Preprocedural risk stratification: Identifying an appropriate population for carotid stenting

Purpose: Given the uncertainties associated with carotid angioplasty and st enting, the initial assessment of the procedure may be best undertaken in a subgroup of patients at increased risk for complications with standard car otid surgery. In an effort to characterize such a subgroup, we reviewed the results of carotid endarterectomy in patients with and without significant medical comorbidity. Methods: During a 10-year period 3061 carotid endarterectomies were perform ed at a single institution and entered prospectively into a registry A high -risk patient subgroup was identified, defined by the presence of severe co ronary artery disease, chronic obstructive lung disease, or renal insuffici ency. The outcome of carotid endarterectomy was assessed with respect to pe rioperative stroke, myocardial infarction, or death, as well as the combine d end point of one or more of the end points. Results: The rate of the composite end point stroke/myocardial infarction/d eath was 3.8% in the total group of 3061 patients who underwent endarterect omy. As individual end points, the rate of stroke was 2.1%, myocardial infa rction 1.2%, and death 1.1%. Among the high-risk subset, the composite end point stroke/myocardial infarction/death occurred in 7.4%. This rate was si gnificantly greater than the corresponding rate of 2.9% in the low-risk sub set (P < .0005). Similarly, the rate of stroke (3.5% vs 1.7%, P = .008) or death (4.4% vs 0.3%, P < .001) as solitary events was significantly greater in high-risk patients. Conclusions: Although carotid endarterectomy is an extremely safe procedure in most patients, results are not as favorable in a high-risk subset with severe coronary, pulmonary, or renal disease. The initial clinical evaluati on of carotid stenting might best be undertaken in such a high-risk populat ion, one that comprises patients for whom standard therapy is associated wi th a high rate of complications.