CAROTID ANGIOPLASTY AND STENTING IN HIGH-RISK PATIENTS

BACKGROUND To examine our initial experience in carotid stenting (CS) for the prevention of stroke in patients with high-grade carotid steno ses. METHODS The authors performed 26 CS procedures in 25 carotid vess els in 22 patients over a 15-month period. All carotid stenoses treate d, except one, were 70% or greater. Of all CS procedures, 84% were per formed for obstructing atherosclerotic plaques. CS was performed in on e patient each for carotid dissection and pseudoaneurysms caused by a gunshot wound, post-radiation stenosis, post-carotid endarterectomy (C EA) restenosis, and a flow-obstructing post-CEA intimal flap. Of all p atients, 68.2% were symptomatic, with a history of stroke or transient ischemic attacks ipsilateral to the treated carotid artery. In additi on, 36.4% of our patients were either hospitalized or required skilled nursing care before CS because of severe neurologic deficits. Using t he Sundt CEA-risk classification system, 59.1% of our patients were cl assified as Grade III and 40.9% were Grade IV pre-CS. All but one pati ent had either a compelling medical or anatomic reason for endovascula r treatment of their carotid disease. We used both Wallstents and Palm az stents, and all procedures were performed via the transfemoral rout e. Three procedures were performed in conjunction with detachable plat inum coil embolization for multiple carotid pseudoaneurysms, a residua l carotid ''stump'' after previous ICA thrombosis, and an ipsilateral MCA saccular aneurysm. RESULTS We had a 96.2% procedural technical suc cess rate. There was one death in our series 3 weeks post-CS attributa ble to myocardial infarction. Despite a high 30-day combined death, st roke, and ipsilateral blindness rate of 27.3% (6/22 patients), only tw o ipsilateral strokes directly related to CS occurred (7.7% per proced ures performed) from which one patient recovered fully within 5 days. The average follow-up post-CS was 5.9 months (range, 3 weeks-15 months ). Of successfully treated vessels, 58.3% have undergone 6-month follo w-up vascular imaging, which has revealed a 14.3% rate of occlusion or restenosis greater than 50%. At or beyond 1 month post-CS, 19 of 21 s urviving patients (90.5%) were ambulatory, fluent of speech, and indep endent, and none has thus far suffered a delayed stroke or TIA. CONCLU SION CS seems to be a reasonable alternative to medical management for the treatment of carotid disease in patients deemed to be poor candid ates for standard carotid surgery. Longer term follow-up is necessary to assess the durability of carotid revascularization using CS.