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Measurement And Impact Of Proximal And Distal Tortuosity In Carotid Stenting Procedures

Gianluca Faggioli, Monica Ferri, Mauro Gargiulo, Antonio Freyrie, Francesca Fratesi, Andrea Stella.
University of Bologna, Bologna, Italy.

OBJECTIVES: Proximal and distal carotid tortuosity is considered of paramount importance in carotid artery stenting (CAS) procedures. Specifically, distal internal carotid coiling or kinking is thought to interfere with proper distal protection devices thus contraindicating CAS. Type of aortic arch is also considered a key factor in CAS success, however no standardize method of evaluation of these parameters is available in the literature. We have evaluated the impact of arch angulation and proximal and distal tortuosity in a series of CAS procedures

METHODS: In pts undergoing CAS, arch angulation, tortuosity of both common and distal internal carotid arteries were evaluated prospectively by calculating the sum of all angles diverging from the ideal straight axis, considering a 90° ideal angle for the origin from the arch (tortuosity index - TI). All procedures were through transfemoral approach and with distal protection. Results were correlated with technical procedural success (residual stenosis <30%) and neurological complication by Student T Test. Multivariate logistic regression analysis was conducted to identify independent predictors of results.

RESULTS: In a group of 256 CAS, technical success was obtained in 232 cases (90.7%) and neurological complications occurred in 20 cases (7.8%, 17 TIA’s, 3 minor strokes). Results according with TI are shown in tables:

By logistic regression analysis, proximal TI >150 was an independent predictor of both neurological complications and technical failure. Age was also independently associated with technical failure. Appropriate distal filter placement was possible in all cases with a crossable stenosis, irrespective of the internal carotid TI.

CONCLUSIONS: Proximal tortuosity index is significatively associated with both technical success and neurological complications after CAS, while distal TI did not influence neither outcome. The presence of distal kinking or coiling should not be considered a contraindication to CAS