Safety and efficacy of simultaneous bilateral carotid angioplasty and 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.