E-050 last chance carotid stenting: treatment and outcomes of carotid artery stenting in very high risk patients

Objectives To characterize carotid stent platform usage, features of the atherosclerotic carotid lesion to be treated, and outcomes of patients who underwent carotid artery stenting (CAS) deemed too high-risk for carotid endarterectomy (CEA). The primary outcomes were stroke and death related to a neurologic or cardiac event during the in-hospital period as well as at 30 and 90 days following CAS. Stroke was defined as new neurologic deficits (motor, sensitive, cognitive) documented on the patient’s medical records following the carotid artery stenting (CAS) procedure and/or MRI evidence of new hyperintense DWI (with corresponding hypointensity on ADC maps) lesions in the ipsilateral hemisphere. Methods We retrospectively reviewed 95 consecutive patients undergoing CAS procedures at a single academic tertiary care center between November of 2010 and December of 2014. Only patients who were considered too high-risk for CEA by their referring physician (neurologist, neurosurgeon, vascular surgeons or primary care physicians) were included in this study. Patients with an acutely occluded internal carotid artery (ICA) and an occluded ipsilateral cerebral vessel (tandem lesions), carotid artery dissection, subarachnoid hemorrhage, acute stroke, or undergoing general anesthesia were excluded from analysis. Overall, it was felt that these excluded patients represented subgroups with even higher procedural risks as opposed to elective cases. Patients who in addition to the above mentioned carotid stents had off-label use of other stents in their carotids (e.g. Wingspan or Neuroform) were also excluded. One patient who received proximal embolic protection was also excluded. We compared baseline clinical characteristics of the patients and characteristics of the treated stenosis, and crude and multivariable adjusted rates of in-hospital combined death/stroke. We compared patients treated with Precise (Cordis Corporation, Bridgewater, New Jersey) as well as Acculink and XACT (both Abbott Laboratories, Abbott Park, Illinois) stents. Last, we compared the immediate postprocedural residual stenosis following CAS. Results Of 95 patients referred for CAS during the study period, 38 high-risk patients met the inclusion criteria and were included for the current analysis: XACT (n = 14), Precise (n = 15), Acculink (n = 5), and combined CAS platforms (e.g. XACT + Precise, n = 4). The overall immediate pre-procedural stenosis degree among the 38 cases was 55% +/- 18% and the overall immediate post-procedural residual carotid stenosis was 18% +/- 14%. There were no significant differences between devices regarding pre-procedural stenosis or post-procedural residual stenosis at this early time point. Most importantly, there were no strokes by discharge, 30 days, and 90 days following CAS. Furthermore, no deaths occurred by discharge and 30 days. One patient had died by 90 days related to multi-organ failure secondary to a septic joint. Conclusions Our study indicates that CAS can be safely performed in patients considered too high-risk for CEA and who were referred to our center as such by their physicians. Disclosures J. Lozano: None. F. Massari: None. C. Brooks: None. M. Perras: None. M. Howk: None. M. Gounis: 1; C; NIH, Philips Healthcare, Covidien/eV3 Neurovascular, Codman Neurovascular, Stryker Neurovascular, Wyss Institute, Tay Sachs Foundation. 2; C; Stryker Neurovascular. N. Henninger: None. A. Wakhloo: 1; C; Phillips Healthcare Medical. 2; C; Stryker. 3; C; Harvard Postgraduate Course, Miami Baptist Vascular Institute. A. Puri: 1; C; Stryker. 2; C; Codman, Covidien.