used to determine freedom from mortality, stroke-related death, ipsilateral fatal/major stroke, and any ipsilateral stroke. Freedom from ISR and from reintervention were also reported. The secondary aim was to identify predictive risk factors for neurological complications and ISR. Results: At 5 years freedom from mortality, stroke-related death, ipsilateral fatal/major stroke, and any stroke rate were 82%, 93.5%, 93.3%, and 91.9%, respectively. The only predictor for neurological complications was the presence of neurological symptoms before CAS (hazard ratio 1.38 [CI 1.05, 1.82] P ‫؍‬ .02). Freedom from restenosis at 1, 3, and 5 years was, respectively, 98.4%, 96.1%, and 94%. Uni-and multi-variate analyses showed that stent characteristics (material/design/freecell area) were not significantly associated with time to in-stent restenosis or time to reintervention. Conclusion: Our long-term results in a large cohort of patients validated CAS as a durable procedure for stroke prevention. The annual rate of neurological complications after CAS was comparable to that of conventional surgery as demonstrated by large RCTs involving both symptomatic patients (North American Symptomatic Carotid Endarterectomy Trial [NASCET] and European Carotid Surgery Trial [ECST]) and asymptomatic patients (Asymptomatic Carotid Atherosclerosis Study [ACAS] and Asymptomatic Carotid Surgery Trial [ACST]). ( J Vasc Surg 2008;48:1431-41.)In recent years, carotid artery stenting (CAS) has rapidly gained recognition worldwide as a possible alternative to carotid endarterectomy (CEA). Although excellent results from centers with a high-volume experience seem to demonstrate that CAS is technically feasible and safe, 1 the few randomized controlled trials (RCTs) conducted so far have not clarified the equivalence of this technique compared to CEA in terms of early results 2-4 in normal-risk patients. Moreover, these trials did neglect to publish longterm results after CAS, and only a few nonrandomized studies have focused their attention on long-term results with Ͼ5 years of follow-up. [5][6][7][8][9] As demonstrated by several RCTs comparing the ...

Late Outcomes After Carotid Artery Stenting Versus Carotid Endarterectomy

“…In the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, 23 CAS with an embolic protection device resulted in a 12.2% 1-year major adverse events 27 Of note, the majority of stenting was done in asymptomatic patients (59%). In this analysis, the rate of stroke or TIA at the end of 2 years was 5.4%, 24 which is similar to the rate seen in our study.…”

“…First, in our cohort, most of the carotid artery revascularization was done in asymptomatic patients. This has been shown consistently in both European registries 24 and American registries. Second, patients who underwent CAS had higher baseline medical comorbidities than patients undergoing CEA; thus, CAS may be considered a reasonable alternative in patients who are poor surgical candidates.…”

Long-Term Outcomes of Carotid Artery Stenting in Clinical Practice

“…Similar to CREST, EVA-3S, and high-volume singlecenter reports, 8,18 in the present analysis, the rate of restenosis after CAS remained relatively low and at the same level as after CEA in randomized trials. Finally, it has to be emphasized that only 2 of the 19 of our patients with restenosis had stroke.…”

“…The overall risk for the primary end point is also comparable with results from other high-volume centers, despite their generally shorter long-term follow-up. 8,[18][19][20] Furthermore, we were able to prevent neurological complications effectively: the observed annual risk for ipsilateral stroke (including the periprocedural period) of 0.6% in the overall cohort compares favorably with the 1.1% of the 10-year CREST data. 5 Our data also support the growing body of evidence that CAS results after the 30-day interval are durable; the flat course of the Kaplan-Meier curves signifying freedom from ipsilateral stroke.…”

“…16 Some high-volume centers report lower event rates in their real-world populations of symptomatic and asymptomatic patients (range from 1.7% to 4.7%). 7,8,[17][18][19][20] However, 3 major issues need to be considered when comparing the current results with older reports. First, a strict, independent neurological assessment before and after the procedure was not mandatory in previous trials and even less so in registries.…”