Multiple Stents In Carotid Artery Stenting Is Associated With Increased Stroke Rates: Review Of The CREST Lead-In Data

Robert W Hobson, II¹, Brajesh K. Lal¹, Thomas Brott², George Howard, PhD Howard³, Gary Roubin⁴, Robert Ferguson⁵, Elie Chakhtura⁶, Jonathan Goldstein⁶, Alice Sheffet^.1
1UMDNJ-New Jersey Medical School, Newark, NJ; ²Mayo Clinic, Jacksonville, FL; ³UAB, Birmingham, AL; ⁴Lennox Hill Hospital, New York, NY; ⁵Forsythe Medical Center, Winston-Salem, NC; ⁶St Michaels Medical Center, Newark, NJ.

OBJECTIVES: Factors that increase the risk associated with carotid artery stenting (CAS) include patient age, history of diabetes, anatomic anomalies (type III aortic arch, primary atherosclerotic lesions, arterial tortuosity, stenoses ≥90%, string sign) or intra-arterial thrombus. While technical aspects may also be important, their influence on peri-procedural complications has not been well-defined. In this study, we evaluated data from the CREST lead-in phase to determine the impact of the number of stents used in CAS on 30-day stroke rates.

METHODS: The lead-in phase of CREST includes CAS procedures performed for symptomatic patients with ≥50% carotid stenosis, and asymptomatic patients with ≥70% stenosis. Data accrued from the inception of the registry in 2000 to 2006 were reviewed for number of stents deployed in each patient. The occurrence of 30-day stroke was recorded, as were demographic and clinical characteristics.

RESULTS: The registry included 1303 patients, of which 26.6% (n=347) were symptomatic and 73.4% (n=956) were asymptomatic; 36.9% were women (n=481) while 63.1% (n=822) were men. The mean age of the cohort was 70.3 years, the mean stenosis treated was 85.7%. Additional demographic features included a history of diabetes (32.7%), CABG (24.4%), dyslipidemia (89.3%), current smoking (18.1%) and hypertension (84.4%). The majority of patients were <80 years old (88.9%) and most lesions treated had a mean diameter stenosis ≥80% (55.7%). Patient populations with 1 versus 2 or 3 stents exhibited no differences in demographics. Strokes were observed in 55 (4.2%) of 1303 CAS procedures. 46/55 (83.6%) strokes were associated with the use of a single stent, while 9/55 (16.4%) strokes had two (n=8) or three (n=1) stents. The 30-day stroke rate with one stent was 4.0% and with 2 or 3 stents was 13.2% (p=0.0002).

CONCLUSIONS: These data confirm that a significant relationship exists between the number of stents used and procedural risk of CAS. Our results emphasize the importance of making every effort to utilize a single stent to cover the carotid lesion in CAS procedures.