Registry: Contralateral Occlusion Poses No Risk for Elective CAS
In patients undergoing elective carotid artery stenting (CAS), the presence of a contralateral occlusion does not complicate the procedure in terms of in-hospital adverse events, according to an observational study published in the January 2013 issue of JACC: Cardiovascular Interventions.
Researchers led by Steven P. Marso, MD, of St. Luke’s Mid America Heart Institute (Kansas City, MO), reviewed data from 13,993 patients enrolled in the CARE (Carotid Artery Revascularization and Endarterectomy) registry who underwent elective CAS between April 2005 and January 2012. The prevalence of contralateral occlusion was 10%. Propensity matching analysis, which accounted for 42 clinical and demographic variables, identified 1,375 patients with 100% occlusion of the contralateral internal carotid artery and 4,125 patients with no such occlusion.
After matching, in-hospital outcomes were unaffected by whether contralateral occlusion was present. The primary composite endpoint of death, nonfatal MI, and nonfatal stroke was similar between the 2 groups, as were the component endpoints (table 1).
Table 1. Propensity-Matched Analysis: In-Hospital Outcomes
|
Contralateral Occlusion |
No Contralateral Occlusion |
P Value |
Composite |
2.1% |
2.6% |
0.316 |
Death |
0.8% |
0.4% |
0.080 |
Nonfatal MI |
0.2% |
0.5% |
0.217 |
Nonfatal Stroke |
1.1% |
1.7% |
0.103 |
Patients experienced equivalent outcomes with or without contralateral occlusion irrespective of symptom status, age (threshold of 70 years), or sex.
On multivariable analysis adjusting for demographic and cardiovascular risk factors and neurological history, contralateral occlusion again did not affect risk of the primary composite (OR 0.88; 95% CI 0.60-1.29; P = 0.50).
Risk Differs from CEA
Previous research suggested that patients with carotid artery stenosis who have contralateral occlusion carry a poor prognosis with medical therapy and are at increased risk of stroke and death with carotid endarterectomy (CEA). “Although the mechanism for increased risk is not fully understood, it is commonly believed to be related to a reduction in blood flow during cross-clamping of the ipsilateral common carotid artery during endarterectomy,” the authors write.
Dr. Marso commented to TCTMD in an e-mail communication, “Prior to this work, there was precious little evidence to support the safety of CAS in the presence of a contralateral occlusion. [Although derived from a nonrandomized and retrospective analysis], these data are the most robust to date to suggest that CAS is safe in the presence of a contralateral occlusion and there does not appear to be increased risk following CAS.”
In an e-mail communication, L. Nelson Hopkins, MD, of University at Buffalo Neurosurgery (Buffalo, NY), said that CEA is unquestionably riskier with contralateral occlusion. “This study supports the fact that CAS is not at increased risk,” he noted, “which makes sense because the average occlusion time [in the treated artery] is over 30 minutes with CEA but only a few minutes with CAS, and this patient cohort has decreased cerebrovascular reserve.”
CAS the Therapy of Choice?
CAS is the preferred treatment for any patient with poor contralateral circulation and decreased reserve, “other risk factors being equal,” Dr. Hopkins advised.
As is always the case with CAS, experience matters. “Experienced operators are generally faster, but these [procedures with contralateral occlusion] are not more difficult,” he noted.
Similarly, Dr. Marso commented that while it is difficult to know with certainty whether operators in the CARE registry might have been more conscientious when performing CAS with contralateral occlusion, there are no procedural approaches specific to such cases. In general, “meticulous attention to detail, procedural technique, the use of embolic protection and being mindful of the hemodynamics during the case are all important [ways] to reduce the risk of procedural complications,” he added.
Clinicians should consider CAS an option in patients with contralateral occlusion based on the current findings, Dr. Marso concluded, cautioning that, “Of course, all carotid revascularization decisions must be individualized and predicated on a number of clinical and anatomical factors.”
Study Details
In the overall, unmatched cohort, patients with contralateral occlusion tended to be younger and male. They also were more likely to have histories of past or current smoking, recent MI, prior neurological events, previous ischemic stroke, restenosis, and target lesion-related symptoms.
Note: William A. Gray, MD, of Columbia University Medical Center (New York, NY), who served as a guest editor of the paper, is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD.
Source:
Mercado N, Cohen DJ, Spertus JA, et al. Carotid artery stenting of a contralateral occlusion and in-hospital outcomes: Results from the CARE (Carotid Artery Revascularization and Endarterectomy) registry. J Am Coll Cardiol Intv. 2013;6:59-64.
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Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…
Read Full BioDisclosures
- Dr. Marso reports receiving research grants and consulting fees from Abbott Vascular, Amylin Pharmaceuticals, Boston Scientific, Novo Nordisk, Terumo Medical, The Medicines Company, and Volcano Corporation, all of which are paid directly to the Saint Luke’s Foundation of Kansas City, MO.
- Dr. Hopkins reports owning stock in Boston Scientific and serving as a consultant to Abbott, Cordis, and Covidien.
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