Long-term outcomes of carotid artery stenting in patients with a contralateral carotid artery occlusion.

OBJECTIVES: To examine the association between a contralateral carotid artery occlusion (CCO) and the rates of subsequent target-lesion restenosis and revascularization after carotid artery stenting (CAS). BACKGROUND: Patients with carotid artery disease undergoing revascularization often have a CCO. The association of a CCO with long-term outcomes after CAS is uncertain. METHODS: At two institutions, 267 CAS procedures were performed from 2006 to 2016 including 47 (18%) with a CCO. Regular follow-up with duplex carotid ultrasound was performed to assess for restenosis. Univariate Cox regression analysis was performed to evaluate the association between the presence of a CCO and repeat revascularization. RESULTS: The mean patient age was 70 years. There was no significant difference (P > 0.05) in procedural indication (asymptomatic vs ischemic symptoms) or medical comorbidities between groups. During 5-year follow up, the rate of duplex-derived >80% stenosis was 6% in the non-CCO group and 9% in the CCO group (P = 0.45). Despite similar rates of >80% restenosis, there was a significant association between CCO and subsequent target-lesion revascularization (TLR), with rates of 6.4% vs 0.9% at 5 years (HR 7.2, confidence interval (CI) 1.2-43, P = 0.04). There were no significant differences between groups in the 5-year rates of stroke (4.3% in CCO group vs 4.5% in non-CCO group, HR 0.53, CI 0.07-4.22, P = 1.0) or MACCE (15% vs 18%, HR 0.55, CI 0.2-1.55, P = 0.68). CONCLUSIONS: Patients undergoing CAS with a CCO were more likely to undergo TLR during long-term follow up, but they did not have any differences in procedural success or short- and long-term outcomes.

Long-term outcomes after carotid artery stenting of patients with prior neck irradiation or surgery.

BACKGROUND: Carotid artery stenting (CAS) is often performed in patients with carotid artery stenosis who have relative contraindications to carotid endarterectomy (CEA), including hostile neck anatomy (e.g., history of neck irradiation or prior surgery). We examined the impact of hostile neck anatomy on long-term outcomes after CAS. METHODS: All carotid artery stent procedures performed at two institutions from 2006 to 2016 were reviewed. Routine duplex carotid ultrasound was used to assess target lesion restenosis at regular intervals. The primary endpoint was rates of target lesion revascularization (TLR). Secondary endpoints included peri-procedural outcomes, restenosis, stroke, major adverse cardiovascular and cerebrovascular events (MACCE), and mortality during long-term follow up. A Cox proportional hazard model was developed to determine the association between hostile neck anatomy and outcome after CAS. RESULTS: 304 CAS procedures were performed in 268 patients (hostile neck=53, non-hostile neck=215). Patients with hostile neck anatomy were more likely to have a history of smoking and history of prior carotid artery revascularization. There were no differences in peri-procedural outcomes including stroke. During follow-up to five years there were no significant differences in rates of TLR (1.4% vs. 3.8%, P=0.25), restenosis (1.9% vs. 5.1%, P=0.31), MACCE (26% vs. 18%, P=0.15), ipsilateral stroke (7.5% vs. 2.8%, P=0.101), or mortality (13% vs. 14%, P=0.89). Hostile neck anatomy was not associated with significantly increased 5-year TLR rates in the Cox regression analysis (HR=2.64; 95% CI: 0.44-15.83; P=0.289). CONCLUSIONS: Despite greater comorbidities, patients with hostile neck anatomy and carotid artery stenosis have favorable outcomes after carotid artery stenting.

High-Intensity Statin Therapy Is Associated With Improved Survival in Patients With Peripheral Artery Disease.

BACKGROUND: The relative benefit of higher statin dosing in patients with peripheral artery disease has not been reported previously. We compared the effectiveness of low- or moderate-intensity (LMI) versus high-intensity (HI) statin dose on clinical outcomes in patients with peripheral artery disease. METHODS AND RESULTS: We reviewed patients with symptomatic peripheral artery disease who underwent peripheral angiography and/or endovascular intervention from 2006 to 2013 who were not taking other lipid-lowering medications. HI statin use was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg. Baseline demographics, procedural data, and outcomes were retrospectively analyzed. Among 909 patients, 629 (69%) were prescribed statins, and 124 (13.6%) were treated with HI statin therapy. Mean low-density lipoprotein level was similar in patients on LMI versus HI (80±30 versus 87±44 mg/dL, P=0.14). Demographics including age (68±12 versus 67±10 years, P=0.25), smoking history (76% versus 80%, P=0.42), diabetes mellitus (54% versus 48%, P=0.17), and hypertension (88% versus 89%, P=0.78) were similar between groups (LMI versus HI). There was a higher prevalence of coronary artery disease (56% versus 75%, P=0.0001) among patients on HI statin (versus LMI). After propensity weighting, HI statin therapy was associated with improved survival (hazard ratio for mortality: 0.52; 95% confidence interval, 0.33-0.81; P=0.004) and decreased major adverse cardiovascular events (hazard ratio: 0.58; 95% confidence interval 0.37-0.92, P=0.02). CONCLUSIONS: In patients with peripheral artery disease who were referred for peripheral angiography or endovascular intervention, HI statin therapy was associated with improved survival and fewer major adverse cardiovascular events compared with LMI statin therapy.