Carotid stenting appears safe in high-risk patients

There was no evidence that the presence of a contralateral carotid artery occlusion was associated with an increased risk of inhospital death, nonfatal MI or nonfatal stroke in patients undergoing elective carotid artery stenting (CAS), based on hospital outcomes in the CARE Registry.

The registry results were published in the January issue of the Journal of the American College of Cardiology: Cardiovascular Interventions.

Although carotid endarterectomy (CEA) is associated with greater long-term survival free of stroke than medical therapy (Lancet 1998;351:1379-1387), patients with high-risk contralateral carotid occlusions, which occur in 6 to 10 percent of patients undergoing CEA, are at much greater risk of periprocedural death, nonfatal MI or stroke (J Am Coll Cardiol 2011;57:1002-1044). Emerging evidence from a high-risk patient population suggests that elective CAS is “an acceptable treatment option for patients if performed by an experienced operator in a thoughtfully selected patient population,” wrote the study authors.

For the CARE (Carotid Artery Revascularization and Endarterectomy) registry, 186 U.S. centers voluntarily participate in collection and validation of demographic, medical history and procedural data from patients undergoing either CAS or CEA.

In this analysis, Nestor F. Mercado, MD, PhD, of St. Luke’s Mid America Heart Institute in Kansas City, Mo., and colleagues sought to study the characteristics and outcomes of patients with contralateral carotid artery occlusions undergoing elective CAS.

The researchers examined inhospital outcomes in patients with and without contralateral carotid artery occlusion undergoing elective CAS in the CARE registry. They defined a contralateral carotid artery occlusion as a 100 percent occlusion of the contralateral internal carotid artery. To minimize differences in measured comorbidities, the researchers also performed a 3:1 propensity matching analysis comparing 42 clinical and demographic variables between contralateral carotid artery occlusion and noncontralateral carotid artery occlusion patients from the CARE registry.

The primary endpoint was a composite of inhospital death, nonfatal MI and nonfatal stroke.

Between April 2005 and January 2012, 13,993 eligible patients underwent elective CAS, of whom 10 percent had contralateral carotid artery occlusion. Mercado et al identified 5,500 CAS procedures (1,375 contralateral carotid artery occlusion and 4,125 noncontralateral carotid artery occlusion) in the propensity analysis.

The primary composite endpoint occurred in 2.1 percent and 2.6 percent patients with and without contralateral carotid artery occlusion, respectively.

The study authors also observed that contralateral carotid artery occlusion was not associated with higher complications following CAS in older patients or individuals with prior neurological symptoms.

“Although we did not directly compare the outcomes of CEA with CAS in patients with a contralateral carotid artery occlusion in the CARE registry, CEA is known to be associated with increased risk in the presence of contralateral carotid artery occlusion, whereas CAS appears to be safe in this group of patients, potentially due to the widespread implementation of embolic protection devices during balloon inflation and stent deployment,” wrote Mercado and colleagues. “CAS appears to be a reasonable revascularization option for patients with a contralateral carotid occlusion if anatomically suitable for CAS.”

Despite the limitations of the data being registry-based, they concluded that these “findings may have implications on the selection of carotid revascularization procedures for such patients.”