Carotid artery stenosis: Routine predilatation or direct stenting?

Stenting is a potential alternative treatment for carotid artery stenosis. Direct stenting may, theoretically, reduce the risk of embolism by minimizing plaque manipulation before tissue scaffolding is achieved. The results of direct carotid stenting are reported and compared with those of stenting with predilatation. One hundred and seventy‐four carotid artery stenoses were treated from July 1998 to February 2002, with 84 lesions directly stented (Group 1) and the other 90 lesions stented after predilatation (Group 2). The criteria for direct stenting were minimal luminal diameter (MLD) > 1 mm and no visible thrombus angiographically. Technical success rates of the two groups were both 100%, without any cross‐over. Reference vessel diameter and lesion length did not differ between the two groups. In Group 1, diameter stenosis was lower (79 ± 8 vs 92 ± 7%, P < 0.001) and MLD was larger (1.1 ± 0.5 vs 0.4 ± 0.4 mm, P < 0.001) than that in Group 2, but the final MLD (4.7 ± 0.9 vs 4.7 ± 0.9 mm, P = 0.94) of the two groups were not statistically different. The periprocedural ipsilateral stroke or death rates were also similar in the two groups (2/84 vs 4/90, P = 0.68). It was concluded that if the MLD of carotid stenosis is larger than 1 mm and no thrombus is present, direct stenting could be carried out safely with results comparable to that of stenting after predilatation.      

Endarterectomy vs stent angioplasty: what is the optimal treatment of carotid stenosis?

Very few operations have been subject to more scientific scrutiny than carotid endarterectomy (CEA). Since its introduction in the 1950s, CEAs have been performed in great numbers with the goal of preventing ischemic stroke. In the mid 1980s concern about over utilization of CEA and reports of excessive perioperative stroke morbidity and mortality prompted the initiation of several multicenter, randomized trials designed to evaluate the efficacy of CEA. As the results of these trials became available, the number and frequency of CEA in the United States increased significantly. However, now a new wave of uncertainty has arisen related to the availability of an alternative to CEA, carotid angioplasty and stent (CAS). Now, more than ever, there is uncertainty as to the proper management of carotid artery stenosis. In this review we summarize the existing data regarding the efficacy of CEA and compare these data to a critical analysis of the recent results of CAS.     

Recurrent Stenosis and Contralateral Occlusion: High-risk Situations in Carotid Endarterectomy?

Carotid angioplasty and stenting (CAS) has been proposed as a treatment option for carotid occlusive disease in high-risk patients including those with recurrent stenosis (RS) and contralateral occlusion (CO). This study reviews the results of carotid endarterectomy (CEA) in patients with RS and CO. We conducted a retrospective review from our vascular registry of 1670 patients who underwent CEAs (n = 1950) from January 1990 through December 2001. Procedures included RS 86 (4.4%), CO 112 (5.7%), and control 1752 (89.9%). There were 37 strokes in the entire group (1.9%). Among the high-risk group with RS and CO, there were 6 strokes, (RS n = 2, CO n = 4) 3%. There were 31 strokes in the control group 1.8% (p = NS). Postoperative TIAs were observed more frequently in patients with CO (n = 2) or RS (n = 2), 1.8% and 2.3%, respectively (p < 0.05). Neck hematomas, intracerebral hemorrhages, and myocardial infarctions did not differ between groups. Three deaths occurred within 30 days (0.15%); one was a patient with CO. Renal failure and symptomatic disease were each associated with a higher risk of perioperative stroke; among patients with renal failure there were 6 strokes (4.6%) p < 0.05, in symptomatic patients there were 26 strokes (2.7%) p < 0.05. Multivariate logistic regression analysis confirmed that preoperative renal disease and surgery for symptomatic disease were both significant predictors of perioperative stroke (p < 0.05; odds ratio 2.177 and 2.943 respectively) while neither RS nor CO was from these results we concluded that the presence of RS and CO do not increase the risk of perioperative stroke in CEA. Presented at the Thirteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, January 31-February 2, 2003.     

Symptomatic carotid stenosis: endarterectomy, stenting, or best medical management?

In the past, management of symptomatic carotid stenosis was uncertain. The results of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) in 1991 demonstrated a significant advantage of Carotid Endarterectomy (CEA) compared to medical management with Aspirin (ASA). Since the publishing of the NASCET results, there have been advances in both the medical management of patients with peripheral arterial disease as well as the introduction and improvement of the technique of minimally invasive carotid angioplasty and stenting. With this progress, the question has to be raised about what is the most appropriate treatment option for patients with symptomatic carotid artery stenosis. A review of the prospective clinical trials regarding the medical, surgical and endovascular management will help to elucidate the optimal therapy for symptomatic carotid stenosis.     

Is Carotid Endarterectomy a Trainee Operation?

Background  Recent dramatic changes in surgical training resulting from working-hour regulations may lead to lack of competence. Traditionally, carotid surgery has been the domain of specialists. This study was designed to compare the outcome of carotid endarterectomy performed by vascular surgical trainees versus vascular surgeon (VS). Methods  A retrospective study of 1,379 consecutive patients who underwent carotid endarterectomy as the sole procedure under local or general anesthesia (from 1995–2004) was performed. All patients were admitted to the intensive care unit for 24 hours. Trainees performed 475 (34.5%) and vascular specialists performed 904 (65.5%) operations. Results  Patient characteristics with regard to preoperative neurological status were similar. Trainees operated on 61.4% symptomatic patients and VS on 56.8% (P = 0.09). Shunt use did not differ (16% trainee vs. 17.8% VS). Clamping time and total operating time were longer among trainees (41.9 vs. 33.5 min, P < 0.001; and 121.2 vs. 101.8 min, P < 0.001, respectively). Postoperative stroke and death rates (3.2% vs. 3.1% and 0.4% vs. 0.9%, respectively) did not differ. Peripheral nerve complications were more common among trainees (12.2% vs. 6.5%; P < 0.0001); 99.6% of these nerve injuries had resolved at 3 months’ follow-up. Conclusions   Carotid endarterectomy can be performed safely by a trainee vascular surgeon when assisted and supervised by a specialist vascular surgeon.     

Long-term outcomes and predictors of iliac angioplasty with selective stenting: is primary stenting necessary?

Percutaneous transluminal angioplasty (PTA) has become one of the initial treatment options in patients with iliac artery occlusive disease. Stents have been recommended to correct procedural complications and improve long-term patency. Many series advocate routine stent placement after an otherwise uncomplicated PTA (primary stenting) in an attempt to prevent recurrent disease. Currently, many physicians in the United States seem to use stents in the iliac artery more liberally, even on a routine basis. There is little evidence to support this practice, however. It is still unclear whether a stent should be inserted primarily or selectively. This article provides the data from an 11-year experience of angioplasty with selective stenting for iliac artery occlusive lesions and reviews the current literatures on the iliac artery stent placement.     

Carotid Endarterectomy in Octogenarians and Nonagenarians: Is it Worth the Effort ?

Purpose: The safety, effectiveness and cost issues of carotid endarterectomy (CEA) in the elderly patient have been debated due to the limited life expectancy and presumably increased rate of complications. This is despite multiple reports in the literature of excellent results in this population. To further examine this issue, we compared characteristics of three populations who underwent CEA at our institution: 53–79 year old patients (youngest group), 80–89 years old patients (middle group), and 90–98 year old patients (oldest group).

Methods: Medical and financial data were obtained by retrospective review of hospital charts and billing records. We analyzed 266 random CEAs performed in 251 patients in the youngest group, 280 CEAs performed in 247 patients in the middle group and 19 CEA in 16 patients in the oldest group performed between 2/1/90 and 2/5/01. Results: Comparing each CEA group, there were no differences in gender (males: 56% vs. 51% vs. 53%), incidence of preoperative symptoms (43% vs. 43% vs. 42%), hypertension (68% vs. 60% vs. 42%), combined perioperative death and stroke rate (1.8% vs. 2.1% vs. 10%) or other complications (11% vs. 10% vs. 10%). Significant differences (p<0.05) were noted between the groups in incidence of diabetes (33% vs. 51% vs. 5% in each group), and heart disease (28% vs. 38% vs. 21%). Length of stay for admissions for CEA only were also similar in all three groups (2.37 days vs. 2.67 days vs. 2.36 days). A cost analysis of the earliest 230 patients in the entire series examining hospital cost per case revealed similar data for the <80 years old and > 80 year old patients ($7,842 vs. $9,400).

Conclusions: Carotid endarterectomy can be performed in the elderly as safely and cost effectively as in the younger population.     

Renal angioplasty and stenting: is it still indicated after ASTRAL and STAR studies?

A renal artery stenosis (RAS) is common among patients with atherosclerosis, up to a third of patients undergoing cardiac catheterization. Fibromuscular dysplasia is the next cause of RAS, commonly found in young women. Atherosclerosis RAS generally progresses overtime and is often associated with loss of renal mass and worsening renal function (RF). Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS according to ACC and AHA guidelines. Several randomized trials have shown the superiority of endovascular procedures to medical therapy alone. However, two studies ASTRAL and STAR studies were recently published and did not find any difference between renal stenting and medical therapy. But these studies have a lot of limitations and flaws as we will discuss (poor indications, poor results, numerous complications, failures, poor technique, inexperienced operators, ecc.). Despite these questionable studies, renal stenting keeps indications in patients with: uncontrolled hypertension; ischemic nephropathy; cardiac disturbance syndrome (e.g. "flash" pulmonary edema, uncontrolled heart failure or uncontrolled angina pectoris); solitary kidney. To improve the clinical response rates, a better selection of the patients and lesions is mandatory with: good non-invasive or invasive imaging; physiologic lesion assessment using transluminal pressure gradients; measurements of biomarkers (e.g., BNP); fractional flow reserve study. A problem remains after renal angioplasty stenting, the deterioration of the RF in 20-30% of the patients. Atheroembolism seems to play an important role and is probably the main cause of this R.F deterioration. The use of protection devices alone or in combination with IIb IIa inhibitors has been proposed and seems promising as shown in different recent reports. Renal angioplasty and stenting is still indicated but we need: a better patient and lesion selection; improvements in techniques and maybe the use of protection devices to reduce the risk of RF deterioration after renal stenting.     

Cost Analysis of Carotid Endarterectomy: Is Age a Factor?

Carotid endarterectomy (CEA) has been demonstrated to be safe and effective in elderly patients. Our aim was to analyze and compare outcome and cost of CEA in both elderly and younger patient groups. A total of 125 consecutive patients who underwent CEA were examined retrospectively and grouped according to age (<80 years old, n = 95; and 80 years old, n = 30). The actual total costs and itemized costs were analyzed, and diagnosis-related group (DRG) code payor mix were identified. Patient demographics and risk factors were similar except for a greater incidence of coronary artery disease (CAD) in the 80 group than in these <80 (43.3% vs. 21.1%, p < 0.05). Patients had similar minor complication rates; however, the 80 group had higher perioperative major complications (16.7% vs. 1.1%, p < 0.01). There were no deaths and there was one perioperative stroke, which occurred in the <80 group. Mean length of stay (LOS), intensive care unit (ICU) LOS, and ICU admissions were greater in the 80 group. Cost figures were normalized to a base value of $100 to maintain proprietary data. Actual total costs of CEA were $131.50 for the 80 group and $100 for the <80 group (p < 0.001). Significant cost differences were found in ICU room costs, and costs for clinical laboratory, radiology imaging, other specialty consults, operating room, and ancillary services in the 80 group compared with the <80 group. These results show that the cost of CEA in the elderly is significantly greater than that for younger patients. This difference can be attributed to a greater number of major complications in the more elderly group, who require increased ICU stay, and thus require more clinical laboratory, radiology imaging, and specialty consult service resources. Consideration should be given for a DRG modifier code to increase hospital reimbursement for increased associated costs in elderly patients undergoing CEA.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Carotid artery stenting: which stent for which lesion?

Although some early reports describe angiographic as well as clinical success for balloon angioplasty alone in the treatment of carotid occlusive disease, most interventionists prefer stent-assisted balloon angioplasty because of the purported advantages, such as avoiding plaque dislodgement, intimal dissection, elastic vessel recoil and late restenosis. Mainly because of the different characteristics of each carotid artery segment, different types of stents are preferred. A carotid artery lesion located in the intrathoracic brachiocephalic trunc or common carotid artery would need a different stent to a lesion at the carotid bifurcation or a lesion of an intracerebral branch of the internal carotid artery.