Carotid artery stenting with patient- and lesion-tailored selection of the neuroprotection system and stent type: early and 5-year results from a prospective academic registry of 535 consecutive procedures (TARGET-CAS).
OBJECTIVE
To develop and prospectively evaluate the safety and efficacy of an algorithm for tailoring neuroprotection devices (NPD) and stent types to the patient/lesion in carotid artery stenting (CAS).


METHODS
From November 2002 to October 2007, 499 patients (360 men; mean age 65.2+/-8.4 years, range 36-88) were prospectively enrolled in a safety and efficacy study of tailored CAS using proximal (flow blockade or reversal) or distal (filters or occlusion) NPDs and closed- or open-cell self-expanding stents. Of the 535 lesions treated in the study, 175 (32.7%) were "high risk" by morphology. Half (50.1%) the patients were symptomatic.


RESULTS
A quarter (137, 25.6%) of the procedures were performed under proximal protection and the remainder (398, 74.4%) with distal NPDs; the direct stenting rate was 66.9%. High-risk lesions were treated predominantly with a proximal NPD and closed-cell stent (77.1% and 82.9%, respectively) and less frequently by direct stenting (37.1%, p<0.0001 versus non-high-risk lesions). The in-hospital death/stroke rate was 2.0% (95% CI 0.85% to 3.23%), and the death/major stroke rate was 0.7% (95% CI 0.02% to 1.48%). There were no myocardial infarctions, but there was 1 (0.2%) further death within 30 days. With the tailored approach, symptom status and high-risk lesion morphology were not risk factors for an adverse outcome after CAS; only age >75 years (p<0.001) was a predictor of short-term death. Long-term survival (95.4% at 1 and 88.3% at 5 years) was similar for symptomatic versus asymptomatic patients, direct stenting versus predilation, and closed- vs. open-cell stent design; only coronary artery disease adversely impacted survival (p = 0.04). The rates of freedom from death/ipsilateral stroke were 94.9% at 1 year and 85.9% at 5 years.


CONCLUSIONS
Tailored CAS is associated with a low complication rate and high long-term efficacy. CAS operators should have a practical knowledge of different NPDs, including at least one proximal type.
Pieniazek
Piotr
P
Department of Cardiac Diseases, Jagiellonian University Institute of Cardiology, Krakow, Poland. kardio@kki.krakow.pl
Musialek
Piotr
P
Kablak-Ziembicka
Anna
A
Tekieli
Lukasz
L
Motyl
Rafal
R
Przewlocki
Tadeusz
T
Moczulski
Zbigniew
Z
Pasowicz
Mieczyslaw
M
Sokolowski
Andrzej
A
Lesniak-Sobelga
Agata
A
Zmudka
Krzysztof
K
Tracz
Wieslawa
W
D000046:Academic Medical Centers; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D005260:Female; D005374:Filtration / Q000295:instrumentation; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D011474:Prosthesis Design; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex