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Rivista di Angiologia
Official Journal of the , the International Union of Phlebology and the
Indexed/Abstracted in: BIOSIS Previews, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
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International Angiology 2016 Dec 01
Remote pre-procedural ischemic stroke was the strongest risk for stroke and death associated with carotid stenting. A single center experience
Mária RAŠIOVÁ 1,2, Ľubomír ŠPAK 1, Ľudmila FARKAŠOVÁ 1, Štefan PATAKY 1, Martin KOŠČO 1, Marek HUDÁK 1, Matej MOŠČOVIČ 1, Norbert LEŠKO 3 ✉
1 Department of Cardiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia; 2 Department of Internal Medicine 4, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia; 3 Department of Neurology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia
BACKGROUND: The goal of carotid artery stenting (CAS) is to decrease the stroke risk in patients with carotid stenosis. This procedure carries an immediate risk of stroke and death and many patients do not benefit from it, especially asymptomatic patients. Patient selection for carotid procedure who benefit from procedure and who is the procedure hazardous for is important. Remote ischemic stroke is known risk factor for stroke reccurence during surgery. The aim of our study was to determine the periprocedural complication risk (within 30 days after CAS) associated with carotid stenting (stroke, death) between patients with remote pre- procedural ischemic stroke and without it; to analyse periprocedural risk in other specific patient subgroups treated with CAS and to determine the impact of observed variables on all- cause mortality during long-term follow-up.
METHODS: We conducted a retrospective review of prospectively collected data from all patients treated with protected CAS between June 20, 2008 and December 31, 2015. Patient age, gender, type of carotid stenosis (symptomatic versus asymptomatic), side of stenosis (right or left carotid artery), type of cerebral protection (proximal versus distal), presence of comorbities (remote ischemic pre-procedural ischemic stroke, coronary artery disease, diabetes mellitus, peripheral artery disease), previous ipsilateral carotid endarterectomy (CEA), contralateral carotid occlusion (CCO) and previous contralateral CAS/ CEA were analysed to identify higher CAS risk and to determine the impact of these variables on all- cause mortality during follow-up. Survival data were obtained from Health Care Surveillance Authority registry. Mean follow-up was 1054 days (interquartile range 547.3; 1454.8). Remote pre-procedural ischemic stroke was defined as any - territory ischemic stroke > 6months prior to CAS.
RESULTS: Primary periprocedural end-point incidence (stroke/death) in total number of 502 patients was 3.8% (n=19) of all patients, 5.4% (n= 10) of symptomatic patients and 2.8% (n=9) of asymptomatic patients. The risk of periprocedural stroke/death was 3.4-times higher in patients with remote ischemic stroke (n=198) compared with patients without it (n=304) (6.6% versus 2.0% of patients without remote ischemic stroke; p=0.008). Periprocedural stroke/death in symptomatic patients (n=186) was non-significantly higher in patients with remote ischemic stroke (n=76) compared with patients without remote ischemic stroke (n=110) (7.9% versus 3.6%; p=0,206). Asymptomatic patients with remote ischemic stroke (n=122) had a 5.6-times higher periprocedural risk of stroke/death compared with asymptomatic patients without remote ischemic stroke (n=194) (5.7% versus 1.0%; p=0.014). Patients ≥ 75years (n=83) had a 3.0-times higher periprocedural risk of stroke/death compared with younger patients (n=419) (8.4% versus 2.9%; p=0.015); a non-significant increase of periprocedural stroke/death was found in both symptomatic (n=35) and asymptomatic (n=48) elderly patients ([11.4% versus 4.0%; p=0.078], [6.3% versus 2.4%; p=0.124]) respectively. Increased periprocedural risk of stroke/death was not documented in other analysed patient subgroups. During long-term follow-up, 1.5-times higher mortality risk was found in patients with remote ischemic stroke compared with patients without remote ischemic stroke in multivariable analysis; other patient subgroups (except older versus younger patients) did not differ in long – term mortality following carotid stenting.
CONCLUSIONS: In our experience all patients with remote pre-procedural any territory ischemic stroke belong to risky subgroup for periprocedural stroke death after CAS. All asymptomatic patients with remote ischemic stroke should not be treated with CAS. Remote ischemic stroke increases all-cause mortality in long-term follow-up after carotid stenting. Patients ≥ 75 years also have increased risk of periprocedural stroke and death after CAS. These factors should help us to be more selective when planning carotid procedures.