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carotid_artery_stenting

Carotid artery stenting (CAS)

see also Bilateral carotid artery stenting.

Carotid artery stenting (CAS) is a neuroendovascular treatment where a stent is deployed within the lumen of the carotid artery to prevent a stroke by treating carotid artery stenosis.

It has emerged as an alternative to carotid endarterectomy. In randomised trials comparing stenting with endarterectomy for symptomatic carotid artery stenosis, stenting was associated with a higher risk of procedure-related stroke, particularly in elderly patients, but with lower risks of myocardial infarction, cranial nerve palsy, and access site haematoma 1) 2) 3) 4).

A systematic review showed that the increase in procedure-related risk was driven by non-disabling stroke, with no evidence for a difference in rates of major or disabling stroke or death between the treatments 5).

Complications

Efficacy

Residual stenosis after carotid artery stenting

A study investigated the effect of residual stenosis after carotid artery stenting (CAS) on periprocedural and long-term outcomes.

Patients treated with CAS for symptomatic or asymptomatic carotid arterial stenosis were consecutively enrolled. Residual stenosis was estimated from post-procedure angiography findings. The effects of residual stenosis on 30-day periprocedural outcome and times to restenosis and clinical outcome were analyzed using logistic regression models and Wei-Lin-Weissfeld models, respectively.

A total of 412 patients (age, 64.7 ± 17.0 years; male, 82.0%) were enrolled. The median baseline stenosis was 80% (interquartile range [IQR], 70-90%), which improved to 10% (0-30%) for residual stenosis. Residual stenosis was significantly associated with periprocedural outcome (adjusted odds ratio, 0.983; 95% confidence interval [CI], 0.965-0.999, P = 0.01) after adjustment for baseline stenosis, age, hypertension, symptomaticity, and statin use. Over the 5-year observation period, residual stenosis did not increase the global hazard for restenosis and clinical outcome (adjusted hazard ratio, 1.011; 95% CI, 0.997-1.025. In the event-specific model, residual stenosis increased the hazard for restenosis (adjusted hazard ratio, 1.041; 1.012-1.072) but not for clinical outcome (adjusted hazard ratio, 1.011; 0.997-1.025).

Residual stenosis after carotid artery stenting may be useful to predict periprocedural outcome and restenosis 6).

Case series

Case reports

A 68-year-old man was admitted. Neurological examination revealed severe left-sided motor weakness. Magnetic resonance imaging showed no cerebral infarction, but magnetic resonance angiography revealed complete occlusion of the right internal carotid artery. Systemic intravenous injection of recombinant tissue plasminogen activator was performed within 4h after the onset. But, magnetic resonance angiography still revealed complete occlusion. Revascularization of the right cervical internal carotid artery was performed via endovascular surgery. The occluded artery was successfully recanalized using the Penumbra System® and stent placement at the origin of the internal carotid artery. Immediately after surgery, dual antiplatelet therapy (aspirin and clopidogrel) was initiated, and then cilostazol was added on the following day. Carotid ultrasonography and three-dimensional computed tomographic angiography at 14days revealed no further obstruction to flow.

When trying to perform emergency carotid artery stenting within 24h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyperperfusion syndrome.

Emergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients 7).

References

1)
Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355: 1660–71.
2)
The SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368: 1239–47.
3)
International Carotid Stenting Study investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375: 985–97.
4)
Brott TG, Hobson RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363: 11–23.
5)
Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev 2012; 9: CD000515.
6)
Kang J, Hong JH, Kim BJ, Bae HJ, Kwon OK, Oh CW, Jung C, Lee JS, Han MK. Residual stenosis after carotid artery stenting: Effect on periprocedural and long-term outcomes. PLoS One. 2019 Sep 9;14(9):e0216592. doi: 10.1371/journal.pone.0216592. eCollection 2019. PubMed PMID: 31498785.
7)
Inoue A, Kohno K, Fukumoto S, Ozaki S, Ninomiya S, Tomita H, Kamogawa K, Okamoto K, Ichikawa H, Onoue S, Miyazaki H, Okuda B, Iwata S. Importance of perioperative management for emergency carotid artery stenting within 24h after intravenous thrombolysis for acute ischemic stroke: Case report. Int J Surg Case Rep. 2016 Jul 27;26:108-112. doi: 10.1016/j.ijscr.2016.07.027. [Epub ahead of print] PubMed PMID: 27478968.
carotid_artery_stenting.txt · Last modified: 2019/09/10 19:38 by administrador