Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke—Early and 12-Month Outcomes in a Comprehensive Stroke Center

doi:10.1016/j.jvir.2018.03.025

Journal of Vascular and Interventional Radiology

Volume 29, Issue 9, September 2018, Pages 1254-1261.e2

https://doi.org/10.1016/j.jvir.2018.03.025 Get rights and content

Abstract

Purpose

To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center.

Materials and Methods

Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed.

Results

Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P = .08). Complication rates were similar between groups. mRS scores showed a significant improvement over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A subanalysis in patients with NIHSS scores ≥ 4 showed no differences in complication rate and outcome.

Conclusions

CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced centers, even after major atherosclerotic stroke.

Section snippets

Materials and Methods

Institutional review board approval for the study and written informed consent from all patients or surrogate decision-makers were obtained. A retrospective analysis of prospective data collected from consecutive patients with TIA or ischemic stroke admitted to a single comprehensive stroke unit between January 2013 and July 2015 was performed. Patients were evaluated in the acute phase by stroke neurologists and managed in accordance with the current international guidelines 24, 25. Among the

Univariate Analyses

Risk factors were found to approximately overlap between groups except for a history of coronary disease and presence of intracranial stenosis, which were more frequent in the CAS group (Table 1). Blood analysis revealed a higher baseline erythrocyte sedimentation rate in patients who received a CAS (P = .02). Patients with TIA and stroke were equally distributed between treatments: 9.7% of the CAS group and 12.5% of the CEA group were admitted following a TIA. The ischemic event was slightly

Discussion

The present study, carried out with the collaboration of experienced interventional radiologists and vascular surgeons, reports early and 12-month outcomes in patients with a recent ipsilateral atherosclerotic stroke undergoing urgent surgical or percutaneous carotid revascularization. The need for early revascularization treatment is suggested by the reported 6% 3-month risk of stroke or death compared with the 18.8% risk in nontreated symptomatic 50%–99% ICA stenoses (31). A direct

References (37)

K.I. Paraskevas et al.
Stroke/death rates following carotid artery stenting and carotid endarterectomy in contemporary administrative dataset registries: a systematic review
Eur J Vasc Endovasc Surg
(2016)
K.I. Paraskevas et al.
Critique of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): flaws in CREST and its interpretation
Eur J Vasc Endovasc Surg
(2013)
C. Setacci et al.
Carotid artery stenting in recently symptomatic patients: a single center experience
Ann Vasc Surg
(2010)
E. Ferrero et al.
A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution
Ann Vasc Surg
(2014)
J.J. Ricotta et al.
Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary
J Vasc Surg
(2011)
L.H. Bonati et al.
Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial
Lancet
(2015)
G.R. Pistolese et al.
Carotid endarterectomy in diabetic patients
J Vasc Surg
(2001)
L. Gates et al.
Characteristics that define high risk in carotid endarterectomy from the Vascular Study Group of New England
J Vasc Surg
(2015)
G. Howard et al.
Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials
Lancet
(2016)
M.B. Malas et al.
Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system
J Vasc Surg
(2017)

L.H. Bonati et al.

New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS)

Lancet Neurol

(2010)

F.L. Silver et al.

Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy versus Stenting Trial

Stroke

(2011)

B. Rantner et al.

Early endarterectomy carries a lower procedural risk than early stenting in patients with symptomatic stenosis of the internal carotid artery: results from 4 randomized controlled trials

Stroke

(2017)

S.H. Ahn et al.

Carotid artery stenting: review of technique and update of recent literature

Semin Intervent Radiol

(2013)

B.K. Nallamothu et al.

Operator experience and carotid stenting outcomes in Medicare beneficiaries

JAMA

(2011)

M.M. Wach et al.

Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis

J Neurointerv Surg

(2014)

J.L. Mas et al.

Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trials

Stroke

(2014)

P.A. Ringleb et al.

30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial

Lancet

(2006)

Cited by (9)

Editor's Choice – Relevance of Infarct Size, Timing of Surgery, and Peri-operative Management for Non-ischaemic Cerebral Complications After Carotid Endarterectomy
2022, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
A large infarct is often associated with severe functional deficit, questioning the benefit of a prophylactic intervention and whether severely affected patients should undergo early carotid intervention before potential successful rehabilitation. Thus, management of carotid endarterectomy (CEA) in patients with a substantial cerebral infarction has gained increasing significance in terms of balancing risk and benefit.4,12 In the present study, the hypothesis that infarct size, timing of CEA, and peri-operative management in patients with symptomatic carotid artery stenosis are associated with post-operative encephalopathy and haemorrhagic stroke was investigated.
To assess the incidence of post-operative non-ischaemic cerebral complications as a pivotal outcome parameter with respect to size of cerebral infarction, timing of surgery, and peri-operative management in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA).
Retrospective analysis of prospectively collected single centre CEA registry data. Consecutive patients with symptomatic carotid stenosis were subjected to standard patch endarterectomy. Brain infarct size was measured from the axial slice of pre-operative computed tomography/magnetic resonance imaging demonstrating the largest infarct dimension and was categorised as large (> 4 cm²), small (≤ 4 cm²), or absent. CEA was performed early (within 14 days) or delayed (15 – 180 days) after the ischaemic event. Peri-operative antiplatelet regimen (none, single, dual) and mean arterial blood pressure during surgery and at post-operative stroke unit monitoring were registered. Non-ischaemic post-operative cerebral complications were recorded comprising haemorrhagic stroke and encephalopathy, i.e., prolonged unconsciousness, delirium, epileptic seizure, or headache.
646 symptomatic patients were enrolled of whom 340 (52.6%) underwent early CEA; 367 patients (56.8%) demonstrated brain infarction corresponding to stenosis induced symptoms which was small in 266 (41.2%) and large in 101 (15.6%). Post-operative non-ischaemic cerebral complications occurred in 12 patients (1.9%; 10 encephalopathies, two haemorrhagic strokes) and were independently associated with large infarcts (adjusted odds ratio [OR] 6.839; 95% confidence interval [CI] 1.699 – 27.534) and median intra-operative mean arterial blood pressure in the upper quartile, i.e., above 120 mmHg (adjusted OR 13.318; 95% CI 2.749 – 64.519). Timing of CEA after the ischaemic event, pre-operative antiplatelet regimen, and post-operative blood pressure were not associated with non-ischaemic cerebral complications.
Infarct size and unintended high peri-operative blood pressure may increase the risk of non-ischaemic complications at CEA independently of whether performed early or delayed.
Editor's Choice – Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis
2022, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
A single centre study reported improved neurological outcomes for interventions performed within 14 days vs. 15 – 30 days of the index event (NIHSS range 0.9 ± 0.4 vs. 0.5 ± 0.2; p = .011).19 Other studies report NIHSS range but with no discriminative data concerning carotid intervention delay from index event.13,18,20 Hospital stay analysis presented a trend towards prolonged stay in patients undergoing CEA between 3 – 14 days after the index event vs. ≤ 2 days, with a mean difference (MD) of −1.28 (95% CI −6.96 – 4.40) (Fig. 7).
This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset.
A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS).
Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 – 0.85) and mortality rates (OR 0.41; 95% CI 0.31 – 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 – 14 and ≤ 7 vs. 8 – 14 days). Expedited CEA (vs. 3 – 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 – 1.8 vs. 1.8%; 95% CI 1.8 – 2.0, with no statistically significant difference. Expedited CAS (vs. 3 – 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 – 5.50).
At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
Meta-analysis of risk factors for restenosis after stent implantation in patients with ischemic cerebrovascular disease
2024, European Review for Medical and Pharmacological Sciences
Timing of carotid intervention in symptomatic carotid artery stenosis: a topical review
2023, Journal of Cardiovascular Surgery
Endovascular Treatment of ICAS Patients: Targeting Reperfusion Rather than Residual Stenosis
2022, Brain Sciences
Efficacy and safety of carotid endarterectomy in the acute phase of ischemic stroke
2021, Meditsinskiy Sovet

View all citing articles on Scopus

: None of the authors have identified a conflict of interest.

: Appendices A–C and Figure E1 are available online at www.jvir.org.

View full text

Clinical StudyCarotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke—Early and 12-Month Outcomes in a Comprehensive Stroke Center

Abstract

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Univariate Analyses

Discussion

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

Ann Vasc Surg

J Vasc Surg

Lancet

J Vasc Surg

J Vasc Surg

Lancet

J Vasc Surg

New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS)

Lancet Neurol

Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy versus Stenting Trial

Stroke

Early endarterectomy carries a lower procedural risk than early stenting in patients with symptomatic stenosis of the internal carotid artery: results from 4 randomized controlled trials

Stroke

Carotid artery stenting: review of technique and update of recent literature

Semin Intervent Radiol

Operator experience and carotid stenting outcomes in Medicare beneficiaries

JAMA

Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis

J Neurointerv Surg

Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trials

Stroke

30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial

Lancet

Clinical Study
Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke—Early and 12-Month Outcomes in a Comprehensive Stroke Center