Primary carotid artery stenting versus carotid artery stenting for postcarotid endarterectomy stenosis
Presented at the 2009 Society of Vascular Surgery Vascular Annual Meeting, Denver, Colo, Jun 11-14, 2009.
Received 16 April 2009; accepted 23 June 2009. published online 25 August 2009.
Background
Carotid artery stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in high-risk surgical patients, including stenosis after CEA. This study compared early and midterm clinical outcomes for primary CAS vs CAS for post-CEA stenosis.
Methods
This study analyzed 180 high-risk surgical patients: 68 had primary CAS (group A), and 112 had CAS for post-CEA stenosis (group B). Patients were followed-up prospectively and had duplex ultrasound imaging at 1 month and every 6 months thereafter. All patients had cerebral protection devices. Kaplan-Meier life-table analysis was used to estimate rates of freedom from stroke, stroke-free survival, ≥50% in-stent stenosis, ≥80% in-stent stenosis, and target vessel reintervention (TVR).
Results
Patients had comparable demographic and clinical characteristics. Carotid stent locations were similar. Indications for CAS were transient ischemic attacks (TIA) or stroke in 50% for group A and 45% for group B. The mean follow-up was comparable, at 21 (range, 1-73) vs 25 (range, 1-78) months, respectively. The technical success rate was 100%. The perioperative stroke rates and combined stroke/death/myocardial infarction (MI) rates were 7.4% for group A vs 0.9% for group B (P = .0294). No perioperative MIs occurred in either group. One death was secondary to stroke. The combined early and late stroke rates were 10.8% for group A and 1.8% for group B (P = .0275). The stroke-free rates at 1, 2, 3, and 4 years for groups A and B were 89%, 89%, 89%, and 89%; and 98%, 98%, 98%, and 98%, respectively (P = .0105). The rates of freedom from ≥50% carotid in-stent stenosis were 94%, 83%, 83%, and 66% for group A vs 96%, 91%, 83%, and 72% for group B (P = .4705). Two patients (3%) in group A and seven patients (6.3%) in group B had ≥80% in-stent stenosis (all were asymptomatic except one). The freedom from ≥80% in-stent stenosis at 1, 2, 3, and 4 years for groups A and B were 100%, 98%, 98%, and 78% vs 99%, 96%, 92%, and 87%, respectively (P = .7005). Freedom from TVR rates at 1, 2, 3, and 4 years for groups A and B were 100%, 100%, 100%, and 100% vs 99%, 97%, 97%, and 92%, respectively (P = .261).
Conclusions
CAS for post-CEA stenosis carried a lower risk of early postprocedural neurologic events than primary CAS, with a trend toward a higher restenosis rate during follow-up.
aDepartment of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV
Correspondence: Ali F. AbuRahma, MD, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Ave, SE, Charleston, WV 25304
ABSTRACT