PCI-Related Stroke Rare, Tied to Modifiable Procedural Factors

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Ischemic stroke related to percutaneous coronary intervention (PCI), while rare, is associated with potentially modifiable technical parameters, according to a study published in the February 2012 issue of JACC: Cardiovascular Interventions. The authors say that the findings suggest the need for careful procedural planning, particularly in patients at increased risk.

For the retrospective study, Rajiv Gulati, MD, PhD, of the Mayo Clinic (Rochester, MN), and colleagues analyzed data from 21,497 PCI hospitalizations from January 1994 to March 2008 at their institution. Patients who had an ischemic stroke or TIA related to PCI (n = 79; 60 strokes and 19 TIAs) were matched to a control group of nonstroke patients (n = 158).

The overall incidence of PCI-related neurologic events was 0.37%. Angiographic characteristics and pre-PCI medications were similar between the 2 groups. Overall procedural success was lower in the stroke group than in controls (71% vs. 85%; P = 0.017). The stroke group was also marked by higher rates of in-hospital death (18% vs. 8%; P = 0.043), requirement for CABG (5% vs. 0%; P = 0.003), and residual stenosis after PCI (18% vs. 10%; P = 0.09).

A number of procedural characteristics were associated with ischemic stroke (table 1).

Table 1. Procedural Characteristics for Stroke Patients vs. Controls

Abbreviation: IABP, intra-aortic balloon pump.

Sixty percent of 8-Fr procedures could have been performed using 6-Fr guides without compromising outcomes. Of the 6-Fr procedures, 53% of them could have been performed using 5-Fr catheters in the current era.

Procedure-related variables that did not influence PCI-related stroke included:

• Total fluoroscopy time
• Use of left ventricle and aortic angiography
• Use of thrombectomy
• Use of glycoprotein IIb/IIIa inhibitors
• Performance of multivessel intervention
• Prophylactic IABP use
• Peak activated clotting time during the procedure

There was also no difference in the rate of ischemic stroke occurring in procedures that employed a radial vs. femoral approach (0.4% vs. 0.4%; P = 0.78).

Modification to Move Forward

Morton J. Kern, MD, of the University of California, Irvine (Irvine, CA), told TCTMD in a telephone interview that this study basically confirms current knowledge.

“Strokes do occur in higher-risk patients, and we have to take appropriate time and caution so that we don’t engender strokes,” he said.

Dr. Gulati and colleagues write that though the rate of PCI-related stroke has remained static over the past 20 years, going forward it will be important to identify modifiable, non-patient-related predictors of stroke.

“Recognition of such associations might allow for the adjustment of procedural techniques when performing PCI, particularly in those patients at greatest risk of a periprocedural cerebrovascular event,” they write.

In a telephone interview with TCTMD, Sunil V. Rao, MD, of Duke University Medical Center (Durham, NC), said that because PCI-related stroke is “exceedingly rare,” the challenge lies in figuring out what to do with the study data.

“Some [stroke predictors] are going to be markers for worse disease no matter how much you adjust,” he said. “There are going to be some patients [for] whom the priority is to treat their coronary disease, and that may require something like a large guide catheter or rotational atherectomy to achieve the goal.”

Further, he suggested that with high-risk patients, it is often difficult to decide which treatment option would be in the patient’s best interest.

“If you’re faced with a situation where you can’t get the job done with a smaller catheter, you’re kind of stuck,” he said. “Do you say, ‘I recognize the risk of stroke and just try medical therapy’? Or do you say, ‘My priority is to treat the patient’s coronary disease’? And I’m not quite sure that this study helps me answer this question.”

Dr. Kern said he was surprised that radial access did not increase the incidence of stroke in the study, as this goes against previous findings.

“Maybe the single-catheter technique or limited catheter techniques from the arm will help reduce the incidence of stroke, although it may be counterbalanced by the complexity of manipulations that are required,” he said.

A ‘Frustrating Endpoint’

Being able to recognize all of the risk factors for stroke would make the informed consent process more sophisticated, Dr. Rao said.

“The biggest lesson to take away from this particular paper for me is that if you are dealing with a patient that has the risk factors [this study identifies], it’s important to talk to that patient not only about the risks of periprocedural myocardial infarction, death, coronary dissection, and bleeding, but you probably ought to mention that there is a small but real risk of stroke as well,” he said.

Because “stroke has been one of the most frustrating endpoints to study,” Dr. Rao said, it will be necessary to understand the mechanisms behind it. “Unless we figure that out, it’s not clear to me that we are actually going to have a target for intervention.”

Study Details

Compared with nonstroke patients, patients who experienced strokes or TIAs were more likely to be older, female, have a prior history of stroke or TIA, have a history of peripheral vascular disease, congestive heart failure, or cardiogenic shock before the procedure, or have had an MI within 7 days of the procedure.

 

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Source:
Hoffman SJ, Routledge HC, Lennon RJ, et al. Procedural factors associated with percutaneous coronary intervention-related ischemic stroke. J Am Coll Cardiol Intv. 2012;5:200-206.

 

 

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