Original Article

Protected Carotid Artery Stenting in Patients at High Risk for Carotid Endarterectomy

Authors: Prasanna Venkatesh Kumar, MD, Aishwarya Lakshmi, MD, Rakesh Shrivastava, MD, Aman Mundi, MD, Anshu Tandon, MD, Kavit A. Desouza, MD, Gloria Caldito, PhD, Enrique Jimenez, MD, Bobby V. Khan, MD, PhD, Neeraj Tandon, MD, FACC, FSCAI

Abstract

Objectives: To compare the 30-day, six-month, and one-year outcomes of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in male veterans, and to identify any predictors of adverse outcomes. CAS has been shown to be non-inferior to CEA in patients at high-risk for CEA. The outcome of CAS compared to low-risk CEA is less clear.


Methods: Retrospective analysis of 96 consecutive patients who underwent CAS (N = 31) or CEA (N = 65). The cumulative 30-day, six-month, and one-year incidence of ipsilateral transient ischemic attack (TIA) or stroke, restenosis or reocclusion, need for target vessel revascularization, non-fatal myocardial infarction (MI), and death were compared.


Results: All patients in the CAS group were at high risk for CEA. Among the CEA group, 50 (76.9%) were at high risk and the remaining 15 (23.1%) were considered to be at low risk. The cumulative incidence of adverse outcomes with CAS and CEA, respectively, at 30 days (3.2% vs 9.2%, P = ns), six months (3.2 vs 18.5%, P = 0.047), and one year (9.7% vs 18.5%, P = ns) favored CAS. This difference was primarily due to adverse events in the high-risk CEA patients. There was no significant difference in outcome between the CAS and low-risk CEA groups. The independent significant predictors for adverse outcomes within six months were the group (P = 0.047) and number of risk factors (P = 0.01). Interestingly, the use of angiotensin-converting enzyme inhibitors (ACE-I) predicted adverse outcomes within one year (P = 0.01).


Conclusion: CAS may be superior to high-risk CEA with better six-month outcomes. The outcomes with CAS were not significantly different compared to low-risk CEA, suggesting that CAS may be non-inferior to low-risk CEA.

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References

1. Chaer RA, DeRubertis B, Patel S, et al. Current management of extracranial carotid artery disease. Rev Recent Clin Trials 2006;1:293-301.
 
2. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415-1425.
 
3. Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379-1387.
 
4. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004;351:1493-1501.
 
5. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Lancet 2001;357:1729-1737.
 
6. SPACE Collaborative Group, Ringleb PA, Allenberg J, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial. Lancet 2006;368:1239-1247.
 
7. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006;355:1660-1671.
 
8. Gurm HS, Yadav JS, Fayad P, et al; SAPPHIRE Investigators. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008;358:1572-1579.
 
9. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363:11-23.
 
10. George JC, White CJ. Carotid artery stenting lessons from CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial). JACC Cardiovasc Interv 2010;3:988-990.
 
11. International Carotid Stenting Study investigators, Ederle J, Dobson J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010;375:985-997.
 
12. Rakugi H, Kim DK, Krieger JE, et al. Induction of angiotensin-converting enzyme in the neointima after vascular injury. Possible role in restenosis. J Clin Invest 1994;93:339-346.
 
13. Heeneman S, Sluimer JC, Daemen MJ. Angiotension-converting enzyme and vascular remodeling.Circ Res 2007;101:441-454.
 
14. Eto H, Biro S, Miyata M, et al. Angiotensin II type 1 receptor participates in extracellular matrix production in the late stage of remodeling after vascular injury. Cardiovasc Res 2003;59:200-211.