Neurologic complications in patients with carotid artery stenting

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting

PURPOSE

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population.

MATERIALS AND METHODS

HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]).

RESULTS

The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003).

CONCLUSION

Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS.

CLINICAL IMPACT

Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

Prevention of in-stent restenosis with drug-eluting balloons in patients with postirradiated carotid stenosis accepting percutaneous angioplasty and stenting

OBJECTIVE

To investigate the technical safety and outcome of in-stent restenosis (ISR) prevention with drug-eluting balloon (DEB) in patients with postirradiated carotid stenosis (PIRCS) undergoing percutaneous angioplasty and stenting (PTAS).

METHODS

Between 2017 and 2021, we prospectively recruited patients with severe PIRCS for PTAS. They were randomly separated into two groups based on endovascular techniques performed with and without DEB. Preprocedural and early postprocedural (within 24 hours) MRI, short-term ultrasonography (6 months after PTAS), and long-term CT angiography (CTA)/MR angiography (MRA), 12 months after PTAS, were performed. Technical safety was evaluated based on periprocedural neurological complications and the number of recent embolic ischemic lesions (REIL) in the treated brain territory on diffusion-weighted imaging of early postprocedural MRI.

RESULTS

Sixty-six (30 with and 36 without DEB) subjects were enrolled, with one failure in techniques. For 65 patients in the DEB versus conventional groups, technical neurological symptoms within 1 month (1/29 (3.4%) vs 0/36; P=0.197) and REIL numbers within 24 hours (1.0±2.1 vs 1.3±1.5; P=0.592) after PTAS showed no differences. Peak systolic velocity (PSVs) on short-term ultrasonography was significantly higher in the conventional group (104.13±42.76 vs .81.95±31.35; P=0.023). The degree of in-stent stenosis (45.93±20.86 vs 26.58±8.75; P<0.001) was higher, and there were more subjects (n=8, 38.9% vs 1, 3.4%; P=0.029) with significant ISR (≥ 50%) in the conventional group than in the DEB group on long-term CTA/MRA.

CONCLUSIONS

We observed similar technical safety of carotid PTAS with and without DEBs. The number of cases of significant ISR were fewer and the degree of stenosis of ISR was less in primary DEB-PTAS of PIRCS than for conventional PTAS in the 12-month follow-up.

Risk and risk factor of ischemic stroke after acute retinal arterial ischemia

PURPOSES

We aimed to confirm the risk and risk factor for ischemic stroke after acute retinal arterial ischemia (ARAI).

METHODS

A retrospective cohort study of patients with a diagnosis of acute retinal arterial ischemia (ARAI) and completing 2-year follow-up was conducted from January 2015 to December 2021 at a general hospital.

RESULTS

A total of 69 patients including 43(62.3%) patients of central retinal artery occlusion (CRAO), 11(15.9%) patients of branch retinal artery occlusion (BRAO) and 15(21.7%) patients of ophthalmic artery occlusion (OAO) were included in the study. Patients age was 58.2 ± 13.0(years), male patients accounting for 51 (73.9%) and 22 (31.9%) patients having at least 70% ipsilateral carotid artery stenosis (ICAS). During the 2-years follow-up period, 11(15.9%) patients of ARAI experienced ischemic stroke. Among them, 3(20%) patients of OAO, 6(14%) patients of CRAO and 2(18.2%) patients of BRAO had ischemic stroke. The cumulative probabilities of ischemic stroke were 13.0% at 12.9 months and 15.9% at 24 months after ARAI. In addition, patients with at least 70% ICAS were more likely than patients without it to have ischemic stroke (p = 0.002). After Cox regression analysis, ICAS (≥ 70%) or occlusion was significantly associated with a high risk of ischemic stroke after ARAI during the 2-years follow-up time (HR,6.769,95%CI [1.792-25.578], p = 0.005).

CONCLUSION

Patients have a high risk of ischemic stroke, particularly those with a diagnosis of ICAS (≥ 70%) or occlusion after the onset of ARAI. Clinical management of ARAI should focus on vascular risk factors control and secondary prevention for stroke.

Mid-/Long-Term Outcome of Neuroendovascular Treatment for Chronic Carotid Artery Total Occlusion

Objective

The natural course of chronic carotid artery total occlusion (CTO) is poor. Previous reports suggested that carotid artery stenting (CAS) improves the clinical outcome of CTO. However, its long-term efficacy has not been established. This study assessed the mid- and long-term clinical outcome of CAS for CTO.

Methods

We evaluated the clinical outcome of 15 patients who underwent CAS for CTO between September 2010 and October 2019.

Results

The technical success rate of recanalization was 93.3% (14 of 15 patients). Eight patients were treated using self-expanding stents, and six were treated using self-expanding coronary stents. Symptomatic procedure-related complications developed in two patients (13.3%). During the follow-up period (mean 34.9 months), symptomatic ipsilateral stroke was not noted. One patient (7.1%) developed asymptomatic re-occlusion, but stent patency was preserved in 13 patients (92.9%).

Conclusion

CAS for CTO may be safe and feasible based on the mid- and long-term outcome.

Carotid Artery Angioplasty and Stenting for Carotid Stenosis: A Single-Center Experience from Saudi Arabia

Purpose

Atherosclerotic stenosis of the extracranial carotid artery accounts for approximately 20% of all strokes. Both carotid artery endarterectomy and carotid artery angioplasty with stenting (CAAS) are recommended for symptomatic patients with 50% or more stenosis or asymptomatic patients with 70% or more stenosis. CAAS is under-reported in Saudi Arabia, as evidenced by a thorough literature search. In this article, we aim to share our experience of CAAS to call for the necessity of conducting more research on stroke and emphasize the local need of utilizing more endovascular treatments like CAAS.

Materials and Methods

A retrospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria consisted of all adult patients (18 years and above) with carotid stenosis who were treated with CAAS.

Results

A total of 16 patients were included in the study. The mean age of the participants was 66.9±13.5 years (range 30–87 years). All patients were symptomatic (had a previous stroke or transient ischemic attack). The procedure was successful in 14 patients (87.5%), while it failed in 2 patients (12.5%) due to technical reasons. All patients had no stroke or myocardial infarction within 30 days of the procedure.

Conclusion

Despite the advancement in medicine with free healthcare services in Saudi Arabia, the interventional procedures for secondary prevention of strokes are underutilized. Collaboration between different hospitals will be extremely helpful since few centers in each city are providing such treatments by an expert neurointerventionist and/or strokologist. The good selection of candidates, optimal management of comorbid conditions, and multidisciplinary care may improve outcomes and reduce mortality.