The safety and efficacy of staged angioplasty for treating carotid stenosis with a high risk of hyperperfusion: A single-center retrospective study

Abstract

Objective Hyperperfusion syndrome (HPS) following carotid artery stenting (CAS) is a rare but life-threatening complication. Staged angioplasty (SAP) is an alternative method that prevents HPS by preventing a sudden increase in cerebral blood flow. In this study, we investigated the safety and efficacy of SAP. Methods A total of 114 patients with carotid stenosis underwent CAS treatment in our hospital between September 2014 and September 2019. Patients with severe stenosis and poor collateral circulation shown on digital subtraction angiography (DSA) and hypoperfusion of the ipsilateral diseased blood vessel shown on computed tomography perfusion (CTP) imaging were subjected to SAP treatment (the SAP group), and other patients received regular CAS treatment (the RS group). Results Twenty-two patients (19.3%) with a high risk of HPS underwent SAP treatment, 1 of whom had carotid dissection after stage I balloon angioplasty and underwent regular CAS. This patient had HPS after surgery. None of the other patients in either group had HPS. One patient in the SAP group (4.5%) had hyperperfusion phenomenon (HPP) after stage II stenting, and 2 patients in the RS group (2.2%) had HPP. One patient in the SAP group (4.5%) and 4 patients in the RS group (4.3%) had symptomatic ischemic complications postoperatively. None of the differences between the 2 groups were statistically significant. Three patients had reduced modified Rankin Scale (mRS) scores at 90 days after discharge. Conclusion This research suggests that SAP appears to be an effective method to prevent HPS for patients with a high risk of HPS.

Staged angioplasty: A sensible approach to prevent hyperperfusion syndrome after carotid artery stenting? A meta-analysis

“…Ten studies were included in this meta-analysis. Among these, one article was randomized control trial 8 and nine articles were non-RCTs (four non-controlled studies 14–17 and five case-control studies 4 , 6 , 9–11 ). The main characteristics of the included studies are provided in Table 1.…”

“…Four studies included all patients with symptomatic carotid stenosis (defined as carotid stenosis associated with stroke or transient ischaemic attack), 8 , 14 , 16 , 17 four studies included patients with asymptomatic or symptomatic carotid stenosis, 6 , 9 , 11 , 15 and two studies only included patients with carotid stenosis without reference to asymptomatic or symptomatic stenosis. 4 , 10 Eight studies reported on elective procedures only, 4 , 6 , 9–11 , 15–17 two studies might recruit acute patients based on the description of their method. 8 , 14 The endpoint of efficacy and the endpoint of safety were evaluated in this meta-analysis as shown in Supplementary Table S3.…”

“…The quality of most articles was moderate (Supplementary Table S2). One RCT 8 was assessed by the Jadad Scale, eight retrospective studies 4 , 9–11 , 14–17 and one prospective study 6 were evaluated by MINORS.…”

“…All included ten studies reported data on HPS. 4 , 6 , 8–11 , 14–17 Among these studies, six case-control studies revealed that the incidence of HPS in the SAP group was significantly lower than that in the regular CAS group [0.6% (95% CI, 0%–3.0%) VS 3.0% (95% CI, 0%–10.4%); OR = 0.35 (95% CI 0.14–0.86), P = 0.02; heterogeneity P = 0.76, I 2 = 0%] (Supplementary Table S4 and Figure 2(a)). When the incidence of post-SAP HPS was synthesized across included ten studies as a single arm, the rate of post-SAP HPS was 1.6% (95% CI, 0%–6.7%).…”

“…8 HPP was defined as an increase of CBF >100% than the baseline detected by TCD or other imaging exams. 8–10 ICH was defined as hyperdensities that were consistent with blood in the parenchyma of the culprit hemisphere on non-contrast CT. 8 , 11 The endpoint of safety was thromboembolic events. The thromboembolic event was defined as the lesions detected by postoperative diffusion-weighted magnetic resonance imaging (DWI) after termination of all the procedure.…”