Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients

BACKGROUND AND PURPOSE

Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS.

METHODS

This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up.

RESULTS

A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014).

CONCLUSION

CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.

Safety and efficacy of remote ischemic preconditioning in patients with severe carotid artery stenosis before carotid artery stenting: A proof-of-concept, randomized controlled trial

Background: Remote ischemic preconditioning (RIPC) has been proposed as a possible potential treatment for ischemic stroke. This study aimed to investigate the frequency of micro-embolic brain infarcts after RIPC in patients with stroke who underwent elective carotid artery stenting (CAS) treatment. Methods: This study was managed at Shiraz University of Medical Sciences in southwest Iran. Patients undergoing CAS were randomly allocated into RIPC and control groups. Patients in the RIPC group received three intermittent cycles of 5-minute arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 30 minutes before CAS treatment. Afterward, stenting surgery was conducted. Magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC), was acquired within the first 24 hours after CAS. Results: Seventy-four patients were recruited (79.7% men, age: 72.30 ± 8.57). Both groups of RIPC and control had no significant difference in baseline parameters (P > 0.05). Fifteen patients (40.5%) in the RIPC group and 19 (54.1%) patients in the control group developed restricted lesions in DWI MRI. In DWI+ patients, there were no significant differences according to the number of lesions, lesion surface area, largest lesion diameter, cortical infarcts percent, and ipsilateral and bilateral infarcts between the two groups. Conclusion: Although RIPC is a safe and non-invasive modality before CAS to decrease infarcts, this study did not show the advantage of RIPC in the prevention of infarcts following CAS. It may be because of the small sample size.

Association between high sensitivity C-reactive protein (hs-CRP) levels and the risk of major adverse cardiovascular events (MACE) and/or microembolic signals after carotid angioplasty and stenting

Background

To evaluate the association between pre/post-procedural high sensitive C-reactive protein (hs-CRP) level and hs-CRP difference, and the risk of major adverse cardiovascular events (MACE) or new diffusion-weighted MRI lesions after carotid angioplasty and stenting (CAS).

Methods

In this study, conducted in 2016 in Shiraz (Iran), patients who underwent diagnostic angiography and CAS were recruited. CAS was performed with distal embolic protection device on patients with both standard and high risk of endarterectomy. Pre/post-procedural hs-CRP, and hs-CRP difference were determined by immunoenzymometric assay method.

Results

A total of 50 patients with diagnostic angiography and 60 patients with CAS were enrolled. No death, myocardial infarction, ischemic or hemorrhagic stroke, and need to revascularization occurred during the 30-days of the post-procedural period. Accordingly, the statistical evaluation in associating MACE and hs-CRP levels was impossible. Angioplasty was associated with higher frequency of elevated post-procedural hs-CRP in comparison to angiography (P=0.003). The higher age, symptomatic lesions, negative history of hypertension, and hs-CRP difference had significant association with the presence of new DWI lesions in univariate analysis (all P<0.05). Angioplasty of left carotid bulb and post-procedural hs-CRP levels was very close to the level of significance (P=0.06). But only left sided lesions had positive association (P=0.037) and hypertension had negative association (P=0.037) in multivariate regression analysis. There were significant association between post-procedural hs-CRP level (P=0.02) and hs-CRP difference (P=0.003), and the number of new lesions; and the hs-CRP difference and the accumulated lesion surface area (P=0.009).

Conclusion

Post-procedural hs-CRP and hs-CRP difference may predict embolic complications of CAS.

Effectiveness and safety of omega-3 fatty acids for the prevention of ischemic complications following carotid artery stenting: An early terminated pilot study

Background: We aimed to study the possible beneficial effects of omega-3 polyunsaturated fatty acids (PUFAs) in carotid artery stenting (CAS) procedure for decreasing post-procedural ischemic complications. Although previous evidence demonstrated that omega-3 PUFAs, present in fish oil, can significantly enhance platelet response to antiplatelet agents after percutaneous coronary intervention (PCI), it is unknown whether they can be used in patients undergoing CAS. Methods: The single-blind, case-control, pilot randomized trial study was planned to perform on 60 patients undergoing CAS (30 in case and 30 in control group). Patients in both groups were pretreated with dual antiplatelet therapy (aspirin 80 mg/day with a loading dose of 325 mg, and clopidogrel 75 mg/day after a loading dose of 600 mg) at least 48 hours before the CAS. 30 patients randomly received 3000 mg loading dose of omega-3 fatty acids 12 hours before the procedure and 1000 mg omega-3 capsule the day after the procedure. All subjects were planned to be visited by neurologist for any peri- and post-procedural complications immediately after the procedure and on first, seventh, and thirtieth days. Results: We ended the study after the enrollment of 18 patients because of an unexpected hemorrhagic transformation in case group. Two patients in this group developed hemorrhagic symptoms less than 12 hours after the procedure. One of the failures occurred in a patient with small vessel disease. Except these two cases, no one showed any neurological deficit symptoms in both groups. Conclusion: In patients already receiving dual antiplatelet treatment before CAS, adding omega-3 PUFAs would increase the incidence of hemorrhagic transformation.

Comparison of Clinical and Radiological Outcome of Carotid Angioplasty and Stenting after Direct Navigation Versus Exchange Methods: A Randomized Clinical Trial

BACKGROUND

The purpose of this study was to compare the frequency of microembolic brain infarcts after direct navigation method versus exchange method in carotid artery stenting and vertebral artery origin angioplasty.

METHODS AND MATERIAL

This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran. Consecutive patients undergoing "carotid angioplasty and stenting" and "vertebral artery origin stenting" were randomly assigned into two groups with "direct navigation method" and "exchange method." Subsequently, postprocedural magnetic resonance imaging (MRI) including diffusion weighted imaging and apparent diffusion coefficient were obtained within the first 24 hours after completion of the procedure.

RESULTS

In total, 89 patients were recruited (67% male, mean age: 72 years). Cases comprised of 38 left internal carotid arteries (ICAs), 38 right ICAs, 6 left vertebral artery origin, and 7 right vertebral artery origin. Forty patients underwent exchange method, while 49 underwent direct navigation method. There was only one clinical stroke that occurred in "exchange method" group. Fifteen patients (37.5%) in exchange group and 23 patients (46.9%) in direct navigation group developed diffusion restricted lesions. In exchange group, 13 patients (32.5%) had at least one diffusion restricted lesion ipsilateral to the target vessel, and three patients (7.5%) had at least one diffusion restricted lesion contralateral to the target vessel. In direct navigation group, these measures were 19 (38.8%) and 9 (18.4%). However, no statistically significant intergroup differences were observed. The only significant difference was bilateral infarct percentile, which was more common in the direct navigation method (0.032).

CONCLUSION

Diffusion restricted lesions were more common in the direct navigation method, both ipsilateral and contralateral to the target vessel, and in both carotid and vertebral artery study subgroups. However, differences were not statistically significant.