Carotid-artery stenting in a high-risk patient population—

Summary

Aims

The aim of this study was to assess the outcome of carotid-artery stenting (CAS) in high-risk patients in routine clinical settings while excluding the impact of multiple operators and the learning curve of individual operators on the outcome, and to determine the impact of individual risk factors, including vascular multimorbidity, on the outcome.

Methods and results

A total of 143 consecutive patients, 100 (69.9%) males and 43 (30.1%) females, mean age 68.7±8 years treated between February 1999 and May 2004 in the Heart Centre Coswig by a single operator for a symptomatic (n=37) and asymptomatic (n=106) on average greater than 70% (82.3±10.7%) or 80% (85.0±9.1%) NASCET carotid-artery stenosis, respectively, were studied. At least one NASCET exclusion criteria was present in 140 patients (97.9%), and vascular multimorbidity was present in 94 (65.7%) patients. In 28 (19.6%) patients there was a complete occlusion of the contralateral internal carotid artery and in 12 (8.4%) patients the procedure was performed prior to emergency coronary bypass surgery. In all, 47 (32.9%) procedures were performed without and 96 (67.1%) were performed with thromboembolic protection. Technical success was achieved in all patients. Combined neurological complications, TIA, PRIND and stroke, occurred in 5 (3.5%) patients, of which 3 (2.1%) were PRIND and 2 (1.4%) were strokes. The neurological complications were more frequent and more severe in symptomatic patients compared to asymptomatic patients (PRIND 2.7% vs 1.9%; stroke 0% vs 5.4%). In patients in whom thromboembolic protection was used, the rate of neurological complications was lower compared to those without protection (PRIND 1.0% vs 4.3%; stroke 1.0% vs. 2.1%). There was no death related to the procedure. Neurological complications were more frequent and more severe in patients with vascular multimorbidity compared to those with an isolated carotid-artery stenosis (4.2% vs 2.0%). The rate of neurological complications was similar in type II diabetics and nondiabetics (2.9% vs 4.1%). In 4.2%, minor complications related to the arterial puncture site were observed (3.5% hematoma not requiring blood transfusion, 0.7% pseudoaneurysm). At follow-up after a minimum of 6 months, 9 (6.3%) patients had died, the majority of whom had died of cardiovascular disease (3.5%).

Conclusions

CAS can be performed with an acceptable risk in high-risk patients in routine clinical settings when it is performed by an experienced operator. The use of thromboembolic protection devices reduces the risk of neurological complications. Presence of vascular multimorbidity, but not diabetes, appears to increase the risk of all causes and of neurological complications.