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Long-Term Results Of Carotid Artery Stenting

Gianmarco de Donato¹, Carlo Setacci¹, Koen Deloose², Jurgen Verbist³, Patrick Peeters³, Fausto Castriota⁴, Alberto Cremonesi⁴, Marc Bosiers.^2
1Department of Vascular and Endovascular Surgery, University of Siena, Siena, Italy;²Department of Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium;³Department of Cardiovascular and Thoracic Surgery of the Imelda Hospital, Bonheiden, Belgium;⁴Interventional Cardio-Angiology Unit, Villa Maria Cecilia Hospital, Cotignola (RA), Italy.

OBJECTIVES: Results regarding the long-term efficacy of carotid artery stenting (CAS) are still scarce. As demonstrated by several major randomized controlled trials (RCT) comparing the efficacy of CEA vs. medical therapy, successful early carotid revascularization might not permanently eliminate all cerebral thromboembolic risk. Therefore, also with CAS major concerns remain about the durability of the procedure in terms of stroke prevention. The purpose of this study is to review long-term results after carotid stent implantation in a large cohort of patients.

METHODS: This retrospective investigation involved 3,179 CAS procedures performed at 4 European carotid high-volume centers. Echo-duplex using modified velocity criteria to recognize in-stent restenosis (ISR) and neurological examinations of all patients were carried out every 6 months after the procedure. Life-table analysis was used to determine freedom from mortality, stroke-related death, ipsilateral fatal/major stroke and all ipsilateral neurological complications including and excluding perioperative complications. Freedom from ISR and from reintervention was also reported. The secondary aim was to identify predictive risk factors for neurological complications and ISR.

RESULTS: At 5 years freedom from mortality, stroke-related death, ipsilateral fatal/major stroke including and excluding perioperative complications were 82%, 93.5%, 93.3% and 94% respectively. The annual rate of any neurological complication during follow-up was 1.36% (CI95%, 1.08-1.69). The only predictor for neurologic complication was the presence of neurological symptoms before CAS [Hazard ratio 1.38, p=.02]. Freedom from restenosis at 1, 3 and 5 years was respectively 98.4%, 96.1% and 94%. The annual rate for ISR and need for reintervention were 1.49% and 1.08%. Uni- and multi-variate analyses showed that stent characteristics (material/design/cell area) were not associated with time to ISR or time to reintervention.

CONCLUSIONS: Our long-term results in a large cohort of patients validated CAS as a durable procedure for stroke prevention. The annual rate of neurological complications after CAS was comparable to that of conventional surgery as demonstrated by large RCTs both for symptomatic (NASCET and ECST) and asymptomatic patients (ACAS and ACST).

AUTHOR DISCLOSURES: G. de Donato, None; C. Setacci, None; K. Deloose, None; J. Verbist, None; P. Peeters, None; F. Castriota, None; A. Cremonesi, None; M. Bosiers, None.