Print this pageRisk factors and angiographic technical considerations to guide carotid intervention
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Matthew A. Corriere, MD, Jeffery B. Dattilo, MD, Michael C. Madigan, BS, Raul J. Guzman, MD, Thomas C. Naslund, MD, Marc A. Passman, MD.
Veterans' Affairs Tennessee Valley Healthcare System and Vanderbilt University Medical Center, Nashville, TN, USA.
BACKGROUND
The Centers for Medicare and Medicaid Services (CMS) has determined that carotid angioplasty and stenting (CAS) with embolic protection is acceptable for patients considered “high risk” for carotid endarterectomy (CEA). The purpose of this study is: to determine what proportion of patients treated with CEA would be categorized as “high risk" by currently accepted criteria, and to determine the potential technical challenges of CAS in these patients based on preoperative cerebrovascular angiography.
METHODS
Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, peri-operative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied and preoperative angiograms were examined for technical limitations to CAS.
RESULTS
Two-hundred and seventy nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%) or stroke (8%). Of these, 35.5% (N=99) would have met one or more “high risk” criteria (Table I):
| Risk Factor | N (%) |
| Pulmonary disease | 36 (12.9%) |
| Cardiac disease | 31 (11.1%) |
| Contralateral ICA occlusion | 24 (8.6%) |
| Age >80 | 22 (7.9%) |
| Recurrent stenosis | 4 (1.4%) |
| Neck radiation/radical dissection | 2 (0.7%) |
| Contralateral laryngeal nerve injury | 2 (0.7%) |
| Any risk factor | 99 (35.5%) |
| Multiple risk factors | 20 (7.2%) |
Pre-operative angiograms were available for review in 83.5% of CEAs (N=233). The distribution of aortic arch configurations included: type I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (N=35) of angiograms. 77.7% (N=181) had one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had findings that would have precluded ability to perform CAS (Table II):
| Technical Limitation | N (%) |
| Type IIb or III arch | 130 (55.8%) |
| Intracranial stenosis | 54 (23.3%) |
| Arch branch occlusion* | 15 (6.4%) |
| ICA near occlusion* | 15 (6.4%) |
| ICA stenosis >2cm length | 12 (5.2%) |
| Distal ICA tortuosity* | 12 (5.2%) |
| Contralateral ICA occlusion | 12 (5.2%) |
| Arch branch tortuosity | 9 (3.9%) |
| Carotid aneurysm* | 1 (0.4%) |
| Intracranial aneurysm | 1 (0.4%) |
| Any limitation | 181 (77.7%) |
| Multiple limitations | 89 (38.2%) |
Overall risks of perioperative stroke, MI, and death were 1.1%, 2.2%, 0.4% (N=279), respectively. Of the 77 “high risk” patients with available preoperative angiograms, 22 (28.6%) had an angiographic contraindication to CAS; risks of perioperative stroke, MI, and death in the remaining 55 patients without contraindications to CAS were 1.8%, 1.8%, and 0%, respectively.
CONCLUSION
A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as "high risk" and be considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which may prevent the ability to perform CAS, are common and should be anticipated when planning CAS.
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