Single Center Experience with Periprocedural Safety in Stenting Cervical and Intracranial Atherosclerotic Disease

Abstract

Introduction: We reviewed our institutional experience to compare our single institution, single surgeon results to larger published series.

Methods: This is a retrospective review of 51 consecutive patients treated from March 2010 through November 2013 by a single surgeon at LSUHSCShreveport. The procedures included were all stents placed for the treatment of both cervical carotid and intracranial atherosclerotic occlusive disease. All cervical carotid procedures were performed with cerebral protection when anatomically possible. Intracranial stenosis was treated with angioplasty and stent and no distal protection.

Results: Of our 51 patients 33 were male (64.7%), 18 were female (35.3%). The mean age was 58.2. The 51 patients represented 52 procedures with 52 different lesions treated with angioplasty and stenting. All patients included had symptomatic disease. Primary endpoint for poor outcome was symptomatic stroke, death, or myocardial infarction within 30 days. There was no incidence of symptomatic stroke, death, or myocardial infarction. Non-stroke morbidity was 5.4%. These included groin hematoma and acute stent thrombosis.

Conclusions: The periprocedural results of our institution with regard to cervical carotid and intracranial angioplasty and stenting of atherosclerotic disease indicate comparable safety in these procedures to internationally published figures.

Keywords: Carotid Stenting; Intracranial atherosclerosis; Endovascular; Carotid angioplasty, Intracranial stenting; Carotid atherosclerosis

Introduction

Cerebrovascular disease has enormous medical and financial toll on the United States each year. Every year it is estimated 795,000 people experience a new or recurrent stroke in the United States. Approximately 610,000 of these are first attacks. The estimated direct medical cost of stroke for the year 2007 was $25.2 billion [1]. While medical and open surgical therapies have been the mainstay of treatment for years, the use of endovascular techniques is a growing and has been the focus of many recent studies [2–8]. The purpose ofthis study is to compare the periprocedural safety of cervical carotid and intracranial angioplasty and stenting for atherosclerotic disease between our single surgeon experience and larger multicenter trials.

Methods

Patient selection

We retrospectively reviewed the charts of consecutive patients from March 2010 through November 2013 who received cervical carotid or intracranial angioplasty and stenting for symptomatic atherosclerotic disease. All procedures were performed by the corresponding author at Louisiana state university health sciences center (LSUHSC) in Shreveport, LA. Angioplasty and stenting procedures for pathology other than atherosclerotic disease were excluded. Other reasons for exclusion were age < 18 and acute stroke intervention. These criteria yielded a total of 51 patients representing 37 and 15 discrete extracranial and intracranial lesions, respectively. All cervical carotid patients were symptomatic and referred for stenting [CAS] over endarterectomy [CEA] due to presence of comorbidities, failure of prior CEA, radiation to the neck, or anatomy not conducive to open surgery. All intracranial stenting patients were referred for treatment of symptomatic stenosis that had failed medical management.

Technique

Patients were treated with preoperative aspirin (ASA) 325 mg and Plavix 75 mg for three days if not already on these medications. The common femoral artery was accessed using a 7F sheath for cervical carotid and a 6F sheath for intracranial lesions. A 7F VBL guiding catheter was used for all cervical lesions and a 6F Envoy or Neuron guiding catheter for all intracranial procedures.

Cervical carotids

The procedures were performed under monitored anesthesia care (MAC). This facilitated intermittent neurologic exams during the procedure. The guiding catheter was placed in the proximal common carotid artery. Cerebral protection devices were used in all cases where it was possible anatomically to deploy the device distal to the stenosis. All lesions were treated with stenting and angioplasty. Prestent angioplasty was employed in cases where the stenosis was too great to traverse with the stent.

Intracranial lesions

The intracranial stenting procedures were performed under general anesthesia in order to have the patient completely immobilized during navigation of the intracranial vasculature. The guiding catheter was placed in the cervical segment of the internal carotid artery. Wingspan intracranial stents were used in combination with balloon angioplasty for all lesions.

Post–operative care

Following stenting, patients were monitored for 24 hours in the neurosurgical intensive care unit and maintained on a heparin drip until the following morning. Upon discharge, patients were maintained on Plavix 75 mg for 6 months and on ASA 325 mg indefinitely.

Data collection

Patient charts were reviewed for age, comorbidities (hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, previous coronary artery bypass, and peripheral arterial disease). Reason for CAS over CAE was recorded. Location of lesions as well as type of stent, presence of cerebral protection, need for pre–angioplasty and procedural complications were recorded. Primary endpoints were presence of stroke, myocardial infarction, or death within 30 days of the procedure. Secondary endpoint was success of procedure defined as < 30% residual stenosis on control digital subtraction angiography (DSA).

Results

There were 51 patients: 33 male and 18 female. The mean patient age was 58.2 +⁄– 7. Comorbidities are listed in Table 1. 37 patients had cervical carotid lesions and 18 had intracranial lesions. In total there were 52 discrete lesions: 37 – cervical carotid, and 15 intracranial. Of the cervical carotid lesions 21 were right sided, 14 were on the left and one bilateral. Of these lesions 35 of 37 were treated using distal cerebral protection. 30 patients were deemed high surgical candidates, 4 had history of previous endarterectomy and 2 had previous radiation to the neck. Of the intracranial lesions, 6 were of the anterior circulation and 9 were of the posterior circulation. All lesions were treated successfully, defined as < 30% of residual stenosis. Primary outcome measure was the periprocedural (30 day) incidence of stroke, myocardial infarction and⁄or death. There was no incidence of stroke, myocardial infarction, or death within the periprocedural period. In the cervical carotid group there was one groin hematoma that resolved without intervention and one acute stent thrombosis requiring thrombolytic. The acute stent thrombosis was in a patient that did not adhere to postoperative antiplatelet regimen. This did not result in permanent neurologic deficit. The total periprocedural morbidity for cervical carotid stenting was 5.4%. There were no periprocedural complications for the intracranial stenting group.

Table 1: 
 

    
Patient    Comorbidities
    
 
    
Percentage
  
  

    
Hypertension
    
37
    
72.5%
  
  

    
Hyperlipidemia
    
28
    
54.9%
  
  

    
Diabetes    Mellitus
    
17
    
33.3%
  
  

    
Coronary    Artery Disease
    
15
    
29.4%
  
  

    
Coronary    Artery Bypass
    
7
    
13.7%
  
  

    
Peripheral    Arterial Disease
    
6
    
11.7%
  

Table 1:  

  

    
Trial
    
Stroke
    
Death
    
MI
    
Use of Embolic Protection Device:
  
  

    
SPACE
    
7.51%
    
0.67%
    
N/A
    
27%
  
  

    
EVA-3S
    
8.8%
    
0.4%
    
0.4%
    
91%
  
  

    
CREST
    
4.1%
    
0.7%
    
1.1%
    
96%
  

Table 2: Summary of Periprocedural Outcomes in Three Noted Trials.

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Citation: Cuellar H, Brown BL, Ambekar S. Single Center Experience with Periprocedural Safety in Stenting Cervical and Intracranial Atherosclerotic Disease. Austin J Clin Neurol 2014;1(2): 1006. ISSN : 2381-9154

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