Relationship of Carotid Artery Stenosis Ratio and Perioperative Stent Complications

Year 2023, Volume: 13 Issue: 2, 187 - 196, 30.06.2023

Cigdem Deniz , Vildan Güzel , Gulistan Halac , Muharrem Nasifov , Ömer Göktekın , Talip Asil

https://doi.org/10.31832/smj.1130202

Abstract

Objective: This study aimed to examine complications that may occur after carotid artery stenting (CAS) and their relationships with carotid artery stenosis rate.
Materials and Methods: Complications, such as cerebral hyperperfusion, stroke, death, stent thrombosis or occlusion and restenosis, were evaluated on the 30th day after CAS and at the end of the first year.
Results: Of the 205 CAS procedures, complications developed in 12 patients. The complication rate for the first 30 days after the procedure was 4,87%, and at the end of the first year, it was 5,85%. Of the 12 patients with complications, 8 had carotid stenosis of ≥90%. Death occurred in 4 of 195 patients with carotid artery stenosis. The mortality rate within the first 30 days and during the 1-year follow-up period was 1,53% and 2,05%, respectively. Ischemic stroke occurred in 6 of 195 patients with carotid artery stenosis. After the first 30 days and one year follow-up, ischemic stroke had occurred in 3,07% of patients. Stent thrombosis and occlusion rate was 4,87% in 205 CAS procedures, and 7 of them occurred in the first 24 hours and another 3 occurred within the first 30 days. Restenosis rates were 0,48% and 0,97% at 6 months and the first year, respectively.
Conclusion: The complications of CAS have been associated with the urgency of treatment (emergency), symptom presence (symptomatic patients) and high degree of stenosis (≥90%); whereas bilateral stenosis is not associated with complications. In addition, stent thrombosis and occlusion were observed as the most common CAS complication.

Keywords

carotid stent, stent complication, carotid artery stenosis, stent thrombosis, stroke

Thanks

We would like to thank Bengu Altunan for English language editing.

Karotid Arter Darlık Oranı ile Perioperatif Stent Komplikasyonları İlişkisi

Abstract

Amaç: Biz bu çalışmada karotid arter stentleme (KAS) sonrası oluşabilecek komplikasyonlar, komplikasyonların karotid arter darlık oranları ile ilişkisini incelemeyi amaçladık.
Gereç ve Yöntemler: Çalışmaya 205 işlem olmak üzere 195 hasta alındı. KAS sonrası ilk 30 günde ve 1 yılda serebral hiperperfüzyon, inme, ölüm, stent trombozu veya oklüzyonu ve restenoz gibi komplikasyonlar değerlendirildi.
Bulgular: 205 KAS işlemde 12 hastada komplikasyon gelişti. 205 KAS işlem sonrası ilk 30 gün için komplikasyon oranı % 4,87 iken, 1. yıl sonunda % 5,85 oranında izlendi. Komplikasyon görülen 12 hastanın 8'inin karotid arterlerinde % 90 ve üzeri darlık mevcuttu. 195 karotid arter hastasının 4’ ünde ölüm gelişti. İlk 30 gün içindeki mortalite oranı % 1,53 iken bir yıllık izlem sürecinde toplam mortalite oranı % 2,05 olarak bulundu. 195 karotid arter hastasının 6’sında iskemik inme saptandı. İlk 30 gün ve bir yıllık takip sonrası iskemik inme oranı % 3,07 olarak saptandı. Stent trombozu ve oklüzyonu oranı 205 KAS işlemde % 4,87 olup, 7’ si ilk 24 saatte, 3’ ü ise ilk 30 gün içinde meydana gelmişti. Restenoz ilk 6 ay sonunda % 0,48 oranında görülürken, bu oran ilk bir yıl sonunda % 0,97 olarak izlendi.
Sonuç:KAS işlem için komplikasyon görülme sıklığının bilateral karotid arter darlığı olan vakalardan çok; darlık oranın yüksek (%90 ve üzeri), acil ve semptomatik vakalarla ilişkili olduğu gözlemlenmiştir. Ayrıca çalışmamızda stent trombozu ve oklüzyonu en sık KAS komplikasyonu olarak tespit edilmiştir.

Keywords

karotid stent, stent komplikasyonu, karotid arter stenozu, stent trombozu

References

• 1. Brott TG, Halperin JL, Abbara S et al. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(4):e54-130 https://doi: 10.1002/ccd.22983.
• 2. Tendera M, Aboyans V, Bartelink ML et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851-906 https://doi: 10.1093/eurheartj/ehr211.
• 3. Brott TG, Hobson RW, Howard G et al. Stenting vs endar¬terectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23 https://doi: 10.1056/NEJMoa0912321.
• 4. Gurm HS, Yadav JS, Fayad P et al. Long-term results of ca¬rotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358(15):1572-1579 https://doi: 10.1056/NEJMoa0708028.
• 5. Barnett HJM, Taylor DW, Haynes RB et al; North American Symp- tomatic Carotid Endarterectomy Trial Collaborators.Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symp-tomatic Carotid Endarterectomy Trial Collaborators. N Eng J Med.1991; 325(7):445-453 https://doi: 10.1056/NEJM199108153250701.
• 6. Ferguson GG, Eliasziw M, Barr HW et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke. 1999;30(9):1751-8 https://doi: 10.1161/01.str.30.9.1751.
• 7. Walker MD, Marler JR, Goldstein M et al. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA.1995;273(18):1421-8 https://doi: 10.1001/jama.1995.03520420037035.
• 8. Phatouros CC, Higashida RT, Malek AM et al. Carotid artery stent placement for atheroschlerotic disease: Rationale, technique, and current status. Radiology. 2000;217(1):26-41 https://doi: 10.1148/radiology.217.1.r00oc2526.
• 9. Peto R, Richards S, Warlow C;.European Carotid Surgery Trialist’s Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet. 1991;337: 1235-1243 https://doi: 10.1016/0140-6736(91)92916-P.
• 10. Brown MM, Rogers J, Bland JM et al. Investigators C. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357(9270):1729-1737
• 11. Ederle J, Bonati LH, Dobson J et al. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long term follow up of a randomised trial. Lancet Neurol. 2009;8(10):898‐907 https://doi: 10.1016/S1474-4422(09)70228-5.
• 12. Yadav JS, Wholey MH, Kuntz RE et al. Protected carotid artery stenting versus endarterectomy in high risk patients. N Engl J Med. 2004;351(15):1493-501 https://doi: 10.1056/NEJMoa040127.
• 13. Mas J L, Arquizan C, Calvet D et al. Long term follow up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trial. Stroke. 2014;45(9):2750‐2756 https://doi: 10.1161/STROKEAHA.114.005671.
• 14. Mas J L, Chatellier G, Beyssen B et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-71 https://doi: 10.1056/NEJMoa061752.
• 15. Eckstein HH, Ringleb P, Allenberg JR et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective,randomised trial. Lancet Neurol. 2008;7(10):893-902 https://doi: 10.1016/S1474-4422(08)70196-0.
• 16. Ringleb PA, Allenberg J, Brückmann H et al; The SPACE Collaborative Group. 30 day results from the SPACE trial of stent protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non inferiority trial. Lancet. 2006;368(9543):1239-1247 https://doi: 10.1016/S0140-6736(06)69122-8.
• 17. Brott TG, Howard G, Roubin GS et al; CREST Investigators. Longterm results of stenting versus endarterectomy for carotid artery stenosis. N Engl J Med. 2016;374(11):1021-1031 https://doi: 10.1056/NEJMoa1505215.
• 18. Sivaguru A, Venables GS, Beard JD, Gaines PA. European carotid angioplasty trial. J Endovasc Surg. 1996;3(1):16-20 https://doi: 10.1583/1074-6218.
• 19. Koenigsberg RA, Dave A, McCormick D et al. Complicated stent supported cerebrovascular angioplasty: case analyses and review of literature. Surg Neurol. 2000;53(5):465-74 https://doi: 10.1016/s0090-3019(00)00209-3.
• 20. Jan A. VOS. Evidence overview: benefit of cerebral protection devices during carotid artery stenting. The Journal of Cardiovascular Surgery. 2017;58(2):170-7 https://doi: 10.23736/S0021-9509.16.09848-7.
• 21. Wholey MH, Al‐Mubarek N, Wholey MH. Updated review of the global carotid artery stent registry. Catheter Cardiovasc Interv. 2003;60(2):259-266 https://doi: 10.1002/ccd.10645.
• 22. Yoo DH, Roh HG, Choi SS et al. Staged carotid artery stenting in patients with severe carotid stenosis: Multicenter experience Journal of Clinical Neuroscience. 2018;53;74-78 https://doi: 10.1016/j.jocn.2018.04.007.
• 23. Egashira Y, Enomoto Y, Yamauchi K, Tsujimoto M, Yoshimura S, Iwama T. Tailored Strategies in Carotid Artery Stenting to Avoid Periprocedural Complications Trends in the Management of Cerebrovascular Diseases. Acta Neurochirurgica Supplement. 2018;129;101-106 https://doi: 10.1007/978-3-319-73739-3_15.
• 24. Köklü E, Yüksel İÖ, Bayar N, Arslan S. Is Acute Carotid Artery Stent Thrombosis an Avoidable Complication? J Stroke Cerebrovasc Dis. 2015;24(10):2219-22 https://doi: 10.1016/j.jstrokecerebrovasdis.2015.05.029.
• 25. Kristensen SD, Groove ECL. Stent thrombosis: definitions, mechanisms and prevention. E-journal of Cardiology Practice. 2007;Volume;5.
• 26. Moulakakis KG, Mylonas SN, Lazaris A et al. Acute carotid stent thrombosis: a comprehensive review. Vasc Endovascular Surg. 2016;50(17): 511-21 https://doi: 10.1177/1538574416665986.
• 27. Seo KD, Lee KO, Kim DJ, Lee KY. Rescue use of tirofiban for acute carotid in-stent thrombosis. Yonsei Med J. 2008;49(1):163-6 https://doi: 10.3349/ymj.2008.49.1.163.
• 28. Kanemaru K, Nishiyama Y, Yoshioka H et al. In-stent thrombosis after carotid artery stenting despite sufficient antiplatelet therapy in a bladder cancer patient. J Stroke Cerebrovasc Dis. 2013;22(7):1196– 200 https://doi: 10.1016/j.jstrokecerebrovasdis.2012.12.015.
• 29. Iancu A, Grosz C, Lazar A. Acute carotid stent thrombosis: review of the literature and long-term follow-up. Cardiovasc Revasc Med. 2010;11(2):110-3 https://doi: 10.1016/j.carrev.2009.02.008.
• 30. Watarai H, Kaku Y, Yamada M et al. Follow-up study on in-stent thrombosis after carotid stenting using multidetector CT angiography. Neuroradiology. 2009;51(4):243-51 https://doi: 10.1007/s00234-009-0498-7.
• 31. Moulakakis KG, Lazaris AM. Emergent carotid stent removal after carotid stent thrombosis. Ann Vasc Surg. 2018;46:401-6 https://doi: 10.1016/j.avsg.2017.08.014.
• 32. Yilmaz U, Korner H, Muhl-Benninghaus R et al. Acute occlusions of dual-layer carotid stents after endovascular emergency treatment of tandem lesions. Stroke. 2017;48(8):2171-5 https://doi: 10.1161/STROKEAHA.116.015965.
• 33. Heck DV, Brown MD. Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage. J Neurointerv Surg. 2015;7(3):170-5 https://doi: 10.1136/neurintsurg-2014-011224.
• 34. Deguchi I, Hayashi T, Neki H et al. Carotid artery stenting for acute ischemic stroke patients after intravenous recombinant tissue plasminogen activator treatment. Intern Med. 2016;55(19):2869-72 https://doi: 10.2169/internalmedicine.55.7038.
• 35. de Borst GJ, Ackerstaff RG, de Vries JP et al. Carotid angioplasty and stenting for postendarterectomy stenosis: long-term follow-up. J Vasc Surg. 2007;45(1):118-123 https:///doi: 10.1016/j.jvs.2006.09.013.
• 36. Lal BK, Beach KW, Roubin GS et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012;11(9):755-763 https://doi: 10.1016/S1474-4422(12)70159-X.
• 37. CaRESS Steering Committee. Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg. 2005;42(2):213-219 https://doi: 10.1016/j.jvs.2005.04.023.
• 38. Arquizan C, Trinquart L, Touboul PJ et al; EVA-3S Investigators. Restenosis is more frequent after carotid stenting than after endarterectomy: the EVA-3S study. Stroke. 2011;42(4):1015-1020 https://doi: 10.1161/STROKEAHA.110.589309.
• 39. Mannheim D, Karmeli R. A prospective randomized trial comparing endarterectomy to stenting in severe asymptomatic carotid stenosis. J Cardiovasc Surg (Torino). 2017;58(6):814-817 https://doi: 10.23736/S0021-9509.16.09513-6.
• 40. Daou B, Chalouhi N, Starke RM et al. Predictors of restenosis after carotid artery stenting in 241 cases. J Neurointerv Surg. 2016;8(7):677-679 https://doi: 10.1136/neurintsurg-2015-011783.
• 41. Van Laanen J, Hendriks JM, Van Sambeek MR. Factors influencing restenosis after carotid artery stenting. J Cardiovasc Surg (Torino). 2008;49(6):743-747.
• 42. Bonati LH, Ederle J, McCabe DJ et al. Long-term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol. 2009;8(10):908-917nhttps://doi: 10.1016/S1474-4422(09)70227-3.
• 43. Cosottini M, Michelassi MC, Bencivelli W et al. In stent restenosis predictors after carotid artery stenting. Stroke Res Treat. 2010;864724 https://doi: 10.4061/2010/864724.
• 44. Khan MA, Liu MW, Chio FL, Roubin GS, Iyer SS, Vitek JJ. Predictors of restenosis after successful carotid artery stenting. Am J Cardiol. 2003;92(7):895-897 https://doi: 10.1016/s0002-9149(03)00912-3.
• 45. Younis GA, Gupta K, Mortazavi A et al. Predictors of carotid stent restenosis. Catheter Cardiovasc Interv. 2007;69(5):673-682 https://doi: 10.1002/ccd.20809.
• 46. Moon K, Albuquerque FC, Levitt MR, Ahmed AS, Kalani MY, McDougall CG. The myth of restenosis after carotid angioplasty and stenting. J NeurointervSurg. 2013;8(10):1006-1010 https://doi: 10.1136/neurintsurg-2015-011938.
• 47. Diehm N, Katzen BT, Iyer SS, White CJ, Hopkins LN, Kelley L; BEACH investigators.Staged bilateral carotid stenting, an effective strategy in high-risk patients—insights from a prospective multicenter trial. J Vasc Surg . 2008;47(6):1227-1234 https://doi: 10.1016/j.jvs.2008.01.035.