CAS, CEA Evaluated for Contralateral Occlusion

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Too Small for Conclusions

There were six late deaths after carotid artery stenting. When you look at those cases, it begs the question as to whether any carotid intervention at all should be done. In my practice, I see patients all the time to whom I just have to say "No," because I know these patients will drag down results and they really have very little life expectancy.

I wonder, what was the timing of the transient ischemic attacks? Were they intraprocedural or late? What we’ve run into recently are cases of platelet resistance. We’re doing platelet inhibition studies before we ever go into the lab to make sure that our dual-antiplatelet therapy is really working.

What are the indications for carotid artery stenting at Emory University right now?

I’m concerned that the numbers are too low to draw any meaningful conclusions. This study shows, like many individual series and meta-analyses, that you can get great surgical results. The problem is, over the last 12 months there have been two very important publications that have looked at large series of carotid endarterectomies and the development of contralateral occlusion. The risk of stroke from carotid endarterectomy with contralateral occlusion was approximately twice as high as without contralateral occlusion in large series of patients – I’m talking about hundreds of patients.

This is still something that we have to take seriously. The carotid artery stenting lobby is not going to give us a free pass on this.

Dr. Charles B. Ross is a vascular specialist at the University of Louisville (Ky.). These comments have been adapted from his remarks as an official discussant of Dr. Brewster’s presentation at the meeting. He has been a board member for Abbott Vascular.



SCOTTSDALE, ARIZ. – The presence of contralateral carotid artery occlusion is no reason to treat carotid artery stenosis with stenting instead of carotid endarterectomy, a review of 713 patients suggested.

Either endarterectomy or carotid artery stenting can be performed on patients with contralateral occlusion with good 30-day and midterm results, Dr. Luke P. Brewster and his associates reported at the annual meeting of the Southern Association for Vascular Surgery.

Sherry Boschert

Dr. Luke P. Brewster

"We do not support contralateral occlusion as an independent criterion for carotid artery stenting" over carotid endarterectomy in patients with contralateral occlusion, said Dr. Brewster of Emory University, Atlanta.

Among 57 patients who underwent carotid artery therapy who also had contralateral occlusion, 7 of 39 patients died after carotid artery stenting (18%), compared with 1 of 18 patients after carotid endarterectomy (6%), during a mean midterm follow-up of 28 and 29 months, respectively.

In general, stroke risk is increased in patients with internal carotid artery occlusion contralateral to a carotid artery with significant stenosis. Contralateral occlusion has been suggested as an indication for stenting because of theoretical advantages from reduced ischemic procedural time, and because the procedure can be done without a vascular shunt and without general anesthesia. Carotid endarterectomy, on the other hand, has been associated with a lower procedural stroke rate.

The investigators retrospectively reviewed Emory University’s data on 713 consecutive patients who underwent either carotid endarterectomy or carotid artery stenting from February 2007 to July 2011.

Among the 8% of patients who had contralateral occlusion, the treatment approach was based on the preference of each patient’s vascular surgeon, cardiologist, and/or interventional radiologist.

Patients in the carotid artery stenting group were more likely to have had prior neck surgery (18 of 39 patients; 46%), compared with patients in the carotid endarterectomy group (1 of 18 patients; 6%). The groups did not differ significantly in age (67 and 70 years, respectively), sex, proportion of symptomatic patients, degree of stenosis, history of carotid artery stenting on the contralateral side, smoking history, or rates of hypertension, transient ischemic attack, stroke, diabetes, myocardial infarction, or other factors.

In the carotid artery stenosis group, six procedures involved flow reversal. The main indications for stenting were prior neck surgery, contralateral occlusion, or radiation of the neck. In the carotid endarterectomy group, two procedures were performed with the patient awake, and 15 involved a shunt.

All the endarterectomies were completed; one stenting procedure was aborted and the patient underwent an endarterectomy during the same hospitalization.

At 30 days after surgery, two patients (5%) in the stenting group had died following an access-site bleed or respiratory failure in a patient with a seizure disorder. No patients in the endarterectomy group died. Two patients in the stenting group developed transient ischemic attacks. There was no MI or stroke in either group, Dr. Brewster said.

Patients in the endarterectomy group stayed in the hospital significantly longer (average, 3 days vs. 2 days in the stenting group). Five patients (28%) in the endarterectomy group were admitted to the ICU, all for observation due to medical morbidities. Seven patients (18%) in the stenting group were admitted to the ICU, three of them due to bradycardia or hypotension.

Midterm results included a mean of 29 months of follow-up in the endarterectomy group and 28 months in the stenting group. Two patients required reinterventions after carotid artery stenting, compared with none after endarterectomy.

Five more patients in the stenting group died at a mean of 23 months after the procedure (excluding the two perioperative deaths), compared with one death at a mean of 42 months after endarterectomy. All six of these late deaths were in patients with hypertension, five of whom also had chronic obstructive pulmonary disease. Three of the six patients had diabetes, and two had a history of prior stroke.

The findings "fail to demonstrate superiority of carotid artery stenting over carotid endarterectomy in patients with contralateral occlusion," Dr. Brewster said.

Dr. Brewster reported having no financial disclosures.

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