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Post Stent Ballooning Increases Postoperative Stroke And Death Rate in Carotid Artery Stenting
Mahmoud Malas, Tammam Obeid, Isibor Arhuidese, Umair Qazi, Chris Abularrage, James Black, Bruce Perler
Johns Hopkins Medical Institutes, Baltimore, MD

Stroke remains the 4th leading cause of death and the leading cause of disability in the US. Carotid Endarterectomy (CEA) has been proven superior to medical therapy alone in decreasing the risk of stroke in patients with high grade stenosis of the internal carotid artery. While CEA remains the gold standard with low perioperative stroke risk, carotid artery stenting (CAS) has seen progressively improved outcomes. Operators follow general guidelines in intraoperative techniques in CAS. However, few of those are evidence based. We believe that an outcome-driven examination of the effect of pre and post stent deployment ballooning is warranted.
We performed a retrospective analysis of all patients who had CAS between 2005 and 2014 in the Vascular Quality Initiative (VQI) database. Logistic regression analyses of the effect of different pre and post stent ballooning combinations on hemodynamic instability and the 30-day stroke and death rate were constructed. We excluded patients who had no protection device, those who received any ballooning prior to protection device deployment and those who had no ballooning at all. The model(s) controlled for patient age, sex, comorbidities, smoking status, symptomatic status, history of previous ipsilateral CEA, preoperative medications (statin, aspirin and beta blockers), lesion site (CCA, ICA or both) and ipsilateral degree of stenosis.
A total of 5,379 patients had undergone CAS between 2005 and 2015. 4,166 patients remained after applying the exclusion criteria mentioned above. Average age of patients was (mean [±SD]) 69.7± 9.6, males represented 63% of the dataset. The overall perioperative stroke/death rate was 3.1%.
Compared to only Pre-SB technique, the combined Pre-SB and Post-SB technique had a 2.2 fold increase in hemodynamic instability (OR 2.2, 95%CI 1.6-3.1, P<0.000) and 2.5 fold increase in perioperative stroke/death rate (OR 2.5, 95%CI 1.1-5.8, P<0.038).
CONCLUSIONS:Compared to pre stent ballooning alone, the use of post stent deployment ballooning increases the chances of perioperative hemodynamic instability and stroke/death rate in patients undergoing carotid artery stenting. Post stent ballooning should be limited to select populations only.

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