December 22, 2008

Carotid Angioplasty and Stenting: Worse Neurological Outcome with 2 Stents Versus Single Stent

Christopher L. Stout, MD, Albert I. Richardson, MD, Susanna H. Shin, MD, Rasesh M. Shah, MD, Jean M. Panneton, MD.
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA, USA.

OBJECTIVES: Important risk factors for poorer outcomes are becoming apparent as more data on carotid angioplasty and stenting (CAS) outcomes is available. Little is reported on having to use one stent versus two stents for endovascular treatment of carotid stenosis.
METHODS: Analysis was performed on 230 CAS procedures in 215 patients between January 2003 and January 2008. Standard statistical methods were used including life table analysis. In-stent restenosis was defined as ≥50%.
RESULTS: The 2-stent group had sixteen procedures and the 1-stent group had 214 procedures. Two stents were needed for extensive lesions in eleven patients, two with tandem lesions, one each with extruded plaque, proximal intimal flap, and proximal misdeployment. Mean follow-up was 16 months (range: 0-64). Demographics, risk factors, and indications for CAS were not significantly different between the groups. Thirty day stroke rate was 3.1% overall. Two strokes occurred in the 2-stent group for a 12.5% rate compared to six in the 1-stent group for a 2.8% rate, (p=0.04) with an odds ratio of 4.95 (95%CI: 1.05-23.40). Thirty day myocardial infarction (MI) rate, 0.9% overall, and death rate, 1.3% overall, were not different, (p=0.70 and p=0.63, respectively). Freedom from ipsilateral-stroke, death, and reintervention was not significant different at 12 months (87% ± 8.6% versus 85% ± 3%, p=0.14). Overall, 95% were free of ipsilateral-stroke/reintervention at four years with only three strokes and three reinterventions occurring after 30 days. Overall, primary patency at four years was 87% with no difference between the two groups (p=0.49). Freedom from a restenosis of greater than 80% was achieved in 95% at four years. Three reinterventions with angioplasty and stenting were successfully performed in two patients of the 2-stent group and one patient in the 1-stent group. Primary-assisted-patency was maintained in all three.
CONCLUSIONS:
The need to place two stents instead of one significantly increases the 30-day periprocedural stroke rate. Long-term results are similar, though, with an excellent survival free from reintervention and stroke.

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