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December 23, 2005
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Christopher L. Skelly, M.D.1, Katherine Gallagher, M.D.2, Ronald M. Fairman, M.D.2, Jeffrey P. Carpenter, M.D.2, Omaida C. Velazquez, M.D.2, Michael A. Golden, M.D.2, Shane S. Parmer, M.D.2, Edward Y. Woo, M.D.2.
1University of Chicago Hospitals, Chicago, IL, USA, 2Hospital of the University of Pennsylvania, Philiadelphia, PA, USA.
OBJECTIVES: With Carotid artery stenting (CAS) becoming an ever increasing procedure, we sought to determine risk factors for recurrent stenoses after CAS
METHODS: Consecutive patients undergoing CAS between January 2002 and August 2004 were retrospectively reviewed at a tertiary care hospital. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant co-morbidities or a hostile neck (prior surgery and/or radiation) and risk factor analysis was performed.
RESULTS: Ninety-eight patients (55 male, 43 female) underwent 104 CAS procedures. Co-morbidities were typical for patients with atherosclerosis. In addition, 39% (n=38) of patients had prior neck surgery of which 31% (n=32) had previous ipsilateral carotid endarterectomy. 13 % (n=13) of patients had prior neck radiation. 40% (n=42) of patients presented with neurologic symptoms including stroke, 22% (n=23); transient ischemic attack (TIA), 20% (n=21); or amaurosis fugax 6 % (n=6). Various balloons and stents were used and 78% (n=81) of procedures were performed with a distal protection device. The technical success rate was 100%. All procedures were performed in the general operating room suites using an OEC 9800 system (GE OEC Medical Systems, Utah) and later on a Siemans Axiom Artis VBIID system (Berlin and Munchen, Germany). Median follow up was 5 months (range 0-22 months). Neurologic complications included 4 TIA’s (3.8%) and 1 non-disabling stroke (0.9%). There were 2 (1.9%) MIs and no peri-procedural deaths (30 days) for a combined stroke, MI, and death rate of 2.9%. A total of ten patients (9.6%) developed asymptomatic recurrent carotid artery stenosis at a mean of 10 months. 5 patients (4.8%) developed asymptomatic >80% recurrent stenoses requiring endovascular intervention with a mean of 7 months to restenosis. One patient required multiple interventions. Five patients (4.8%) also developed asymptomatic >60% stenoses, which are being followed (mean of 16 months). Of the 13 patients who had previous radiation to the neck, 5 (39%) developed recurrent carotid stenosis after CAS, of which 2 patients required intervention. Alternatively, 50% (n=5, p=0.03) of patients with restenosis following CAS had prior neck radiation. Prior neck surgery was also a risk factor for restenosis, although, only 3 patients with prior CEA developed restenosis after CAS.
CONCLUSIONS: CAS has been shown to be performed safely and effectively in high risk patients. Patients that had previous radiation to the neck were at an increased risk for restenosis after CAS requiring reintervention. Although these patients are at an increased risk for recurrent carotid artery stenosis all were asymptomatic at presentation.
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Increased Rate of Restenois Following Carotid Artery Angioplasty and Stenting in Patients with Prior Neck Radiation
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Christopher L. Skelly, M.D.1, Katherine Gallagher, M.D.2, Ronald M. Fairman, M.D.2, Jeffrey P. Carpenter, M.D.2, Omaida C. Velazquez, M.D.2, Michael A. Golden, M.D.2, Shane S. Parmer, M.D.2, Edward Y. Woo, M.D.2.
1University of Chicago Hospitals, Chicago, IL, USA, 2Hospital of the University of Pennsylvania, Philiadelphia, PA, USA.
OBJECTIVES: With Carotid artery stenting (CAS) becoming an ever increasing procedure, we sought to determine risk factors for recurrent stenoses after CAS
METHODS: Consecutive patients undergoing CAS between January 2002 and August 2004 were retrospectively reviewed at a tertiary care hospital. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant co-morbidities or a hostile neck (prior surgery and/or radiation) and risk factor analysis was performed.
RESULTS: Ninety-eight patients (55 male, 43 female) underwent 104 CAS procedures. Co-morbidities were typical for patients with atherosclerosis. In addition, 39% (n=38) of patients had prior neck surgery of which 31% (n=32) had previous ipsilateral carotid endarterectomy. 13 % (n=13) of patients had prior neck radiation. 40% (n=42) of patients presented with neurologic symptoms including stroke, 22% (n=23); transient ischemic attack (TIA), 20% (n=21); or amaurosis fugax 6 % (n=6). Various balloons and stents were used and 78% (n=81) of procedures were performed with a distal protection device. The technical success rate was 100%. All procedures were performed in the general operating room suites using an OEC 9800 system (GE OEC Medical Systems, Utah) and later on a Siemans Axiom Artis VBIID system (Berlin and Munchen, Germany). Median follow up was 5 months (range 0-22 months). Neurologic complications included 4 TIA’s (3.8%) and 1 non-disabling stroke (0.9%). There were 2 (1.9%) MIs and no peri-procedural deaths (30 days) for a combined stroke, MI, and death rate of 2.9%. A total of ten patients (9.6%) developed asymptomatic recurrent carotid artery stenosis at a mean of 10 months. 5 patients (4.8%) developed asymptomatic >80% recurrent stenoses requiring endovascular intervention with a mean of 7 months to restenosis. One patient required multiple interventions. Five patients (4.8%) also developed asymptomatic >60% stenoses, which are being followed (mean of 16 months). Of the 13 patients who had previous radiation to the neck, 5 (39%) developed recurrent carotid stenosis after CAS, of which 2 patients required intervention. Alternatively, 50% (n=5, p=0.03) of patients with restenosis following CAS had prior neck radiation. Prior neck surgery was also a risk factor for restenosis, although, only 3 patients with prior CEA developed restenosis after CAS.
CONCLUSIONS: CAS has been shown to be performed safely and effectively in high risk patients. Patients that had previous radiation to the neck were at an increased risk for restenosis after CAS requiring reintervention. Although these patients are at an increased risk for recurrent carotid artery stenosis all were asymptomatic at presentation.
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