Predictors of Stroke Complicating Carotid Artery Stenting

Abstract

Background-The evolving technique of carotid stenting is being evaluated as an alternative to endarterectomy.Identification of the factors that predispose a patient to neurological complications would facilitate further refinement of the technique and optimize patient selection. Methods and Results-We analyzed the impact of various clinical, morphological, and procedural determinants on the development of procedural strokes in 231 patients who underwent elective (primary) stenting of 271 extracranial carotid arteries. The mean age of the patients was 68.7Ϯ10 years, 165 (71%) were males, and 139 (60%) had symptoms attributed to the lesion treated. This series represented a high-risk subset with 164 patients (71%) having significant coronary artery disease, 91 (39%) having bilateral disease, and 28 (12%) having contralateral carotid occlusion. Of the treated vessels, 59 (22%) had prior carotid endarterectomy, 66 (24%) had ulcerated plaques, and 87 (32%) had calcified lesions. Only 37 treated vessels (14%) would have been eligible for inclusion in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). There were 17 (6.2%) minor and 2 (0.7%) major strokes during and within 30 days of the procedure. NASCET-eligible patients had a low (2.7%) risk of procedural strokes after carotid stenting.The results of multivariate analysis revealed advanced age (Pϭ.006) and presence of long or multiple stenoses (Pϭ.006) as independent predictors of procedural strokes. Conclusions-During this procedural developmental phase of carotid stenting, neurological complications were highly dependent on patient selection. Advanced age and long or multiple stenoses were independent predictors of procedural stroke.

Simultaneous Bilateral Carotid Stenting in High-Risk Patients

“…9,17,26,27 The reported rate of severe bilateral carotid stenosis and/or occlusion varies widely (3.2%-39%) 8,9,17,28 and was encountered in 14.6% of the patients at high surgical risk in our prospective CAS data base. Although bilateral carotid stenosis has been shown to potentially increase the risk for complications during CEA or CAS and has been included as 1 of the high risks for CEA, our data revealed that there was no significant difference in outcome at 30 days or at 6 months between the bilateral and unilateral stent-placement patient groups.…”

“…4,5 Since Mathur et al 6 first reported the feasibility of staged CAS for bilateral carotid stenosis, some small series have been published in an attempt to promote staged or simultaneous revascularization. [7][8][9][10][11][12][13][14][15][16] However, the results have been equivocal, and there is an obvious need for larger trials to firmly establish the superiority of the simultaneous or the staged approach. Nonetheless, patients with bilateral carotid artery disease have been excluded from most prospective trials due to concerns regarding possible complications and/or poor outcomes.…”

“…17 Bilateral carotid severe stenosis, presumed to be 1 of the high risk factors in CEA, is generally treated by a staged stentplacement procedure. [7][8][9]17 On the other hand, despite the additional medical cost and physical burden to the patient of using the staged procedure, simultaneous SBCAS is not usually recommended because of the risk of cerebral HPS and HD, such as severe bradycardia or hypotension. 17,18 Some reports supporting SBCAS have demonstrated that it is feasible and has theoretic advantages over staged stent placement, including potentially minimizing both hospitalization and medical costs.…”

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

“…All patients underwent neurological examination the day after the procedure. Post-procedural complications, according to Mathur et al [17] classification, were defined as follows:…”

Preprocedural C-Reactive Protein Levels Predict Stroke and Death in Patients Undergoing Carotid Stenting

“…The clinical outcome measures were minor or major stroke or death within 30 days and were defined as follows 17 :…”