Carotid Stenting Safe in Risky Patients
By Todd Neale, Senior Staff Writer, MedPage Today
Published: January 22, 2013
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
• Among patients undergoing elective carotid artery stenting, presence of a contralateral carotid artery occlusion was not associated with worse in-hospital outcomes.
• Note that there were no between-group differences for any of the individual components of the endpoint (in-hospital death, nonfatal myocardial infarction, or nonfatal stoke).
Among patients undergoing elective carotid artery stenting, presence of a contralateral carotid artery occlusion was not associated with worse in-hospital outcomes, researchers found.
In a propensity-matched analysis, the rate of death, MI, or stroke in the hospital -- the primary composite endpoint -- was 2.1% in the patients with a contralateral occlusion and 2.6% in those without one, a nonsignificant difference (OR 0.81, 95% CI 0.53 to 1.23), according to Steven Marso, MD, of Saint Luke's Mid America Heart Institute in Kansas City, Mo., and colleagues.
Likewise, there were no between-group differences for any of the individual components of the endpoint, the researchers reported in the January issue of JACC: Cardiovascular Interventions.
The findings could help guide the choice of carotid revascularization procedure, they said.
"Although we did not directly compare the outcomes of carotid endarterectomy with carotid artery stenting in patients with a contralateral carotid artery occlusion ... endarterectomy is known to be associated with increased risk in the presence of [a contralateral occlusion], whereas stenting appears to be safe in this group of patients, potentially due to the widespread implementation of embolic protection devices during balloon inflation and stent deployment," the researchers wrote.
Thus, they wrote, "carotid artery stenting appears to be a reasonable revascularization option for patients with a contralateral carotid occlusion if anatomically suitable for [stenting]."
Carotid endarterectomy has been shown to improve outcomes when compared with medical therapy, but patients with contralateral occlusions have an increased risk of periprocedural death, MI, or stroke following surgery.
"Although the mechanism for increased risk is not fully understood, it is commonly believed to be related to a reduction in blood flow during cross-clamping of the ipsilateral common carotid artery during endarterectomy," Marso and colleagues explained.
A treatment alternative for these patients may be elective carotid artery stenting, although post-stenting outcomes in this high-risk population have been studied only in smaller retrospective studies totalling fewer than 500 patients.
To explore the issue in a larger cohort, the researchers used data from the CARE registry, which collects information on carotid revascularization procedures from 186 centers in the U.S.
The study included, 13,993 patients who underwent elective carotid stenting from April 2005 to January 2012; 10% had a contralateral occlusion, defined as complete blockage of the contralateral internal carotid artery.
To account for differences between patients with and without a contralateral occlusion, the researchers used propensity matching of 42 clinical and demographic variables. The matching process resulted in a comparison between 1,375 procedures among patients with contralateral occlusions and 4,125 among patients without such an occlusion. The mean age of the patients was 69, and about two-thirds were male.
The lack of a difference in in-hospital outcomes based on the presence of a contralateral occlusion was consistent whether the procedures were performed on restenotic or de novo lesions and also in subgroups defined according to symptom status, age, and sex.
The authors acknowledged that the study was limited by the lack of intermediate and long-term follow-up, the fact that retrospective findings are subject to unmeasured confounding, and the lack of a comparison between stenting and either carotid endarterectomy or medical therapy.
"Nonetheless," the authors wrote, "we believe that an indirect inference regarding the potential advantages of carotid artery stenting relative to other strategies in this group of patients is warranted."