Device selection for carotid stenting: reviewing the evidence

Long-term imaging follow-up to evaluate restenosis in patients with carotid stenosis after angioplasty and stenting

BACKGROUND

Stent patency after carotid angioplasty and stenting (CAS) correlates not only with stroke prevention but also with improvements in cognition and quality of life by positively influencing cerebral perfusion. The long-term outcomes of CAS after more than 5 years have still not been well described. This retrospective study was designed to evaluate the stent patency and significant restenosis (SR) after CAS with more than 5 years of follow-up.

METHODS

Between 2006 and 2012, 118 patients with carotid stenosis who underwent 131 CAS procedures with regular annual imaging follow-up for more than 5 years were enrolled. We evaluated their demographic characteristics and the risk factors related to stent restenosis. Patients with SR (restenosis ≥ 50%) were compared with those with no significant restenosis (NSR, patency or restenosis < 50%) to identify the restenosis predictors and restenosis-free survival.

RESULTS

Of the 131 CAS procedures, 16.0% (21/131) had SR. A history of head and neck radiotherapy (HNRT) was a predictor for SR (HR, 6.352; 95% CI, 2.504-16.112; p < 0.001) and was associated with shorter restenosis-free survival (log-rank test p value < 0.001, median time of restenosis-free survival was 38 months). Left-sided stenting was an associated factor for SR (HR, 3.007; 95% CI, 1.068-8.467; p = 0.037) with a trend of less restenosis-free survival (log-rank test p value 0.067).

CONCLUSION

Both HNRT and left-sided carotid stenosis were predictors of SR after CAS in more than 5 years of long-term follow-up. Restenosis-free survival was significantly shorter in patients with prior HNRT than in patients without previous irradiation treatment. We suggest close follow-up and aggressive medical treatment for patients with prior HNRT and left-sided carotid stenosis undergoing CAS.

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

Patient selection for endovascular intervention in extracranial carotid disease is centered on vascular anatomy. We review anatomical considerations for non-traumatic disease and offer guidelines in patient selection and management. We conducted a systematic literature review without meta-analysis for studies involving anatomical considerations in extracranial carotid intervention for non-traumatic disease. Anatomical considerations discussed included aortic arch variants, degree of vessel stenosis, angulation, tortuosity, and anomalous origins, and atheromatous plaque morphology, composition, and location. Available literature suggests that anatomical risks of morbidity are largely secondary to increased procedural times and difficulties in intervention system delivery. We recommend the prioritization of endovascular techniques on an individual basis in cases where accessible systems and surgeon familiarity provide an acceptable likelihood of rapid access and device deployment.

Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience

PURPOSE

To evaluate the safety and efficacy of carotid artery stenting (CAS) performed without an embolic protection device (EPD) in a selected group of asymptomatic patients with primary internal carotid artery (ICA) stenosis or restenosis after carotid endarterectomy (CEA).

MATERIALS AND METHODS

Between May 2015 and May 2018, 77 patients (mean age 77 years; 60 men) underwent CAS without any embolic protection device. Forty-seven (61%) patients had primary ICA stenosis and were excluded from CEA because of high surgical risk; the other 30 (39%) patients had post-CEA restenosis (n=26) or a distal ICA flap after eversion CEA (n=4). The mean ICA stenosis was 82%. All procedures were performed from a femoral artery access. Pre- and/or postdilation were used in 64 patients. The primary outcome was the incidence of major complications (death, stroke, or myocardial infarction) during the procedure and within 30 days; the secondary outcome was the incidence of restenosis in follow-up.

RESULTS

No relevant bradycardia was encountered during CAS. The combined rate of stroke, death, or myocardial infarction at 30 days was 1.3%. The single stroke patient recovered fully after 2 months. Over a follow-up that ranged to 3 years (mean 24±18 months), no further neurological events were recorded. One (1.3%) patient had a >70% restenosis after 6 months; the lesion was dilated, successfully restoring the lumen contour.

CONCLUSION

In our series, endovascular treatment of carotid stenosis without the use of protection devices in patients with primary stenosis or postsurgical restenosis can achieve satisfactory safety and efficacy outcomes. The choice of performing CAS without using EPDs should follow a tailored approach based on the appropriate patient anatomy and specific clinical parameters to minimize neurological complications.