Predisposing Factors and Management of Hemodynamic Depression Following Carotid Artery Stenting

Carotid artery stenting (CAS) involves dilatation of carotid bulb which can trigger a series of neuronal responses resulting in hemodynamic depression that might influence the outcome of the procedure. This is a frequent but underdiagnosed complication of CAS. Although it is mild, transient and self-limiting in majority of cases, it can result in significant morbidity and mortality if persistent. Neurologists should be aware of the predisposing factors and management of this common complication. In patients who present with stroke following carotid stenting, neurologists should be aware of hypoperfusion secondary to hemodynamic depression as a cause of stroke apart from the stent thrombosis and occlusion.

Meta-Analysis of Studies Evaluating the Effect of Cilostazol on Major Outcomes After Carotid Stenting

PURPOSE

To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS).

METHODS

A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI).

RESULTS

Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis.

CONCLUSION

Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.

Primary Stroke Prevention: Medical Therapy Versus Revascularization

Asymptomatic carotid-artery atherosclerotic vascular disease identifies patients at heightened risk of major adverse cardiovascular events including ischemic stroke. Observational and registry analyses demonstrate that this risk extends beyond that attributable to carotid atherosclerosis itself and includes events manifesting in other vascular territories, such as myocardial infarction. However, randomized trials aimed specifically at treating carotid stenosis have shown benefit in terms of reducing ischemic stroke in appropriately selected patients. Therefore, the approach to primary prevention in patients with stable carotid disease must include a comprehensive strategy to reduce cerebrovascular-specific and overall cardiovascular risk through lifestyle changes and intensive medical therapies.