Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits.
BACKGROUND
Carotid stenting has been advocated in patients with grade III blunt carotid artery injuries (hereafter referred to as "blunt CAIs") because of the persistence of the pseudoaneurysm and concern for subsequent embolization or rupture.


OBJECTIVE
Carotid stenting is safe and effective for blunt CAIs.


METHODS
Analysis of a prospective database of all patients with blunt CAIs.


METHODS
A state-designated, level I, urban trauma center.


METHODS
In January 1, 1996, we initiated comprehensive screening for blunt CAIs with angiography based on injury patterns. Patients without contraindications receive anticoagulation therapy immediately for documented lesions. Patients with persistent pseudoaneurysms on a second angiography at 7 to 10 days after injury are candidates for stent placement.


RESULTS
During the study period (January 1, 1996, to May 1, 2004), 46 patients sustained blunt carotid pseudoaneurysms; 23 (50%) underwent carotid stent placement. There were 4 complications in patients undergoing carotid stent placement: 3 strokes and 1 subclavian dissection. Follow-up angiography was performed in 38 patients (18 patients with stents who received antithrombotic agents, 20 patients who received antithrombotic agents alone); 8 patients had poststent carotid occlusion despite having received concurrent anticoagulation therapy. Carotid occlusion rates were significantly different (45% in patients with stents vs 5% in those who received antithrombotic agents alone). In the patients not undergoing stent placement, the only complication was a middle cerebral artery stroke in a patient not treated with antithrombotic therapy.


CONCLUSIONS
Patients who have carotid stents placed for blunt carotid pseudoaneurysms have a 21% complication rate and a documented occlusion rate of 45%. In contrast, patients treated with antithrombotic agents alone had an occlusion rate of 5%; no asymptomatic patient treated with antithrombotic agents for their injury had a stroke. Antithrombotic therapy remains the recommended therapy for blunt CAIs, but the role of intraluminal stents remains to be defined.
Cothren
C Clay
CC
Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO 80204, USA. clay.cothren@dhha.org
Moore
Ernest E
EE
Ray
Charles E
CE
Ciesla
David J
DJ
Johnson
Jeffrey L
JL
Moore
John B
JB
Burch
Jon M
JM
D000328:Adult; D017541:Aneurysm, False / Q000628:therapy*; D000925:Anticoagulants / Q000627:therapeutic use; D020212:Carotid Artery Injuries / Q000000981:diagnostic imaging / Q000628:therapy*; D002533:Cerebral Angiography; D000077144:Clopidogrel; D016208:Databases, Factual; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D018570:Risk Assessment; D015607:Stents / Q000009:adverse effects; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000628:therapy*
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine