Patient- and lesion-tailored algorithm of endovascular treatment for arterial occlusive disease of extracranial arteries supplying the brain: safety of the treatment at 30-day follow-up
OBJECTIVE Carotid angioplasty and stenting (CAS) remains the primary modality of treating individuals with carotid stenosis and significant comorbidities or anatomically difficult lesions. The use of embolization protection devices (EPD) has been mandated by the cerebrovascular community even though the ability of these devices to prevent symptomatic strokes is not supported by the current literature. Our goal was to assess the clinical and radiological outcomes of patients who underwent CAS without EPDs at our hospital from 1996 to 2006. METHODS We performed a retrospective chart analysis of all patients who underwent CAS without EPDs at the Jefferson Hospital for Neuroscience in Philadelphia, PA. The clinical and angiographic outcomes of these patients were studied retrospectively using chart reviews and operative, angiographic, and radiological reports. The mean clinical and radiological follow-up period was 18.6 months. RESULTS One hundred five patients (97.2%) had clinical follow-up at 1 month. During this period, the following complications were observed: cerebrovascular accidents in 2 patients (1.9%), myocardial infarctions in 2 patients (1.9%), femoral hematoma in 1 patient (0.9%), retroperitoneal hematomas in 3 patients (2.8%), and cervical carotid dissections in 4 patients (3.7%); 2 patients (1.9%) died. Seventy-six patients (80.9%) had a mean clinical follow-up period of 18.6 months. During this period, 2 patients (2.6%) had cerebrovascular accidents, 1 of which was fatal. The long-term morbidity and mortality rate was 2.6%. In the same follow-up period, the restenosis (>50% stenosis from baseline) rate was 9.2% (7 patients). Three (3.9%) of these patients went on to require repeat CAS. CONCLUSION Our experience reveals that CAS can be performed safely with risks similar to those reported in series in which EPDs were used. Any procedure or device that adds risk and cost to the patient should be evaluated with a randomized, controlled trial to evaluate its efficacy, especially in situations in which published data provide conflicting results. The use of EPDs should be no exception to this paradigm.