CAPTURE 2 risk-adjusted stroke outcome benchmarks for carotid artery stenting with distal embolic protection

Proximal versus distal protection: dissecting clinical trials

Carotid artery stenting (CAS) is a valid alternative to conventional carotid endarterectomy for treatment of carotid artery stenosis. Distal embolization of atherosclerotic debris causing cerebrovascular accidents during CAS has been the most significant concern limiting widespread application of CAS technology. A variety of embolic protection devices (EPDs) with different mechanism of action, have been designed to minimize the risk of major embolization causing stroke and their use is recommended by current guidelines. Two general types of EPDs are available: proximal protection devices (PPDs) and distal protection devices (DPDs). However, there is no convincing clinical evidence of the clinical superiority of one device over another. This review will examine the different types of available devices and also innovative devices and techniques, including strengths and weaknesses of each, and present the available evidence and rationale for their routine use during CAS.

Clinical Outcomes of Second- versus First-Generation Carotid Stents: A Systematic Review and Meta-Analysis

Background: Single-cohort studies suggest that second-generation stents (SGS; “mesh stents”) may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Objectives: To compare clinical outcomes of SGS in relation to first-generation stents (FGSs; single-layer) in CAS. Methods: We performed a systematic review and meta-analysis of clinical studies with FGSs and SGS (PRISMA methodology, 3302 records). Endpoints were 30-day death, stroke, myocardial infarction (DSM), and 12-month ipsilateral stroke (IS) and restenosis (ISR). A random-effect model was applied. Results: Data of 68,422 patients from 112 eligible studies (68.2% men, 44.9% symptomatic) were meta-analyzed. Thirty-day DSM was 1.30% vs. 4.11% (p < 0.01, data for SGS vs. FGS). Among SGS, both Casper/Roadsaver and CGuard reduced 30-day DSM (by 2.78 and 3.03 absolute percent, p = 0.02 and p < 0.001), whereas the Gore stent was neutral. SGSs significantly improved outcomes compared with closed-cell FGS (30-day stroke 0.6% vs. 2.32%, p = 0.014; DSM 1.3% vs. 3.15%, p < 0.01). At 12 months, in relation to FGS, Casper/Roadsaver reduced IS (−3.25%, p < 0.05) but increased ISR (+3.19%, p = 0.04), CGuard showed a reduction in both IS and ISR (−3.13%, −3.63%; p = 0.01, p < 0.01), whereas the Gore stent was neutral. Conclusions: Pooled SGS use was associated with improved short- and long-term clinical results of CAS. Individual SGS types, however, differed significantly in their outcomes, indicating a lack of a “mesh stent” class effect. Findings from this meta-analysis may provide clinically relevant information in anticipation of large-scale randomized trials.

Intraoperative electroencephalographic changes during transcarotid artery revascularization are more frequent than previously reported

OBJECTIVE

Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring will require shunt placement because of EEG changes. However, the initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR.

METHODS

We conducted a retrospective review of patients who underwent TCAR at two urban hospitals within an integrated healthcare network from May 2017 to January 2020. The data included demographic information, patient comorbidities, symptom status, previous carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction [MI], and death) both initially and at 30 days postoperatively. The Fisher exact test was used for categorical data and the Wilcoxon rank sum test for continuous data.

RESULTS

A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) received intraoperative EEG neuromonitoring. Of the 89 patients, 70.8% were men and 29.2% were women. The median age was 75 years (IQR, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who received continuous neuromonitoring, 9 experienced EEG changes during TCAR (12.7%). The changes resolved in seven patients with pressure augmentation in three and switching to a low flow toggle in three. One patient who had sustained EEG changes had a new postoperative neurologic deficit. The median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .01). No correlation was found between symptom status or 30-day stroke in patients with and without EEG changes (P = .49 and P = .24, respectively). Overall, three postoperative strokes, two postoperative deaths, and one MI occurred, for a composite 30-day stroke, death, and MI rate of 6.7%.

CONCLUSIONS

Changes in continuous EEG monitoring were more frequent in our study than previously reported. Less severe carotid stenosis might be associated with a greater incidence of EEG changes. Limited data are available on the prognostic ability of EEG to detect clinically relevant changes during TCAR, and further studies are warranted.

Anesthetic choice during transcarotid artery revascularization and carotid endarterectomy affects the risk of myocardial infarction

OBJECTIVE

Previous studies have shown no differences in the outcomes of transcarotid artery revascularization (TCAR) performed with general anesthesia (GA) vs local or regional anesthesia (LRA). To date, no study has specifically compared the outcomes of TCAR to those of carotid endarterectomy (CEA) stratified by anesthetic type. The aim of the present study was to identify the effect of the anesthetic type on the outcomes of TCAR vs CEA.

METHODS

Patients undergoing CEA and TCAR for carotid artery stenosis from 2016 to 2019 in the Vascular Quality Initiative were included. We excluded patients who had undergone concomitant procedures, patients with more than two stented lesions, and patients who had undergone the procedure for a nonatherosclerotic indication. Propensity score matching was performed between the two procedures stratified by the anesthetic type for age, sex, race, presenting symptoms, major comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease), previous coronary artery bypass grafting or percutaneous transluminal coronary intervention, previous CEA or carotid artery stenting, degree of ipsilateral stenosis, the presence of contralateral occlusion, and preoperative medications. Intergroup differences between the treatment groups and differences in the perioperative outcomes were tested using the McNemar test for categorical variables and the paired t test or Wilcoxon matched pairs signed rank test for continuous variables, as appropriate. The relative risk (RR) and 95% confidence intervals (CIs) were estimated as the ratio of the probability of the outcome event for the patients treated within each treatment group.

RESULTS

A total of 65,337 patients were included. Of the 65,337 patients, 59,664 had undergone carotid revascularization under GA (91%). When performed with LRA, TCAR and CEA had similar rates of stroke, death, and MI. However, when performed with GA, patients undergoing TCAR had a 50% decreased risk of MI compared with those undergoing CEA under GA (0.5% vs 1.0%; RR, 0.50; 95% CI, 0.32-0.80; P < .01). When stratified by symptomatic status, patients undergoing TCAR with GA for symptomatic carotid disease had a 67% decreased risk of MI compared with those undergoing CEA with GA for symptomatic disease (0.4% vs 1.2%; RR, 0.33; 95% CI, 0.15-0.75; P < .01). In contrast, no difference was found in the risk of MI between patients undergoing CEA vs TCAR for asymptomatic carotid disease (0.6% vs 0.9%; RR, 0.64; 95% CI, 0.37-1.14; P = .13).

CONCLUSIONS

The results from the present study have confirmed previous studies suggesting that TCAR confers a lower risk of MI compared with CEA. However, our findings demonstrated no differences in the MI rates between TCAR and CEA when performed with LRA. Patients undergoing TCAR under GA had lower rates of MI compared with patients undergoing CEA under GA. When stratified by symptomatic status, the benefit of TCAR persisted only for the symptomatic patients.

Proximal balloon occlusion versus distal filter protection in carotid artery stenting: A meta-analysis and review of the literature

INTRODUCTION

Carotid artery stenting (CAS) is typically performed using embolic protection devices (EPDs) as a means to reduce the risk of procedure-related stroke. In this study, we compared procedural morbidity and mortality associated with distal (D-EPD) vs. proximal (P-EPD) protection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1998 through May 2015. Only studies comparing (D-EPD) and (P-EPD) were included. Two independent reviewers selected and appraised studies and extracted data in duplicate. Random-effects meta-analysis was used to pool outcomes across studies. Heterogeneity of treatment effect among studies was assessed using the I² statistics. Publication bias was assessed using inspection of funnel plots. The primary endpoints included 30-day mortality and stroke. Secondary endpoints included new cerebral lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) and contralateral lesions on DW-MRI.

RESULTS

A total of 12,281 patients were included from 18 studies (13 prospective and 5 retrospective) comparing (D-EPD) and (P-EPD) in the setting of CAS. The mean patient age was 69 years and 64% of patients were male. No evidence of publication bias was detected. There was no significant difference between the two modalities in terms of the risk of stroke (risk difference [RD] 0.0, 95% confidence interval [CI] -0.01 to 0.01) or mortality (RD 0.0, 95% CI -0.01 to 0.01) nor was there any difference in the incidence of new cerebral lesions on DW-MRI or contralateral DW-MRI lesions.

CONCLUSIONS

In patients undergoing CAS, both D-EPD and P-EPD provide similar levels of protection from peri-procedural stroke and 30 days mortality. © 2016 Wiley Periodicals, Inc.

Comparative effectiveness of carotid revascularization therapies: evidence from a National Hospital Discharge Database

BACKGROUND AND PURPOSE

Clinical equipoise of carotid revascularization therapies remains controversial. We sought to determine whether adverse outcomes after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) were similar using propensity score-matched analysis of retrospective data from a large hospital discharge database.

METHODS

All CEA and CAS cases were identified from the 2006 to 2011 Premier Perspective Database and subjected to 1:1 propensity score matching using 33 clinical covariates associated with carotid revascularization. A primary composite end point of peri- or postoperative mortality, stroke, or acute myocardial infarction and a modified composite end point excluding acute myocardial infarction were used to compare our findings with recent prospective controlled trials. Multivariate regression and Cox-proportional hazard ratio survival analysis were performed to compare revascularization therapy outcomes.

RESULTS

After 1:1 propensity score matching, 24 004 (12 002 CEA and CAS) asymptomatic and 3506 (1753 CEA and CAS) symptomatic procedures were included. The risk of the primary composite end point was significantly higher after CAS than CEA in both asymptomatic (odds ratio, 1.40 [1.19-1.65]; P<0.0001) and symptomatic (odds ratio=2.31 [1.78-3.00]; P<0.0001) presentations, irrespective of age (P=0.28) or sex (P=0.35). Similar findings were observed using the modified composite end point for both asymptomatic (odds ratio, 1.49 [1.25-1.78]; P<0.0001) and symptomatic (odds ratio, 3.02 [2.25-4.07]; P<0.0001) presentations. Acute myocardial infarction risk was not significantly different between revascularization therapies, regardless of clinical presentation (P=0.71 and 0.24).

CONCLUSIONS

Among individuals undergoing carotid artery revascularization from a large sample of US hospitals, CAS was associated with higher risk of perioperative mortality, stroke, and unfavorable discharges compared with CEA for all ages and clinical presentations.

Endarterectomy or carotid artery stenting: the quest continues part two

BACKGROUND

Although randomized trials on carotid artery stenting (CAS) could not establish its equivalence to carotid endarterectomy (CEA) in patients with symptomatic carotid disease, CAS is rapidly evolving. Data on long-term outcome after CAS from randomized trials have now become available and ongoing, prospectively held registries frequently publish their results in increasing numbers of patients. We have therefore reviewed the currently available literature and provide an update of our previous article on this topic.

DATA SOURCES

PubMed literature searches were performed to identify relevant studies regarding current status of CEA and stenting for symptomatic carotid stenosis.

CONCLUSIONS

The efficacy of CAS in patients with symptomatic carotid artery stenosis remains unclear because of varying results in randomized trials. Although multiple registries do report promising results after CAS, peri-interventional stroke/death rates still exceed those rates currently found after CEA. Therefore, CEA remains the "gold standard" in treating these patients.

State of the art in carotid artery stenting: trial data, technical aspects, and limitations

The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.

Carotid revascularization: a systematic review of the evidence

OBJECTIVE AND BACKGROUND

The aim of this study is to provide an evidence-based review of the periprocedural safety and long-term effectiveness of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA), with particular attention paid to the use of embolic protection devices and patients at high risk for CEA.

METHODS

Electronic databases (Ovid Medline, Cochrane central register of controlled trials, Pubmed, and Embase) were searched to identify: (1) randomized controlled trials (RCT) comparing outcomes of CEA and CAS, and (2) prospective clinical trials assessing the safety of CAS in patients at high surgical risk. Pooled incidence rates and one-sided 95% confidence interval for the periprocedural and long-term composite end-point of stroke, myocardial infarction, or death among high surgical risk patients were generated and compared to objective performance criteria (OPC) reported by previous trials.

RESULTS

Six RCTs and 14 prospective clinical trials met our search criteria. Selected RCTs showed inconsistency in reported periprocedural and long-term outcome rates. Pooled incidence rates of the periprocedural and long-term composite end-point of stroke, myocardial infarction or death in high surgical risk candidates were 5.59% and 7.92%, respectively. These results were noninferior to selected OPCs (P-value <0.001).

CONCLUSIONS

CAS represents a safe and effective stroke prevention strategy in high surgical risk patients when compared with CEA. The inconsistent results from the RCTs and the improved outcomes in the prospective clinical trials are likely related to variability in operator experience, use of embolic protection devices, and patient selection strategies.

Advances in the management of carotid artery disease: focus on recent evidence and guidelines

Recent landmark randomized trials and society guidelines have significantly revised the management of carotid artery disease. Duplex ultrasonography is the recommended initial diagnostic test for the assessment of extracranial carotid artery stenosis. Carotid artery imaging is reasonable in select patients scheduled for coronary artery bypass graft (CABG) surgery. Carotid revascularization can be achieved safely and effectively with carotid endarterectomy or carotid artery stenting. Because each procedure has a different risk/benefit profile, the optimal approach is to match the particular patient to the intervention that maximizes outcome benefit. Carotid revascularization is recommended in patients scheduled for CABG surgery when the carotid artery stenosis is symptomatic and/or bilateral. Further trials are required to guide the management of asymptomatic unilateral carotid artery stenosis in patients undergoing CABG surgery. Aggressive medical therapy remains the gold standard for intracranial carotid artery disease because landmark trials have shown no outcome improvement with vascular bypass or percutaneous angioplasty and stenting. A large recent trial showed that local anesthesia, as compared with general anesthesia, for carotid endarterectomy has no major clinical outcome advantage. Although carotid artery stenting is associated with a reduced risk of myocardial ischemia, it still has important risks of stroke and hemodynamic instability that significantly affect clinical outcome. The timing and choice of carotid revascularization technique ultimately depends on multiple clinical factors.

Interventional management of asymptomatic extracranial carotid stenosis

Carotid artery stenosis is a major risk factor for stroke and transient ischemic attack. Although carotid endarterectomy is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS)-proven by large randomized clinical trials and rigorous registries and supported by improving stent designs, embolic protection, and increasing neurointerventionalist experience-is developing into a safer and more efficacious method of stroke prevention. Today, protected CAS is approved for symptomatic and asymptomatic patients with severe carotid stenosis with high surgical risk. We reviewed recently published data regarding new developments in the use of protected CAS, particularly in patients with carotid stenosis who are either asymptomatic or at low surgical risk.