Carotid Artery Stenting with Patient- and Lesion- Ta ilo r ed Selection of the Neuroprotection System and Stent Type: Early and 5-Year Results from a Prospective Academic Re g istry of 535 Cons e cu t ive Procedures (TARGET-CAS)

Abstract

Purpose:

To develop and prospectively evaluate the safety and efficacy of an algorithm for tailoring neuroprotection devices (NPD) and stent types to the patient/lesion in carotid artery stenting (CAS).

Methods:

From November 2002 to October 2007, 499 patients (360 men; mean age 65.2±8.4 years, range 36–88) were prospectively enrolled in a safety and efficacy study of tailored CAS using proximal (flow blockade or reversal) or distal (filters or occlusion) NPDs and closed- or open-cell self-expanding stents. Of the 535 lesions treated in the study, 175 (32.7%) were “high risk” by morphology. Half (50.1%) the patients were symptomatic.

Results:

A quarter (137, 25.6%) of the procedures were performed under proximal protection and the remainder (398, 74.4%) with distal NPDs; the direct stenting rate was 66.9%. High-risk lesions were treated predominantly with a proximal NPD and closed-cell stent (77.1% and 82.9%, respectively) and less frequently by direct stenting (37.1%, p<0.0001 versus non-high-risk lesions). The in-hospital death/stroke rate was 2.0% (95% CI 0.85% to 3.23%), and the death/major stroke rate was 0.7% (95% CI 0.02% to 1.48%). There were no myocardial infarctions, but there was 1 (0.2%) further death within 30 days. With the tailored approach, symptom status and high-risk lesion morphology were not risk factors for an adverse outcome after CAS; only age >75 years (p<0.001) was a predictor of short-term death. Long-term survival (95.4% at 1 and 88.3% at 5 years) was similar for symptomatic versus asymptomatic patients, direct stenting versus predilation, and closed-vs. open-cell stent design; only coronary artery disease adversely impacted survival (p=0.04). The rates of freedom from death/ipsilateral stroke were 94.9% at 1 year and 85.9% at 5 years.

Conclusion:

Tailored CAS is associated with a low complication rate and high long-term efficacy. CAS operators should have a practical knowledge of different NPDs, including at least one proximal type.

Keywords

carotid artery stenosis stroke prevention carotid artery stenting cerebral protection devices carotid stents open-cell stents closed-cell stents

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