The Benefits of Combined Anti-platelet Treatment in Carotid Artery Stenting

AbstractObjectiveTo assess the benefits of a combined anti-platelet regime of aspirin and clopidogrel in carotid artery stenting.MethodsA randomised controlled trial was performed comparing aspirin and 24-h heparin with aspirin and clopidogrel for patients undergoing carotid artery stenting. Outcome measures included 30-day bleeding and neurological complications and 30-day stenosis rates.ResultsBleeding complications (groin haematoma or excessive bleeding at the groin site) occurred in 17% of the heparin and 9% of the clopidogrel group (p=0.35; n.s). The neurological complication rate in the 24-h heparin group was 25% compared to 0% in the clopidogrel group (p=0.02). The 30-day 50–100% stenosis rates were 26% in the heparin group and 5% in the clopidogrel group (p=0.10; n.s).ConclusionsThe dual anti-platelet regime has a significant impact on reducing adverse neurological outcomes without an additional increase in bleeding complications. This study was terminated prematurely due to an unacceptable level of complications in the heparin arm of the trial

Safety of Arch Aortography for Assessment of Carotid Arteries

AbstractPurposeTo retrospectively review the safety of arch aortography and compare complication rates with published figures for selective catheter angiography.MethodsThe medical records of patients undergoing arch aortography over the last 3 years (n=311; 180 male, 131 female; mean±SD age 71.0±9.2 years, range 42–90 years) were retrospectively reviewed. Any peri-procedural (0–48h) complications were recorded. A certified neurologist (MSR/GSV) classified all questionable neurological events.ResultsThere were no focal neurological events or deaths (n=0; 0%; CI: 0–0.96%). Non-focal neurological events included mild disorientation (n=2; 0.6%; CI: 0.176–2.31) and unequal pupils (n=1; 0.3%; CI: 0.056–1.79%). Cardiovascular events included symptomatic hypotension (n=4; 1.3%; CI: 0.50–3.25%), angina (n=1; 0.3%; CI: 0.056–1.79%) and arrhythmia (n=4; 1.3%; CI: 0.50–3.25). There were 27 minor access site complications (8.7%; CI: 6.0–12.3). None of these complications extended hospital stay. None of the arch angiograms had to be followed by selective carotid angiography.ConclusionArch aortography appears to have a lower neurological complication rate than selective carotid angiography

Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk

Background Brain lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS), but their clinical relevance remains unclear. Objectives This study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy (CEA) are associated with an increased risk of recurrent cerebrovascular events. Methods In the magnetic resonance imaging (MRI) substudy of ICSS (International Carotid Stenting Study), 231 patients with symptomatic carotid stenosis were randomized to undergo CAS (n = 124) or CEA (n = 107). MRIs were performed 1 to 7 days before and 1 to 3 days after treatment. The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up. Time to occurrence of the primary outcome event was compared between patients with (DWI+) and without (DWI-) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately. Results Median time of follow-up was 4.1 years (interquartile range: 3.0 to 5.2). In the CAS group, recurrent stroke or transient ischemic attack occurred more often among DWI+ patients (12 of 62) than among DWI- patients (6 of 62), with a cumulative 5-year incidence of 22.8% (standard error [SE]: 7.1%) and 8.8% (SE: 3.8%), respectively (unadjusted hazard ratio: 2.85; 95% confidence interval: 1.05 to 7.72; p = 0.04). In DWI+ and DWI- patients, 8 and 2 events, respectively, occurred within 6 months after treatment. In the CEA group, there was no difference in recurrent cerebrovascular events between DWI+ and DWI- patients. Conclusions Ischemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events. Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS. (A Randomised Comparison of the Risks, Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy: International Carotid Stenting Study; ISRCTN25337470