Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies

Comparison the effects of carotid endarterectomy with carotid artery stenting for contralateral carotid occlusion

Background

There have been inconsistent results regarding the use of carotid artery endarterectomy (CEA) versus carotid artery stenting (CAS) for contralateral carotid occlusion (CCO). This study aimed to determine the optimal revascularization technique for patients with CCO.

Methods

We systematically searched the PubMed, Embase, and Cochrane Library databases to identify eligible studies published from inception to January 2, 2021. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate pooled effect estimates using a random-effects model. Sensitivity, subgroup, and publication bias analyses were also performed.

Results

Six studies involving 6,953 patients were selected for inclusion in this meta-analysis. Our results showed that while CEA was not associated with an increased risk of stroke compared to CAS (OR: 1.07; 95% CI: 0.75–1.51; P = 0.713), CEA was associated with a reduced risk of death compared to CAS (OR: 0.45; 95% CI: 0.29–0.70; P < 0.001). Furthermore, there were no significant differences between CEA and CAS for the risks of myocardial infarction (OR: 1.38; 95% CI: 0.73–2.62; P = 0.319) or major adverse cardiovascular events (OR: 1.03; 95% CI: 0.56–1.88; P = 0.926). Finally, the risk of myocardial infarction for CEA versus CAS was affected by disease status, while the risk of major adverse cardiovascular events was affected by the proportions of patients with male gender, coronary artery disease, and current or prior smoking.

Conclusion

This study found that CEA and CAS resulted in similar outcomes for patients with CCO, while the risk of death was reduced in patients treated with CEA. Further high-level evidence should be collected to verify the results of this study.

High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.

BACKGROUND

Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.

METHODS

We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.

RESULTS

We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).

CONCLUSIONS

We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.

REGISTRATION

This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

Carotid artery stenting: Current state of evidence and future directions

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.

Systematic and Comprehensive Comparison of Incidence of Restenosis Between Carotid Endarterectomy and Carotid Artery Stenting in Patients with Atherosclerotic Carotid Stenosis

OBJECTIVE

The purpose of the present study was to conduct a meta-analysis to systematically compare the incidence rates of in-stent restenosis after carotid artery stenting (CAS) and restenosis after carotid endarterectomy (CEA) for patients with atherosclerotic carotid stenosis.

METHODS

We retrieved potential academic reports comparing restenosis between CEA and CAS from the MEDLINE, PubMed, and EMBASE databases and the Cochrane Library from the date of the first CEA (January 1951) to July 20, 2018. The references of the identified studies were carefully reviewed to ensure that all available reports were included in the present study.

RESULTS

Our meta-analysis included 27 studies (15 randomized controlled trials, 12 nonrandomized controlled trials) and 20,479 participants with atherosclerotic carotid stenosis. A statistically significant difference was found in the cumulative incidence of restenosis >70% between CEA and CAS (risk difference, -0.033, 95% confidence interval [CI] -0.054 to -0.013; P = 0.002). For the restenosis >70% outcomes, although CEA was relevant with a lower rate of restenosis than CAS within 6 months (odds ratio [OR], 0.495; 95% CI, 0.285-0.861; P = 0.013) and 1 year (OR, 0.626; 95% CI, 0.483-0.811; P < 0.001), no statistically significant differences were found at 1.5 years (P = 0.210), 2 years (P = 0.123), 4 years (P = 0.124), 5 years (P = 0.327), or 10 years (P = 0.839). For the restenosis >50% outcomes, a significant difference was found in the rate of restenosis between the CEA and CAS groups within 1 year (OR, 0.317; 95% CI, 0.228-0.441; P < 0.001) but not at 1.5 years (P = 0.301), 2 years (P = 0.686), or 5 years (P = 0.920). No nominally significant effects were demonstrated with respect to the cumulative incidence of occlusion (P = 0.195) or the cumulative incidence of restenosis for symptomatic patients (P = 0.170) between CEA and CAS.

CONCLUSIONS

Although CAS was preferred over CEA, regardless of restenosis >50% or >70% after revascularization within 1 year, no significant difference was observed with extension of the follow-up period to >1 year. CAS was not associated with a greater cumulative incidence of occlusion or the cumulative incidence of restenosis for symptomatic patients.

Cost-effectiveness of Carotid Surgery

BACKGROUND

The purpose of this study is to determinate the cost-effectiveness of carotid endarterectomy (CEA) versus transfemoral stenting (TFS) and transcervical stenting (TCS) in a short- and long-term basis in symptomatic and asymptomatic patients.

METHODS

From January 2003 to December 2014, patients from the vascular department, with symptomatic or asymptomatic carotid stenosis, who were clinically and anatomically suitable for TFS, TCS, or CEA, were included. Prospective cost data for each individual procedure and complication during follow-up were obtained from the diagnosis-related group. The quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios were estimated. Analysis of data was by treatment received. All statistical tests were two-sided. The significance level was 5%.

RESULTS

A total of 349 patients were enrolled: 61 for CEA (17.5%), 159 for TFS (45.5%), and 129 for TCS (37%). A total of 220 (63%) patients were symptomatic and 129 (37%) were asymptomatic. The median procedural cost and overall cost were lower on CEA (5499€ and 5595€, respectively). However, QALYs, for symptomatic patients, were better on TCS (7.3), whereas for asymptomatic patients, QALYs were better on CEA (9.6). Cost-effectiveness for symptomatic patients was better with TCS (803€/QALY), and for asymptomatic patients, it was with CEA (654€/QALY).

CONCLUSIONS

TFS and TCS were associated with clinical outcomes equivalent to CEA on both symptomatic and asymptomatic patients. Cost-effectiveness ratios for symptomatic patients were better on TCS, whereas the CEA showed the best results in asymptomatic patients.

Meta-analysis of the costs of carotid artery stenting and carotid endarterectomy

BACKGROUND

Carotid artery stenting (CAS) is currently associated with an increased risk of 30-day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques.

METHODS

A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost-effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random-effects models. The in-hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures.

RESULTS

The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long-term cost analysis revealed no difference in costs or quality of life after 1 year of follow-up.

CONCLUSION

Hospitalization and long-term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.

Headache after carotid artery stenting

INTRODUCTION AND OBJECTIVES

Headache after carotid artery stenting is a headache with onset during the procedure or in the first few hours after it, and where there is no evidence to suggest a complication of that procedure. The purpose of this study is to describe the main features of these headaches based on our clinical experience.

PATIENTS AND METHODS

Observational prospective study of a sample of patients undergoing carotid artery stenting at Hospital Clínico Universitario Lozano Blesa, in Zaragoza, Spain. We recorded sociodemographic characteristics, cardiovascular risk factors, carotid artery disease, and history of primary headache; data were gathered using structured interviews completed before and 24hours after the procedure.

RESULTS

We included 56 patients (mean age 67±9.52 years); 84% were men. Twelve patients (21.4%) experienced headache, 83.3% of whom were men; mean age was 60.58±9.31 years. Headache appeared within the first 6hours in 7 patients (58.4%) and during the procedure in 4 (33.3%). Pain lasted less than 10minutes in 4 patients (33.3%) and between 10 and 120minutes in 5 (41.7%). Headache affected the frontotemporal area in 7 patients (58.3%); 7 patients (58.3%) described pain as unilateral. It was oppressive in 8 patients (66.7%) and of moderate intensity in 6 (50%). Nine patients (75%) required no analgesics. We found no statistically significant associations with any of the variables except for age (P=.007; t test).

CONCLUSIONS

In our sample, headache after carotid artery stenting was mild to moderate in intensity, unilateral, oppressive, and short-lasting. Further studies are necessary to gain a deeper knowledge of its characteristics and associated risk factors.

Economic impact of endarterectomy vs carotid artery stenting: a one year, single centre study

AIMS

Carotid artery stenting (CAS) has been suggested by some clinicians as an alternative to endarterectomy (CEA), especially in some specific subgroups of the population. The aim of this study is to evaluate the costs of these two procedures.

METHODS AND RESULTS

A review of costs was performed on all patients who underwent elective treatment of carotid artery stenosis between January and December 2006 (184 CAS vs 97 CEA). Clinical data had been prospectively gathered from both the CAS and the CEA groups, while financial data was obtained retrospectively to match hospital admissions with the generated charge from the hospital business office. In this series there was one major event in CEA and one transient ischaemic attacks (TIA) in CAS. One death procedure-related event occurred in CEA. The mean total cost associated with a single CEA was slashed integral 3,897.86, whereas the cost associated with CAS was slashed integral 3,806.66. It was apparent that the increasing costs involved in purchasing material for CAS, were balanced by the lower spending for hospital stay.

CONCLUSIONS

Costs for CAS and CEA are comparable. In our experience, the choice between CAS and CEA is based on the comorbidity of the patient, the type of the lesion and the preferences of the patient, without economic criteria being important.

Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST)

BACKGROUND AND PURPOSE

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines.

METHODS

We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups.

RESULTS

Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%.

CONCLUSIONS

Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

Evidence-based treatment of carotid artery stenosis

Carotid atheromatous disease is an important cause of stroke. Carotid endarterectomy (CEA) is a well-established option for reducing the risk of subsequent stroke due to symptomatic stenosis (> 50%). With adequately low perioperative risk (< 3%) and sufficient life expectancy, CEA may be used for asymptomatic stenosis (> 60%). Recently, carotid angioplasty and stent placement (CAS) has emerged as an alternative revascularization technique. Trial design considerations are discussed in relation to trial results to provide an understanding of why some trials were considered positive whereas others were not. This review then addresses both the original randomized studies showing that CEA is superior to best medical management and the newer studies comparing the procedure to stent insertion in both symptomatic and asymptomatic populations. Additionally, recent population-based studies show that improvements in best medical management may be lowering the stroke risk for asymptomatic stenosis. Finally, the choice of revascularization technique is discussed with respect to symptom status. Based on current evidence, CAS should remain limited to specific indications.

Carotid stenting versus endarterectomy

Since the landmark NASCET and ECST trials demonstrated the superiority of carotid endarterectomy over medical therapy in the prevention of stroke for patients with symptomatic carotid artery stenosis, surgical intervention as a part of secondary prevention of stroke has become widespread. However, the newer technology of carotid artery angioplasty and stenting challenges this mode of intervention, promising the benefits of a procedure under local anesthesia and potentially avoiding the surgical complications of cranial nerve palsy and hematoma. Pooled evidence from randomized controlled trials of endarterectomy versus stenting shows a higher rate of stroke or death in the stenting groups-but this finding is mitigated to an extent by the lower incidence of myocardial infarction and cranial nerve palsy in patients undergoing stenting. At present, carotid endarterectomy combined with optimal drug therapy remains the standard of care for symptomatic 70%-99% stenosis of the internal carotid artery, but stenting might be an option in younger patients and in those not suitable for endarterectomy.

Management of risk factors for accelerated atherosclerosis

Atherosclerosis is a relentlessly progressive process of segmental vessel narrowing or occlusion involving several vascular beds. It accounts for the majority of strokes, which remain a global leading cause of death and long-term disability. The limited options for acute stroke therapy make stroke prevention an important therapeutic approach, particularly in patients who have already experienced stroke. Given the multifactorial pathogenesis of atherosclerotic disease, an aggressive multimodal preventive strategy is required to mitigate risk of recurrent stroke. Such a strategy would incorporate proven treatments specifically targeting the underlying disease process. A vast number of strokes could be prevented by optimal treatment of modifiable vascular risk factors. This paper presents current evidence-based management of conventional and novel vascular risk factors in patients with ischemic stroke whose underlying pathophysiologic mechanism is accelerated atherosclerosis. Therapies discussed include antithrombotics, statins, antihypertensives, and surgical/endovascular treatments.

Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial

OBJECTIVES

To evaluate the cost-effectiveness of carotid stenting vs. carotid endarterectomy using data from the SAPPHIRE trial.

BACKGROUND

Carotid stenting with embolic protection has been introduced as an alternative to carotid endarterectomy for prevention of cerebrovascular and cardiovascular events among patients at increased surgical risk.

METHODS

Between August 2000 and July 2002, 310 patients with an accepted indication for carotid endarterectomy but at high risk of complications were randomized to and subsequently underwent either carotid stenting (n = 159) or endarterectomy (n = 151). Clinical outcomes, resource use, costs, and quality of life were assessed prospectively for all patients over a 1-year period. Life expectancy, quality-adjusted life expectancy, and health care costs beyond the follow-up period were estimated for patients alive at 1 year, based on observed clinical events during the first year of follow-up.

RESULTS

Although initial procedural costs were significantly higher for stenting than for endarterectomy (mean difference: $4,081/patient; 95% CI, $3,849-$4,355), mean post-procedure length of stay was shorter for stenting (1.9 vs. 2.9 days; P < 0.001) with significant associated cost offsets. As a result, initial hospital costs were just $559/patient higher with stenting (95% CI, $3,470 less to $2,289 more). Neither follow-up costs after discharge nor total 1-year costs differed significantly. The incremental cost-effectiveness ratio for stenting compared with endarterectomy was $6,555 per quality-adjusted life year (QALY) gained, with over 98 percent of bootstrap estimates < $50,000/QALY gained.

CONCLUSIONS

Although carotid stenting with embolic protection is more costly than carotid endarterectomy, by commonly accepted standards, stenting is an economically attractive alternative to endarterectomy for patients at high surgical risk.

Carotid stenting and bivalirudin with and without vascular closure: 3-year analysis of procedural outcomes

OBJECTIVES

The purpose of this study was to examine the outcome of carotid stenting using bivalirudin and the influence of vascular closure devices (VCD) on the incidence and severity of peri-procedural hypotension.

BACKGROUND

Bivalirudin, a short-acting direct thrombin inhibitor, has been shown to be an effective anticoagulant in coronary interventions, with less risk of bleeding compared with heparin. Routine use of VCD has become the standard of care, facilitating patient ambulation after percutaneous carotid and coronary interventions. The combined use of these two therapies (bivalirudin and VCD) may improve outcomes in carotid interventions where prolonged patient immobilization may exacerbate hypotension following stenting.

METHODS

A total of 514 patients underwent 536 carotid stenting procedures in the 3-year period from September 2004 to September 2007. All patients received adjunctive bivalirudin, with and without VCD. This cohort was analyzed for peri-procedural and 30-day clinical outcomes and length of hospitalization.

RESULTS

Thirty-day stroke and death rate was 1.7%. A total of 83 patients (15.4%) experienced intra- or post-procedural hypotension (systolic BP < 80 mm Hg). There were four (0.7%) major bleeding complications requiring transfusion, and length of stay was delayed more than 24 hr in five patients (0.93%), all of whom were in the manual compression group.

CONCLUSIONS

This was a negative study, with no significant difference on prolonged hypotensive events in patients with vascular closure device and bivalirudin, compared with those with manual compression and bivalirudin. Vascular closure devices were safe and effective with a low incidence of complications. In carotid artery stenting, bivalirudin is safe with low incidence of major bleeding and acceptable 30-day adverse event rates (stroke and death).

In stent restenosis predictors after carotid artery stenting

Purpose. The long-term efficacy of carotid artery stenting is debated. Predictors of stent restenosis are not fully investigated. Our aim was to assess the incidence of long term restenosis after CAS and to identify some predictors of restenosis. Methods. We retrospectively selected 189 treated patients and we obtained the survival Kaplan-Meier curves for overall survival, for freedom from stroke or death and from restenosis. To correlate clinical, radiological, and procedural variables to stent restenosis, an univariate analysis was performed while to determine independent predictors of restenosis, a multivariate analysis was applied. Results. At 1, 3, and 5 years, the cumulative overall survival rate was 98%, 94%, and 92% with a cumulative primary patency rate of 87%, 82.5%, and 82.5%. The percentage residual stenosis after CAS and multiple stents deployment were independent predictors of restenosis, while diabetes and tumors are suggestive but not significant predictors of restenosis. Conclusions. In our CAS experience, encouraging long-term results seem to derive from both neurological event free rate and restenosis incidence. Adequate recanalization of the treated vessel is important to limit the development of stent restenosis. Multiple stents deployment, and with less evidence, diabetes, or neoplasms has to be considered to facilitate restenosis.

Refractory In-stent Restenosis Following Carotid Artery Stenting: A Case Report and Review of Operative Management

In-stent restenosis following carotid artery stenting is a challenging problem that vascular surgeons will likely encounter with increasing frequency. The following describes a patient who developed progressive in-stent restenosis 3 years after carotid artery stenting, which was treated with operative therapy after failed balloon angioplasty. A review of the literature describing surgical approaches to the treatment of in-stent restenosis was also performed.

Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005

OBJECTIVE

Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available.

METHODS

All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality.

RESULTS

During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05).

CONCLUSIONS

Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.

Recurrent carotid stenosis after CEA and CAS: diagnosis and management

Carotid endarterectomy (CEA) is the preferred method for cerebral revascularization in patients with symptomatic and asymptomatic high-grade extracranial carotid artery stenosis. Carotid artery stenting (CAS) has recently emerged as a less invasive alternative to endarterectomy. Carotid stenting has been demonstrated to be technically feasible and safe in high-risk patients. It has been approved as an acceptable method for revascularization in circumstances where CEA yields suboptimal results. While the final role of CAS in carotid revascularization will be determined on the basis of ongoing randomized trials, it is clear that stenting will continue to be performed in subgroups of patients with carotid stenosis. Therefore, it is anticipated that there will be a corresponding increase in the number of in-stent restenosis cases. Considerable controversy exists regarding the clinical significance, natural history, threshold for management, and appropriate intervention of recurrent carotid stenosis after endarterectomy and after stenting. This review analyzes current information on this important clinical problem and presents evidence-based recommendations for the diagnosis and management of recurrent carotid stenosis.

The effect of age and procedure on resource use for patients with cerebrovascular disease

Objective

Many studies have described the impact of population ageing on health care expenditures, but few have assessed its impact on specific diseases adjusted for severity and procedure. This study examined the relationship between an ageing population and resource use in patients with cerebrovascular disease (CVD).

Methods

A total of 13,856 CVD patients were treated in 82 academic and 92 community hospitals. Demographic variables, clinical variables, length of stay (LOS) and total charges were analysed by age group (under 65 years, 65-74 years and 75 years or older). The independent effects of age on LOS and total charge were determined using multivariate analysis.

Results

There were 5172 (37%) patients under 65 years of age, 4096 (30%) 65-74 years and 4588 (33%) 75 years or older. Intracranial infarction or ischaemia was diagnosed in 69% of the patients, haemorrhage in 23% and subarachnoid haemorrhage in 9%. The overall mortality was 6% (5% in under 65 years, 5% in 65-74 years and 9% in 75 years or older; P < 0.001). There were significant differences in the proportion of procedures performed in each age category. Age and procedure were significantly associated with LOS, particularly the latter. Age had no significant association with total charge, but procedure was highly associated.

Conclusions

Ageing has no significant impact on total charge. Instead policy-makers should acknowledge the effect of procedures on health care costs, conduct economic evaluations and monitor use of procedures.

The CAPTURE Registry

BACKGROUND

Although previous reports of carotid stenting with embolic protection (CAS) have focused on clinical outcomes of death, stroke and myocardial infarction, there are few data available characterizing the strokes that occur during CAS, thus limiting understanding of potential mechanisms. This report examines the timing, location, severity, and type of strokes occurring with CAS in the Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) study.

METHODS

The CAPTURE is a prospective, multicenter registry conducted to assess outcomes of CAS in the postapproval setting after device approval. A neurologist examined the patients before the procedure, at 24 hours and 30 days post-procedure. The primary end point was a composite of death, any stroke, or myocardial infarction within 30 days post-procedure. Strokes and all neurologic events suspected to be strokes were adjudicated by an independent Clinical Events Adjudication Committee using prespecified definitions. Source documents of all patients with strokes in this cohort were reviewed.

RESULTS

The 30-day results were available for 3500 patients. The 30-day primary end point event rate of death, stroke, and myocardial infarction was 6.3% (95% confidence interval: 5.5%-7.1%), and the rate of major stroke and death was 2.9% (95% confidence interval: 2.4 to 3.5). 4.8% of patients experienced a stroke (3.9% ipsilateral and 0.9% nonipsilateral, 2% major). A majority of stroke symptoms (57.7%) were noted post-procedure and pre-discharge, whereas 22.3% were noted during the procedure and 20% postdischarge. A similar timing distribution regardless of preprocedural symptomatic status was found.Overall, 41% (69 of 170) of all strokes were major. The incidence of major strokes was statistically significantly greater among symptomatic compared with asymptomatic patients, 4.6% (22 of 482) and 1.6% (47 of 3018), respectively. There were more minor than major strokes in asymptomatic patients (63% vs. 37%; P=0.10), whereas stroke severity was equally distributed in symptomatic patients. Among the ipsilateral strokes, almost half (44%) were major, whereas only one-quarter (26%) of the nonipsilateral strokes were major.Overall, 23% of the major strokes were hemorrhagic and 94% of these strokes were noted on the ipsilateral side. There was a tendency toward more major hemorrhagic strokes in symptomatic than in asymptomatic patients (36% vs. 17%; P=0.07). Fifty-four percent of the strokes post-procedure and pre-discharge were major, whereas 27% of the strokes postdischarge were major. Furthermore, 65% of hemorrhagic strokes were noted post-procedure and pre-discharge, 30% postdischarge.

CONCLUSIONS

Strokes related to CAS seem to become clinically apparent after the procedure but before discharge in the majority of events. Nevertheless, a significant minority of stroke symptoms follows discharge from the hospital, typically after 24 hours. Timing of stroke after CAS seems to be similar to timing of stroke after carotid endarterectomy. Moreover, nearly 1 in 5 strokes occur in a nonipsilateral distribution, with the exception of intraprocedural events, which were all ipsilateral to the stent being implanted. Hemorrhagic stroke seemed to be more prevalent in the strokes occurring in the post-procedure period. These descriptors of stroke severity, location, and timing may provide insight in to the mechanistic causes of adverse neurologic outcomes in CAS.

Economic Evaluation of Carotid Artery Stenting Versus Carotid Endarterectomy for the Treatment of Carotid Artery Stenosis

BACKGROUND

The clinical effectiveness of carotid endarterectomy (CEA) is well established. But the economic impact of CEA and carotid artery stenting (CAS) is still uncertain. The objective of this study was to compare hospital costs and reimbursement for CAS and CEA.

STUDY DESIGN

We performed a retrospective database analysis on pair-matched patients who underwent CEA (n = 31) and CAS (n = 31) at the Richard M Ross Heart Hospital in Columbus, OH. The hospital's clinical and financial databases were used to obtain patient-specific information and procedural charges. Cost data were generated by applying the hospital's ratio of cost to charges for all DRG charges. The Wilcoxon signed-rank test was used to examine the differences between costs of these procedures.

RESULTS

Data are reported as mean +/- SD. The mean age of patients in CAS group was 70.14 years (+/- 1.60 years) versus 68.64 years (+/- 1.75 years) for CEA patients (p < 0.05). The total direct cost associated with CEA ($3,765.12+/-$2,170.82) was significantly lower than the CAS cost ($8,219.71+/-$2,958.55, p < 0.001). The mean procedural cost for CAS ($7,543.61+/-$2,886.54) was significantly higher than that for CEA ($2,720.00+/-$926.38, p < 0.001). The hospital experienced cost savings of $9,690.87 for CEA versus $4,804.79 for CAS from private insurance. Similarly, savings obtained by Medicare-enrolled CEA patients were higher than those for CAS patients ($1,497.79).

CONCLUSIONS

CAS is significantly more expensive than CEA, with a major portion of cost attributed to the total procedural cost. The hospital experienced significant savings from CEA procedures compared with CAS under all DRG classifications and insurers. Hospitals must develop new financial strategies and improve the efficiency of infrastructure to make CAS financially viable.

The Relationship between Carotid Artery Diameter and Percentage of Stenosis

In order to understand percentage of stenosis from the residual lumen of the carotid artery, we explored the relationship between the residual diameter at the carotid stenosis, its stenosis percentage and the size of the internal carotid artery. Diameters of 103 carotid arteries of Taiwan residents were retrospectively measured from digital subtraction angiograms. Severe cases of near occlusion with the angiographic string sign, and cases with tandem lesions or intracranial occlusion were excluded. Of the total 103 carotid arteries, 22 (21%) had one or both of the following signs of reduced distal arterial caliber: (1) obvious narrowing of the distal carotid artery; (2) the caliber of the cervical internal carotid artery was smaller than the caliber of the corresponding external carotid artery. That the diameter of the distal carotid artery was smaller when the stenosis was greater at the site of minimal lumen was true in the group of patients with signs of reduced distal caliber and in the group of patients without such signs. Therefore, reduced distal caliber may be present in patients without such signs. After excluding cases with at least one of the above signs of reduced distal arterial caliber, the relation between percentage of stenosis (y) and the absolute value of the diameter at the stenosis (x) can be represented by the formula: y = 96.83-18.27 x. From our data, a diameter of 2 mm is about 60% stenosis and 1.5 mm is 70% stenosis. According to this formula, we can estimate percentage of carotid stenosis using residual diameter at the site of minimal lumen obtained from other imaging modalities, such as carotid Doppler, CT angiogram or MR angiogram.

[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.

The CAPTURE registry: results of carotid stenting with embolic protection in the post approval setting

BACKGROUND

Pivotal study data examining carotid stenting with embolic protection as a less invasive alternative to endarterectomy for high surgical risk patients have been acquired under controlled conditions with highly selected physicians and hospitals. This report examines outcomes of carotid stenting post-approval after diffusion of this technology to a broader cross-section of physicians and hospitals.

METHODS

The Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) is a prospective, multi-center registry to assess two important aspects of the post-IDE experience: the safety of carotid stenting by physicians with varying levels of experience as a measure of the adequacy of physician training, and the identification of rare/unexpected device-related complications. The primary endpoint was a composite of death, any stroke, or myocardial infarction within 30 days post-procedure.

RESULTS

3,500 patients were enrolled by 353 physicians at 144 sites. The 30-day primary endpoint event rate was 6.3% (95% CI: 5.5-7.1%) and did not differ among the three operator experience levels (5.3%, 6.0%, and 7.4%; P = 0.31) from most to least experienced, respectively. There were no differences in outcomes among physician specialties when adjusted for case mix. There were no unanticipated device related adverse events.

CONCLUSIONS

The results of the CAPTURE study compare favorably to those achieved in the predicate pivotal investigations, and suggest that the post-approval transfer of this new therapy to the community practice setting via carotid stent training programs is effective in preparing physicians with varying experience levels and specialty training backgrounds.

Follow-up results of carotid angioplasty with stenting as assessed by duplex ultrasound surveillance

BACKGROUND

Carotid artery stenting (CAS) has become an alternative modality to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. We report a retrospective review of our institution's experience with CAS versus CEA.

METHODS

Postprocedure surveillance duplex, recurrent symptoms, postprocedure strokes, progression of lesions, and rates of re-operation were analyzed in 46 patients who underwent CAS and 48 patients who underwent CEA. The mean length of follow-up evaluation was 13 months. All CAS procedures included neuroprotection devices.

RESULTS

Statistically significant differences in progression to critical restenosis (2% vs 2%, P = 1.0), rate of subsequent symptoms or stroke (2% vs 10%, P = .1), or rate of re-interventions were not observed between CAS and CEA groups (2% vs 4%, P = .98). Total mortality (0% vs 2%, P = .33), and the occurrence of major adverse events (2% vs 10%, P = .18) also were not significantly different in the CAS compared with the CEA patients. The average rate of increase in internal carotid velocity at 6 to 12 months (-1% vs 1.1%, P = NS) and 12 to 24 months (-5% vs -6.5%, P = NS) also were equivalent.

CONCLUSIONS

Our observed results indicate that CAS may be performed with comparable clinical outcomes and durability of repair comparable with CEA.

Patient selection for carotid stenting versus endarterectomy: A systematic review

Carotid artery stenting has emerged as an alternative to carotid endarterectomy for the treatment of severe extracranial carotid stenosis in patients with anatomic or clinical factors that increase their risk of complications with surgery, yet there remains a substantial amount of variability and uncertainty in clinical practice in the referral of patients for stenting vs endarterectomy. By undertaking a thorough review of the literature, we sought to better define which subsets of patients with "high-risk" features would be likely to preferentially benefit from carotid stenting or carotid endarterectomy. Although only a single randomized trial comparing the outcomes of carotid stenting with distal protection and endarterectomy has been completed, a wealth of observational data was reviewed. Relative to endarterectomy, the results of carotid stenting seem favorable in the setting of several anatomic conditions that render surgery technically difficult, such as restenosis after prior endarterectomy, prior radical neck surgery, and previous radiation therapy involving the neck. The results of stenting are also favorable among patients with severe concomitant cardiac disease. Carotid endarterectomy, alternatively, seems to represent the procedure of choice among patients 80 years of age or older in the absence of other high-risk features. Overall, existing data support the concept that carotid stenting and endarterectomy represent complementary rather than competing modes of therapy. Pending the availability of randomized trial data to help guide procedural selection, which is likely many years away, an objective understanding of existing data is valuable to help select the optimal mode of revascularization therapy for patients with severe carotid artery disease who are at heightened surgical risk.

Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy

BACKGROUND

Recently, carotid angioplasty with stenting (CAS) has evolved as an alternative to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. Some concerns have arisen regarding the high cost of stents and neuroprotection devices, which may inflate the overall procedural costs relative to CEA. We report here a review and analysis contrasting the clinical outcomes and associated hospital costs incurred for patients treated with either CAS or CEA.

METHODS

Ninety-four consecutive patients with surgically amenable carotid stenosis were offered CAS or CEA. Forty-six patients elected CAS, and 48 patients underwent CEA. CAS was performed with the Smart Precise or Acculink stents, and all procedures included neuroprotection (Filter Wire or Accunet). CEA was performed with patients under general anesthesia with routine shunting and with Dacron or bovine pericardium patches. Clinical outcomes such as perioperative mortality, major adverse events (myocardial infarction, stroke, and death), length of stay, and the incidence of hemodynamic instability were analyzed. Total costs, indirect costs, and direct procedural costs associated with hospitalization were also reviewed.

RESULTS

CAS was associated with a shorter length of stay compared with CEA (1.2 vs 2.1 days; P = .02). Differences in perioperative mortality (0% vs 2%; P = NS), major adverse events (2% vs 10%; P = .36), strokes (2% vs 4%; P = NS), myocardial infarctions (0% vs 4%; P = .49), and hypotension necessitating pressor support (21% vs 18%; P = NS) were not statistically significant. By using cost to charge ratio methodology according to the Medicare report, CAS was associated with higher total procedural costs (US dollars 17,402 vs US dollars 12,112; P = .029) and direct costs (US dollars 10,522 vs US dollars 7227; P = .017). The differences in indirect costs were not significant (US dollars 6879 vs US dollars 4885; P = .063).

CONCLUSIONS

CAS with neuroprotection was associated with clinical outcomes equivalent to those with CEA but had higher total hospital costs. These higher costs reflect the addition of expensive devices that have improved the technical success and the clinical outcomes associated with CAS.

Cost-effectiveness of Intraoperative Imaging in Carotid Endarterectomy

OBJECTIVE:

There has never been a large, randomized controlled trial to assess the impact of intraoperative imaging on the success of carotid endarterectomy (CEA). This comparison involves cost-effectiveness analysis.

METHODS:

We constructed a decision-analytic model to compare effectiveness and costs of intraoperative ultrasound (IUS) and completion angiography as adjuncts to CEA. Data on procedural mortality, morbidity, and costs were obtained from the English-language literature. The review included a total of 52 reports, encompassing more than 22,000 patients. The main components of costs were those of the monitoring interventions and the care of perioperative stroke.

RESULTS:

Mean perioperative outcome without completion imaging is approximately 96.7% of what it would be in the absence of perioperative stroke or death. IUS and completion angiography each result in approximately 2% improvement in expected outcome. Mean perioperative costs are $396.50 for IUS, $721.30 for no monitoring, and $840.90 for completion angiography. Because IUS is significantly more effective at detecting technical errors that would likely result in perioperative stroke than no imaging and is significantly less costly than angiography, this strategy dominates the other two (i.e., it provides greater effectiveness at lower cost).

CONCLUSION:

Although surgical complications are uncommon, IUS substantially lowers the rate of perioperative stroke and mortality and thus is significantly more cost-effective than either completion angiography or no operative imaging.

Management of the Near Total Internal Carotid Artery Occlusion

OBJECTIVES

The risk of stroke in patients with near total internal carotid artery (ICA) occlusion is perceived to be high as stroke risk increases with severity of the stenosis. The management of this entity has not been addressed specifically in the existing randomised trials and thus it remains controversial.

METHODS

Systematic review of the relevant literature.

RESULTS

The management of patients with near total ICA occlusion remains controversial: some favour intervention whereas others have condemned it as dangerous or of no benefit. A prospective multicentre randomised trial regarding intervention versus best medical treatment for patients with symptomatic near total ICA occlusion seems difficult because of the large number of patients required to power the study. Nevertheless, it appears hard to decline surgery based on the current evidence.

CONCLUSIONS

Because of the current controversy over the best management of the near total ICA occlusion, prospective observational studies are needed to demonstrate its prevalence in the symptomatic and asymptomatic population and any associated excess stroke risk. Based on the current evidence, surgery is the treatment of choice in most centres but its validity over best medical treatment remains untested.

Percutaneous carotid artery stenting: a strategy in evolution

BACKGROUND

Carotid stenting was initially proposed as an alternative to surgical endarterectomy for selected high-risk patients. More recently, patients of standard surgical risk are being considered for percutaneous treatment of their carotid disease.

AIMS

To describe the clinical outcomes of an initial consecutive cohort of patients treated by carotid stenting at one institution.

METHODS

Between December 1997 and July 2003, 111 patients underwent stenting of 118 carotid arteries. Peri-procedural and long-term outcome data were collected.

RESULTS

Most patients (>70%) were high-risk candidates for endarterectomy. Stents were successfully placed in 117/118 carotid arteries (99.2%). Distal protection devices were used in 43/118 (36.4%). The peri-procedural rate of death or disabling stroke was 3/118 (2.5%). Death or any stroke occurred in 11/118 (9.3%). However, only 7/118 (5.9%) procedures resulted in death or any persistent stroke (neurological deficit >1 week post-procedure). No myocardial infarction occurred. Median length of post-procedure hospitalization was 1 day. Long-term follow up was possible for 101 patients (91.0%) over a mean period of 27.1 months. The Kaplan-Meier estimate of survival free of ipsilateral stroke 36 and 66 months after carotid stenting was 77.0 +/- 9.5% and 68.2 +/- 15.1%, respectively. The estimated survival free of any stroke or stent failure was 70.9 +/- 10.7% and 60.7 +/- 17.4%, respectively. The majority of late deaths (7/11) were due to cardiac disease.

CONCLUSION

We conclude that stenting of carotid stenoses is feasible, with a high procedural success rate and low complication rate. Carotid stenting should be considered the procedure of choice for high-risk patients.

Toward clinical equipoise: the current case for carotid angioplasty and stent placement

Recent advances in carotid artery (CA) stent placement procedures have propelled this technology into the forefront of treatment options for both symptomatic and asymptomatic patients with CA stenosis. Until recently, endarterectomy was the only surgical option for patients with CA occlusive disease. For high-risk surgical candidates, periprocedural stroke rates remained unacceptable and were significantly higher than those associated with the natural history of the disease. Advances in stent technology and improvements in antiplatelet and antithrombotic regimens, in conjunction with distal protection devices, have significantly lowered the risk of periprocedural complications for high-risk surgical candidates requiring CA revascularization. In this paper the authors review data gleaned from the important recent CA stent trials and address questions concerning the safety, efficacy, and durability of stent-assisted angioplasty for extracranial CA occlusive disease. Additionally, they review the role of noninvasive imaging modalities for the diagnosis and surveillance of CA disease in these high-risk patients.

Patient selection for revascularization in cervical carotid artery disease: angioplasty and stenting vs. endarterectomy

Cervical carotid stenosis is a major cause of stroke and disability. Although carotid endarterectomy is an established and effective treatment for some patients with carotid artery stenosis, angioplasty and stenting has emerged in recent years as a viable alternative, particularly for patients who may be less suited for surgery. This article reviews patient selection for the two alternative approaches. The authors review the findings of the major clinical trials of carotid endarterectomy, summarize the development of carotid angioplasty and stenting, and identify patient characteristics that may guide selection of surgical or endovascular treatment.

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy

Object. Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET. There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion.

Methods. Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A long-standing CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was $10,628, whereas that for CEA was $10,148 (p = 0.495).

Conclusions. In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

Traitement d’une sténose carotide : angioplastie, un choix raisonné

MASTERING THE SURGICAL ACT: Over the last decade, the technique of carotid angioplasty has progressed and it can now be considered as mastered thanks to the combination of platelet antiaggregants, miniaturisation of the material, stenting and the use of cerebral protection devices. POTENTIAL COMPLICATIONS: Notably the occurrence of cerebral embolism despite protection. Haemorrhagic complications are also possible. After a delay of 6 months, the re-stenosis rate is of around 10%. RESULTS OF RANDOMISED STUDIES: These globally demonstrate the equivalence between endoluminal treatment and surgery, notably in patients at high surgical risk.

IN PRACTICE

Carotid angioplasty can be proposed in cases of severe non-atheromatous stenosis localised away from the bifurcation. It is contraindicated in the case of asymptomatic atheromatous stenosis without surgical comorbidity and when the particular anatomic conditions complicate catheterism of the carotid axis.

A new approach to carotid angioplasty and stenting with transcervical occlusion and protective shunting: Why it may be a better carotid artery intervention

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and demonstrate the advantages of a new technique for carotid angioplasty and stenting (CAS) with proximal cerebral protection through a direct transcervical approach, as compared with a percutaneous transfemoral approach.

METHODS

CAS procedures were carried out in 25 consecutive patients, 4 with the femoral approach and 21 through a 2-cm incision at the base of the neck, with the patient under local anesthesia. For transcervical occlusion and protective shunting (TOPS), a short 9F sheath was inserted directly into the common carotid artery and connected to a 6F sheath placed percutaneously in the ipsilateral internal jugular vein. After clamping the common carotid artery proximal to the 9F sheath, internal carotid artery blood flow reversal was confirmed or an occluding external carotid balloon was placed. A filter interposed between the arterial and venous sheaths collected embolic debris from transcarotid manipulations. The arterial puncture was directly repaired with suture. Neurologic status was assessed with the National Institutes of Health stroke scale by an independent neurology consultant before and after the procedure.

RESULTS

One of the four percutaneous femoral approaches that failed because of tortuous anatomy was successfully treated with TOPS. Angiographic confirmation demonstrating resolution of asymptomatic (>80%; n = 12) stenosis or symptomatic (>60%; n = 12) stenosis was achieved in all patients with stents. A 0% technical failure rate and 0% combined 30-day stroke or mortality rate were achieved in all CAS attempted with TOPS. There were no hematomas in the cervical group, despite pretreatment with clopidogrel bisulfate and heparin, and one hematoma in the femoral group after failure of a Perclose arterial closure device. In one of the patients in the femoral group bilateral cholesterol emboli to the toes developed.

CONCLUSION

TOPS solves problems of access, embolization into the cerebral and peripheral circulation, and specialized cerebral protection devices, and enables secure closure of the access vessel in patients given anticoagulation therapy. TOPS may provide a safer, more effective, economical means for performing CAS.