Procedural Success Rates and Mortality in Elderly Patients With Percutaneous Coronary Intervention for Cardiogenic Shock

ObjectivesThe aim of this study was to determine the impact of age on procedural and clinical outcomes in patients with cardiogenic shock (CS).BackgroundThe use of early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcome in patients with acute myocardial infarction (AMI) complicated by CS.MethodsData from consecutive patients with AMI and CS treated with PCI enrolled into the prospective ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte) PCI registry were centrally collected and analyzed. Patients were divided into 4 groups according to their age (<65, 65 to 74, 75 to 84, and >85 years). Patients’ characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared among the 4 groups.ResultsBetween 2010 and 2015, a total of 2,323 consecutive patients with AMI and CS were treated by PCI in 51 hospitals. TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 patency after PCI decreased with increasing age from 84% to 78%, while in-hospital mortality increased from 32% to 56%. Bleeding rates were low (2.0% to 2.3%) and not different among age groups. In the multivariate analysis, higher age, TIMI flow grade <3 after PCI, 3-vessel disease, and left main PCI were independent predictors of mortality.ConclusionsPCI in patients with AMI and CS is associated with a high procedural success rate and a low bleeding rate, even in very elderly patients, while mortality increases with increasing age. Because mortality in elderly patients with CS without revascularization therapy is very high, it seems justified to perform PCI in selected patients to reduce mortality.     

Impact of coronary artery disease on in-hospital mortality in patients with aortic valve disease

Objective

Although aortic valve disease (AVD) is frequently associated with coronary artery disease (CAD), little is known about the impact of significant coronary artery disease on mortality after diagnostic cardiac catheterization in patients with AVD.

Methods

We analyzed data of the coronary angiography registry of the “Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte” (ALKK) in Germany. The primary endpoint was in-hospital mortality.

Results

A total of 1427 consecutive patients with AVD (438 patients with CAD versus 989 patients without CAD) underwent diagnostic catheterization in 2006 in 42 hospitals. All cause in-hospital mortality was more than threefold higher in patients with CAD (16/438; 3.7%) as compared to patients without CAD (12/989; 1.2%; p?<?0.01; OR 3.09, 95% CI 1.45–6.58). Even after adjustment for age, sex, presence of diabetes mellitus and renal insufficiency, in-hospital all cause mortality remained statistically significant different between the two groups (OR 2.4; 95% CI 1.09–5.28; p?<?0.01). Several factors, such as transient ischemic attack/stroke, volume of contrast agent, and left heart catheter-associated complications could not be identified as possible causes for the increase in mortality.

Conclusion

This analysis in patients with the leading diagnosis of AVD shows a significantly higher in-hospital mortality after diagnostic cardiac catheterization in case of an accompanying CAD. However, further studies are necessary to identify the driving force for the increase in mortality.     

Carotid Artery Stenting in Clinical Practice: Does Sex Matter? Results From the Carotid Artery Stenting Registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Background:

Carotid artery stenting (CAS) is increasingly used for treatment of severe carotid artery stenosis, but only few procedural risk factors for complications of CAS are clearly defined yet. A possible impact of the patient's gender on the outcome of patients undergoing CAS has not been investigated properly and only little information about this topic is available so far.

Methods:

We analysed data of the German prospective, multicenter CAS Registry of the Arbeitsgemeinschaft leitende kardiologische Krankenhausärzte.

Results:

From July 1996 to May 2009 5130 patients underwent CAS at 35 German hospitals and were enrolled into the prospective ALKK CAS Registry. Therefrom 1443 (28.1%) patients were female. There was no significant time‐related difference in the proportion of women undergoing CAS over the years. Women undergoing CAS were significantly older than men (73 years vs. 70 years, p < 0.01) and had a longer in hospital stay in comparison to men (p < 0.01). The majority of patients treated with CAS was between 60 and 80 years of age (～73%). No significant differences between women and men could be found regarding in‐hospital events like death (0.5% vs. 0.5%, p = 0.99), major or minor stroke (1.7% vs. 1.6%, p = 0.97; 1.0% vs. 1.6%, p = 0.12), TIA (2.8% vs. 2.6%, p = 0.64), amaurosis fugax (0.3% vs. 0.5%, p = 0.25) , intracranial bleeding (0.5% vs. 0.3%, p = 0.43), myocardial infarction (0.1% vs. 0.0%, p = 0.48) or all non‐fatal strokes and all death (3.0% vs. 3.4%, p = 0.47). 30 day event rates did not show gender related differences in the combined endpoint of the outcome of patients undergoing CAS, as well (♀ n = 31/882 [3.5%] vs. ♂ n = 109/2273 [4.8%], p = 0.12).

Conclusion:

Our results do not suggest any gender‐related differences in success rates and complications in CAS. In clinical practice approximately 30% of patients treated with CAS are women. The institutions and people who participated in the ALKK CAS Registry are listed in Zahn et al. 16. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Interventional treatment and outcome in elderly patients with stable coronary artery disease

Background

The number of elderly and very elderly patients undergoing percutaneous coronary interventions (PCI) is increasing. We therefore analyzed data from the German ALKK registry (Arbeitsgemeinschaft Leitende Krankenhausärzte; Working Group of Hospital Cardiologists) to determine differences in procedural features, antithrombotic treatment, and in-hospital outcome in patients with coronary artery disease (CAD) according to age in a large series of patients.

Methods and results

The present analysis was based on the data of 35,534 consecutive patients undergoing elective PCI who were enrolled in the ALKK registry. Of these 27,145 (76.4?%) were younger than 75 years, 7,645 (21.5?%) were aged between 75 and 84 years, and 744 (2.1?%) patients were older than 85 years. Mean age was 68.5 years (60.9–74.5 years), and 25,784 patients (72.6?%) were male. Overall intraprocedural events were very low (1.1?%) and there was no significant difference between the three age groups [<?75 years (1.1?%); 75-<?85 years (1.2?%); ≥?85 years (0.5?%) (p?= not significant)]. Rates of in-hospital death, stroke and transient ischemic attack (TIA), as well as the combined endpoint in-hospital major adverse cardiac and cerebrovascular events (MACCE) were also very low (0.6?% vs. 0.9?% vs. 0.9?%; p?<?0.001) but significantly higher in elderly patients with no further increase in the very elderly patient group.

Conclusion

We found no differences in this registry in intraprocedural complications during elective PCI between younger and elderly patients. Although in-hospital MACCE were somewhat higher in the elderly, the overall event rate was low and thus elderly patients should not be deprived from this therapy because of age alone.     

Carotid artery stenting without post-dilation

Introduction: The aim of this study is to report the feasibility, safety, and 1‐year restenosis rate of carotid artery stenting (CAS) without post‐dilation. Methods: Between April 2006 and November 2009, 254 consecutive patients (68.7 ± 8.5 years old, 31% symptomatic) underwent 308 CAS procedures with the intention of avoiding post‐dilation (eligibility criteria were stenosis of less than 30% after stent placement with no overt signs of calcification). Comparison and analysis of mid‐term clinical outcomes and restenosis rates of CAS with or without post‐dilation was performed retrospectively. Results: Overall, 27 patients (study group) were eligible for treatment without post‐dilation. No significant difference in adverse events was found between the study and control group. In the study group, 2 transient ischemic attacks (7.4%) occurred immediately after the procedure and no other neurological complications were reported during the 30‐day, 6‐month, and 1‐year follow‐ups (3 patients died from causes unrelated to the procedure). Two asymptomatic restenosis cases were diagnosed in the study group within the first 12‐months after the procedure compared to 16 significant restenosis cases diagnosed in the control group (7.4% vs 5.7%, NS). All of them were successfully treated with repeated intervention. Conclusion: We suggest that CAS without post‐dilation is feasible and probably safe with a low rate of cerebrovascular events and restenosis in a selected group of patients. We also suggest that CAS with postdeployment stenosis of less than 20% and without overt signs of severe calcification might be performed without post‐dilation. (J Interven Cardiol 2012;25:190–196)     

Carotid artery stenting in octogenarians: results from the ALKK Carotid Artery Stent (CAS) Registry.

AIMS: We tried to determine the influence of age on complication rates of carotid artery stenting (CAS). METHODS AND RESULTS: Two thousand seven hundred eighty CAS procedures were included in the registry. Median age of the patients was 70.8 years, with a proportion of octogenarians of 11.2% and a significant increase between 1996 (5.9%) and 2005 (13.7%; P for trend = 0.002). In octogenarians, a symptomatic stenosis was a more frequent indication for CAS (60.7% vs. 48%, P < 0.001), the CAS procedure was aborted more frequently (6.9% vs. 2.2%; P < 0.001) and the duration of intervention was longer (Median 45 vs. 40 min; P = 0.008). Increasing age was associated with a significant increase in the in-hospital death or stroke rate (P for trend: 0.001). In-hospital death or stroke rate was also higher in octogenarians compared with younger patients (5.5 vs. 3.2%; P = 0.032, OR = 1.79; 95%CI: 1.04-3.06). Logistic regression analysis showed that age analysed as a continuous variable was a strong predictor of in-hospital death or stroke (P < 0.001), whereas octogenarians had only a trend towards a higher event rate (P = 0.062). CONCLUSION: CAS in octogenarians is performed in an increasing proportion of patients. In-hospital stroke or death rates increase significantly with older age; however, there was no excess complication rate in octogenarians.     

Embolic protection devices for carotid artery stenting: better results than stenting without protection?

AIMS: Carotid artery stenting (CAS) for carotid artery stenoses has become an alternative to carotid endarterectomy. However, CAS itself can cause cerebral ischaemic events. Embolic protection devices (PD) promise to reduce the incidence of these events. METHODS AND RESULTS: From July 1996 to March 2003, 1483 patients from 26 hospitals were included in the prospective CAS Registry of the ALKK study group. A PD was used in 668 of 1483 patients (45%). The use of a PD has grown rapidly over the years and reached 100% in 2003. Patients treated with a PD had prior carotid artery dilatation more often (3.5% versus 1%, p < 0.001), a prior myocardial infarction (34% versus 27.4%, p = 0.007) and a history of arterial hypertension (89.9% versus 78.6%, p = 0.007) compared to patients treated without a PD. A thrombus was more often visible in patients treated under distal protection (16.5% versus 8%, p < 0.001). The use of a PD led to a 10-min longer intervention (45 min versus 35 min median, p < 0.001). Patients treated with a PD had a lower rate of ipsilateral stroke (1.7% versus 4.1%, p = 0.007) and a lower rate of all non-fatal strokes and all deaths (2.1% versus 4.9%, p = 0.004) during the hospital stay. This was confirmed by multiple logistic regression analysis (adjusted OR = 0.45, 95% CI: 0.23-0.91, p = 0.026). A similar reduction could be found for symptomatic as well as asymptomatic carotid artery stenoses. CONCLUSION: Since 1996 there has been a steady increase in the use of PDs for CAS, with a 100% use in 2003. The use of a PD may lower the rate of ipsilateral strokes during CAS.     

Carotid artery stenosis is related to blood glucose level in an elderly Caucasian population: the Hoorn Study

Summary Cross-sectional associations between carotid artery stenosis (CAS) on the one hand, and parameters of glycaemia and specific insulin levels on the other, were investigated in an age, sex, and glucose tolerance stratified random sample from a 50–74-year-old Caucasian population. Subjects treated with insulin or oral hypoglycaemic agents were classified as having known diabetes mellitus (KDM) (n = 66). Using two oral glucose tolerance tests, and based on the World Health Organisation criteria, all other participants were classified as having a normal (NGT) (n = 287), an impaired (IGT) (n = 169) or a diabetic (NDM) (n = 106) glucose tolerance. CAS was defined haemodynamically using duplex scanning. The crude prevalences of only moderate (16–49 %) CAS were 6.6 %, 7.1 %, 5.7 % and 12.1 % in NGT, IGT, NDM and KDM subjects, respectively. For any severe ( ≥ 50 %) CAS, crude prevalences were 2.8 %, 4.7 %, 9.4 % and 7.6 %. The prevalence of any severe CAS was higher in NDM (p < 0.01) and KDM subjects (p = 0.07) than in NGT subjects. The prevalence of a history of stroke or transient ischaemic attack was 1.7 %, 1.8 %, 2.8 % and 1.5 % in NGT, IGT, NDM and KDM, respectively. In univariate logistic regression analysis, HbA_{1 c}, serum fructosamine, fasting and 2-h post-load glucose were significantly associated with any severe CAS. In multivariate analyses controlling for other risk factors, only HbA_{1 c} and 2-h post-load plasma glucose remained significantly associated (odds ratios: 1.29 per % and 1.09 per mmol/l, respectively) in separate models. No association could be shown between either fasting or 2-h post-load specific insulin and any severe CAS in either univariate or multivariate analyses. In conclusion, HbA_{1 c} and 2-h post-load plasma glucose are independently associated with any severe CAS, whereas specific insulin is not. [Diabetologia (1997) 40: 290–298] Received: 2 February 1996 and in final revised form: 22 November 1996     

Carotid artery stent placement is safe in the very elderly (≥80 years)

Background: Carotid artery stent (CAS) placement is an alternative to carotid endarterectomy (CEA) for stroke prevention. Clinical adoption of CAS depends on its safety and efficacy compared to CEA. There are conflicting reports in the literature regarding the safety of CAS in the elderly. To address these safety concerns, we report our single‐center 13‐year CAS experience in very elderly (≥80 years of age) patients. Methods: Between 1994 and 2007, 816 CAS procedures were performed at the Ochsner Clinic Foundation. Very elderly patients, those ≥80 years of age, accounted for 126 (15%) of all CAS procedures. Independent neurologic examination was performed before and after the CAS procedure. Results: The average patient age was 82.9 ± 2.9 years. Almost one‐half (44%) were women and 40% were symptomatic from their carotid stenoses. One‐third of the elderly patients met anatomic criteria for high surgical risk as their indication for CAS. The procedural success rate was 100% with embolic protection devices used in 50%. The 30‐day major adverse coronary or cerebral events (MACCE) rate was 2.7% (n = 3) with all events occurring in the symptomatic patient group [death = 0.9% (n = 1), myocardial infarction = 0%, major (disabling) stroke = 0.9% (n = 1), and minor stroke = 0.9% (n = 1)]. Conclusion: Elderly patients, ≥80 years of age, may undergo successful CAS with a very low adverse event rate as determined by an independent neurological examination. We believe that careful case selection and experienced operators were keys to our success. © 2008 Wiley‐Liss, Inc.     

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis

BackgroundThis meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT).Material and methodsThe Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized.ResultsOverall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312–0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810–6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548–14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668–50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361–0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223–1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found.ConclusionsCEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.     

Carotid angioplasty and stenting in octogenarians: Is it safe?

Purpose: Elderly patients have a higher risk of complications in carotid endarterectomy. The aim of the study was to evaluate whether carotid artery stenting (CAS) performed in octogenarians also increases the procedure related risk. Methods: 870 patients (male 626) mean age 70.9 ± 9.3 years underwent 930 CAS for de novo lesions (n = 851) restenoses (n = 54) post radiation (n = 14) inflammatory arteritis (n = 9) post trauma aneurysms (n = 2). Indications for treatment: symptomatic carotid stenosis ≥ 70% (n = 577) or asymptomatic stenosis ≥ 80%. Patients were separated into two age groups: <80 years (749 patients, 806 CAS) and >80 years (121 patients, 124 CAS). 187 CAS performed without protection (N.P?) 6 patients >80 years, 743 with protection (NP+) (occlusion balloon: 334, filters: 404, reversal flow: 6) 118 patients >80 years. Data analysis included neurological complications, death and myocardial infarction (MI) rate at 30 days, anatomical particularities. Technical points will be described depending on the age of the patient. Results: Technical success 804/806 in patients <80 years, 123/124 in patients >80 years (NS). 30 days outcomes: in the patient group <80 years we observed 9 TIA (1.1%) 3 without NP (1.7%) 6 with NP (0.9%), 5 minor strokes (0.6%) 2 without NP (1.1%) 3 with NP (0.5%), 3 major strokes: 2 without NP (1.1%) 1 with NP (0.2%), 5 deaths (0.6%) 2 without NP (1.1%) 3 with NP (0.5%). Death/stroke/MI: 14 (1.8%) 6 without NP (3.3%), 8 with NP (1.3%). In the group >80 years, we observed 2 TIA (1.7%) 1 without NP 1 with NP (0.92%) 1 minor stroke without NP (17%) no major stroke, no death. Death/stroke/MI 1 without NP (17%). Conclusion: CAS can be performed in elderly patients without higher risk than in younger patients. But good indications, a meticulous technique, protection devices are mandatory and some technical points must be pointed out to avoid neurological complications and failures. © 2008 Wiley‐Liss, Inc.     

Protected Carotid Stenting in High‐Risk Patients: Results of the SpideRX Arm of the Carotid Revascularization with ev3 Arterial Technology Evolution Trial

Purpose: A prospective nonrandomized multicenter registry of 160 patients with severe carotid stenosis and high‐risk features for carotid endarterectomy was conducted during the 3‐month period from March to May 2005. Methods: Carotid artery stenting (CAS) was performed with the SpideRX? Embolic Protection System (ev3, Inc., Plymouth, MN, USA) as part of an investigational device exemption from the Food and Drug Administration. Results: The primary end‐point of major adverse cardiac and cerebrovascular events at 30 days after CAS was observed in nine patients (5.6%), including death in four patients (2.5%), nonfatal stroke in five patients (3.1%), and nonfatal myocardial infarction in one patient (0.6%). A secondary end‐point of technical success (defined as successful deployment of all devices, filter retrieval, and final diameter stenosis <50%) was achieved in 156 of 160 patients (97.5%). The only independent predictor of death or stroke at 30 days was baseline stenosis severity (P < 0.05). Conclusion: CAS with distal embolic protection using the SpideRX? Embolic Protection System is a reasonable alternative for revascularization of some high‐risk patients with severe carotid stenosis. (J Interven Cardiol 2010;23:491–498)     

Carotid artery stenting in asymptomatic and surgically high-risk patients: single-centre, single-operator results

BACKGROUND:

Stroke represents the third leading cause of death in developed countries and the leading cause of disability in the elderly. Because asymptomatic, surgically high-risk patients have been systematically excluded from randomized trials of carotid endarterectomy and medical therapy, the management of this group of patients is still controversial. A single-centre, single-operator registry was analyzed to evaluate feasibility and safety of carotid artery stenting (CAS) with distal protection devices in consecutive, asymptomatic, surgically high-risk patients who were scheduled for endovascular treatment of significant carotid stenoses.

METHODS:

A total of 122 consecutive, surgically high-risk, asymptomatic patients (150 carotid arteries, 59% men, mean [± SD] age 69±9 years) with severe carotid stenosis and one or more high-risk features for carotid endarterectomy were scheduled for CAS. All procedures were performed in a single centre by a single operator. All patients were prospectively asked to undergo a clinical 30-day follow-up.

RESULTS:

A total of 154 stents were implanted in 150 carotid arteries. The primary success rate was 98.7%. The rates of stenosis before and after direct CAS were 81%±9% and 10%±13%, respectively. The median of fluoroscopic time of direct CAS was 6 min (range 2.5 min to 31.5 min). At 30 days, data were available in all patients. The combined 30-day mortality and stroke rate was 1.3%.

CONCLUSIONS:

Short-term outcomes of CAS in asymptomatic, surgically high-risk patients treated by a single operator suggest a low periprocedural complication rate.     

Clinical Impact of Contralateral Carotid Occlusion in Patients Undergoing Carotid Artery Revascularization

BackgroundThe presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA.ObjectivesThe purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry.MethodsAll patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes.ResultsAmong 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p < 0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p < 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64).ConclusionsCCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.     

Carotid artery stenting in octogenarians using a proximal endovascular occlusion cerebral protection device: A multicenter registry

Background : Carotid stenting (CAS) has been proposed as an alternative to carotid endoarterectomy also in elderly patients with discrepant results. However, the use of proximal neuroprotection devices have not been evaluated in octogenarians. Purpose : The aim of this multicenter prospective registry was to demonstrate that CAS in octogenarians is safe and effective if performed in high‐volume centers by experienced operators. Methods : From July 2005 to May 2009, a total of 198 octogenarians patients, in three different institutions, were included in this registry. All patients underwent CAS using proximal endovascular occlusion device (Mo.Ma. device Invatec, Roncadelle, Italy). An independent neurologist evaluated all patients. The primary endpoint was death and stroke rate at 30 days. Results : 198 octogenarians (135 men; mean age: 83.2 years) were included in the registry. 39.4% of the patients were symptomatic. Procedural success was 100%. In‐hospital complications: Two minor and two major strokes (2.02%) occurred. No device‐related complications and no serious access site complication were noted. Between discharge and 30‐day follow‐up, one patient died due to a cardiac arrest. The overall 30‐day combined stroke/death rate was 2.52%, resulting in 1.61% event incidence in asymptomatic and 3.9% in symptomatic patients (P = ns). Logistic regression did not identify independent predictor of neurological events, except in the female gender. Conclusion : This multicenter prospective registry shows that CAS performed with proximal flow blockage is safe and feasible also in octogenarians. Thirty days death/stroke rates are similar to those of the overall population and within the International guidelines. © 2010 Wiley‐Liss, Inc.     

Carotid stenting in high-risk patients: early and late outcomes

Purpose: Some patients with severe carotid stenosis have anatomical or clinical comorbidities that place them at high risk for carotid endarterectomy (CEA). The early and late outcomes after carotid artery stenting (CAS) were evaluated in patients at high risk for CEA. Methods: Between 2002 and 2009, 186 patients were enrolled in a high‐risk CAS institutional registry. The primary outcome was major adverse cardiac and cerberovascular events (MACCEs) at 30 days, including death, stroke, and myocardial infarction. Secondary outcomes were technical, procedural, and clinical success; nonstroke neurological events; and death and ipsilateral stroke at 5 years. Results: Twenty‐five patients (13.2%) were symptomatic. Thirty day MACCE occurred in 2.6%, including death in 1 (0.5%), stroke in 3 (1.6%), and myocardial infraction in 1 (0.5%) patient. Strokes were nonfatal in 3 (1.6%), major in 2 (1.1%), and minor in 1 (0.5%) patients. Other neurological events included transient ischemic attack in 9 (4.7%) and retinal artery occlusion in 2 (1.1%) patients. After stroke, 2 patients had complete resolution of neurological deficit within 30 days, and 1 patient had improvement in neurological deficit. By Kaplan–Meier analysis, all‐cause mortality was 47.5% and ipsilateral stroke was 4.5% at 5 years. Conclusions: In patients who are high risk for CEA, CAS can be performed with low MACCE at 30 days and ipsilateral stroke at 5 years. However, nearly half of these patients die within 5 years from causes unrelated to stroke. (J Interven Cardiol 2011;24:247–253)     

Carotid angioplasty and stenting under protection. State of the art

A carotid stenosis is responsible for about 30% of strokes occurring. Carotid endarterectomy (CEA) is considered to be the gold standard treatment of a carotid stenosis. Carotid angioplasty and stenting (CAS) is emerging as a new alternative treatment for a carotid artery stenosis, but the risk of neurological complications and brain embolism remain the major drawback to this procedure. So as to reduce the risk, we need: good indications, good patient and lesion selection; correct techniques; brain protection devices (cerebral protection devices should be routinely used and are mandatory for any procedure. Three types of protection devices are available: filters are the most commonly used. Nevertheless, all protection devices have limitations and cannot prevent from embolic events. However neurological complications can be reduced by 60%. New protection devices will be discussed); good choice of the stent and correct implantation (all stents are not equivalent and have different geometrical effects); pharmacological adjuncts; good team. Indications are well accepted for high-risk patients and recent studies have shown that CAS has superior short-term outcomes than CEA in this group of patients. Indications for low-risk and asymptomatic patients are controversial. New selection criteria have to be discussed. But there are enough reported data to conclude that CAS is also not inferior to CEA in low-risk and asymptomatic patients. In our series of 844 procedures, without protection (n = 187) 30-day death and stroke rate was 3.7% and with protection (n = 657) 1% (1.3% for symptomatic patients, 0.9% for asymptomatic patients, 1.4% in high-risk patients, 0.4% in low-risk patients). CAS under protection is the standard of care and is maybe becoming the gold standard treatment of a carotid stenosis at least in some subgroups of patients.     

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.     

Hospital Variation in Carotid Stenting Outcomes

ObjectivesThe aim of this study was to examine variation in outcomes for patients receiving carotid artery stenting (CAS) across a sample of U.S. hospitals and assess the extent to which this variation was attributable to differences in case mix and procedural volume.BackgroundAs CAS is increasingly being used throughout the United States, assessing hospital variation in CAS outcomes is critical to understanding and improving the quality of care for patients with carotid artery disease.MethodsHospitals participating in the National Cardiovascular Data Registry–Carotid Artery Endarterectomy and Revascularization Registry contributing more than 5 CAS procedures from 2005 through 2013 were eligible for inclusion. We estimated unadjusted and risk-standardized rates of in-hospital stroke or death for each participating hospital using a previously validated prediction model and applying hospital-level random effects.ResultsThere were 188 hospitals contributing 19,381 CAS procedures during the period of interest. Unadjusted and risk-standardized in-hospital stroke or death rates ranged from 0% to 18.8% and 1.2% to 4.7%, respectively. Operator and hospital volumes were not significant predictors of outcomes after adjustment for case mix (p = 0.15 and p = 0.09, respectively).ConclusionsCAS outcomes vary 4-fold among hospitals, even after adjustment for differences in case mix. Future work is needed to identify the sources of this variation and develop initiatives to improve patient outcomes.     

Predictors of Carotid Occlusion Intolerance During Proximal Protected Carotid Artery Stenting

ObjectivesThe aim of this study was to identify predictors of occlusion intolerance (OI) developing during proximal protected carotid artery stenting (CAS).BackgroundThe use of proximal embolic protection devices, such as endovascular occlusion, during CAS has been demonstrated to be particularly safe and effective. However, endovascular occlusion can expose the ipsilateral hemisphere to hypoperfusion and produce transient neurological symptoms (OI).MethodsFrom March 2010 to March 2012, 605 consecutive patients underwent proximal protected CAS at our institution. To identify independent predictors of OI, a multivariate logistic regression model was developed that included all patients’ clinical/angiographic and procedural characteristics.ResultsOI developed in a total of 184 patients (30.4%). Compared with patients in whom OI did not develop, those who experienced OI had lower occlusion pressure (OP) (42.3 ± 12.7 mm Hg vs. 61.9 ± 15.4 mm Hg, p < 0.001). Receiver-operating characteristic curve analysis demonstrated that OP was the most consistent predictor of OI with a C-statistic of 0.85 (95% confidence interval [CI]: 0.82 to 0.88) with best cutoff being ≤40 mm Hg (sensitivity, 68.5%; specificity, 93.3%). By logistic regression analysis, the most powerful independent predictor of OI developing was an OP ≤40 mm Hg (odds ratio: 33.2, 95% CI: 19.1 to 57.7) and the most powerful clinical predictor of such OP was the presence of contralateral internal carotid artery occlusion (odds ratio: 3.1, 95% CI: 1.5 to 6.2).ConclusionsOI may occur in as many as one-third of the patients undergoing proximal protected CAS. This event is more common in those patients with an OP ≤40 mm Hg. Patients presenting with concomitant occlusion of the contralateral internal carotid artery more frequently have an OP ≤40 mm Hg.