Do Angiographic Lesion Characteristics Predict Adverse Outcomes After Carotid Artery Stenting

Shariq Sayeed, MD, Stephen F. Stanziale, MD, Luke K. Marone, MD, Shan-e-Ali Haider, MD, Laurie S. Rieger, Katherine Hill, RN, Mark H. Wholey, MD and Michel S. Makaroun, MD
University of Pittsburgh Medical Center, Pittsburgh, PA and Pittsburgh Vascular Center, Pittsburgh, PA

Objective: Selection of patients for Carotid Artery Stenting (CAS) is important for improving clinical results. Although some patient and ultrasound characteristics have been found to predict adverse outcomes, no distinct angiographic lesion marker has been linked to inferior clinical outcomes.
Methods: Three hundred sixty three consecutive patients, who underwent carotid artery stenting between June 1996 and March 2004 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Angiograms were reviewed for carotid lesion characteristics including length of lesion (0-5 mm, 5-10mm, 10-15mm, and ≥15mm), percent stenosis, location of lesion (ostial involvement vs. isolated internal carotid artery), lesion ulceration, calcification, and presence of contralateral internal carotid occlusion. Periprocedural (≤30 days) stroke (CVA) or periprocedural adverse outcomes (stroke, myocardial infarction, and death) were recorded for each of the patients. Categorical variables were compared by using the Fisher exact test.
Results: Lesion length ≥15mm was associated with increased periprocedural CVA (16.3% vs. 2.8%, P=0.001) and periprocedural adverse outcomes (18.6% vs. 3.4%, P = .0006) when compared to lesions shorter than 15mm. Ostial lesions were also associated with increased rates of periprocedural adverse outcomes (7.9% vs. 2.8%, P=0.047); CVA occurrence, however, only approached statistical significance with ostial lesions (6.7% vs 2.3%, P=0.059). Lesion ulceration, lesion calcification, percent stenosis, and contralateral carotid occlusion were not significant risk factors associated with periprocedural CVA or adverse outcomes.
Conclusions: Carotid stenting is a novel method for the treatment of carotid artery stenosis. Carotid lesions with long lengths were associated with a markedly increased risk for 30 day periprocedural CVA. Ostial involvement was also associated with increased adverse outcomes. These risks should be weighed when considering CAS.