Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis

Methods: Between 8/1994 and 8/1999, 528 patients (604 arteries) underwent CS at the University of Alabama at Birmingham Hospital and subsequently at Lenox Hill Hospital. Of these, 264 patients were “NASCET” ineligible, defined as symptomatic patients ineligible for enrollment in the North American Symptomatic Carotid Endarterectomy Trial (Prior CEA, 79 years of age, atrial fibrillation, etc). Patients enrolled had symptomatic (ⱖ50%) or asymptomatic (ⱖ60%) carotid artery stenosis. The same three operators performed all the procedures. Long-term outcomes evaluated included neurological events and deaths. Neurological events were defined as A) transient ischemic attack (complete recovery within 24 hours); B) minor non-fatal stroke (new deficit persisting ⬎30 days or increasing NIH Stroke scale by ⱕ3; C) major non-fatal stroke (new deficit persisting ⬎30 days or increasing NIH Stroke scale by ⱖ4 and D) fatal stroke. Results: 275 patients had bilateral carotid artery disease and 10% had occlusion of the controlateral ICA. The mean stenosis was 74⫾14% before stenting and 5⫾9% after stenting. There were 12 (2%) unsuccessful procedures due to failure to deliver the stent (nine inadequate guiding sheath placement, two air embolism and one failure to cross with the guidewire). There was one procedure-related minor stroke (air embolism) and one major non-fatal stroke. Event rates at 30 days were: 4.8% minor non-fatal stroke, 1% major non-fatal stroke, 0.6% fatal stroke, 1% nonneurological deaths, 2.6% major non-fatal stroke and death and 7.4% all non-fatal strokes and death. The 3-year freedom from fatal and non-fatal ipsilateral stroke was 92⫾1%, including 30-day events, and 99⫾1%, excluding 30-day events. Events rates were similar in symptomatic and asymptomatic patients and in men when compared with women. The highest event rate was observed in elderly patients (73% event-free survival at 3 years for patients ⱖ80 years of age compared with 90% event-free survival for patients ⬍80 years of age, p ⬍ 0.0001). Conclusions: Carotid stenting can be performed with a low rate of 30-day fatal and non-fatal stroke, and it results in favorable long-term outcomes. Perspective: The report provides very promising results in a large number of patients, many of whom were less than ideal candidates for CEA. The planned Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) study will likely determine if carotid stenting is equivalent or perhaps superior to the current “gold standard” of carotid endarterectomy. MM

tive of this study was to compare PMBV with open commissurotomy in pregnancy. Methods: The clinical and obstetric complications of 45 women treated with PMBV (21 patients treated between 1990 and 1995) or MVC (24 patients treated between 1985 and 1990) were compared. MVC was performed using general anesthesia and extracorporeal circulation, while PMBV was performed using the transseptal antegrade approach. The PMBV was considered successful if the final valve area was ⬎1.5 cm2 without significant mitral insufficiency. Partial success was defined as ⱖ25% increase in valve area with a final valve area ⬍1.5 cm2. Results: Baseline demographic data were similar among the two groups. There was only one death in the entire group of patients, which occurred in the surgical group. In the PMBV group, the procedure was successful in 95% of cases and partially successful in two cases. There were no major complications including cardiac perforation, tamponade or embolization. In the PMBV group, there was only one neonatal death (4.8%) in a premature child with an esophageal malformation, while in the MVC group, there were six fetal and two neonatal deaths (37.9% overall fetal and neonatal mortality, p ⫽ 0.025 when compared with the PMBV group). Conclusions: When compared with MVC, PMBV in pregnancy is associated with a significantly lower fetal and neonatal mortality. Perspective: Although the small sample size and the retrospective, non-randomized design can be perceived as limitations of this study, the results are compelling. The superiority of PMBV over MVC in term of fetal and neonatal mortality supports the use of PMBV as the treatment of choice for severe mitral stenosis in pregnancy. MM

Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis: A 5-Year Prospective Analysis Roubin GS, New G, Iyer SS, et al. Circulation 2001;103:532–7. Study Question: Carotid stenting (CS) is emerging as a new strategy for the management of obstructive carotid artery disease. The objective of this study was to determine the incidence of immediate and late stroke in a large series of patients undergoing CS.

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