Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting

Abstract

Purpose: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. Materials and Methods: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. Results: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2–month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. Conclusion: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Commentary: Double-Layer Carotid Stents: From the Clinical Need, through a Stent-in-Stent Strategy, to Effective Plaque Isolation… the Journey Toward Safe Carotid Revascularization Using the Endovascular Route

“…45 This stent-graft-dependent embolic mechanism cannot be mitigated by using a safer access to perform the intervention, such as the retrograde access used for deploying stent-grafts in the innominate artery. 46,47 Another important concern regarding stent-grafts is the prohibitively high risk of in-stent restenosis, 48,49 which notably has not been seen with the MicroNET mesh-encased self-expanding stent design at up to 3 years. 16 In the August 2019 issue of the JEVT, Myouchin and colleagues 50 share their experience with a stent-in-stent "a priori" implantation strategy using Carotid Wallstents (Boston Scientific, Marlborough, MA, USA) to prevent plaque prolapse in soft, high-risk carotid lesions.…”

Innominate Artery Stenting: The Continuing Saga of “Who, When, and How”?

“…5 Of the 182 patients, 39 (21%) showed an interarm difference in systolic BP >15 mm Hg. Although these patients are not strictly comparable to the cohort in the Ammi analysis, 4 the ICSS substudy was in fact the first to affirm the clinical need for the measurement of interarm BP differences, not merely for revascularization of the inflow stenosis causing the ipsilateral BP decrease but especially for BP control measures and medication. 5,6 In the Ammi et al 4 study, the innominate artery was either preocclusive (30%) or occluded (9%) in over onethird of cases.…”

“…The innominate origin configuration changes over time, taking a more dorsal course with higher age; this results in a type III arch configuration that creates a steeper access when performing endovascular interventions from the groin. In the Ammi study, 4 the majority of interventions were performed using a retrograde carotid access (61, 65.6%), combined carotid + brachial access (11, 11.8%), or combined carotid + femoral access (14, 15.1%). Selective primary femoral access was performed in only 7 (7.5%) patients.…”

“…The outcomes reported by Ammi et al 4 included perioperative stroke (in hospital vs 30-day), restenosis, and reintervention. Four (4.3%) strokes were noted; 3 (5.6%) in 54 symptomatic patients and 1 (2.6%) in 39 asymptomatic patients.…”

“…14 The stents used were a wide variety of BMS in 57 (61.3%) patients vs an Advanta V12 balloon-expandable covered stent in 36 (38.7%). Since the BMS group was implanted with various stent types, the analysis in the study by Ammi et al 4 in fact reflects the comparison of the Advanta stent-graft to any type of BMS. Again, as we do not know the reason for opting for one specific stent-graft type at the time of revascularization, no strong conclusions can be drawn from this comparison on neurologic outcomes or on restenosis.…”