Periprocedural Outcomes of Carotid Artery Stenting in Elderly Patients

Nanto, Masataka; Goto, Yudai; Yamamoto, Hiroyuki; Tanigawa, Shin‐ichi; Takado, Michiko; Ogawa, Takahiro; Nakahara, Yoshikazu

doi:10.1016/j.jstrokecerebrovasdis.2017.08.010

Cited by 8 publications

(5 citation statements)

References 16 publications

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“…This result was similar to the preliminary data of CREST lead‐in phase 10 and was further confirmed by an analysis led by Voeks et al 11 Furthermore, data from 13.086 patients undergoing CAS across 2‐year period in Germany, showed that age was strongly related with in‐hospital stroke and death 12 . On the other hand, there is a growing evidence that, in high‐volume centers with high operators' experience and after proper selection of both the patients and the appropriate technique and materials, good results can be obtained in all the patients' strata 13–17 . Usually, the worst outcomes reported in the elderly are related to the higher rate of ischemic stroke due to the distal embolization as a consequence of the catheters manipulation in the aortic arch, 18 owing the more challenging anatomy in this population.…”

Section: Discussionsupporting

confidence: 82%

“…12 On the other hand, there is a growing evidence that, in high-volume centers with high operators' experience and after proper selection of both the patients and the appropriate technique and materials, good results can be obtained in all the patients' strata. [13][14][15][16][17] Usually, the worst outcomes reported in the elderly are related to the higher rate of ischemic stroke due to the distal embolization as a consequence of the catheters manipulation in the aortic arch, 18 owing the more challenging anatomy in this population. Our study confirms the significantly higher complexity of the anatomy (type III and very calcified aortic arch) in the elderly group, but not the higher rate of ischemic stroke: the tailored approach with use of both guiding catheters along with the more flexible open cell stents, in order to overcome the tortuosities, and with the operator's skill have probably allowed to minimize the embolizations (Figure 2).…”

Section: Discussionmentioning

confidence: 99%

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Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high‐volume interventional cardiology center

Varbella

Cerrato

Rolfo

et al. 2021

Cathet Cardio Intervent

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Background: Carotid artery stenting (CAS) is an attractive option in order to treat carotid artery stenosis. However, its safety in elderly patients is questioned. Aim of this single-center retrospective study was to assess data of elderly patients undergoing CAS, and to compare them with those of the younger (< 75 years). Methods:We collected data of 580 consecutive patients undergoing CAS between December 2007 and June 2020 and compared clinical and procedural characteristics as well as in-hospital major adverse events (MACCE) and long-term mortality between patients < 75 years and patients ≥ 75 years old.Results: There were 272 patients (46.9%) with age ≥ 75 years and 308 patients (53.1%) with age < 75 years. The median follow-up was 48 months (range 2-144).There was no significant difference about in-hospital MACCE between the two groups (4.7% in the older vs. 3.5% in the younger group, p = 0.9), but a higher rate of cerebral hemorrhage occurred in the older group (1.8% vs. = 0.3%, p = 0.07), even if not significant. Long-term mortality was significantly higher in the older group (27.9 vs. 20.1%, p = 0.027). Multivariate predictors of 12-months mortality were neurologic symptoms within 6 months (OR: 4.83; 95% CI: 2.04-11.42; p ≤ 0.001), smoking

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Section: Discussionsupporting

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high‐volume interventional cardiology center

Varbella

Cerrato

Rolfo

et al. 2021

Cathet Cardio Intervent

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“…The use of the carotid artery stent (CAS) has become the preferred method for the management of asymptomatic severe carotid artery stenosis in patients considered to be at high risk for surgery. Patients who may have a poor outcome following CAS include patients of advanced age, patients with severe cardiopulmonary dysfunction, patients with advanced renal disease, and patients with anatomical changes that may challenge surgical access, or with prior irradiation to the neck [3,7]. Previously published studies have demonstrated the safety of CAS in the elderly, including patients who are more than 80 years of age [5,7].…”

Section: Discussionmentioning

confidence: 99%

Transcervical Carotid Artery Stenting Without Flow Reversal: A Report of Two Cases

2019

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Case seriesPatients: Male, 78 • Male, 69Final Diagnosis: Severe carotid artery stenosisSymptoms: AsymptomaticMedication: —Clinical Procedure: Carotid artery stentingSpecialty: CardiologyObjective:Unusual or unexpected effect of treatmentBackground:The use of a carotid artery stent (CAS) is a management option for high-risk patients with carotid artery stenosis. An access site for CAS that involves the transcervical approach may be performed percutaneously or may require a cutdown, and usually includes a flow-reversal system to reduce the risk of embolization. Two cases are presented where the transcervical approach to CAS incorporated a distal filter for embolic protection, with a successful outcome.Case Report:1. A 78-year-old man with a history of prior irradiation for head and neck cancer presented for CAS after clinical evaluation showed that he was a poor candidate for carotid endarterectomy (CEA). A femoral approach for carotid artery access was not successful due to a tortuous type III aortic arch. A surgical cutdown of the carotid artery was performed with the use of a distal filter, and the CAS was inserted with no embolic events. 2. A 69-year-old man with an anatomically high bifurcation of his carotid artery was not a candidate for CEA due to limited carotid artery access. Diagnostic carotid angiography was also difficult to perform. The CAS was successfully sited with the use of a distal filter and with no post-procedural complications.Conclusions:CAS is an option for carotid artery stenosis in patients with high surgical risk for CEA. Although a flow-reversal system is usually used to reduce embolic events, these two cases demonstrate that one can also avoid embolism with a distal filter instead.

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“…Identification of factors that are predictive of the development of instability is of considerable clinical importance, given its association with adverse outcomes. 12,13,[15][16][17] Some research suggests that bradycardia can be prevented by the prophylactic use of anticholinergics before angioplasty. [18][19][20] Given the high rate of comorbid coronary artery disease in this population, 21 selective use of anticholinergic drugs may be desirable to avoid cardiac ischemic events related to tachycardia.…”

mentioning

confidence: 99%

“…Identification of factors that are predictive of the development of instability is of considerable clinical importance, given its association with adverse outcomes 12,13,15–17. Some research suggests that bradycardia can be prevented by the prophylactic use of anticholinergics before angioplasty 18–20.…”

mentioning

confidence: 99%

Plaque Characteristics on CT Angiography Do Not Improve the Ability to Predict Hemodynamic Instability During and After Carotid Angioplasty and Stenting

Jensen

Eesa²,

Walker

et al. 2020

Journal of Neurosurgical Anesthesiology

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Background: Hemodynamic instability is commonly seen during carotid angioplasty and stenting. Although prophylactic treatment with anticholinergics is beneficial, selected use in high-risk patients is desirable. This study examines whether plaque characteristics on computed tomography angiography in addition to demographic factors improve predictive capability.Methods: We retrospectively collected information from 298 carotid angioplasty procedures between January 2013 and December 2018. Nine individuals were excluded due to a previous ipsilateral endarterectomy. Our primary outcome was a decrease of 20% or more in heart rate or blood pressure at angioplasty. Data were analyzed using χ 2 tests and regression statistics.Results: Of the 289 patients included for analysis, 57 had intraoperative instability and 26 had postoperative instability. Radiologist interpretation was found to have a risk ratio of 1.63 (95% confidence interval: 1.00-2.65) for intraoperative instability (P = 0.080). Intraoperative instability was significantly associated with subsequent postoperative instability (P = 0.005). Our regression model included previous endarterectomy and diabetes as predictive factors with a sensitivity of 11.3% and a specificity of 100.0%. Anticholinergic usage was associated with hypotension without coexisting bradycardia with a risk ratio of 2.36 (95% confidence interval: 1.06-5.26; P = 0.047).Conclusions: Individuals without a previous contralateral endarterectomy and/or history of diabetes are at lower risk of hemodynamic instability. The addition of computed tomography angiographic variables does not improve this prediction. Future prospective, randomized work is required to improve our ability to identify and treat individuals at high risk of instability during carotid angioplasty and stenting.

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Periprocedural Outcomes of Carotid Artery Stenting in Elderly Patients

Cited by 8 publications

References 16 publications

Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high‐volume interventional cardiology center

Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high‐volume interventional cardiology center

Transcervical Carotid Artery Stenting Without Flow Reversal: A Report of Two Cases

Plaque Characteristics on CT Angiography Do Not Improve the Ability to Predict Hemodynamic Instability During and After Carotid Angioplasty and Stenting

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