Carotid angioplasty and stenting in anatomically high-risk patients: Safe and durable except for radiation-induced stenosis.

Abstract

OBJECTIVE:

Carotid angioplasty and stenting (CAS) is used in patients considered high-risk for carotid endarterectomy (CEA). Patients qualify as high-risk because of medical comorbid conditions or for anatomic considerations (previous CEA, radical neck dissection, radiation). We compared the technical feasibility and durability of CAS in medically high-risk patients (MED) vs anatomically high-risk patients (ANAT).

METHODS:

A retrospective review was performed of all consecutive patients undergoing CAS by a single vascular surgery group. All patients were high risk and evaluated with duplex ultrasound imaging and angiography. Primary end points were technical success, 30-day stroke, myocardial infarction (MI), death, and in-stent restenosis. Standard statistical analysis included Kaplan-Meier life tables.

RESULTS:

From January 2003 to December 2007, 230 CAS (98 ANAT, 132 MED) procedures were attempted. The ANAT cohort comprised 84 patients with a single anatomic risk factor: 71 with a previous ipsilateral CEA, 6 high lesions, 6 history of neck radiation, and 1 with a tracheostomy. Ten patients had two or three anatomic risk factors: nine with radical neck dissection and radiation and one with neck radiation and ipsilateral CEA. The mean age was 71.1 years for ANAT vs 73.9 years for MED (P = .021). Technical success rates were 98% in ANAT and 98.5% in MED (P = .76). Thirty-day stroke rate was 1.0% in ANAT and 5.3% in MED (P = .14); the mortality rate was 2.0% in ANAT and 0.8% in MED (P = .79). The 2-year survival free from stroke was MED, 93.6% and ANAT, 98.9% (P = .118); and from restenosis was MED, 91.9%; and ANAT, 91.0% (P = .98). Two-year overall survival was significantly better in ANAT (84.6%) vs MED (70.1%; P = .026). Four of the seven restenoses in the ANAT group occurred in patients with previous neck radiation. The restenosis rate for radiation-induced (RAD) stenosis treated with CAS was significantly higher at 22.2% (4 of 18) compared with 3.8% (3 of 78) in ANAT group patients without a history of radiation (non-RAD; P = .028). The 2-year restenosis-free survival was 72.7% in the RAD group vs 95.9% in the non-RAD group (P = .017).

CONCLUSION:

CAS is as technically feasible, safe, and durable in anatomically high-risk patients as in medically high-risk patients, with similar rates of periprocedural stroke and death and late restenosis. However, patients with radiation-induced stenosis appear to be at an increased risk for restenosis.

• Authors: Susanna H Shin, Christopher L Stout, Albert I Richardson, Richard J DeMasi, Rasesh M Shah, Jean M Panneton
• Journal: Journal of vascular surgery (J Vasc Surg) Vol. 50 Issue 4 Pg. 762-7; discussion 767-8 (Oct 2009) ISSN: 1097-6809 [Electronic] United States
• PMID: 19786237 (Publication Type: Comparative Study, Journal Article)

Topics

• Aged
• Angioplasty, Balloon (methods, mortality)
• Blood Vessel Prosthesis Implantation
• Carotid Stenosis (diagnostic imaging, mortality, therapy)
• Cohort Studies
• Comorbidity
• Feasibility Studies
• Female
• Follow-Up Studies
• Graft Occlusion, Vascular (diagnostic imaging, epidemiology)
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Probability
• Radiation Injuries (complications, therapy)
• Retrospective Studies
• Risk Assessment
• Severity of Illness Index
• Stents
• Survival Rate
• Time Factors
• Treatment Outcome
• Ultrasonography, Doppler, Duplex
• Vascular Patency