From the Department of Medicine, Divisions of Cardiovascular Disease
(A.M., G.S.R., S.S.I., C.P., M.W.L., J.S.Y., H.D.C., L.S.D.) and Neurology
(C.R.G.), Department of Biostatistics (L.M.F.), and Department of Radiology
(J.J.V.), The University of Alabama at Birmingham.
Correspondence to Gary S. Roubin, MD, PhD, Lenox Hill Hospital, Black Hall, 130 E 77th St, New York, NY 10021-1803.
Methods and Results—We analyzed the impact of various
clinical, morphological, and procedural determinants on the development
of procedural strokes in 231 patients who underwent elective (primary)
stenting of 271 extracranial carotid arteries. The mean age of the
patients was 68.7±10 years, 165 (71%) were males, and 139 (60%) had
symptoms attributed to the lesion treated. This series
represented a high-risk subset with 164 patients (71%)
having significant coronary artery disease, 91 (39%) having
bilateral disease, and 28 (12%) having contralateral carotid
occlusion. Of the treated vessels, 59 (22%) had prior carotid
endarterectomy, 66 (24%) had ulcerated plaques,
and 87 (32%) had calcified lesions. Only 37 treated vessels (14%)
would have been eligible for inclusion in the North American
Symptomatic Carotid Endarterectomy
Trial (NASCET). There were 17 (6.2%) minor and 2 (0.7%) major strokes
during and within 30 days of the procedure. NASCET-eligible patients
had a low (2.7%) risk of procedural strokes after carotid stenting.
The results of multivariate analysis revealed
advanced age (P=.006) and presence of long or multiple
stenoses (P=.006) as independent predictors of
procedural strokes.
Conclusions—During this procedural developmental phase of carotid
stenting, neurological complications were highly dependent on patient
selection. Advanced age and long or multiple stenoses were
independent predictors of procedural stroke.
The risk of neurological complications related to surgical and
nonsurgical cerebral revascularization procedures
concerns both surgeons and vascular interventionists. The risk of
procedural stroke or death with surgery was 5.8% in NASCET and 2.3%
in ACAS. However, in high-risk patients undergoing
endarterectomy, morbidity and mortality rates as
high as 18% have been reported.12 13 Ongoing
refinements in the technique of carotid stenting are aimed at reducing
the incidence of neurological complications. The clinical and anatomic
heterogeneity of patients with carotid disease might
expectedly lead to differences in outcomes with this procedure. The
present report describes the impact of various clinical,
morphological, and procedural substrates on the development of
short-term complications of carotid stenting. This will help
standardize the characterization of patients considered for this
procedure and formulate strategies to reduce these complications.
Patients were excluded from the study in case of (1) presence of an
intracranial tumor or arteriovenous malformation, (2) presence of
intracranial stenosis that exceeded the severity of
extracranial stenosis, (3) presence of peripheral
vascular disease sufficiently severe to prevent adequate vascular
access, (4) presence of severe disability due to previous stroke or
dementia, or (5) inability to give informed consent.
Carotid Stenting Protocol
Carotid stenting was performed by use of coaxial
catheterization techniques adopted from
coronary and other endovascular interventions.
Percutaneous access was gained through the femoral
artery. Appropriately sized guiding catheters or sheaths were placed in
the carotid artery just proximal to the segment to be treated.
Angulated angiographic views were recorded to fully display the
stenosis. On-line quantitative coronary angiography was
performed to measure the vessel diameter to facilitate sizing of
balloons and stents. Stenoses were crossed with flexible
coronary guidewires, which were replaced with extra-support,
coronary-type guidewires before balloon dilation of the
lesions. Peripheral balloons were used for predilation
until January 1995, after which coronary balloons of lower
profile were used.
In the 231 patients, a total of 363 stents were implanted. Of these,
166 (46%) were Palmaz medium biliary (Johnson & Johnson Interventional
Systems Co), 38 (10%) were Gianturco-Roubin Flex-stents (Cook Inc),
and 159 (44%) were Wallstents (Schneider). The Palmaz medium biliary
stents were deployed over noncompliant balloons that were sized to give
a balloon-to-artery ratio of 1.1:1. Wallstents were usually sized to
the diameter of the common carotid artery. High-pressure (10 to 16 atm)
balloon inflations were routinely performed within the stents after
placement.
Vascular sheaths were removed the same day, and patients were
discharged and instructed to take aspirin 325 mg BID and ticlopidine
250 mg BID for 3 weeks. Aspirin 325 mg/d was continued
indefinitely.
Clinical and Imaging Protocol
Definitions
Category 1 minor stroke—a new neurological deficit that changed the
NIH stroke scale by 1 point and persisted for >24 hours but completely
resolved or returned to baseline within 1 week.
Category 2 minor stroke—a new neurological deficit that either
resolved completely or returned to baseline within 30 days or that
changed the NIH stroke scale by 2 or 3 points. By definition, both
categories of minor strokes are nondisabling neurological events.
Major stroke—a new neurological deficit that persisted after 30 days
and that changed the NIH stroke scale by
Eccentric lesion—angiographic appearance of the stenotic lumen
in the outer one-quarter diameter of the apparent normal
lumen.15
Bifurcation lesion—the external carotid artery originated within the
stenosis and was completely surrounded by significant
stenotic portions of the lesion to be dilated.
Lesion calcification—radiological densities readily seen within the
apparent vascular wall of the artery at the site of the
stenosis.15
Residual irregularity—vascular margin after stent deployment was rough
or had a saw-toothed appearance.15
Ulcerated lesion—plaque was classified as ulcerated if it fulfilled
radiographic criteria of ulcer niche, seen in profile as a
crater from the lumen into a stenotic plaque and (when visible)
a double density on face view.16
Long/multiple lesions—lesion length (measured with calipers as
distance from proximal to distal shoulder of lesion in a projection
that best elongates the stenosis) >10 mm and/or presence
of >1 lesion separated by normal vessel
wall.10
Bilateral carotid disease—presence of
Combined procedure—performance of carotid artery stenting and
coronary angioplasty during the same procedure.
Bilateral simultaneous stenting performance of
carotid stenting on both right and left arteries during the same
procedure.
Data Collection
Statistical Analysis
Prior carotid endarterectomy of the stented carotid
artery had been performed in 59 patients (22%). Lesion severity of
Of the 139 patients (60%) with symptomatic carotid
stenosis in this series who met the angiographic criteria, only
37 would have been eligible for inclusion in NASCET. The reasons for
NASCET exclusion were as follows: age older than 79 years (30
patients); severe comorbidity, ie, severe coronary artery,
pulmonary, or renal disease or any cancer that would limit
survival to <5 years (97 patients); substrate for cardiogenic embolism
(14 patients); and prior ipsilateral endarterectomy
(59 patients).
Procedural Outcomes
Two neurological events with known etiology, which were not directly
related to the defined clinical or morphological variables being
evaluated, were excluded from our univariate and
multivariate analysis of stroke predictors.
These events, however, were included in the overall computation of
significant procedural neurological complications. One of these was a
minor stroke from air embolism that occurred during angiography, and
the second was a major nonprocedural stroke due to a cardiogenic
embolus to the contralateral middle cerebral artery. Thus, of the 19
total neurological events, 17 were entered into the
univariate and multivariate
analysis.
Predictors of Neurological Events
Lesion severity was also associated with the risk of stroke (Fig 2
On multivariate analysis, the odds ratios for
increasing age and long and/or multiple lesions were significant at the
.05 level at 80% power. The odds ratio for lesion severity did not
reach significance at the .05 level, suggesting that its significance
by univariate analysis was an artifact of arbitrary
division into the groups and the small number of neurological events
(Table 4
It has been suggested17 18 19 that if the
neurological complications and mortality are higher than that observed
in the recent carotid endarterectomy trials (4% to
8%), the overall benefit of the procedure would be eliminated. When
the safety of carotid stenting is evaluated, it is important to note
that our patient population has more significant comorbidity than that
included in the recent randomized endarterectomy
trials. In addition to patients aged 80 years and older, the
present series included patients with previous carotid
endarterectomy, contralateral carotid occlusion,
and severe cardiopulmonary disease, all characteristics that
constitute increased risk for endarterectomy.
Despite the unfavorable risk profile, the overall incidence of
procedural stroke and death in the present study was 7.7% of the
treated vessels, whereas in the subpopulation of NASCET-eligible
patients (ie, low-risk subgroup) the risk of any stroke or death was
only 2.7%. This compares well with endarterectomy,
keeping in mind that the prospective critical scrutiny of a new
technique is likely to detect more adverse events.
The description of the neurological end points used in recent carotid
endarterectomy trials has not been uniform. In the
MRC European carotid surgery trial,3 the primary
end points were fatal or disabling strokes and surgical death, and the
secondary end points included nondisabling strokes lasting >7 days. In
the ACAS2 and NASCET5
studies, any new focal neurological deficit lasting >24 hours and
occurring anytime within 30 days after randomization for surgery was
called perioperative stroke. Major stroke in
ACAS2 was defined as one resulting in moderate or
severe disability, persistent vegetative state, or death, and this
included categories 2 to 5 of the Glasgow Outcome Scale.
It is important that a realistic and comprehensive classification of
the neurological complications be used when a newly evolving technique
such as carotid stenting is evaluated. The temporal sequence of
ischemic brain damage may be regarded as a
physiological continuum. The duration and severity
of hypoperfusion dictate the amount of tissue injury that follows
arterial occlusion. Stable neurological signs lasting
beyond 24 hours represent some degree of permanent tissue
injury and have been recognized as completed brain infarcts that are
often too small to be detected by imaging studies. The definition of
minor and major strokes used in the present study incorporates both
the extent of neurological deficit and the degree of functional
disability produced. Minor strokes are essentially nondisabling and in
this study have been further categorized to draw attention to those
minimal neurological deficits that are only detected by detailed
neurological examination, often not noted by the patient, and that
resolve within a week. In the present study, major disabling
strokes were uncommon (0.7%). Minor nondisabling strokes occurred in
6.3% of vessels treated, and half of these represented
rapidly resolving category 1 minimal neurological deficits that were
probably due to small amounts of embolic debris. Comparison with
similar events after endarterectomy must await the
results of prospective randomized trials.
The importance of independent neurological oversight when the incidence
of neurological complications is assessed cannot be overemphasized. In
a recent comprehensive review, Rothwell et al20
documented the increased incidence of neurological complications of
carotid endarterectomy when a neurologist was a
coauthor of the report. On average, the mean risk of a stroke and death
in this meta-analysis was 5.6%, but it was only 2.3% in
studies with a single author affiliated with the department of surgery,
whereas it was 7.7% in studies in which patients were assessed by a
neurologist after surgery. Each patient in the present study was
closely evaluated by a neurologist at frequent intervals for
recording and classifying of neurological complications, and
the clinical end points were critically reviewed by members of the
surgical team at the institution.
Recently, McCrory et al21 retrospectively
analyzed clinical data of 1160 patients who underwent carotid
endarterectomy and correlated it with occurrence of
postoperative adverse events, ie, nonfatal strokes, myocardial
infarction, and death. Significant predictors of adverse events in that
study were age
Advanced age is the most important predictor of procedural neurological
events in the present study. The overall incidence of strokes in
patients <80 years of age after carotid stenting was only 5.6% versus
19.2% in patients
We observed that increasing lesion severity, especially >90% diameter
stenosis, and long or multiple lesions were associated with
increased incidence of neurological complications. This significance
for lesion severity, however, could not be reproduced by
multivariate analysis. It is not known whether
surgical risk also increases with lesion length. Long or multiple
lesions have a larger atherosclerotic plaque burden and carry a risk of
dislodging embolic particles during balloon dilation and stenting. If
these findings can be reproduced in additional studies, they may have
implications in terms of patient selection and evolution of the
technique. The availability of low-profile embolic capture devices for
use in carotid interventions may have particular application in these
patient subsets to further reduce complications.
In contrast, the present study has demonstrated a relatively
low incidence of complications in patients with prior
endarterectomy of the treated site, those with
contralateral carotid occlusions, and those undergoing combined carotid
and coronary interventions. These subsets have been shown to
have a high incidence (11%, 14%, and 24%, respectively) of
complications when they undergo carotid
endarterectomy.21 24 25
Ulcerated carotid lesions represent a poor prognosis for the
development of neurological complications with medical management
alone. In NASCET, it was observed that the risk of ipsilateral stroke
within 24 months in medically treated patients with ulcerated
plaques increased incrementally (from 26% to 73%) as the degree of
stenosis increased (from 75% to 95%). For patients without
ulcers, the risk of stroke remained constant at 21% for all degree of
stenosis.16
Endarterectomy in patients with ulcerated plaques
also involves a higher risk of neurological
complications.5 In contrast, patients with
ulcerated lesions who underwent stenting in the present study had a
low incidence of procedural strokes.
In the present study, we noted a similar complication rate in
asymptomatic and symptomatic patients
(P=.883). The asymptomatic patients, like the
overall study group, had a higher risk profile than patients included
in randomized surgery trials, and only 20% of these patients met ACAS
eligibility criteria. Although the present study is the largest of
its kind, it lacks statistical power to adequately differentiate the
relative importance of several other variables, which occurred at a
low frequency in the study group. Validation of these risk factors
requires larger prospective studies. Assessment of carotid artery
morphology is subjective, and the use of these data in clinical
decision making will require strict attention to the details of the
definitions used.
Conclusions
Alternatively, patients at high risk for
endarterectomy in the present study, ie,
contralateral carotid occlusion, prior carotid
endarterectomy, and combined carotid and
coronary procedures, had a low risk of complications with
carotid stenting. In addition, NASCET-eligible patients had a low
(2.7%) risk of complications. Technical advances including the
development of low-profile stents and emboli filter devices are needed
to enhance results in the higher-risk subsets of patients.
The complications of carotid stenting and
endarterectomy are both highly dependent on patient
selection. The relative roles of these methods must await the results
of prospective randomized trials that study comparable patient subsets.
However, some well-established, high-risk subsets for
endarterectomy appear to have lower complication
rates with carotid stenting.
Received July 21, 1997;
revision received November 6, 1997;
accepted December 1, 1997.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Predictors of Stroke Complicating Carotid Artery Stenting
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—The evolving technique of
carotid stenting is being evaluated as an alternative to
endarterectomy. Identification of the factors that
predispose a patient to neurological complications would facilitate
further refinement of the technique and optimize patient
selection.
Key Words: stroke • carotid arteries • stents
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
There are nearly
500 000 strokes and 150 000 deaths due to cerebrovascular disease
each year in the United States. There is sufficient evidence of the
benefit of relieving high-grade symptomatic and
asymptomatic carotid artery atherosclerotic obstruction by
surgical endarterectomy.1 2 3 4 5
The North American Symptomatic Carotid
Endarterectomy Trial (NASCET) demonstrated the
superiority of endarterectomy over medical
management of symptomatic carotid artery plaques causing
stenoses of 
70%.1 The
Asymptomatic Carotid Atherosclerosis Study
(ACAS) showed that endarterectomy in patients with
asymptomatic carotid artery stenosis of 60% was
statistically superior to conservative management in the prevention of
stroke.2 Carotid angioplasty and stenting are
also being investigated as an alternative treatment for extracranial
carotid artery disease.6 7 8 9 10 The feasibility and
relative safety of percutaneous transfemoral
extracranial carotid stenting has been reported recently in a high-risk
group of patients.11
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Patient Population
Two hundred thirty-one consecutive patients referred for
elective stenting of extracranial carotid arteries at the University of
Alabama at Birmingham Hospital between September 1994 and January 1997
constituted the study population. Symptomatic and
asymptomatic patients with 60% stenosis in the
extracranial carotid arteries were included in a protocol approved by
the Institutional Review Board. For patient screening and enrollment
purposes, stenoses were measured manually with calipers from
radiographic films recorded during previous
diagnostic cerebral angiography.
All patients took aspirin 325 mg/d beginning at least 2 days
before the procedure and ticlopidine 250 mg twice daily starting a day
before the procedure. Heparin, given as an intra-arterial
bolus, was titrated to maintain the activated clotting time
between 200 and 250 seconds. Neurological status was monitored
constantly during the procedure. Femoral venous access was gained in
patients, and a transvenous pacemaker was immediately available.
Atropine 1 mg was given as required during balloon inflation. Blood
pressure was monitored throughout the procedure and was modulated by
administration of intravenous metaraminol or
nitroglycerin as required.
A complete neurological evaluation was performed on all patients
by an experienced neurologist, and the National Institutes of Health
(NIH) Stroke Scale was recorded before the procedure and at 24
hours, 4 weeks, and 6 months after the
procedure.14 MRI or computed tomography of the
head was performed before the procedure and repeated if the patient had
neurological complications. Quantitative coronary angiography
was performed on all vessels before angioplasty, after stenting, and at
6-month follow-up by use of an on-line system (Integris-Phillips
Medical Systems). Diameter stenosis was determined by use of
the NASCET criteria, with the distal nontapering portion of the
internal carotid artery serving as the reference
segment.1 Minimum lumen diameter was measured
after calibration of the system with the known diameter of the guiding
catheter.
Significant neurological complications were defined as
follows: 4 points. The definitions of
minor and major stroke have been adopted from those previously used at
our center.11 60% diameter narrowing in
internal and/or common carotid arteries on both sides or presence of
60% diameter narrowing in left internal and/or common carotid artery
with 60% diameter narrowing of the innominate artery.
All baseline clinical and stenting data and angiographic
measurements were prospectively recorded on standard forms.
Clinical and laboratory details were continuously recorded during
the hospitalization. Primary clinical end points analyzed in
this study were minor or major strokes and death within 30 days of the
procedure. The clinical end points were critically reviewed by the
surgical members at this institution. Morphological data were
recorded retrospectively by reviewing the angiographic films. The
clinical and demographic variables analyzed were age, sex,
presence of symptoms in the last 120 days, presence of coronary
artery disease, diabetes mellitus, hypertension,
hypercholesterolemia, current smoking habit,
bilateral carotid disease, prior endarterectomy on
same side, and contralateral occlusion. The morphological variables
considered were site (right or left carotid arteries), lesion location
at bifurcation, lesion length and presence of multiple
stenoses, eccentricity, calcification, plaque ulceration,
lesion severity, residual stenosis, and residual irregularity.
The procedural variables considered were the use of
noncoronary balloons for predilating lesions and the
performance of combined or simultaneous
procedures.
All values are expressed as mean±SD. Univariate
analysis was performed on all clinical, morphological, and
procedural variables with 
2 test
used for categorical variables and Student's t test for
continuous variables. The 2 test
for linear trend was used to analyze the trend of event
occurrence for different groups of age and lesion severity. A value of
P<.05 was considered to be statistically significant.
Multivariate analysis was performed with the
use of multiple logistic regression analysis to determine the
independent correlates of postprocedural neurological events. Age and
lesion severity were considered as continuous variables for
multivariate analysis. We designed the study
model by selecting variables considered likely to influence
neurological complications on the basis of our experience over the past
3 years. The logistic model was tested for goodness of fit using the
-2 log-likelihood statistic, which was significant with a value of
P=.0003.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Demographic, Clinical, and Morphological Characteristics
In the 231 patients, a total of 271 vessels were treated during
259 procedures. The demographic, clinical, and morphological
characteristics of the patients are shown in Tables 1
, 2, and 3. The
mean age of the patients was 68.7±10 years. One hundred nineteen
patients (52%) were younger than 70, 86 (37%) were between 70 and 79,
and 26 (11%) were older than 79 years of age. Significant
coronary artery disease was present in 164 patients (71%).
Significant disease in both carotid arteries was present in 91
patients (39%), and contralateral carotid artery occlusion was
present in 28 (12%).
View this table:
[in a new window]
Table 1. Correlation of Demographics and Clinical
Characteristics With Postprocedural Events
View this table:
[in a new window]
Table 2. Correlation of Morphological Features With
Postprocedural Events
View this table:
[in a new window]
Table 3. Correlation of Procedural Variables With
Neurological Events 90% was present in 47 vessels (17%), and long or multiple
lesions were present in 88 (33%). Ulcerated lesions were
present in 66 vessels (24%), and calcified lesions were
present in 87 (32%). A bilateral carotid procedure was undertaken
in 19 patients (8%), whereas combined carotid and coronary
procedures were performed in 32 (14%).
A total of 19 significant neurological events (7%) were noted
after stenting of 271 carotid arteries. These included 8 category 1
minor strokes (2.9%) , 9 category 2 minor strokes (3.3%), and 2 major
strokes (0.7%). None of the patients developed a Q-wave myocardial
infarction within 30 days of the procedure. There was 1 in-hospital
death resulting from retroperitoneal bleeding and a second sudden
cardiac death that occurred 4 days after discharge.
On univariate analysis, increased age was
associated with the risk of procedural strokes (Fig 1). Patients younger than 70 had a 2.6%,
1.7%, and 0% incidence of category 1 minor strokes, category 2 minor
strokes, and major strokes, respectively. Patients aged 70 to 79 years
had a 3.5%, 4.7%, and 0% incidence of these events, and patients
80 years had a 7.7%, 7.7%, and 3.8% incidence of these events
(P<.001). Sex, presence or absence of neurological
symptoms, and presence of coronary artery disease, diabetes
mellitus, hypercholesterolemia, or smoking did
not show a significant association with procedural neurological events
(Table 1
). Prior
endarterectomy, presence of bilateral carotid
lesions, or contralateral carotid occlusion also did not significantly
influence the incidence of neurological complications.
View larger version (19K):
[in a new window]
Figure 1. Incidence of minor (category 1 and category 2) and
major strokes in relation to age in 231 patients. ). Lesions with <70% diameter
narrowing had a 1.2%, 2.4%, and 0% incidence of category 1 minor
strokes, category 2 minor strokes, and major strokes, respectively.
Lesions with 70% to 89% diameter narrowing had a 2.9%, 1.5%, and
0.7% incidence of these events, whereas lesions 90% diameter
narrowing had a 6.4%, 8.5%, and 0% incidence of these events
(P=.007). Long and/or multiple lesions were associated with
increased risk of stroke. Single discrete lesions had a 2.2%, 1.6%,
and 0% incidence of category 1 minor strokes, category 2 minor
strokes, and major strokes, respectively, whereas long and/or multiple
lesions had a 4.6%, 5.7%, and 1.1% incidence of these events
(P=.012). Lesions at the common carotid bifurcation,
ulcerated lesions, and residual irregularity after carotid stenting did
not have any significant association with procedural neurological
events (Table 2). The type of stents
used, performance of bilateral carotid stenting during the same
procedure, or performance of combined carotid stenting and
coronary angioplasty during the same procedure also did not
have a significant association with procedural strokes (Table 3).
View larger version (17K):
[in a new window]
Figure 2. Incidence of minor (category 1 and category 2) and
major strokes in relation to lesion severity in 271 vessels. ).
View this table:
[in a new window]
Table 4. Result of Multivariate
Analysis for Predictors of Minor and Major Strokes After
Carotid Stenting
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
The rapidly evolving technique of carotid stenting is currently
undergoing investigation in a number of centers as an alternative to
surgical endarterectomy. This study is the first to
critically analyze the neurological complications of carotid
artery stenting and examine their clinical, morphological, and
procedural descriptors. Our findings suggest that advanced age,
presence of long or multiple lesions, and severe stenosis are
significant predictors of procedural strokes after carotid
stenting. 75 years, presence of ipsilateral hemispheric
neurological instability, severe hypertension,
endarterectomy performed in preparation of bypass
surgery, evidence of internal carotid artery thrombus, and internal
carotid artery stenosis near the carotid siphon. The presence
of two or more factors was associated with a twofold increase in risk
of an adverse event. Similarly, in the present study we correlated
various clinical, morphological, and procedural factors with
neurological adverse events. 80 years old. Results of medical management in
patients >80 years old with significant carotid disease are not known.
Most randomized surgical endarterectomy trials have
excluded such patients.21 22 A few surgical
series that have included elderly patients have not commented
specifically on this subgroup.23 24 The
appropriateness of carotid stenting in patients aged >80 years needs
to be addressed in a larger randomized cohort of patients.
This study carefully defined the demographic, clinical, and
anatomic characteristics of a large population of patients undergoing
carotid stenting. In this high-risk cohort of patients,
multivariate analysis identified advanced age
and long or multiple stenoses as independent predictors of a
neurological complication.
Acknowledgments
The authors wish to acknowledge the valuable contributions of
Kimberley Kretzer, BSN, Virginia Yates, BSN, Carole Liu, RN, and Diane
Alred, BSN, Division of Cardiovascular Disease, and Van
R. Wadlington, MD, Division of Neuroradiology,
University of Alabama at Birmingham.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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 G. S. Roubin, S. Iyer, A. Halkin, J. Vitek, and C. Brennan Realizing the Potential of Carotid Artery Stenting: Proposed Paradigms for Patient Selection and Procedural Technique Circulation, April 25, 2006; 113(16): 2021 - 2030. [Abstract] [Full Text] [PDF]
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M.D. Hill, W. Morrish, G. Soulez, A. Nevelsteen, G. Maleux, C. Rogers, K.E. Hauptmann, A. Bonafe, R. Beyar, L. Gruberg, et al. Multicenter evaluation of a self-expanding carotid stent system with distal protection in the treatment of carotid stenosis. AJNR Am. J. Neuroradiol., April 1, 2006; 27(4): 759 - 765. [Abstract] [Full Text] [PDF]
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S. Kohyama, K. Kazekawa, M. Iko, H. Aikawa, M. Tsutsumi, Y. Go, S. Nagata, T. Kodama, K. Nii, S. Matsubara, et al. Spontaneous Improvement of Peristent Ulceration after Carotid Artery Stenting AJNR Am. J. Neuroradiol., January 1, 2006; 27(1): 151 - 156. [Abstract] [Full Text] [PDF]
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C. H. Timaran Clinical Predictors of Transient ischemic Attack, Stroke, or Death Within 30 Days of Carotid Angioplasty and Stenting Perspectives in Vascular Surgery and Endovascular Therapy, December 1, 2005; 17(4): 384-1 - 385. [Abstract] [PDF]
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 K. I. Paraskevas, S. S. Daskalopoulou, M. E. Daskalopoulos, and C. D. Liapis Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence? Angiology, September 1, 2005; 56(5): 539 - 552. [Abstract] [PDF]
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J. J. Vitek, N. Al-Mubarak, S. S. Iyer, and G. S. Roubin Carotid Artery Stent Placement with Distal Balloon Protection: Technical Considerations AJNR Am. J. Neuroradiol., April 1, 2005; 26(4): 854 - 861. [Abstract] [Full Text] [PDF]
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A. Kastrup, K. Groschel, J. B. Schulz, T. Nagele, and U. Ernemann Clinical Predictors of Transient Ischemic Attack, Stroke, or Death Within 30 Days of Carotid Angioplasty and Stenting Stroke, April 1, 2005; 36(4): 787 - 791. [Abstract] [Full Text] [PDF]
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L. J. Coward, R. L. Featherstone, and M. M. Brown Safety and Efficacy of Endovascular Treatment of Carotid Artery Stenosis Compared With Carotid Endarterectomy: A Cochrane Systematic Review of the Randomized Evidence Stroke, April 1, 2005; 36(4): 905 - 911. [Abstract] [Full Text] [PDF]
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H. G. Roh, H. S. Byun, J. W. Ryoo, D. G. Na, W.-J. Moon, B. B. Lee, and D.-I. Kim Prospective Analysis of Cerebral Infarction After Carotid Endarterectomy and Carotid Artery Stent Placement by Using Diffusion-Weighted Imaging AJNR Am. J. Neuroradiol., February 1, 2005; 26(2): 376 - 384. [Abstract] [Full Text] [PDF]
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M. M. Brown, R. L. Featherstone, and L. J. Coward Carotid Artery Stenting With and Without Cerebral Protection Stroke, November 1, 2004; 35(11): 2434 - 2435. [Full Text] [PDF]
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R. T. Higashida, P. M. Meyers, C. C. Phatouros, J. J. Connors III, J. D. Barr, D. Sacks, and for the Technology Assessment Committees of the Am Reporting Standards for Carotid Artery Angioplasty and Stent Placement Stroke, May 1, 2004; 35(5): e112 - e134. [Full Text] [PDF]
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 I. Linfante, J. A. Hirsch, M. Selim, G. Schlaug, L. R. Caplan, and A. S. Reddy Safety of Latest-Generation Self-expanding Stents in Patients With NASCET-Ineligible Severe Symptomatic Extracranial Internal Carotid Artery Stenosis Arch Neurol, January 1, 2004; 61(1): 39 - 43. [Abstract] [Full Text] [PDF]
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S. Sabeti, M. Schillinger, W. Mlekusch, T. Nachtmann, W. Lang, R. Ahmadi, and E. Minar Contralateral High-Grade Carotid Artery Stenosis or Occlusion Is Not Associated with Increased Risk for Poor Neurologic Outcome after Elective Carotid Stent Placement Radiology, January 1, 2004; 230(1): 70 - 76. [Abstract] [Full Text] [PDF]
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 F. Liistro and C. Di Mario Carotid artery stenting Heart, August 1, 2003; 89(8): 944 - 948. [Full Text] [PDF]
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A. Cremonesi, R. Manetti, F. Setacci, C. Setacci, and F. Castriota Protected Carotid Stenting: Clinical Advantages and Complications of Embolic Protection Devices in 442 Consecutive Patients Stroke, August 1, 2003; 34(8): 1936 - 1941. [Abstract] [Full Text] [PDF]
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A. Kastrup, K. Groschel, H. Krapf, B. R. Brehm, J. Dichgans, and J. B. Schulz Early Outcome of Carotid Angioplasty and Stenting With and Without Cerebral Protection Devices: A Systematic Review of the Literature Stroke, March 1, 2003; 34(3): 813 - 819. [Abstract] [Full Text] [PDF]
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