Follow-up results of carotid angioplasty with stenting as assessed by duplex ultrasound surveillance

BACKGROUND: Carotid artery stenting (CAS) has become an alternative modality to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. We report a retrospective review of our institution's experience with CAS versus CEA. METHODS: Postprocedure surveillance duplex, recurrent symptoms, postprocedure strokes, progression of lesions, and rates of re-operation were analyzed in 46 patients who underwent CAS and 48 patients who underwent CEA. The mean length of follow-up evaluation was 13 months. All CAS procedures included neuroprotection devices. RESULTS: Statistically significant differences in progression to critical restenosis (2% vs 2%, P = 1.0), rate of subsequent symptoms or stroke (2% vs 10%, P = .1), or rate of re-interventions were not observed between CAS and CEA groups (2% vs 4%, P = .98). Total mortality (0% vs 2%, P = .33), and the occurrence of major adverse events (2% vs 10%, P = .18) also were not significantly different in the CAS compared with the CEA patients. The average rate of increase in internal carotid velocity at 6 to 12 months (-1% vs 1.1%, P = NS) and 12 to 24 months (-5% vs -6.5%, P = NS) also were equivalent. CONCLUSIONS: Our observed results indicate that CAS may be performed with comparable clinical outcomes and durability of repair comparable with CEA.     

Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy

ObjectiveCarotid revascularization procedures, carotid artery stenting (CAS) and carotid endarterectomy (CEA), are among the most common vascular interventions performed in the United States, with significant resource utilization. Whereas multiple studies have reported outcomes after these procedures, data regarding 30-day readmission rates after these interventions remain scant.MethodsThe U.S. Nationwide Readmission Database (2010-2014) was queried to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for CEA or CAS.ResultsAmong 476,260 patients included, 13.5% underwent CAS and 86.5% underwent CEA. The combined 30-day readmission rate for all carotid revascularization procedures was 9.2% (10.6% after CAS and 9.0% after CEA). After 1:3 propensity matching, CAS was associated with higher risk of readmission compared with CEA (10.4% vs 9.4%). Neurologic complications and cardiac conditions were the two most common causes of readmission after both CAS (29.7% and 23.7%, respectively) and CEA (28.2% and 21.7%, respectively). The 30-day readmission rates were higher in CAS patients across all age groups as well as in those with a low or high baseline burden of comorbidities.ConclusionsIn this large nationwide study, CAS was associated with higher 30-day readmission rates compared with CEA irrespective of age or baseline burden of comorbidities. Neurologic or cardiac adverse events were responsible for >50% of readmissions after CAS and CEA.     

Endarterectomy or carotid artery stenting: the quest continues

BACKGROUND: Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS. METHODS: A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS. RESULTS: Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery stenosis. CONCLUSIONS: CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.     

Clinical results of carotid artery stenting compared with carotid endarterectomy

OBJECTIVES: Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for treating carotid artery stenosis. We conducted a systematic review and meta-analysis of the clinical trials to date comparing these two procedures to determine their relative safety and efficacy. METHODS: Searches of the Cochrane Controlled Trials Register, MEDLINE, and EMBASE identified two cohort studies and eight randomized, controlled trials (RCTs) comparing CEA and CAS. Meta-analysis was performed for the primary outcome of 30-day stroke or death, using an intention-to-treat analysis. Between-trial heterogeneity was assessed using the chi2 test, and fixed-effects models were used to pool estimates in the absence of heterogeneity. Meta-regression was conducted to investigate potential effect differences by patient, intervention, and trial characteristics. To evaluate the effect of study design and inclusion criteria, sensitivity and subgroup analyses were performed. RESULTS: Ten trials encompassing 3580 patients were analyzed. Patients who underwent CAS had a higher risk of 30-day stroke/death relative to patients who underwent CEA (risk ratio [RR], 1.30; 95% CI, 1.01-1.67). Meta-analysis and meta-regression demonstrated no between-trial heterogeneity. Sensitivity analysis of only RCTs showed similar higher risk for stroke/death (RR, 1.38; 95% CI, 1.06-1.79) in CAS patients. Subgroup analysis of trials enrolling only symptomatic patients showed higher risk of 30-day stroke/death (RR, 1.63; 95% CI, 1.18-2.25), but trials enrolling both symptomatic and asymptomatic patients showed no significant differences (RR, 0.89; 95% CI, 0.59-1.35). CONCLUSIONS: Meta-analysis of trials to date shows CAS is associated with higher 30-day risk of stroke/death compared with CEA. Thus, for the patient at average surgical risk, the role of CAS is unproven, especially for symptomatic patients. And for the patient at high surgical risk, the role of any intervention is uncertain in the setting of competing comorbidities. The results of ongoing clinical trials in this area will likely provide additional evidence to support treatment choices for carotid artery stenosis.     

Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients

PURPOSE: Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy (CEA) for treatment of severe carotid artery stenosis. Because CAS does not require general anesthesia and is less traumatic, it might be especially advantageous in older patients, but data comparing these 2 treatment methods in older patients are scarce. METHODS: The periprocedural complication rates in 53 patients aged 75 years or older who had undergone protected CAS between June 2001 and April 2004 were compared with those in a group of 110 patients aged 75 years or older who had undergone CEA between January 1997 and December 2001, before widespread introduction of CAS procedures at our institution. All patients were evaluated by a neurologist both before and after surgery. According to the criteria set forth by the large trials the occurrence of minor, major, or fatal stroke, and myocardial infarction within 30 days was determined. RESULTS: The demographic characteristics and indications for an intervention were similar in both treatment groups. Thirty patients (57%) in the CAS group had symptomatic carotid stenosis, compared with 69 patients (63%) in the CEA group. In neither group was there any fatal stroke or myocardial infarction. The 30-day stroke rate was significantly higher in the CAS group (4 minor, 2 major strokes; 11.3%) than in the CEA group (no minor, 2 major strokes; 1.8%; P < .05). Although the 30-day major stroke rate between CAS and CEA groups was comparable (3.8% vs 1.8%; P = 0.6), this effect was mainly attributable to a significantly higher rate of minor stroke in the CAS group (7.5% vs 0%; P < .05). CONCLUSION: Despite the use of cerebral protection devices the neurologic complication rate in patients aged 75 years and older associated with CAS was significantly higher than with CEA performed by highly skilled surgeons at our academic institution. Although this finding is mainly based on a significantly higher rate of minor stroke in the CAS group, the common practice of preferentially submitting older patients to CAS is questionable, and should be abandoned until the results of further randomized trials are available.     

Current status of carotid artery stenting

This Clinical Update summarizes the results of larger case series, industry-sponsored registries, and randomized trials of carotid artery stenting (CAS). In >20 case series that studied >24,000 patients undergoing CAS, 51% of patients were symptomatic, most procedures (97%) resulted in successful stent deployment, and 30-day stroke rates varied from 1% to 8%, with a trend toward lower rates as experience and embolic protection device (EPD) use increased. In 12 industry-sponsored registries (none were published in peer-reviewed journals), 30-day stroke rates varied from 2% to 7%, and 30-day combined adverse events, including stroke, death, and myocardial infarction, were 3% to 9%. More than 12 randomized trials comparing CAS and carotid endarterectomy (CEA) have been initiated since 1998. Results have varied over time, depending on the population studied and the technology used. However, the largest and most recent results of the completed SAPPHIRE trial in high-risk patients undergoing CAS with the use of EPDs demonstrated that CAS is at least not inferior to CEA, with a 1-year combined adverse event rate of 12% for CAS and 20% for CEA (P = .05). Other ongoing trials will address not only whether CAS could be superior to CEA in high-risk patients but also, more importantly, whether CAS is beneficial in other subgroups, such as low-risk and asymptomatic patients.     

近端血流阻塞式脑保护装置下颈动脉支架成形术的临床研究

目的 研究近端血流阻塞式脑保护装置MO.MA系统在颈动脉支架成形术中预防脑血管栓塞的疗效,并评价其安全性及可操作性.方法 2007年10月至2008年7月,23例符合外科治疗指征的颈动脉硬化狭窄患者入选本研究,其中19例(82.6%)患者有神经系统症状.全脑血管造影后在脑保护装置MO.MA系统下行颈动脉球囊扩张及支架成形术,计算术中脑缺血时间,观察术中及术后30 d神经系统事件的发生情况.结果 颈动脉造影示,6例(26.1%)颈动脉狭窄50%～70%,17例(73.9%)颈动脉狭窄>70%.所有病例在MO.MA系统保护下颈动脉球囊扩张及支架植入均顺利进行,颈动脉平均阻断时间(5.3±1.2)min.术中及围手术期无死亡及脑卒中发生;2例在颈总动脉球囊阻断时出现短暂意识丧失伴对侧肢体短暂抽搐;2例术后出现心动过缓和低血压,持续时间分别为6 h及1周.9例患者术中颈动脉抽血中可见细小斑块碎片.术后30 d随访有1例TIA发作,1例对侧新发脑卒中,术后30 d累积脑卒中发生率及病死率为4.3%.结论 应用近端血流阻断式脑保护装置MO.MA系统在颈动脉支架成形术中预防神经系统事件发生是安全有效的,尤其适合重度及不稳定性斑块的颈动脉硬化狭窄支架成形术治疗.     

Concomitant ipsilateral carotid endarterectomy and stenting is an effective treatment for tandem carotid artery lesions

ObjectiveData regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal ipsilateral carotid artery stenting confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution.MethodsA retrospective chart review was performed including patients who underwent CEA + ipsilateral carotid artery stenting for treatment of atherosclerotic carotid artery disease between December 2007 and April 2017. Primary endpoints were postoperative myocardial infarction, neurologic event, and perioperative mortality.ResultsTwenty-two patients (15 male [68%]) underwent CEA + ipsilateral carotid artery stenting with a mean follow-up of 67 ± 77 months. The mean age was 70.0 ± 6.1 years old, all with a prior smoking history (eight current smokers [64%]). Twelve patients (55%) were treated for symptomatic disease and three had a prior ipsilateral CEA (one also with CAS). Computed tomographic angiography imaging was performed preoperatively in 21 patients (95%). CEA was performed first in 18 patients (82%) followed by ipsilateral carotid artery stenting. CEA was performed with a patch in 20 and eversion endarterectomy in two patients. Ipsilateral CCA was stented in 21 patients (96%) and one innominate was stented in a patient with a right CEA. Additional endovascular interventions were performed in three patients: 1 innominate stent, 1 distal ipsilateral internal carotid artery stent, and 1 right subclavian artery stent. All proximal stents were placed with sheath access through the endarterectomy patch in 12 (55%), CCA in 7 (32%), and through the arteriotomy before patching in 3 (14%). Distal internal carotid artery clamping was performed in 18 (90%, available 20) of patients before ipsilateral carotid artery stenting. All proximal lesions were successfully treated endovascularly with no open conversion. One dissection was created and treated effectively with stenting. One perioperative stroke (4.5%) occurred in a patient treated for symptomatic disease, 1 postoperative myocardial infarction (4.5%), and 2 patients (9.1%) with cranial nerve injuries. There was one patient who expired within 30 days, shortly after discharge for unknown reasons. The mean length of stay was 2.6 ± 2.0 days.ConclusionsIn appropriately selected patients, concomitant CEA and ipsilateral carotid artery stenting can be safely performed in high-risk patients with a low risk of myocardial infarction, neurologic events, and perioperative mortality when careful surgical technique is used, using direct carotid access, and distal carotid clamping for cerebral protection before stenting.     

Are there predictive risk factors for complications after carotid artery stenting?

AIM: The aim of this study was to identify predictive risk factors for complications during and after carotid artery stenting (CAS). METHODS: A multivariate analysis was performed on the databases of 4 European high-volume centers regarding risk factor distribution between patients presenting with or without neurological complications 30 days after CAS. The cumulative 30-day neurological complication rate (death, major stroke, minor stroke and transient ischemic attack) was 2.8% in the total examined cohort of 3 179 consecutive CAS procedures. The following risk factors were taken into consideration for statistical analysis: age, symptomatic, male gender, nicotine abuse, hypertension, hypercholesterolemia, polyvascular disease, diabetes, restenosis after carotid endarterectomy (CEA)/CAS, calcified internal carotid artery. RESULTS: Symptomatic (P=0.02) or hypercholesterolemic (P=0.02) patients are at significantly increased risk for neurological events 30 days after CAS. Asymptomatic women and men without hypercholesterolemia have the lowest risk on any 30-day neurological complications after CAS. CONCLUSIONS: CAS is a safe technique in experienced hands. Preprocedural neurological complaints and hypercholesterolemia can be defined as predisposing factors for 30-day neurological complications after CAS.     

Meta-analysis of randomized trials comparing carotid endarterectomy and endovascular treatment.

OBJECTIVE AND DESIGN: In order to evaluate the comparative efficacy and safety of carotid angioplasty with or without stent placement (CAS) versus carotid endarterectomy (CEA) we performed a meta-analysis of the presently available randomized studies. MATERIALS AND METHODS: A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. RESULTS: Seven trials totalling 2972 patients (1480 randomized to CEA and 1492 randomized to CAS) were included in the meta-analysis. Results significantly favoured CEA over CAS in terms of death or any stroke at 30 days after procedure; the risk of death, any stroke, or myocardial infarction at 30 days; ipsilateral ischaemic stroke at 30 days; any stroke at 30 days; death or stroke at 6 months; and the risk of procedural failure. There was a significantly reduced risk of cranial neuropathy at 30 days after CAS. There was no significant difference between CAS and CEA groups in the odds of death or disabling stroke at 30 days, death or stroke at 1 year after the procedure, and ipsilateral intracerebral bleeding at 30 days. CONCLUSIONS: The results of this meta-analysis suggest that CEA can be performed with more safety than CAS. As a result, CEA remains the "gold standard" treatment for suitable de novo carotid stenosis and CAS should only be performed within randomized trials of stenting versus surgery.     

Clinical impact of sex on carotid revascularization

BackgroundThe impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS).MethodsWe included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics.ResultsA total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS.ConclusionsFemales with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.     

颈动脉狭窄血管内支架植入和内膜切除术治疗的临床选择

目的 探讨在不同条件下如何合理选择颈动脉狭窄的治疗方式.方法 回顾性分析经颈动脉血管内支架植入术(CAS)和颈动脉内膜切除术(CEA)治疗的133例颈动脉狭窄患者的临床资料.其中46例患者行CAS,87例行CEA.观察两组患者的住院天数和治疗前后的美国国立卫生研究院卒中评分量表(NIHSS)评分、前向血流,治疗前和治疗后1-24个月狭窄处收缩期血流速度峰值及狭窄程度,以及治疗后死亡、脑卒中或心肌梗死等终点事件的发生率.结果 两组住院天数和治疗后NIHSS评分>20层次时差异有统计学意义(P<0.05);两组治疗前后的前向血流评定差异无统计学意义(P>0.05);多普勒频谱测定两组治疗前后颈动脉狭窄程度有显著性差异(P<0.05);两组治疗后30 d内,终点事件的累计发生率差异有统计学意义(P<0.05);31 d～2年终点事件的累计发生率差异无统计学意义(P>0.05);6个月后再狭窄发生率CAS组高于CEA组.结论 CAS和CEA对颈动脉狭窄的效果无显著差异,狭窄的部位、原因及对侧病变是选择CAS和CEA的重要因素.     

高危颈动脉狭窄患者内膜剥脱术和支架术的对比分析

目的对比颈动脉内膜剥脱术（carotid endarterectomy,CEA）与颈动脉支架置入术（carotid artery stenting,CAS）在治疗高危颈动脉粥样硬化性狭窄中的作用。方法对58例颈动脉粥样硬化性狭窄患者进行回顾性对照研究。其中32例为CEA组;26例为CAS组。术后30d、6个月、1年均进行颈部B超、CTA复查或DSA和神经系统检查。初级观察终点设定为术后30d内发生死亡、卒中事件、心血管不良事件,或随访6个月内的死亡或同侧卒中事件;次级观察终点为与CEA或CAS相关的并发症,或1年内的重度再狭窄。比较2组术后治疗的效果。结果CEA组有3例达到初级观察终点,发生率为9.4%;CAS组有4例达到初级观察点,累积发生率为15.4%（χ2=0.086,P=0.769）。CEA组有4例达到次级观察终点,发生率为12.5%;CAS组有4例达到次级观察终点,发生率为15.4%（χ2=0.000,P=1.000）。结论CAS在治疗高危颈动脉粥样硬化性狭窄时,在安全性和有效性方面与CEA是相同的。     

Selection of treatment for patients with carotid artery disease: medication, carotid endarterectomy, or carotid artery stenting

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.     

Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses

PURPOSE: Although many studies have well established that carotid endarterectomy (CEA) is beneficial in selected patients with severe carotid disease, only a few large studies have focused on the durability of the surgical procedure. Carotid artery angioplasty and stenting (CAS) has recently been proposed as a potential alternative to CEA. We analyzed the incidence of late occlusion and recurrent stenosis after CEA. METHODS: Over 13 years 1000 patients underwent 1150 CEA procedures to treat symptomatic and asymptomatic high-grade carotid stenosis. CEA procedures involving either traditional CEA with patching (n = 302) or eversion CEA (n = 848) were all performed by the same surgeon, with patients under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months, and yearly thereafter. New neurologic events, late occlusions, and recurrent stenoses 50% or greater were recorded. Complete follow-up (mean, 6.2 years; range, 6-156 months) was obtained in 95% of patients (949 of 1000), for an overall average of 95% of procedures (1092 of 1150). Survival analysis was performed with the Kaplan-Meier life table method. RESULTS: Perioperative (30-day) mortality rate was 0.3% (3 of 1000), and stroke rate was 0.9% (11 of 1150), with a combined mortality and stroke rate of 1.2%. The incidence of late occlusion and recurrent stenosis 70% or greater was 0.6% and 0.5%, respectively, with a combined occlusion and restenosis rate of 1.1%. Kaplan-Meier analysis showed that the rate of freedom from occlusion, restenosis 70% or greater, and combined occlusion and restenosis 70% or greater at 12 years was 99,4%, 99.5%, and 98.8%, respectively. Occlusion and restenosis developed asymptomatically. CONCLUSIONS: CEA is a low-risk procedure for treating severe symptomatic and asymptomatic carotid disease, with excellent long-term durability. Proponents of CAS should bear this in mind before considering CAS as a routine alternative to CEA.     

Carotid stent-assisted angioplasty: the newest addition to the surgeons' armamentarium in the management of carotid occlusive disease

Carotid artery angioplasty and stenting (CAS) has been accomplished in multiple centers with short-term and midterm results similar to carotid endarterectomy (CEA). Until completion of multicentered prospective evaluation of the benefit of CAS versus established therapy (CEA) clinical judgment must be used to determine whether an individual patient with unusual technical challenges and/or risks might be best suited for CEA or CAS. We report our experience with 41 CAS procedures in 39 patients treated from November 1996 through November 2001. Six patients had primary lesions (three symptomatic and three asymptomatic). Thirty-three patients had 35 procedures for recurrent carotid stenosis (11 symptomatic and 24 asymptomatic). Technical success was achieved in 40 of 41 procedures. No deaths occurred. The 30-day major stroke rate was one in 41 (2.4%), and the overall 30-day stroke/transient ischemic attack rate was three in 41 (7.3%). No recurrence or late neurologic events were seen in patients treated for primary carotid stenosis. A 23 per cent recurrence rate was observed in patients treated for recurrent carotid stenosis, after one or more CEAs, with mean follow-up of 18 +/- 14 months. Recurrence requiring operative correction with carotid resection and interposition grafts occurred in three patients treated with CAS in this group. Late deaths occurred in six patients; one of these was due to stroke. Overall freedom from late stroke and/or need for reintervention (by Kaplan-Meier analysis) was 64 +/- 13 per cent at 48 months in the group treated by CAS for post-CEA recurrence. CAS represents a technically simplistic means of providing carotid revascularization. However, its role remains undefined and benefits unproven. Surgical revascularization remains appropriate for patients with operable carotid lesions. However, surgical revascularization is not always an ideal option when we are faced with difficult carotid lesions and risks. For this reason we advocate that all surgeons who intend to remain specialists in the management of carotid disease should attain, master, and maintain the skills necessary for CAS.     

颈动脉内膜剥脱术和颈动脉支架的前瞻性随机对照研究

目的 评价颈动脉内膜剥脱术和颈动脉支架治疗颈动脉狭窄的近期和中期临床效果.方法 前瞻性单中心随机对照研究,自2004年5月至2006年12月,将同意入组的40例有症状(狭窄程度>50%)和无症状(狭窄程度>70%)颈动脉狭窄患者随机分为两组,即颈动脉内膜剥脱术组(CEA)和颈动脉支架组(CAS).一期观察终点是术后30 d内出现严重脑梗死或死亡;二期观察终点是各种手术并发症、急性脑缺血发作、偏瘫、急性心肌梗死和术后18个月内的脑卒中、死亡和再狭窄等,同时回顾性分析两组总的住院费用.结果 CEA和CAS两组患者术前一般资料、临床症状、伴随疾病等因素均无差异.CEA组20例23支颈动脉手术(3例分别行双侧CEA),术中应用转流管9条(39.1%),颈动脉补片12条(52.2%);CAS组20例23支颈动脉支架(3例行双侧CAS),应用脑保护装置21个(91.3%).CEA和CAS两组术后30 d内神经系统并发症(4.3%对8.7%,P=0.46)、急性心肌梗死(4.3%对0,P=0.31)和伤口血肿(8.7%对0,P=0.14)等差异均无统计学意义,至术后18个月无短暂性脑缺血发作和再狭窄病例.CEA和CAS两组平均住院费用分别为(16 450.95±6188.76)和(70 130.15±11 999.02)元人民币,差异有统计学意义(P<0.01).结论 CEA和CAS术后30 d和术后18个月的并发症、病死率和临床疗效无明显差异,但CAS的住院花费明显高于CEA.     

Outcome of carotid artery stenting for primary versus restenotic lesions

Carotid artery stenting (CAS) for restenosis (RS) after carotid endarterectomy (CEA) is presumed to have fewer complications than CAS for primary atherosclerotic (PA) lesions. It has been proposed that interventionalists may limit themselves to CAS for RS initially, while they gain additional experience during their learning curve. However, there are few studies objectively comparing the outcomes of the two groups of patients to substantiate this assumption. We analyzed prospectively collected data on CAS performed at our institution from 1996 to April 2006. Complication rates were compared between CAS performed for RS versus PA lesions. Specific end points studied included in-hospital and 30-day stroke and death rates. The incidence of transient ischemic attack (TIA) was also recorded. Patient demographic features (gender, age, hypertension, diabetes mellitus, coronary artery disease, smoking, hypercholesterolemia, and presence of preoperative neurological symptoms) were recorded. A neurologist examined all patients before and after CAS. Patients with previous CAS with in-stent RS and tandem common carotid artery-internal carotid artery or arch ostial stenoses were excluded from this analysis. CAS procedures (n = 217) performed on 210 patients fulfilled inclusion criteria for this study. Indications for CAS included RS (n = 118, 54%) and PA (n = 99, 46%). The two groups were well matched for all demographic features except hypercholesterolemia, which was more common in the PA group. Thirty-day stroke and stroke + death rates for the entire series were 2.8% and 4.1%, respectively. Within this cohort, 30-day stroke and stroke + death rates were not significantly different between the RS (2.5% and 5.1%) and PA (3.0% and 3.0%) groups. Within the RS group, these outcomes were also similar when patients treated for late recurrence (>24 months after CEA, n = 49) were compared to those treated for early recurrence (< or = 24 months after CEA, n = 67). Only when stroke and TIA were combined was a difference observed between the late recurrence (10.0%) and the early recurrence (1.5%) groups (p = 0.049). Contrary to general opinion, 30-day stroke and stroke + mortality rates from CAS for RS versus PA were not significantly different. Lower neurological event rates were only seen in CAS for early RS compared with late RS after endarterectomy when TIAs were included as an end point in the analysis. CAS for RS must therefore not be considered a low-risk procedure. Technical proficiency for CAS must be equivalent regardless of the etiology of the stenosis. These observations also underscore the need for appropriate patient selection and close follow-up of all patients undergoing CAS.     

Carotid artery disease: clinical features and management

The most common cause of ischaemic carotid territory stroke, around 50% of cases, is thromboembolism from stenoses at the origin of the extracranial internal carotid artery (ICA). Embolism is usually preceded by acute changes in plaque morphology, which predisposes towards overlying thrombus formation and embolization. The management of patients with carotid artery disease involves cardiovascular risk factor modification, antiplatelet and statin therapy in everyone. There is grade A, level I evidence that recently symptomatic patients with 50–99% stenoses gain significant benefit from carotid endarterectomy (CEA), despite a small risk of perioperative stroke. Maximum benefit is conferred if CEA is performed as soon as possible after onset of symptoms. Carotid artery stenting (CAS) is an alternative to CEA. Excluding operative risks, 9-year rates of ipsilateral stroke are virtually identical (i.e. CAS is durable), but (at present) 30-day death/stroke is significantly higher after CAS, compared to CEA. The management of patients with asymptomatic carotid stenoses (ACS) remains controversial. The 2018 European Society for Vascular Surgery (ESVS) carotid guidelines advise that patients with a 60–99% ACS who have one or more clinical/imaging features that make them ‘higher risk for stroke’ on best medical therapy (BMT) should be considered for CEA, with the remainder being treated medically.     

Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital

OBJECTIVE: Carotid endarterectomy (CEA) is effective in reducing the risk of stroke in individuals with more than 60% carotid stenosis. Carotid angioplasty and stenting (CAS) has been proffered as effective and used in treating individuals with asymptomatic carotid stenosis despite the absence of proven clinical equivalency. This randomized trial was designed to explore the hypothesis that CAS is equivalent to CEA for treating asymptomatic carotid stenosis. METHODS: A total of 85 individuals presenting with asymptomatic carotid stenosis of more than 80% were selected randomly for CAS or CEA and followed up for 48 months. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique, as determined by carotid ultrasonography. No major complications such as cerebral ischemia or death occurred. Procedural complications associated with CAS (n = 5) were hypotension and/or bradycardia; those concomitant with CEA (n = 3) were cervical nerve injury or complications related to general anesthesia (n = 4). Both procedures were well tolerated in the context of pain and discomfort. Hospital stay was similar in the two groups (mean, 1.1 versus 1.2 d). The occurrence of complications associated with CAS or CEA prolonged hospitalization by 3 days (mean, 4.0 versus 4.5 d). Return to full activity was achieved within 1 week by more than 85% of patients; all returned to their usual lifestyle by 2 weeks. Although hospital charges were slightly higher for CAS, costs were similar. CONCLUSION: CAS and CEA may be equally effective and safe in treating individuals with asymptomatic carotid stenosis.