Prospective Randomized Trials of Carotid Artery Stenting Versus Carotid Endarterectomy: An Appraisal of the Current Literature

Early Outcomes of Carotid Revascularization in Retrospective Case Series

Background: Most data in carotid stenosis treatment arise from randomized control trials (RCTs) and cohort studies. The aim of this meta-analysis was to compare 30-day outcomes in real-world practice from centers providing both modalities. Methods: A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Only studies reporting on 30-day outcomes from centers, where both techniques were performed, were eligible for this analysis. Results: In total, 15 articles were included (16,043 patients). Of the patients, 68.1% were asymptomatic. Carotid artery stenting (CAS) did not differ from carotid endarterectomy (CEA) in terms of stroke (odds ratio (OR) 0.98; 0.77–1.25; I² = 0%), myocardial ischemic events (OR 1.03; 0.72–1.48; I² = 0%) and all events (OR 1.0; 0.82–1.21; I² = 0%). Pooled stroke incidence in asymptomatic patients was 1% (95% CI: 0–2%) for CEA and 1% for CAS (95% CI: 0–2%). Pooled stroke rate in symptomatic patients was 3% (95% CI: 1–4%) for CEA and 3% (95% CI: 1–4%) for CAS. The two techniques did not differ in either outcome both in asymptomatic and symptomatic patients. Conclusion: Carotid revascularization, performed in centers providing both CAS and CEA, is safe and effective. Both techniques did not differ in terms of post-procedural neurological and cardiac events, both in asymptomatic and symptomatic patients. These findings reiterate the importance of a tailored therapeutic strategy and that “real-world” outcomes may only be valid from centers providing both treatments.

Jaw claudication in the era of carotid stenting

Jaw claudication could result from external carotid artery (ECA) occlusive disease. Carotid artery stenting (CAS) has been shown to worsen the disease in the ECA. This could potentially worsen the symptoms in patients with pre-existing jaw claudication undergoing CAS. Meanwhile, ECA endarterectomy is routinely done during internal carotid artery endarterectomy (CEA). This has been shown to alleviate jaw claudication symptoms. We report a case of a high-risk patient for CEA who presented with symptomatic carotid disease as well as bilateral jaw claudication. Both symptoms resolved after CEA. We also present the case of another patient treated for recurrent high-grade carotid disease with CAS resulting in acute ECA occlusion and jaw claudication. High-risk patients with symptomatic carotid disease and jaw claudication should be considered for CEA and not only CAS.

Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study

OBJECTIVES

A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting.

MATERIALS AND METHOD

Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of ≥ 50% on duplex ultrasound examination.

RESULTS

In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34%) and the patch closure group (1 case, 1.53%, P = 0.08). At 12 months, 2 stenting patients (6.88%) and 2 patch closure patients (3.07%) had $50% restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention.

CONCLUSION

Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

The hostile neck does not increase the risk of carotid endarterectomy

INTRODUCTION

Hostile neck anatomy is assumed to be associated with increased surgical risk for patients undergoing carotid endarterectomy (CEA) and is often considered a reason to choose carotid stenting or medical management. This retrospective case-control study evaluated whether, and how much, anatomically hostile necks represent a condition of higher surgical risk of early and late mortality and major or minor morbidity.

METHODS

The data for 966 homogeneous CEA patients was prospectively entered in a computer database. Seventy-seven had a hostile neck anatomy due to previous oncologic surgery or neck irradiation, restenoses after CEA, high carotid bifurcation, or bull-like and inextensible neck. A case-control matched-pair cohort study considered sex, age (5-year intervals), and year of operation. Regional anesthesia was used for all operations for atherosclerotic stenosis >or=70%, conforming to the European Carotid Surgery Trial (ECST) in symptomatic and asymptomatic patients, at a single center and by one surgeon or under his direct supervision.

RESULTS

The hostile neck patients and the control group were matched for age, sex, carotid-related symptoms, degree of stenoses, and main risk factors for cardiovascular diseases. Intraoperative variables were substantially equivalent in the two groups; however, procedure length and clamping time were, respectively, about 22 minutes (P = .0001) and 7 minutes longer (P = .01) in the hostile neck group. Rates of postoperative mortality and neurologic events were equivalent. Peripheral nerve lesions were multiple and significantly more frequent in the hostile neck patients (21% with >or=1 cranial nerve lesion vs 7% of controls, P = .03), yet all were transient and limited to a few months. The subgroups of patients with hostile neck, restenoses, and bull-like inextensible necks required the longest operative and clamping time, and those with bull-like and high bifurcation had the most frequent cranial nerve dysfunctions. At the respective follow-up of 47 and 45 months, survival curves (P = .48) and the incidence of restenoses and fatal and nonfatal strokes were similar (5 and 4, respectively).

CONCLUSIONS

Hostile necks led to more complex CEA procedures but without substantial consequences in early and late morbidity and mortality. Most patients with hostile neck can undergo CEA at low risk, with the benefit of effective long-lasting stroke prevention similar to standard patients. In our opinion, the more frequent but temporary cranial nerve dysfunctions that occur are not sufficient to consider hostile neck patients noneligible for CEA.

Assessment of aortic pathology and peripheral arterial disease using multidetector computed tomographic angiography

The development of multidetector computed tomography represents a remarkable diagnostic advancement because this imaging modality has been widely used in the evaluation of the cardiovascular system. With scanner-adjusted image acquisition and contrast medium administration, multidetector computed tomographic angiography provides a cost-effective and accurate imaging assessment in patients with aortic pathologies or peripheral arterial occlusive disease. Multidetector computed tomographic angiography is associated with several advantages, including high image spatial resolution and rapid imaging acquisition speed. This diagnostic methodology allows accurate detection of a variety of intravascular lesions in the carotid artery, thoracic and abdominal aorta, renal arteries, and peripheral arterial systems. This article provides an overview of multidetector computed tomographic angiography in the assessment of arterial disease and reviews current literature about this diagnostic technology in the evaluation of aortic and peripheral arterial pathologies.