Complications and Follow-up after Unprotected Carotid Artery Stenting

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

Percutaneous injection of lidocaine within the carotid body area in carotid artery stenting: an "old-new" technique

Severe bradycardia is a common untoward effect during balloon angioplasty when performing carotid artery stenting. Therefore atropine injection even before dilatation and the presence of an anesthesiologist are advocated in all patients. In the surgical literature, injection of a local anesthetic agent into the carotid sinus before carotid endarterectomy was performed in an attempt to ameliorate perioperative hemodynamic instability. This study was undertaken to test the hypothesis that percutaneous infiltration of the carotid sinus with local anesthetic immediately before balloon dilatation reduces bradycardia and ameliorates the need for atropine injection or the presence of an anesthesiologist. Infiltration of the carotid sinus with 5 ml of 1% lidocaine, 3 min before dilatation, was performed in 30 consecutive patients. No one exhibited any significant rhythm change that required atropine injection. The anesthesiologist did not face any hemodynamic instability during the carotid artery stenting procedure.

Cutting Balloon Angioplasty (CBA) Versus Conventional Balloon Angioplasty (PTA) in the Pre-Dilatation of Carotid Artery Stenosis: Our Preliminary Experience

A retrospective study was carried out to evaluate the efficacy and safety of cutting-balloon angioplasty (CBA) for the predilatation of tight fibrocalcified carotid stenosis before carotid artery stenting (CAS). We also compared the intraprocedural results of CBA with those of conventional percutaneous transluminal angioplasty (PTA) in terms of postdilatation rate. The study population was composed of 32 patients who underwent CAS requiring predilatation before stent implantation. In detail, predilatation was performed by using a conventional balloon (PTA) in 14 patients (group A) and a cutting balloon (CBA) in 18 patients (group B). Intraprocedural and periprocedural mortality, major and minor procedural and neurologic complications, arterial damage, and embolic debris found in the distal filter were recorded. We statistically compared the rate of postdilatation obtained in the two groups. Technical success was obtained in 100% of the cases. No death, major neurologic or periprocedural complications, or arterial damage were recorded in either group. Minor neurologic reactions were recorded in 1 patient from group A (4%) and in 1 patient from group B (3%). Embolic debris was found in the distal filter in 2 patients from group A (8%) and in 3 patients from group B (10%). Postdilatation was necessary in 14 patients from group A (100%) and in 9 patients from group B (50%) (p < 0.05). Although limited to a small number of patients, compared with PTA, CBA seems to be a safe and effective procedure for the predilatation of tight fibrocalcified carotid stenoses before stent placement and may decrease the need for postdilatation in this patient population.

Exclusion of Atherosclerotic Plaque from the Circulation Using Stent-Grafts: Alternative to Carotid Stenting with a Protection Device?

PURPOSE

To retrospectively assess the feasibility, safety, and clinical mid-term outcome of patients undergoing carotid artery stenting with stent-grafts.

METHODS

Over a 4 year period stent-grafts were used in the endovascular treatment of symptomatic internal carotid artery stenosis in 12 patients (2 women, 10 men, aged 47-83 (mean 64) years). Protection devices were not used. Possible microembolic complications were evaluated by magnetic resonance imaging (MRI) examinations of the brain before and the day after the procedure in all patients. Mean follow-up was 22 months (range 1-42 months), by Doppler ultrasonography and conventional angiography as well as clinical examination.

RESULTS

The technical success rate was 100%. A total of 13 coronary stent-grafts were used. The mean stenosis rate (in terms of diameter) was 85% and the mean length of stent-grafts used was 20.9 mm. The mean diameter to which the stent-grafts were dilated was 4.66 mm. In-hospital complications occurred in 1 patient who suffered a minor femoral access hematoma that did not require transfusion or surgical decompression. Post-stenting diffusion-weighted MRI revealed several ipsilateral silent microemboli in only 1 case, which was completely asymptomatic. Two patients had a major stroke after 2 years of follow-up. Restenosis was found in 2 patients who underwent successful balloon dilatation followed by placement of a self-expandable bare stent within the stent-grafts.

CONCLUSIONS

Stent-grafts may prevent microembolic complications during stenting of atherosclerotic carotid lesions in selected cases, offering immediate exclusion of the atherosclerotic lesion from the circulation by pressing the plaque against the vessel wall. Comparative, randomized studies in larger series of patients are needed with carotid-dedicated stent-graft designs.

[Carotid Stenting in France after the EVA 3S and SPACE publications]

Angioplasty of stenoses of the carotid bifurcation is a revascularization procedure that is used successfully in many patients. With more than 10 years of experience now, the feasibility of carotid stenting has been demonstrated. Its distribution is highly variable depending on the country, with a mean penetration rate in Europe of 15% of the number of carotid revascularizations. However, the complication rate is highly variable from one series to another and depends on the type of patient treated and the operator's learning curve. The results of the first two randomized studies comparing endarterectomy and carotid stenting, EVA 3S in France and SPACE in Germany, have just been published. The conclusions of these studies only relate to symptomatic patients, who make up a small proportion of revascularized patients. At 30 days, the French study concluded that surgery was better, and the German study showed no advantage to stenting. The analysis of these results compared to other publications should make it possible to best define the current indications for carotid stenting.