title: Measurement and impact of proximal and distal tortuosity in carotid stenting procedures.
abstract: BACKGROUND
  Proximal and distal carotid tortuosity is considered of paramount importance in carotid artery stenting (CAS) procedures. Specifically, distal internal carotid coiling or kinking is thought to interfere with proper distal protection devices, thus contraindicating CAS. The type of the aortic arch is also considered a key factor in CAS success; however, no standardized method of evaluation of these indicators is available in the literature. We have evaluated the impact of arch angulation and proximal and distal tortuosity in a series of CAS procedures.
  
  
  METHODS
  In patients undergoing CAS, arch angulation and tortuosity of both common and distal internal carotid arteries were evaluated prospectively by calculating the sum of all angles diverging from the ideal straight axis, considering a 90 degrees ideal angle for the origin from the arch (tortuosity index, TI). All procedures were through a transfemoral approach and with distal protection. Results were correlated with technical procedural success (residual stenosis <30%) and neurologic complication by Student t test. Multivariate logistic regression analysis was conducted to identify independent predictors of results.
  
  
  RESULTS
  In a group of 298 CAS procedures, the mean proximal TI was 111.9 degrees +/- 96.77 degrees and the mean distal TI was 123.4 degrees +/- 117.47 degrees . Technical success was obtained in 272 patients (91.2%). Causes for the 26 technical failures were incapacity to obtain stable proximal access in 25 (96.1%), and uncrossable stenosis in one (3.9%). Neurologic protection was achieved with distal filters in all cases. Neurologic complications occurred in 23 patients (7.7%), consisting of 16 transient ischemic attacks and seven minor strokes. The proximal TI was significantly greater in the 26 cases of technical failure (158.4 degrees +/- 102.2 degrees vs 107.6 degrees +/- 95.3 degrees , P = .01). The distal TI was not different in the two groups (89 degrees +/- 99.1 degrees vs 126.5 degrees +/- 118.6 degrees , P = .11). Similarly, the proximal TI was significantly greater in neurologic complications (162.8 degrees +/- 111.8 degrees vs 107.6 degrees +/- 18.2 degrees , P = .03); the distal TI was not different in the two groups (112.6 degrees +/- 110.1 degrees vs 124.3 degrees +/- 96.1 degrees , P = .5) By logistic regression analysis, a proximal TI >150 was an independent predictor of both neurologic complications and technical failure. Age was also independently associated with technical failure. Appropriate distal filter placement was possible in all cases with a crossable stenosis, irrespective of the internal carotid TI.
  
  
  CONCLUSIONS
  The proximal TI is significantly associated with both technical success and neurologic complications after CAS, whereas the distal TI did not influence either outcome. The presence of distal kinking or coiling should not be considered a contraindication to CAS.
authors.affiliation: Department of Vascular Surgery, University of Bologna, Bologna, Italy. gianluca.faggioli@unibo.it
authors.forename: Gianluca
authors.initials: G
authors.lastname: Faggioli
authors.forename: Monica
authors.initials: M
authors.lastname: Ferri
authors.forename: Mauro
authors.initials: M
authors.lastname: Gargiulo
authors.forename: Antonio
authors.initials: A
authors.lastname: Freyrie
authors.forename: Francesca
authors.initials: F
authors.lastname: Fratesi
authors.forename: Lamberto
authors.initials: L
authors.lastname: Manzoli
authors.forename: Andrea
authors.initials: A
authors.lastname: Stella
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017536:Carotid Artery, Common / Q000473:pathology / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000473:pathology / Q000601:surgery*; D016893:Carotid Stenosis / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D016015:Logistic Models; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation*