Anatomical/Technical Predictors of Perioperative Clinical Outcomes after Carotid Artery Stenting
Ali F AbuRahma, John E Campbell, Aravinda Nanjundappa, Trevor DerDerian, Nizar Hariri, Elliott Adams, L Scott Dean, Joseph AbuRahma
Robert C. Byrd Health Sciences Center of W. Va. Univ., Charleston, WV
Background: Only a few studies have reported on the impact of anatomical/technical factors on clinical outcomes of carotid artery stenting (CAS). This study will analyze the effect of these factors on perioperative stroke/death after CAS.
Population and Methods: This is a retrospective analysis of prospectively collected data on 456 CAS patients. A logistic regression analysis was used to determine the impact of anatomical factors (lesion length, location, severity, calcification, and arch type) and technical factors (stent type, number, diameter, and length; filter type, filter insertion to recovery time, and pre- and post-stent PTA) on perioperative stroke, death, and myocardial infarction (MI;major adverse events [MAE]).
Results: The MAE and stroke rates for the whole series were 4.7% and 2.2%. The stroke rate for asymptomatic patients was 0.46% (p=0.01). The MAE rates for patients with transient ischemic attacks (TIA) were 7% versus 3.2% for other indications (p=0.077). The stroke rates for calcific lesions were 6.3% versus 1.2% for non-calcific lesions (p=0.046). There were no significant differences in stroke and MAE rates in regards to other anatomical features.
The stroke rate for patients with dilatation prior to filter insertion with pre-stent and/or post-stent PTA was 9.1% versus 1.8% for patients without (p=0.07;) and 2.6% for patients with post-stenting dilatation versus 0% for patients without (p=0.36). MAE rates for patients with post-stenting dilatation were 5.6% versus 0% for patients without (p=0.0536). MAE rates for patients with ACCUNET filters were 1.9% versus 6.7% for other filters (p=0.029). There were no significant differences between stroke and MAE rates in regards to stent type, number, diameter, length of stent, and time from filter insertion to recovery time.
A regression analysis showed that the odds ratio for stroke was 0.1 (p=0.031) for asymptomatic indications, 13.7 (p=0.014) for TIA indications, 6.1 (p=0.0303) for dilatation performed prior to filter insertion, and 1.7 (p=0.4413) for PTA performed prior to stenting. It also showed that the MAE odds ratio was 0.46 (p=0.0858) for asymptomatic indications, 2.1 (p=0.35) for pre-dilatations performed prior to filter insertion, and 2.2 (p=0.22) for post-stent dilatations. A multivariate analysis showed that patients with TIA indications had an odds ratio of stroke of 15.26 (p=0.0113); and patients with dilations performed prior to filter insertion with pre-stent and/or post-stent PTA had an odds ratio of 7.98 (p=0.0193). The MAE odds ratio for ACCUNET versus other filters was 0.27 (p=0.0389, Tables).
Conclusions: PTA prior to filter insertion had higher stroke rates and post-stenting PTA was associated with higher MAE rates. The ACCUNET filter was associated with lower stroke and MAE rates. There was no correlation between other anatomical/technical variables.
PTA Combination and Perioperative Stroke and Major Adverse Events
|Post-stent only||2/130 (1.5)||6/130 (4.6)|
|Pre-EPD & pre-stent||0/2||0/2|
|Pre-EPD & post-stent||1/8 (12.5)||1/8 (12.5)|
|Pre-stent & post-stent||5/192 (2.6)||11/192 (5.7)|
|Pre-EPD, pre-stent & post- stent||1/11 (9.1)||1/11 (9.1)|
Logistic Regression Analysis
|Univariate - Early Stroke|
|Gender (Male vs Female)||0.86||(0.23,3.24)||0.8223|
|Coronary Artery Disease||1.33||(0.27,6.51)||0.7215|
|Congestive Heart Failure||1.63||(0.4,6.61)||0.4977|
|Pre-ProcedureStenosis (70-99 vs 50-69)||0.56||(0.07,4.6)||0.5852|
|Lesion Length (> 15 mm)||0.96||(0.25,3.62)||0.9501|
|Pre-dilatation Performed Prior to EPD*||6.09||(1.19,31.2)||0.0303|
|Pre-dilatation Performed Prior to Stent||1.73||(0.43,7.01)||0.4413|
|Univariate - Early MI/Stroke/Death|
|Gender (Male vs Female)||1.00||(0.42,2.38)||0.9913|
|Coronary Artery Disease||1.01||(0.39,2.65)||0.981|
|Congestive Heart Failure||0.94||(0.34,2.62)||0.9102|
|Pre-procedureStenosis (70-99 vs 50-69)||0.58||(0.13,2.66)||0.4833|
|Lesion Length (> 15 mm)||0.43||(0.17,1.12)||0.0831|
|EPD* (ACCUNET vs Other)||0.27||(0.08,0.95)||0.0413|
|Pre-dilatation Performed Prior to EPD*||2.07||(0.45,9.45)||0.35|
|Pre-dilatation Performed Prior to Stent||1.03||(0.44,2.43)||0.9463|
|Post-Stent Dilatation Performed||2.16||(0.63,7.43)||0.2232|
|Pre-dilatation Performed Prior to EPD*||7.98||(1.4,45.43)||0.0193|
|EPD* - ACCUNET vs Other||0.27||(0.08,0.94)||0.0389|
* EPD (Embolic Protection Device)
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