Ischemic complications after tailored carotid artery stenting in different subpopulations with high-grade stenosis: Feared but rare

Although the procedural and postoperative safety profile of carotid artery stenting (CAS) has been steadily improving, many centers still recommend carotid endarectomy (CEA) over CAS. We assessed outcomes (procedural and postoperative stroke) following tailored CAS in a cohort of patients managed at a single academic medical center. Outcomes for patients with carotid artery stenosis treated from 2005–2013 with CAS were retrospectively reviewed. Stenosis was assessed with Doppler ultrasonography and/or CT angiogram, and angiography. Symptomatic and asymptomatic patients were dichotomized (based on the North American Symptomatic Carotid Endarterectomy Trial [NASCET] and the Asymptomatic Carotid Atherosclerosis Study [ACAS]). CAS technique was chosen based on angiographic and clinical characteristics; procedures were performed with/without pre-angioplasty, cerebral protection, and post-dilation. Endpoints were cumulative incidence of ipsilateral stroke, myocardial infarction, and death within 30 days (primary) or 12 months (secondary). Overall 249 patients (151 men/98 women; mean age 69.9 years) with 254 carotid stenoses were included; 148 lesions (58%) were asymptomatic, and 106 (42%) were symptomatic. CAS was successfully performed in all lesions. At 30 days, ipsilateral transient ischemic attack (TIA)/minor stroke was seen in 6/104 (5.8%) symptomatic patients and no asymptomatic patients; there was no myocardial infarction or ipsilateral major stroke. At 12 months, there was ipsilateral TIA/minor stroke in an additional 3/98 (3.1%) symptomatic and 1/127 (0.8%) asymptomatic patients, and major stroke in 1/98 (1%). The incidence of stroke after CAS compares favorably with rates reported after CEA. The majority of peri-procedural ischemic events following CAS are TIA/minor strokes causing only transient or minor functional impact; major disabling stroke is rare with current techniques.