The effects of carotid artery stenting on short-term clinical outcomes and evaluation of restenosis

Öz

Objectives: Data on restenosis and long-term outcomes of carotid stenting are limited. The aim of this study was to investigate cardiovascular effects of carotid stenting on clinical outcome and restenosis in patients with symptom­atic severe carotid artery stenosis. Materials and methods: Twenty patients (mean age: 68±7 years, 11 male) who have been decided to perform stenting in joint Committee of Cardiology, Cardiovascu­lar Surgery and Neurology Clinics were included.Patients were evaluated both clinically and Doppler ultrasono­graphically for frequency of cardiovascular events and restenosis. Restenosis is defined as the reapperance of stenosis with a diameter reduction of ≥%50 with peak sys­tolic velocity higher than 224 cm/s. Results: Comorbidities in patients were; coronary artery disease in 14, peripheral artery disease in three, and both chronic renal failure and congestive heart failure in two. Stent diameters were ranged from 6 to 8 mm, and stent lengths were 30 and 40 mm. During the procedure 5 pa­tients had predilatation and 19 had postdilatation. None of the patients had >%30 resudial stenosis after the proce­dure. All procedures were technically successful. After the procedure only one transient ischemic attack was seen. There were no restenosis, myocardial infarction, death or stroke at 30th day end of the first year of follow up. Diabetes and heart failure were found as predictors for restenosis. Conclusion: In highly selected cases, carotid artery stenting is an effective and safe method in the short term. Restenosis did not seem to be a restricting problem for the success of carotid artery stenting.

Anahtar Kelimeler

• Carotid artery stenosis, stenting, restenosis, clinical outcomes

Karotis arter stentlemenin kısa dönem klinik sonuçlara etkisi ve restenozun değerlendirilmesi

Öz

Amaç: Karotis stentlemede restenoz ve uzun dönem so­nuçlarla ilgili veriler sınırlıdır. Bu çalışmanın amacı semp­tomatik ağır karotis arter darlıklı hastalarda stentleme işleminin klinik sonuçlara ve restenoz oranlarına etkisini araştırmaktır. Gereç ve yöntem: Çalışmaya Kalp Damar Cerrahisi, Kardiyoloji ve Nöroloji ortak konseyinde stent implantas­yonu kararı alınan 20 hasta (yaş ortalaması 68±7 yıl, 11\'i erkek) alındı. Hastalar perioperatif (ilk 30 gün ) ve birinci yıl sonunda hem klinik hem de Doppler ultrasonografi ile değerlendirilerek kardiyovasküler olay sıklığı ve restenoz oranları değerlendirildi. İzlemde karotis Doppler ultraso­nografi ile %50 ve üzeri darlığa karşılık gelen instent zirve akım hızının ≥224 cm/sn olması restenoz olarak kabul edildi. Bulgular: Hastalarda ek hastalık olarak 14\'ünde koroner arter hastalığı, 3\'ünde periferik arter hastalığı, 2\'sinde kro­nik böbrek yetmezliği, 2\'sinde ise kalp yetersizliği mevcut­tu. İşlemde kullanılan stentlerin çapı 6 ile 8 mm arasında, stent uzunluğu ise 30 ile 40 mm idi. Beş (%25) hastaya predilatasyon yapılırken, postdilatasyon 19(%95) hastaya uygulandı. Postdilatasyon sonrası hiçbir hastada ≥%30 rezidüel darlık izlenmedi. İşlem başarısı %100\'dü. İşlem sonrası periprosedürel olay kapsamında 1(%5) hastada geçici iskemik atak gelişti. Otuz günlük ve bir yıllık takip­lerde inme, miyokard infarktüsü veya ölüm görülmedi. Hiçbir hastada restenoz izlenmedi. Diyabet ve kalp yeter­sizliği restenoz öngördürücü faktörleri olarak saptandı. Sonuç: Karotis arter stentleme iyi seçilmiş olgularda kısa dönemde etkin ve güvenilir bir yöntemdir. Restenoz karo­tis arter darlığında işlem başarısını etkileyen kısıtlayıcı bir faktör olarak görünmemektedir.

Anahtar Kelimeler

• Karotis arter darlığı, stent, restenoz, klinik sonuçlar

Kaynakça

1. ACCF/SCAI/SVMB/SIR/ASITN Clinical expert consensus document committee on carotid stenting review article. J Am Coll Cardiol 2007;49(1):126-70.
2. AbuRahma AF, Abu-Halimah S, Bensenhaver J, et al. Opti- mal carotid duplex velocity criteria for defining the sever- ity of carotid in-stent restenosis. J Vasc Surg 2008;48(3): 589-94.
3. De WM, Greving JP, de Jong AW, Buskens E, Bots ML. Prevalence of asymptomatic carotid artery stenosis accord- ing to age and sex: Systematic review and metaregression analysis. Stroke 2009;40(4):1105-13.
4. Ahmed B, Al-Khaffaf H. Prevalence of significant asymp- tomatic carotid artery disease in patients with periferal vascular disease: A metanalysis Eur J Vasc Endovasc Surg 2009;37(3):262-71.
5. Oderich GS, Faries P. Carotid artery angioplasty and stent- ing: where do we stand? Perspect Vasc Surg Endovasc Ther 2008;20(3):237-8.
6. Ricotta JJ, Malgor RD. A review of the trials comparing ca- rotid angioplasty and stenting. Perspect Vasc Surg Endo- vasc Ther 2008;20(3):299-308.
7. Vogel TR, Dombrovskiy VY, Haser PB, Scheirer JC, Graham AM. Outcomes of carotid artery stenting and endarterec- tomy in the United States. J Vasc Surg 2009;49(2):325-30.
8. Yadav JS, Sneed D, Ouriel K, et al. Durability of carotid stenting for the prevention of stroke: 3-year follow-up of the SAPPHIRE trial and the US Carotid Feasibility (abstr). Circulation 2005;112: Suppl: II- 416.

9. CaRESS Steering Committee. Carotid Revascularization Us- ing Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg 2005; 42(2): 213-9.
10. Ringleb PA, Allenberg JR, Bruckmann H, et al. 30 day results from the SPACE trial of stent-protected angio- plasty versus carotid endarterectomy in symptomatic pa- tients: a randomised non-inferiority trial. Lancet 2006; 368(9543):1239-47.
11. EVA-3S Investigators. Endarterectomy vs. angioplasty in patients with symptomatic severe carotid stenosis (EVA- 3S) trial. Cerebrovasc Dis 2004;18(1): 62-5.
12. Brott TG, Hobson RW II, Howard G, et al; CREST Investi- gators. Stenting vs endarterectomy for treatment of carotid- artery stenosis. N Engl J Med 2010;363(1):11-23.
13. Bonati LH, Jongen LM, Haller S, et al; ICSS-MRI Study Group. New ischaemicbrain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a sub- study of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010;9(4):353-62.
14. Bonati LH, Jongen LM, Haller S, et al. ICSS-MRI Study Group. New ischaemicbrain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a sub- study of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010;9(4):353-62.
15. David J. C, Lessio S, O’Donoghue M, Tsalamandris C, Schainfeld, Rosenfield K. Mechanisms and predictors of carotid artery stent restenosis: A serial ıntravascular ultra- sound study original research article. JACC 2006;47(12): 2390-6.
16. Vogel TR, Dombrovskiy VY, Haser PB, Graham AM. Ca- rotid artery stenting: Impact of practitioner speciality and volume on outcomes and resource utilization. J Vasc Surg 2009;49(5):1166-71.
17. Verzini F, De Rango P, Parlani G, Panuccio G, Cao P. Carotid artery stenting: technical issues and role of operators’ expe- rience. Perspect Vasc Surg Endovasc Ther 2008;20(3):247- 57.
18. Gröschel K, Riecker A, Jörg B. Schulz, Ernemann U, Kas- trup A. Systematic review of early recurrent stenosis after carotid angioplasty and stenting. Stroke 2005;36(2):367- 73.
19. 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):895-7.