Carotid highly-calcified de novo stenosis and cutting-balloon angioplasty: a tool to prevent haemodynamic depression?
OBJECTIVE
Severe highly-calcified de-novo lesions of carotid arteries are important predictors of haemodynamic depression (HD) after carotid artery stenting (CAS). Cutting-balloon angioplasty (CBA) using low-inflation pressures has been described as an effective method to achieve important luminal gain and avoid HD.


METHODS
from January 2005 to December 2007 102 consecutive patients (mean age 76.36+/-7.54 years) with severe highly-calcified de novo lesions of carotid artery undergoing CAS were prospectively observed and randomized in two groups: group 1 (N=50) underwent standard CAS, group 2 (N=52) underwent CAS with CBA. Patients with prior ipsilateral carotid endarterectomy (CEA), betablockers therapy or arrhytmias were excluded. HD was defined as periprocedural hypotension (systolic blood pressure <90 mmHg) or bradycardia (heart rate <60 beats/min). CBA angioplasty was carried out using CB coronary device, 0.014 inch compatible, from 3 to 4 mm or CB peripheral device, 0.018 inch compatible, from 5 to 6 mm in diameter, inflated at a mean-maximum value of 8.6 atmospheres; the average number of cuts per lesion was 2.7.


RESULTS
Demographic and clinical characteristic of both groups at the basal conditions were comparable. HD occurred in 18/50 (36%) procedures in group 1, and in 3/52 (5.76%) in group 2. The difference between the two groups concerning HD incidence was statistically significant (P<0.001). There was a strong (P<0.001) association between HD and CBA and the OR=0.109 (95%CI 0.019-0.425) confirmed the protective role of CBA. No major intraprocedural complications were observed in this series. Postprocedural Doppler ultrasound scan showed one case (2%) of in-stent restenosis in group 1 representing early failure due to recoil, and only 1 (1.92%) neurological adverse event (transient ischemic attack, TIA) in group 2.


CONCLUSIONS
HD is a common occurrence after CAS, especially in patients with both long and calcified plaque. Only a tailored procedure with a correct remodelling of the plaque allows to avoid both HD and elastic recoil of the target lesion.
Setacci
F
F
Department of Surgery, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy. setacci@unisi.it
Sirignano
P
P
de Donato
G
G
Chisci
E
E
Galzerano
G
G
Iacoponi
F
F
Setacci
C
C
D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D001919:Bradycardia / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007022:Hypotension / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D016017:Odds Ratio; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler