Feasibility of simultaneous bilateral carotid artery stenting

Simultaneous bilateral angioplasty and stenting for carotid stenosis - a single center experience

Carotid artery stenosis is responsible for up to 12% of all ischemic strokes. The prevalence of bilateral carotid artery stenosis is nearly 8–39% among patients with stroke, and its management is still controversial. This study aimed to report the treatment results of bilateral carotid artery stenosis with simultaneous bilateral angioplasty and stenting (sbCAS) in a single institution during the last 10 years. 315 patients underwent carotid stenting in the Scientific-Practical Center of Endovascular Neuroradiology, NAMS of Ukraine during 2010–2020. 39 (12.4%) patients (mean age 57.9±2.1 – 28 men) underwent sbCAS. Primary clinical endpoints (stroke, myocardial infarction, or death) and secondary endpoints (hemodynamic depression (HD) – hypotension (<90 mmHg) or bradycardia (<60 bpm) and hyperperfusion syndrome (HPS) were evaluated. All sbCAS were technically successful, and a reduction of stenosis was noted in each case. There were two periprocedural neurological complications, one transient ischemic attack (TIA), and one minor stroke with the Modified Rankin Scale (mRS) – 3 at discharge. No myocardial infarction (MI) or death during hospitalization was noted. 28 patients (71.8%) had HD, and 2 (5.1%) had HPS. All patients except those with periprocedural stroke were discharged or transferred to another hospital without neurological deterioration. sbCAS is an effective and relatively safe procedure for carefully selected patients with bilateral carotid stenosis. Patients with bilateral carotid stenosis should be carefully examined, and the best treatment strategy should be assessed using a multidisciplinary approach taking into account the possibility of sbCAS.

Safety of simultaneous bilateral carotid artery stenting for bilateral carotid artery stenosis

BACKGROUND

Bilateral carotid artery stenting (BCAS) is often performed in two stages (staged BCAS) but it is also an option to be performed in one stage (simultaneous BCAS). To confirm the safety of simultaneous BCAS, we retrospectively analyzed perioperative and postoperative course of simultaneous BCAS compared with staged BCAS.

MATERIALS AND METHODS

Patients with symptomatic stenosis of ≥50% or asymptomatic stenosis of ≥80% of bilateral carotid arteries underwent BCAS. Procedure time, symptomatic ischemic complications, presence/absence of high-intensity spots on postoperative diffusion-weighted image, duration of postoperative hospital stays and 30 days outcome of patients performed with simultaneous BCAS (group A, 8 patients with 16 stenotic lesions (8 procedures)) were compared with those of staged BCAS (group B, 4 patients with 8 stenotic lesions (8 procedures)).

RESULTS

In groups A and B, procedure time was 146.0 ± 53.8 and 103.5 ± 39.4 min; intraoperative hypotension was observed in 62.5% and 50.0%; postoperative hypotension occurred in 37.5% and 50.0%; diffusion-weighted image showed high-intensity spots in 37.5% and 12.5%; and duration of postoperative hospital stays was 5.1 ± 1.8 and 5.3 ± 2.3 days. No patients suffered symptomatic ischemic complications. In simultaneous BCAS, there was a tendency that procedure time was longer and high-intensity spots on postoperative diffusion-weighted image was more frequent, but there was no increase in symptomatic ischemic complications and duration of hospital stays compared to staged BCAS.

CONCLUSIONS

Safety of simultaneous BCAS may not be inferior to staged BCAS. In terms of duration of hospital stays, simultaneous BCAS can be superior to staged BCAS for patients with bilateral carotid artery stenosis.

A systematic review and meta-analysis of results of simultaneous bilateral carotid artery stenting

BACKGROUND

Although staged procedures to treat bilateral carotid artery stenosis are mainstream, a growing number of articles on simultaneous bilateral carotid artery stenting (SBCAS) have been published. Thus, this meta-analysis was performed to evaluate the efficacy and safety of SBCAS.

METHODS

The PubMed and Embase databases were searched to identify all studies reporting SBCAS from January 1, 2000, to October 1, 2017. Patients' characteristics, comorbidities, technical success, deaths, and complications were collected and analyzed. Forest plots were drawn with either a random-effects model or fixed-effects model according to their heterogeneities. Publication biases were tested by funnel plots and linear regression test.

RESULTS

Overall, 333 patients with bilateral carotid stenosis in 10 retrospective studies were enrolled in this meta-analysis. The mean age was 67.4 years; 75% of the patients were male, and 85.6% of them were symptomatic. The mean severity of stenosis was 82.1%. The overall technical success rate reached 99.38% (95% confidence interval [CI], 96.58%-100.00%). The pooled incidences of periprocedural complications were as follows: hemodynamic depression, 46.12% (95% CI, 33.16%-59.35%); hyperperfusion syndrome, 3.33% (95% CI, 1.66%-5.55%); stroke, 3.20% (95% CI, 1.59%-5.36%); myocardial infarction (MI), 0.60% (95% CI, 0.00%-1.43%); and death, 1.20% (95% CI, 0.03%-2.38%). The occurrence of a periprocedural primary end point, defined as a combination of any stroke, MI, and death, affected 4.28% (95% CI, 2.37%-6.71%) of patients. For long-term patency, there were too few follow-up results available to evaluate.

CONCLUSIONS

Except for hyperperfusion syndrome, all other periprocedural complications including hemodynamic depression, stroke, and MI were comparable with the literature reporting unilateral carotid artery stenting. However, the analysis was based on retrospective studies. Further studies, including prospective and randomized controlled studies, are needed to confirm these results.

The Feasibility and Safety of Separate Carotid Artery Stenting Using the Restrict Protective Method for Bilateral Carotid Stenosis

BACKGROUND AND OBJECTIVE

The treatment strategy for bilateral carotid stenosis (BCS) is not clear. We report our experience of treating 12 patients with BCS using separate carotid artery stenting (CAS) using the restrict protective method. The order of treatment site and the protective method are also discussed.

METHODS

Between April 2012 and November 2016, 24 lesions in 12 patients (range, 44-83 years; mean, 71 years; 1 woman) underwent CAS at Kariya Toyota General Hospital. These cases were reviewed retrospectively. In all cases, CAS was first performed on the more severely stenosed site. All procedures were performed using the proximal protective method involving balloons and a filter device. We took into consideration adverse events including death from any cause, major stroke within 30 days, and death between 30 days and 1 year later from any stroke.

RESULTS

All procedures were successfully performed under local anesthesia. There was not a single case that showed intolerance during flow arrest to prevent distal embolisms. We observed no adverse events, restenosis, or recurrent symptoms during follow-up.

CONCLUSIONS

Good outcomes can be achieved in patients with BCS when attempting separate CAS using the restrict protective method.

Simultaneous Bilateral Carotid Stenting for Symptomatic Bilateral High-Grade Carotid Stenosis: A Retrospective Clinical Investigation

Background

This retrospective clinical investigation aimed to evaluate the short-term effectiveness and safety of SBCAS for symptomatic bilateral high-grade CS.

Material/Methods

From 2009 to 2014, 145 patients were recruited. Among them, 70 underwent SBCAS, and other 75 patients underwent SAMM and served as controls. The immediate postprocedural complications and postprocedural neurological evaluation, as well as restenosis at 6-month and 1-year follow-ups in the SBCAS group are reported. Additionally, baseline risk factors for ischemic stroke, adverse effects of drugs, and outcomes at 30-day, 6-month, and 1-year follow-ups were compared between the 2 groups.

Results

Our data did not reveal significant differences between the 2 groups in baseline risk factors for ischemic stroke. In the SBCAS group, both HPS (5.7%) and HD (40%) occurred, but they were not very severe, and no patients had postprocedural neurological deficit. Moreover, restenosis only occurred in 3 patients at 3 stent placement sites (4.3%) at 1-year follow-up. Adverse effects of drugs did not occur in SBCAS group, but adverse effects of Bayer aspirin and Lipitor occurred in 4 patients (5.4%) and 18 patients (24.3%), respectively, at 6-month follow-up in the control group. Furthermore, there were significant differences in outcomes between the 2 groups at 30-day, 6-month, and 1-year follow-ups, in that NIHSS, CS ratio, and incidence of endpoint events, as well as 1-year cumulative probability of endpoint events, were all lower in the SBCAS group than in the control group (p<0.05).

Conclusions

Compared to SAMM, we found that SBCAS was more effective and safer for symptomatic bilateral high-grade CS.

Feasibility and Safety of Simultaneous Carotid Endarterectomy and Carotid Stenting for Bilateral Carotid Stenosis: A Single-Center Experience using a Hybrid Procedure

BACKGROUND

The treatment for bilateral carotid stenosis (BCS) is challenging, and the optimal treatment strategy is not clear. We report our experience of treating 8 patients with BCS by simultaneous carotid endarterectomy (CEA) and carotid stenting (CAS), thereby providing an alternative for vascular surgeons.

METHODS

Between October 2010 and August 2014, 8 patients (5 males and 3 females; range, 53-82 years; mean, 69 ± 8.8 years) underwent simultaneous CEA and CAS in our hospital. CEA before CAS was done in 5 patients, and CAS before CEA was done in 3 patients. One patient also underwent simultaneous coronary artery bypass grafting due to unstable angina. Intraoperative transcranial Doppler ultrasonography, carotid shunts, patches, and embolic protection devices were used in all patients. Instances of hyperperfusion syndrome (HPS), hemodynamic depression, stroke, myocardial infarction (MI), and death were recorded.

RESULTS

All patients completed the procedure. One patient developed postprocedural HPS. After systemic treatment, he recovered completely. There were no deaths, major and/or minor strokes, or MI, nor did any patient exhibit lower palsy in cranial nerves in the perioperative period (<30 days) or on clinical follow-up (3 and 6 months). We observed no restenosis and no recurrent symptoms during follow-up.

CONCLUSIONS

After careful preoperative assessment and preparation, simultaneous CEA and CAS for high-grade BCS may be considered as an alternative management strategy in carefully selected patients.

Simultaneous Bilateral vs Unilateral Carotid Artery Stenting: 30-Day and 1-Year Results

PURPOSE

To evaluate clinical outcomes of simultaneous bilateral carotid artery stenting (sbCAS) compared with unilateral CAS (uCAS).

METHODS

The database in our institution was queried to identify all patients treated with CAS from January 2005 to December 2012. In this time frame, 120 (18.8%) patients (mean age 64.9 ± 7.7 years; 96 men) underwent sbCAS and 517 (81.2%) patients (mean age 65.7 ± 7.7 years; 421 men) received uCAS. The primary endpoint was the composite of stroke, myocardial infarction, or death within 30 days or any ipsilateral stroke within 1 year.

RESULTS

There was no significant difference in the rates of the primary endpoint between the sbCAS and uCAS groups (6.7% vs 4.6%, p=0.358). The rates of the primary endpoint among symptomatic patients was 8.0% in the sbCAS group and 5.0% in the uCAS group (p=0.299) and 3.1% and 4.0%, respectively (p=0.821) among asymptomatic patients. During the 30-day periprocedural period, the rates of the primary endpoint did not differ significantly between the sbCAS and uCAS groups among all patients (5.8% vs 4.4%, p=0.479), symptomatic patients (6.8% vs 5.0%, p=0.594), or asymptomatic patients (3.1% vs 3.5%, p>0.999). After this period, the incidences of any ipsilateral stroke were similarly low (0.8% and 0.2%, respectively; p=0.342).

CONCLUSION

The study showed that simultaneous bilateral CAS had no more adverse events than unilateral CAS during the periprocedural period or within 1 year. This 1-stage strategy may become a valuable alternative in the treatment of patients with severe bilateral carotid stenosis.

Simultaneous bilateral carotid stenting in a series of 9 patients: a single-center experience with review of literature

Objectives:

Simultaneous bilateral carotid artery stenting (SBCAS) is a challenging procedure, and selection criteria play an important role in determining the final outcome. The aim of the present study was to determine the efficacy and safety of the SBCAS in a series of 9 patients with significant bilateral carotid artery disease (>50% on the symptomatic side and >60% on the asymptomatic side).

Materials and Methods:

The present study is a retrospective study of 9 patients from January 2005 to December 2012 in a tertiary care center. There were 8 males and 1 female in the age range 50 to 75 years and an average mean age of 63 years. Inclusion criteria of the present study were patients with bilateral internal carotid artery stenosis >50% (50 - 99%) in the symptomatic side and >60% in the asymptomatic side as seen on digital subtraction angiography (DSA). SBCAS with use of distal protection device (Spider device, ev3), to prevent intra-procedural embolic migration, was done in all the patients.

Results:

Technical success was achieved in all patients (100%). Post-procedural events in the form of hypotension and bradycardia occurred in 3 patients after the placement of stent on both the sides, in 2 patients after the placement of the first stent, and in 1 patient after the placement of the second stent. We did not encounter any cases of hyperperfusion, which was a concern in these patients. There were no deaths, major or minor strokes, or myocardial infarction either in the post-procedural period (up to 1 month) or on clinical follow-up 3 and 6 months post-treatment.

Conclusion:

SBCAS was an effective and safe alternative treatment method in a select group of patients with bilateral carotid artery disease. It can be considered as a feasible treatment option with acceptable risks.

Simultaneous bilateral carotid stenting in high-risk patients

BACKGROUND AND PURPOSE

The safety and efficacy of SBCAS have not been evaluated in detail. The purpose of our study was to evaluate the outcome after SBCAS in high-risk patients compared with unilateral stent placement.

MATERIALS AND METHODS

Between March 2002 and October 2008, a total of 205 consecutive high-risk patients underwent CAS at our institution. Of these patients, 30 (14.6%) underwent SBCAS (n = 24) and staged SBCAS (n = 6). Patients who underwent unilateral CAS (n = 175) during the same period served as controls. The stroke risk factors, procedural results, and outcome at 30 days and 6 months, as well as the restenosis rate at 6 months, were compared by using either the chi(2) test or the Kruskal-Wallis equality-of-populations rank test.

RESULTS

Our data revealed no significant differences in the stroke risk factors between the SBCAS and the control group. HPS occurred more commonly in SBCAS (ie, 16.7%, 4/24) compared with 2.9% (5/175) in the control group (P = .014). However, there was no statistical significance between 2 groups in the event rate of stroke (minor and/or major stroke), death, or restenosis at 6 months.

CONCLUSIONS

There was no significant difference in outcome at 6 months following stent placement between SBCAS and unilateral CAS in the high-risk patient group, even though HPS occurred more commonly after SBCAS.

The brain first or the heart: the approach to revascularizing severe co-existing carotid and coronary artery disease

Combined symptomatic severe cerebralvascular disease and significant obstructive coronary artery disease frequently exist. For the past few decades, clinicians have debated the various treatment strategies for these high-risk patients including staged procedures and hybrid revascularization. While some recommend addressing the more unstable vascular territory first, others prefer to intervene on the carotids prior to performing coronary revascularization. Both surgical and percutaneous options have been explored in various clinical settings, but there are no treatment guidelines to date. Given the frequency and magnitude of this problem, we performed an extensive review of the literature in an attempt to add some much needed clarity. An illustrative case and recommendations are provided.

The optimal treatment of carotid atherosclerosis: a 2008 update and literature review

Carotid and cerebrovascular disease have major public health implications given the associated morbidity and mortality. However, the best treatment for this disease is uncertain. Carotid endarterectomy has proven useful in primary and secondary prevention of strokes for patients with significant internal carotid artery stenoses. Many patients are considered at high risk for such surgical procedures and therefore have relatively few treatment options. Carotid stenting is currently being investigated as an alternative therapeutic intervention for these patients. This article reviews the literature pertaining to carotid intervention and its current status in 2008.

Simultaneous Bilateral Carotid Stenting under the Circumstance of Neuroprotection Device. A Retrospective Analysis

SUMMARY

In this study, in order to evaluate the feasibility and outcomes of simultaneous bilateral carotid artery stenting (CAS) with the use of neuroprotection in symptomatic patients, we conducted a retrospective analysis of 27 patients (19 men, eight women; median age, 69.2 years), all of whom had been scheduled to undergo bilateral CAS in a single setting. All patients presented with severe atherosclerotic bilateral carotid stenosis (> 50% for symptomatic side, > 80% for asymptomatic side), exhibiting symptoms of either a cerebrovascular accident or of a transient ischemic attack on at least one side. 48 arteries were treated with self-expandable stents. Neuroprotection devices were utilized for bilateral CAS in 11 patients, and in 16 unilateral CAS patients. We did not perform the second procedure in six patients, in cases in which a patient exhibited (a) hemodynamic instability, (b) a new neurological impairment, or (c) restlessness after a prolonged time for the first CAS. The second procedure was postponed in a staged manner. We achieved a mean residual stenosis of 8.1 +/- 5.0 % in the treated lesions. The mean procedural time for bilateral CAS was three hours and 18 minutes. 17 patients (63%) developed transient bradycardia during the balloon dilatation of one or both of the relevant arteries. Three patients (11%) exhibited persistent bradycardia and hypotension, which required the administration of intravenous vasopressors for several days (2~7 days). None of the patients ultimately required pacemakers, or any further therapy. Two of the patients (7%) developed transient ischemic attack during the periprocedural period, but recovered completely. One patient developed a new minor stroke after the first procedure, and the second procedure was delayed in a staged manner.We observed no periprocedural deaths, major strokes, or myocardial infarctions, nor did we detect any cases of hyperperfusion syndrome within 30 days. In summary, simultaneous bilateral CAS with neuroprotection can be performed in a single setting without increased concerns with regard to hyperperfusion syndrome, hemodynamic instability, thrombo-embolism, or procedure time, when the first CAS has been safely completed with no evidence of complications in a wellmanaged procedure time.

Bilateral carotid angioplasty and stenting

Bilateral carotid stenosis is generally treated by staged stenting procedure and rarely simultaneously due to concerns about hemodynamic impairment from stimulation of the carotid sinus baroreflex (severe bradycardia, hypotension) and the risk of cerebral hyperperfusion syndrome. Most of the accounts of bilateral carotid stenting are of small series. The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral carotid angioplasty and stenting (CAS) in comparison with staged procedure. We retrospectively analyzed the procedural outcome and complications of bilateral CAS done between February 1995 and June 2004 in a consecutive series of 57 high-risk patients. Mean age was 64 +/- 9 years (male, 43; female 14). One hundred fifteen arteries were treated (one patient had bilateral internal carotid artery stenosis associated to an ostial common carotid artery stenosis). Thirty-nine patients were symptomatic (70%). Thirty-six patients had severe coronary artery disease. Seventeen patients underwent a simultaneous bilateral CAS (group 1), 40 in a staged manner (group 2). Among these 40 patients 10 were treated with a time interval of 24 hr, while the 30 other ones were treated with a time interval of 2 days to 2 months. A neuroprotection device was used in the last 42 patients. There was technical success in all patients and transient bradycardia and/or hypotension in 25 patients (44%). There was no prolonged bradycardia or hypotension. At 30 days, we observed in group 1 (simultaneous bilateral CAS) no transient ischemic attack (TIA), no minor stroke, one (5.8%) major stroke (hyperperfusion syndrome with brain hemorrhage leading to death in a patient under IIb/IIIa inhibitors), one myocardial infarction leading to death, and two (11.7%) death/stroke/myocardial infarction; in group 2 (staged procedure), two (5%) TIAs, no minor stroke, no major stroke, and one (2.5%) hyperperfusion syndrome with rapid recovery. Among the 10 patients treated with a time interval of 24 hr, we observed one TIA. Among carefully selected patients, bilateral CAS is feasible simultaneously or the day after, with a safety and complication rate comparable to that of large published series of CAS or endarterectomies in high-risk patients. Nevertheless, careful monitoring of the patient, blood pressure, and heart rate is mandatory to avoid complications related to hyperperfusion syndrome. Routine use of neuroprotection device and meticulous technique should improve the outcomes of bilateral CAS.