Percutaneous carotid artery stenting in high-risk patients

Recent studies have shown that percutaneous carotid artery angioplasty and stenting can be safely performed in patients with carotid artery stenosis, especially those considered to be at high-risk for surgery. Aim: We evaluated the safety and feasibility of carotid artery angioplasty and stenting, with and without distal protection devices in patients at high-risk for surgical endarterectomy. Methods: A total of 169 consecutive patients underwent 185 procedures and 189 stents were deployed successfully in 195 lesions. The majority of patients (51%) had restenosis after a prior carotid endarterectomy, 40% were considered to be ineligible for carotid endarterectomy by both the vascular surgeons and the interventional cardiologist and 7% were considered ineligible for surgery due to hostile neck anatomy. Results: Distal embolic protection devices were used in 52% of all cases. Procedural success was achieved in 181 of 185 procedures (98%). The overall rate of in-hospital major adverse cerebrovascular events (death, major stroke, and myocardial infarction) was 2.4%. In-hospital event rates in patients with prior carotid endarterectomy were comparable to patients with de novo lesions with 3.3% vs. 1.1% death/stroke at 30 days, and 3.3% and 3.3% stroke/death rates at 30 days, respectively. When distal protection devices were used death/stroke rates were 0% as compared to 4.7% when distal protection was not used (P=NS). However, minor embolic phenomena were observed in both primary and secondary lesions independent of the use of distal protection. Conclusions: These results support the use of carotid artery angioplasty and stenting in high-risk patients with significant primary or secondary carotid artery stenosis. In both types of lesions, acceptable results justify its use as a valid revascularization method. While clinical embolic events occur in a minority of patients in both lesion types, they are not entirely prevented by distal protection devices.