Introduction The most current randomized clinical trial comparing carotid artery stenting (CAS) to carotid endarterectomy for short-term and long-term prevention of strokes demonstrated comparable results. In our study, we present a retrospective review of a real-world single-center experience in the treatment of elective CAS, with a focus on peri-procedural and long-term outcomes and a comparison of outcomes with those reported by CREST for CAS.
Materials and Methods All elective CAS cases from January 2015 to December 2019 were retrospectively reviewed. Cases were performed by three experienced neuro-interventionalists. Data regarding patient characteristics, intra-procedural findings, and post-procedural events were extracted from the medical record. The primary endpoint was defined as peri-procedural (<30 days) stroke, myocardial infarction, or death and post-procedural ipsilateral stroke.
Results Seventy-three patients who underwent elective CAS were identified (median age 71, 59% male, 78% Caucasian). Major comorbidities included hypertension (88%), dyslipidemia (82%), and diabetes mellitus (40%). Eighty-one percent of the patients were former or current smokers. Left-sided disease was treated in 39 patients (53.4%), with a median stenosis of 75% (IQR 70–88.8%), and 89.0% of cases were symptomatic. Asymptomatic stenting was most commonly performed due to concern for artery-to-artery embolism in patients with a prior history of artery-to-artery stroke of the contralateral side. Contralateral disease was present in 41.1%, with median stenosis of 50%. Angioplasty was used prior to stenting in 97.3% of patients and embolic protection devices in 93.2%, with a 100% procedural technical success rate. Pre-procedure and post-procedure dual antiplatelet (DAPT) prescribing rates were 100%. Aspirin platelet inhibition was therapeutic in 69.8% of cases and clopidogrel inhibition in 87.7% of cases.
Median follow up time was 17.4 months (IQR 6.8–29.5 months). No peri-procedural (<30 days) stroke, MI, or death occurred in this cohort. Post-procedural stroke, including ipsilateral or contralateral anterior circulation and posterior circulation stroke, occurred in three patients (4.1%). One experienced a major ipsilateral stroke at 10 months, in the setting of interrupted anticoagulation due to spontaneous subdural hematoma. Major posterior circulation stroke occurred in two patients, one at 5 weeks and one at five years post-procedure. Repeat ipsilateral intervention occurred in three patients (4.1%), including one for acute in-stent thrombosis on the day of procedure in the setting of sub-therapeutic DAPT, despite being previously therapeutic. There were three (4.1%) patient deaths in the first year post-procedure from metabolic encephalopathy, status epilepticus, and one unknown cause. End-points of data collected from our institution are compared to data reported after CAS in the CREST trial (table 1).
Conclusion Elective carotid artery stenting at our institution is a safe procedure, with rates of peri-procedural stroke, MI, and death lower than those reported in the CREST trial.
Disclosures A. Forrest: None. C. Sellers: None. P. Ramakrishnan: None. W. Leesch: None. F. Sanderson: None.
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