Advances in stroke: advances in interventional neuroradiology.

Abstract

Carotid artery stenting (CAS) has not been shown to be as safe as carotid endarterectomy for treatment of symptomatic extracranial carotid artery stenosis in the immediate postoperative period. However, beyond the postoperative period, data continues to support a role for CAS in selected patients. A large systematic review of 206 individual studies (54 713 total patients) undergoing CAS found the cumulative 30-day risk of stroke or death to be 7.6% in symptomatic and 3.3% in asymptomatic patients.1 Factors associated with increased risk of adverse outcomes in both groups were age 75 years (relative risk [RR] 1.88), hypertension (RR 1.86), and coronary artery disease (RR 1.41). Use of embolic protection devices significantly reduced the risk of stroke or death (RR 0.57). Although reports of adverse events vary widely in the literature, there has been a trend toward overall reduction in risk over the past several years, suggesting that use of embolic protection devices, careful patient selection, and increasing operator experience may be important factors in minimizing risk. The vast majority of these data (97%) are outside the standards of a randomized controlled trial (RCT), emphasizing the need for data from the trials that are currently enrolling patients. Among the larger studies currently enrolling patients are the Carotid Stenting for High Risk Surgical Patients (CHOICE, Abbott Vascular, target 5000 patients), Asymptomatic Carotid Surgery Trial-2 (ACST-2, target 5000 patients), and Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis versus Endarterectomy trial (SPACE-2, target 3640 patients). This year, we received our first update from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the largest RCT to date comparing the periprocedural safety and long-term (4 years) efficacy of CAS versus carotid endarterectomy.2 Data from the lead-in phase demonstrated an overall 30-day stroke and death rate of 4.4%. Restenosis rates in the lead-in phase were reported to be 13% with 1.2% of patients requiring repeat revascularization by 1-year follow-up. These numbers compare to restenosis rates of 10.7% and 4.6% in patients undergoing CAS and carotid endarterectomy, respectively, in the SPACE trial3 and 19% of CAS patients in the Stenting and Angioplasty with Protection in Patients at High Risk of Endarterectomy (SAPPHIRE) study.4 The Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) trial, a prospective, nonrandomized comparative cohort study reported no difference in rates of death, nonfatal stroke, and myocardial infarction (MI) at 4 years postprocedure (27% versus 22%, carotid endarterectomy versus CAS, P 0.27).5 However, consistent with data from other studies, restenosis rates were higher in the CAS group (P 0.014). Thirty-day results from 4007 patients enrolled in the SAPPHIRE trial were published demonstrating a 4.4% rate of all MI, stroke, and death.6,7 Still one of the most intriguing and controversial subjects is that of CAS in octogenarians. A single-center retrospective study of 24 octogenarians undergoing CAS reported a 30-day morbidity and mortality of 4.2%.8 Prospectively acquired data pooled from 3 centers demonstrated no difference in 30-day rates of death, transient ischemic attack, or MI between 2 cohorts selected by age (mean age 69.9 and 83.5 years, respectively).9 Touze et al, however, pooled data from 22 individual studies (14 184 patients 75 years of age) and found that patients in the older subgroup had a RR of 1.88 (P 0.01) for death, MI, and stroke. These conflicting findings again emphasize the need for large randomized cohorts including patients of advanced age. The cumulative data suggest that excellent outcomes are viable with CAS performed by seasoned experts in selected patients.

DOI: 10.1161/STROKEAHA.111.642652

Cite this paper

@article{Pierot2012AdvancesIS, title={Advances in stroke: advances in interventional neuroradiology.}, author={L. Pierot and I M J van der Bom and Ajay K. Wakhloo}, journal={Stroke}, year={2012}, volume={43 2}, pages={310-3} }