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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
No. (%)
No. (%)
Pre-EPD only0/10/1
Pre-stent only0/390/39
Post-stent only2/130 (1.5)6/130 (4.6)
Pre-EPD & pre-stent0/20/2
Pre-EPD & post-stent1/8 (12.5)1/8 (12.5)
Pre-stent & post-stent5/192 (2.6)11/192 (5.7)
Pre-EPD, pre-stent & post- stent1/11 (9.1)1/11 (9.1)

Logistic Regression Analysis
Univariate - Early Stroke
VariableOR95% CIp-value
Gender (Male vs Female)0.86(0.23,3.24)0.8223
Coronary Artery Disease1.33(0.27,6.51)0.7215
Congestive Heart Failure1.63(0.4,6.61)0.4977
Renal Failure1.00(0.21,4.91)0.9971
Asymptomatic Indication0.10(0.01,0.81)0.031
TIA Indication13.69(1.7,110.47)0.014
Stroke Indication1.10(0.14,9.02)0.9273
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 Stent1.73(0.43,7.01)0.4413
Univariate - Early MI/Stroke/Death
VariableOR95% UCLp-value
Gender (Male vs Female)1.00(0.42,2.38)0.9913
Coronary Artery Disease1.01(0.39,2.65)0.981
Congestive Heart Failure0.94(0.34,2.62)0.9102
Renal Failure1.34(0.51,3.51)0.5558
Asymptomatic Indication0.46(0.19,1.12)0.0858
TIA Indication2.04(0.86,4.82)0.1055
Stroke Indication0.88(0.2,3.87)0.8603
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 Stent1.03(0.44,2.43)0.9463
Post-Stent Dilatation Performed2.16(0.63,7.43)0.2232
Early Stroke
VariableOR95% CIp-value
TIA Indication15.26(1.85,125.66)0.0113
Pre-dilatation Performed Prior to EPD*7.98(1.4,45.43)0.0193
Early MI/Stroke/Death
VariableOR95% LCLp-value
EPD* - ACCUNET vs Other0.27(0.08,0.94)0.0389

* EPD (Embolic Protection Device)

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