title: Angiographic lesion characteristics can predict adverse outcomes after carotid artery stenting.
abstract: BACKGROUND
  Carotid artery angioplasty and stenting (CAS) is an evolving and increasingly common endovascular treatment for carotid artery stenosis. Risk factors associated with an increased incidence of adverse periprocedural neurologic outcomes are being recognized. The goal of this study was to determine if certain angiographic lesion characteristics were predictive of higher risks of adverse outcomes.
  
  
  METHODS
  A total of 421 patients who underwent 429 carotid artery stenting procedures between June 1996 and June 2005 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Demographic data and procedural variables were recorded, including the presence or absence of the use of a cerebral protection device. Angiograms were reviewed for the following carotid lesion characteristics: length of lesion, percentage of stenosis, ostial involvement, lesion ulceration, calcification, and presence of contralateral carotid occlusion. Periprocedural stroke and 30-day adverse event rates (stroke, myocardial infarction, and death) were recorded for each patient.
  
  
  RESULTS
  The periprocedural all-stroke rate was 3.7%. Octogenarians had a higher incidence of 30-day adverse events at 10.0% vs 3.8% (P = .029). The incidence of periprocedural stroke was increased in lesions > or =15 mm long, at 17.0% (8 of 47) vs 2.1% (8 of 382; P < .001), and in ostial centered lesions, 7.1% (11 of 154) vs 1.8% (5 of 275; P = .007). Multivariate regression also identified these two variables as independently associated with 30-day stroke rate: lesion length > or =15 mm (odds ratio [OR], 6.38; 95% confidence interval [CI], 35 to 17.29) or ostial involvement (OR, 3.12; 95% CI, 3.12 to 8.36). Other variables, including lesion calcification, ulceration, degree of stenosis, or presence of contralateral occlusion, were not associated with adverse outcomes. When studied separately, the use of cerebral protection devices in 241 patients (56%) did not change our observed correlations between angiographic characteristics and adverse procedural events.
  
  
  CONCLUSIONS
  Certain lesion characteristics on angiography, such as length and ostial location, can predict adverse outcomes. The indication for CAS should be carefully evaluated in these cases.
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, 299 Lothrop Street, Pittsburgh, PA 15213, USA. makarounms@upmc.edu
authors.forename: Shariq
authors.initials: S
authors.lastname: Sayeed
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Stanziale
authors.forename: Mark H
authors.initials: MH
authors.lastname: Wholey
authors.forename: Michel S
authors.initials: MS
authors.lastname: Makaroun
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D017130:Angioplasty / Q000009:adverse effects* / Q000295:instrumentation; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D016017:Odds Ratio; D018579:Patient Selection; D011474:Prosthesis Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome