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SAN DIEGO – The 30-day periprocedural outcomes in patients who underwent carotid artery stenting with closed-cell design stents were not significantly inferior to outcomes of those treated with carotid endarterectomy, a large meta-analysis demonstrated.
However, patients who underwent carotid endarterectomy (CEA) had significantly better 30-day periprocedural outcomes, compared with those who underwent carotid artery stenting (CAS) with open-cell design stents.
"A number of randomized clinical trials and meta-analyses have consistently showed the higher risk of periprocedural stroke in patients undergoing stenting when compared to endarterectomy," Dr. Mohammed A. Almekhlafi said at the annual meeting of the Society of Neurointerventional Surgery.
"One of the factors that has been implicated as a determinant of periprocedural neurological events is the stent cell design. The small free-cell area between the struts of a closed-cell stent theoretically provides better scaffolding of the vessel wall and superior plaque stabilization compared to the larger uncovered gaps in open-cell stents."
Dr. Almekhlafi, an interventional neurology fellow at the University of Calgary (Alta.), and his associates set out to investigate the impact of stent cell design on the outcome of randomized controlled trials comparing CAS vs. CEA. The stent cell design was divided into closed (meaning all stent struts are interconnected) or open (meaning not all stent-struts are interconnected). The primary outcome was a composite of the 30-day risk of stroke or death.
The final analysis included 4,949 patients from nine randomized clinical trials. Of these, 807 underwent CAS with closed-cell stenting, 1,657 underwent CAS with open-cell stenting, and 2,485 underwent CEA.
Dr. Almekhlafi reported that the primary outcome was significantly lower among patients in the CEA arm, compared with those in the CAS open-cell design arm (odds ratio, 1.84; P = .003). The primary outcome was lower among patients in the CEA arm, compared with those in the CAS closed-cell design arm, although this difference did not reach statistical significance (OR, 1.54; P = .29).
When the researchers limited their analysis to risk of 30-day periprocedural stroke, this outcome remained nonsignificant among patients in the CEA arm, compared with those in the CAS closed-cell design arm (OR 2.92; P = .22). However, the risk of 30-day periprocedural stroke remained significantly higher among patients in the CAS open-cell design arm, compared with those in the CEA arm (OR, 1.97; P = .0007).
"Uncertainty still exists regarding the impact of stent characteristics on CAS outcome," Dr. Almekhlafi said. "The size of the emboli might also be relevant."
He acknowledged certain limitations of the study, including the fact that trials included in this analysis did not randomize patients to open vs. closed stents, and that trials using the closed-design stents recruited fewer patients than did those using open-cell stents.
Dr. Almekhlafi said that he had no relevant financial disclosures to make.
Several randomized carotid trials have compared the outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) over the past several years, with the majority, if not all, concluding that CAS had a higher rate of stroke than CEA, particularly in symptomatic patients. This has been thought to be secondary to the excessive microembolic burden during CAS. Several embolic protection devices have been designed to improve the safety profile of CAS, which have also been shown to induce new hyperintensities on diffusion-weighted magnetic resonance imaging (DWMRI) of the brain. There is also compelling evidence to suggest that distal filter protection devices are suboptimal, and that these embolic devices may actually increase the microembolization, compared with unprotected CAS procedures. Therefore, many authorities are advocating the use of proximal embolic protection devices (flow reversal system).
| Dr. AbuRhama |
In a recent systemic review (Stroke 2008;39:1911-19), comprised of 32 studies including a mix of CEA and CAS cases (incorporating 1,363 CAS procedures), demonstrated that closed-cell stents significantly reduced the new white lesion rate on DWMRI compared to open-cell stents. A recent study by Carlos Timaran of a randomized clinical trial of open- versus closed-cell stents for carotid stenting showed that cerebral embolization as detected by TCD and DWMRI occurred with similar frequency after CAS with open- and closed-cell stents.
The author did not support the superiority of any stent design in respect to cerebral embolization. Meanwhile, a recent study presented by Fritz Wodarg at the European Stroke Conference found that a primary outcome event of any stroke or death within 30 days of CAS occurred significantly less often in patients treated with closed-cell stents (6.1%) than in those with open-cell stents (10.1%, P = 0.003). Other trials, including the SPACE trial, showed that the use of closed-cell stents was associated with a significantly better outcome than open-cell stents. This present study will only add to the controversy of CAS and whether the stent design, open versus closed, has an impact on the outcome of this procedure and its future acceptance.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston W.V., and an associate medical editor for Vascular Specialist.
Several randomized carotid trials have compared the outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) over the past several years, with the majority, if not all, concluding that CAS had a higher rate of stroke than CEA, particularly in symptomatic patients. This has been thought to be secondary to the excessive microembolic burden during CAS. Several embolic protection devices have been designed to improve the safety profile of CAS, which have also been shown to induce new hyperintensities on diffusion-weighted magnetic resonance imaging (DWMRI) of the brain. There is also compelling evidence to suggest that distal filter protection devices are suboptimal, and that these embolic devices may actually increase the microembolization, compared with unprotected CAS procedures. Therefore, many authorities are advocating the use of proximal embolic protection devices (flow reversal system).
| Dr. AbuRhama |
In a recent systemic review (Stroke 2008;39:1911-19), comprised of 32 studies including a mix of CEA and CAS cases (incorporating 1,363 CAS procedures), demonstrated that closed-cell stents significantly reduced the new white lesion rate on DWMRI compared to open-cell stents. A recent study by Carlos Timaran of a randomized clinical trial of open- versus closed-cell stents for carotid stenting showed that cerebral embolization as detected by TCD and DWMRI occurred with similar frequency after CAS with open- and closed-cell stents.
The author did not support the superiority of any stent design in respect to cerebral embolization. Meanwhile, a recent study presented by Fritz Wodarg at the European Stroke Conference found that a primary outcome event of any stroke or death within 30 days of CAS occurred significantly less often in patients treated with closed-cell stents (6.1%) than in those with open-cell stents (10.1%, P = 0.003). Other trials, including the SPACE trial, showed that the use of closed-cell stents was associated with a significantly better outcome than open-cell stents. This present study will only add to the controversy of CAS and whether the stent design, open versus closed, has an impact on the outcome of this procedure and its future acceptance.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston W.V., and an associate medical editor for Vascular Specialist.
Several randomized carotid trials have compared the outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) over the past several years, with the majority, if not all, concluding that CAS had a higher rate of stroke than CEA, particularly in symptomatic patients. This has been thought to be secondary to the excessive microembolic burden during CAS. Several embolic protection devices have been designed to improve the safety profile of CAS, which have also been shown to induce new hyperintensities on diffusion-weighted magnetic resonance imaging (DWMRI) of the brain. There is also compelling evidence to suggest that distal filter protection devices are suboptimal, and that these embolic devices may actually increase the microembolization, compared with unprotected CAS procedures. Therefore, many authorities are advocating the use of proximal embolic protection devices (flow reversal system).
| Dr. AbuRhama |
In a recent systemic review (Stroke 2008;39:1911-19), comprised of 32 studies including a mix of CEA and CAS cases (incorporating 1,363 CAS procedures), demonstrated that closed-cell stents significantly reduced the new white lesion rate on DWMRI compared to open-cell stents. A recent study by Carlos Timaran of a randomized clinical trial of open- versus closed-cell stents for carotid stenting showed that cerebral embolization as detected by TCD and DWMRI occurred with similar frequency after CAS with open- and closed-cell stents.
The author did not support the superiority of any stent design in respect to cerebral embolization. Meanwhile, a recent study presented by Fritz Wodarg at the European Stroke Conference found that a primary outcome event of any stroke or death within 30 days of CAS occurred significantly less often in patients treated with closed-cell stents (6.1%) than in those with open-cell stents (10.1%, P = 0.003). Other trials, including the SPACE trial, showed that the use of closed-cell stents was associated with a significantly better outcome than open-cell stents. This present study will only add to the controversy of CAS and whether the stent design, open versus closed, has an impact on the outcome of this procedure and its future acceptance.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston W.V., and an associate medical editor for Vascular Specialist.
SAN DIEGO – The 30-day periprocedural outcomes in patients who underwent carotid artery stenting with closed-cell design stents were not significantly inferior to outcomes of those treated with carotid endarterectomy, a large meta-analysis demonstrated.
However, patients who underwent carotid endarterectomy (CEA) had significantly better 30-day periprocedural outcomes, compared with those who underwent carotid artery stenting (CAS) with open-cell design stents.
"A number of randomized clinical trials and meta-analyses have consistently showed the higher risk of periprocedural stroke in patients undergoing stenting when compared to endarterectomy," Dr. Mohammed A. Almekhlafi said at the annual meeting of the Society of Neurointerventional Surgery.
"One of the factors that has been implicated as a determinant of periprocedural neurological events is the stent cell design. The small free-cell area between the struts of a closed-cell stent theoretically provides better scaffolding of the vessel wall and superior plaque stabilization compared to the larger uncovered gaps in open-cell stents."
Dr. Almekhlafi, an interventional neurology fellow at the University of Calgary (Alta.), and his associates set out to investigate the impact of stent cell design on the outcome of randomized controlled trials comparing CAS vs. CEA. The stent cell design was divided into closed (meaning all stent struts are interconnected) or open (meaning not all stent-struts are interconnected). The primary outcome was a composite of the 30-day risk of stroke or death.
The final analysis included 4,949 patients from nine randomized clinical trials. Of these, 807 underwent CAS with closed-cell stenting, 1,657 underwent CAS with open-cell stenting, and 2,485 underwent CEA.
Dr. Almekhlafi reported that the primary outcome was significantly lower among patients in the CEA arm, compared with those in the CAS open-cell design arm (odds ratio, 1.84; P = .003). The primary outcome was lower among patients in the CEA arm, compared with those in the CAS closed-cell design arm, although this difference did not reach statistical significance (OR, 1.54; P = .29).
When the researchers limited their analysis to risk of 30-day periprocedural stroke, this outcome remained nonsignificant among patients in the CEA arm, compared with those in the CAS closed-cell design arm (OR 2.92; P = .22). However, the risk of 30-day periprocedural stroke remained significantly higher among patients in the CAS open-cell design arm, compared with those in the CEA arm (OR, 1.97; P = .0007).
"Uncertainty still exists regarding the impact of stent characteristics on CAS outcome," Dr. Almekhlafi said. "The size of the emboli might also be relevant."
He acknowledged certain limitations of the study, including the fact that trials included in this analysis did not randomize patients to open vs. closed stents, and that trials using the closed-design stents recruited fewer patients than did those using open-cell stents.
Dr. Almekhlafi said that he had no relevant financial disclosures to make.
SAN DIEGO – The 30-day periprocedural outcomes in patients who underwent carotid artery stenting with closed-cell design stents were not significantly inferior to outcomes of those treated with carotid endarterectomy, a large meta-analysis demonstrated.
However, patients who underwent carotid endarterectomy (CEA) had significantly better 30-day periprocedural outcomes, compared with those who underwent carotid artery stenting (CAS) with open-cell design stents.
"A number of randomized clinical trials and meta-analyses have consistently showed the higher risk of periprocedural stroke in patients undergoing stenting when compared to endarterectomy," Dr. Mohammed A. Almekhlafi said at the annual meeting of the Society of Neurointerventional Surgery.
"One of the factors that has been implicated as a determinant of periprocedural neurological events is the stent cell design. The small free-cell area between the struts of a closed-cell stent theoretically provides better scaffolding of the vessel wall and superior plaque stabilization compared to the larger uncovered gaps in open-cell stents."
Dr. Almekhlafi, an interventional neurology fellow at the University of Calgary (Alta.), and his associates set out to investigate the impact of stent cell design on the outcome of randomized controlled trials comparing CAS vs. CEA. The stent cell design was divided into closed (meaning all stent struts are interconnected) or open (meaning not all stent-struts are interconnected). The primary outcome was a composite of the 30-day risk of stroke or death.
The final analysis included 4,949 patients from nine randomized clinical trials. Of these, 807 underwent CAS with closed-cell stenting, 1,657 underwent CAS with open-cell stenting, and 2,485 underwent CEA.
Dr. Almekhlafi reported that the primary outcome was significantly lower among patients in the CEA arm, compared with those in the CAS open-cell design arm (odds ratio, 1.84; P = .003). The primary outcome was lower among patients in the CEA arm, compared with those in the CAS closed-cell design arm, although this difference did not reach statistical significance (OR, 1.54; P = .29).
When the researchers limited their analysis to risk of 30-day periprocedural stroke, this outcome remained nonsignificant among patients in the CEA arm, compared with those in the CAS closed-cell design arm (OR 2.92; P = .22). However, the risk of 30-day periprocedural stroke remained significantly higher among patients in the CAS open-cell design arm, compared with those in the CEA arm (OR, 1.97; P = .0007).
"Uncertainty still exists regarding the impact of stent characteristics on CAS outcome," Dr. Almekhlafi said. "The size of the emboli might also be relevant."
He acknowledged certain limitations of the study, including the fact that trials included in this analysis did not randomize patients to open vs. closed stents, and that trials using the closed-design stents recruited fewer patients than did those using open-cell stents.
Dr. Almekhlafi said that he had no relevant financial disclosures to make.
Major Finding: The 30-day risk of stroke or death was significantly lower among patients who underwent CEA, compared with those who underwent CAS with open-cell design stents (OR, 1.84; P = .003). The risk was also lower among patients who underwent CEA, compared with those who underwent CAS with closed-cell design stents, but this difference did not reach statistical significance (OR, 1.54; P = .29).
Data Source: Data are from a meta-analysis of 4,949 patients from nine randomized controlled trials comparing CAS vs. CEA.
Disclosures: Dr. Almekhlafi said that he had no relevant financial conflicts to disclose.
