Follow-up after carotid stenting with the CASPER stent system: A duplex ultrasound evaluation

The Efficacy of Dual-layer Stent Compared to Single-layer Stent in Carotid Revascularization: A Systematic Review and Meta-analysis

BACKGROUND

Prior studies have demonstrated the dual-layer stent (DLS) was associated with encouraging results in carotid revascularization. This meta-analysis aimed to study the comparative efficacy between DLS and single-layer stent (SLS).

METHODS

The studies were retrieved from PubMed, Embase, and Scopus up to June 2023. The methodological evaluation was performed using the corresponding scale. Pooled analysis was conducted using R Studio to calculate the effects, including odds ratio (OR) and mean difference (MD). Heterogeneity among results was assessed using the I2 statistic. Sensitivity analysis and subanalysis were also performed.

RESULTS

In this meta-analysis, nine articles comprising 1,127 patients who underwent carotid stenting (606 with DLS) were studied. No significant difference between DLS and SLS was found in stroke (at 30 days DLS: 4/555 vs. SLS: 11/496; OR 0.38, 95% confidence interval [CI] 0.14-1.03; at 12 months DLS: 1/249 vs. SLS: 4/152; OR 0.21, 95% CI 0.03-1.36), death (at 30 days DLS: 3/526 vs. SLS: 0/467; OR 0.80, 95% CI 0.20-3.11; at 12 months DLS: 5/249 vs. SLS: 3/152; OR 1.12, 95% CI 0.25-5.03), stroke/death (at 30 days DLS: 6/526 vs. SLS: 11/467; OR 0.43, 95% CI 0.16-1.17; at 12 months DLS: 6/249 vs. SLS: 7/152; OR 0.52, 95% CI 0.17-1.61), new lesions (DLS: 56/202 vs. SLS: 96/254; OR 0.62, 95% CI 0.28-1.40), lesion count (MD = -0.24, 95% CI -0.82-0.34), lesion diameter (MD = -0.03, 95% CI -1.21-1.15), in-stent restenosis (ISR; DLS: 5/204 vs. SLS: 8/190; OR 0.61, 95% CI 0.21-0.74) and acute thrombosis (DLS: 4/146 vs. SLS: 1/122; OR 2.03, 95% CI 0.31-13.26). Subgroup analysis indicated that CGuard and Casper had shown similar efficacy in preventing stroke, death, and new brain lesions.

CONCLUSION

DLS has shown comparable prognoses to the first-generation stent concerning stroke, stroke/death, new magnetic resonance imaging lesion incidence, lesion count, lesion diameter, ISR and acute thrombosis. Further randomized trials are warranted to demonstrate whether patients with high-risk carotid plaques can benefit significantly from DLS.

Seven years of CRAFT: Clinical results of a multicenter cohort of carotid artery relining with the CASPER RX stent

BACKGROUND AND PURPOSE

Carotid artery stenting (CAS) is an established treatment for carotid stenosis or occlusion. Use of the dual-layer microporous CASPER RX stent has had mixed results in prior reports. The CaRotid Artery Filtering Technique (CRAFT) uses the distal end of the CASPER stent as an embolic protection device during deployment. We present the largest cohort of patients having undergone CAS with the CASPER stent and report our multicentre experience with CRAFT over the last seven years.

MATERIALS AND METHODS

All patients undergoing CAS at three tertiary neurointerventional centres in Australia from April 2016 to April 2023 were included. Patient demographic, procedural and clinical data were retrospectively collected. All included patients underwent CAS with CASPER stent insertion using CRAFT.

RESULTS

215 patients (74 % male, mean age 70) were included in the study. Most patients (89 %) were treated on an emergent basis with 81 % of these representing tandem lesions in acute ischaemic stroke. Median NIHSS score was 12 on admission and 6 post-procedure. 98 % achieved an mTICI score of 2b or higher. Median mRS score was 1 at the time of earliest outpatient follow-up. 90 % of patients received intraprocedural antiplatelet therapy. 10 % suffered symptomatic intracranial haemorrhage and 7 % had stent occlusion. An 8 % all-cause mortality rate was observed.

CONCLUSION

Emergent CAS with the CASPER RX stent and CRAFT is both safe and efficacious, with low rates of stent occlusion and restenosis as well as a low risk of major complication. Given the limited sample of elective patients in our cohort, further studies are required to corroborate the safety profile of CRAFT in elective CAS.

Incidental neck mass in a young adult: A case report

INTRODUCTION

While true extracranial internal carotid aneurysms (tECAAs) are extremely rare and often asymptomatic, they can lead to serious complications including rupture, thrombosis or embolization. Surgery has been the standard, even in asymptomatic patients, due to safety and long-term outcomes. However, advancements in technology have introduced endovascular interventions and observation as options.

PRESENTATION OF CASE

A 32-year-old obese man presented with sudden right-sided facial numbness lasting 3 h. Personal, family, social and trauma history were unremarkable. Cardiac and neurological examinations were normal. Imaging revealed a non-flow-limiting stenosis and a left internal carotid saccular artery aneurysm (15 × 16 mm). After considering the pros and cons of each treatment and thorough shared decision-making, left carotid stenting (6 × 25 mm ViabahnGORE) was performed. The postoperative course was uneventful. Patient was discharged on the postoperative day 2 with Clopidogrel.

DISCUSSION

The choice of treatment approach for tECAAs depends on various factors, including patient characteristics, surgeon experience, and equipment availability. In general, symptomatic aneurysms (regardless of diameter), expanding aneurysms, and larger aneurysms (>20 mm), and those with identified thrombus are typically indications for repair.

CONCLUSION

Endovascular techniques are gaining traction due to their potential advantages, including avoidance of cranial nerve injury and general anesthesia, enhanced access and control of lesions that may be difficult to navigate surgically, and lower rates of perioperative morbidity and mortality.

Finite element analysis of braided dense-mesh stents for carotid artery stenosis

When braided dense-mesh stents are used to treat carotid stenosis, the structural mechanics of vascular stents, the contact mechanics with blood vessels, and the fluid mechanics in the blood environment need to be studied in depth to reduce the damage of stents to blood vessels and the incidence of in-stent restenosis. Three types of braided stents with 8, 16, and 24 strands and laser-cut stents with the corresponding size parameters were designed, and the bending behavior of each of these types of stent, deployment, and fluid dynamic analysis of the 24-strand braided stent were simulated. The results show that the bending stress of the 8-, 16-, and 24-strand braided stents is 46.33%, 50.24%, and 31.86% of that of their laser-cut counterparts. In addition, higher strand density of the braided stents was associated with greater bending stress; after the 24-strand braided stent was expanded within the stented carotid artery, the carotid stenosis rate was reduced from 81.52% to 46.33%. After stent implantation, the maximum stress on the vessel wall in a zero-pressure diastolic environment decreased from 0.34 to 0.20 MPa, the maximum pressure on the intravascular wall surface decreased from 4.89 to 3.98 kPa, the area of high-pressure region decreased, the wall shear force of the stenotic segment throat decreased, and blood flow increased in the stenosis segments. The braided stent had less bending stress and better flexibility than the laser-cut stent under the same stent size parameters; after the 24-strand braided stent was implanted into the stented vessel, it could effectively dilate the vessel, and the blood flow status was improved.

Strategy of carotid artery stenting as first-line treatment and carotid endarterectomy for carotid artery stenosis: A single-center experience

Background:

The main surgical options for stenosis of the carotid artery are carotid endarterectomy (CEA) and carotid artery stenting (CAS). The number of CAS procedures performed in Japan greatly exceeds that of CEA procedures. In this study, we used data from a single center to examine CAS and CEA for carotid artery stenosis.

Methods:

The subjects were patients with carotid artery stenosis who underwent CAS or CEA between January 2012 and May 2020. CAS was the first-choice treatment. CEA was used in cases with vulnerable plaques, a relatively low risk of general anesthesia, and no anatomical features disadvantageous for endarterectomy.

Results:

A total of 140 cases (102 CAS and 38 CEA) were examined. There were more elderly patients in the CAS group. The CEA group had a higher rate of vulnerable plaques and only one case with an unfavorable anatomy for CEA. Major adverse events (stroke) occurred in two CAS cases. In multivariate logistic analysis, postoperative ischemic lesions were independently associated with age (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.01–1.26, P = 0.026) and vulnerable plaque (OR = 5.54, 95% CI: 1.48–20.70, P = 0.011) in the CAS group, but not in the CEA group.

Conclusion:

The results reflect the treatment algorithm at our hospital, indicating that triage is accurate. Thus, it is beneficial to assign cases based primarily on plaque vulnerability and anatomical risk for CEA, and to not hesitate to perform CEA simply because of old age. CAS as first-line treatment and CEA are effective and safe, which reflect the treatment situation in Japan.

Comparison of Restenosis Risk in Single-Layer versus Dual-Layer Carotid Stents: A Duplex Ultrasound Evaluation

PURPOSE

The aim of this study was to report intermediate-term results of duplex ultrasound follow-up of carotid artery stenting performed with the dual-layer stent as compared to concurrent patients treated with other commercially available single-layer carotid stents.

MATERIALS AND METHODS

A single centre, retrospective, nonrandomized study including 162 non-consecutive patients with 199 implanted carotid stents treated over a 7-year period was conducted. Patients with at least one ultrasound examination after treatment were included. Procedural and follow-up data for patients treated with the dual-layer stent implantation (83 stents) vs first-generation carotid stents implantations (116 stents) were compared.

RESULTS

The median follow-up time was 24.0 months (IQR 10-32 months) for dual-layer stents and 27.5 months (IQR 10.3-59 months) for single-layer stents. The rate of severe restenosis was significantly higher in the dual-layer stent group than in the single-layer group (13.3% [11/83] vs 3.4% [4/116], p = 0.01). Seven reinterventions were performed in 5 patients with dual-layer stents. The rate of reintervention was significantly higher compared to no reinterventions in single-layer stents (6% [5/83] vs 0% [0/116], p = 0.012). Patients with restenosis had significantly higher presence of dyslipidaemia (100% [12/12] vs 63.3% [95/150], p = 0.009).

CONCLUSIONS

In this real-world cohort of patients undergoing carotid artery stenting, the patients treated with low-profile dual-layer micromesh stent showed higher rates of restenosis and reinterventions compared to first-generation single-layer stents.