title: Carotid artery stenting according to the tailored-CAS algorithm is associated with a low complication rate at 30 days: data from the TARGET-CAS study.
abstract: BACKGROUND
  The rate of early complications of carotid artery stenting (CAS) should not exceed 3% in asymptomatic and 6% in symptomatic patients. However, some recent studies/registries failed to reach this threshold, fueling a debate on the role of CAS in the treatment of patients with carotid artery stenosis.
  
  
  OBJECTIVE
  To evaluate 30-day safety of CAS using different embolic protection devices and different stent types according to the tailored-CAS algorithm and to identify risk factors for complications.
  
  
  METHODS
  Between 2002 and 2010, we performed 1176 CAS procedures in 1081 patients (age 38-86 years, mean 66.3 ± 8.4 years, 51.5% symptomatic) according to the tailored-CAS algorithm that included extracranial ultrasound and computed tomography angiography to select the most appropriate embolic protection device (EPD) and stent type. Proximal EPD and closed-cell (CC) stents were preferentially used for high-risk lesions (HR - soft/thrombus-containing/tight/ulcerated, 36.14% of all lesions) and in symptomatic patients.
  
  
  RESULTS
  Procedural success rate was 99.8%. In symptomatic patients, proportion of HR lesions was higher (41.1%) than in the asymptomatic group (30.8%, p = 0.001) and the usage of CC stents (76.2% vs 71.7%, p = 0.103) and proximal EPD (P-EPD, 34.8% vs 27.7% among asymptomatic patients, p = 0.010) was more frequent. CC stents were used in 82.4% of CAS procedures involving HR lesions (vs 69.1% for non-HR lesions, p < 0.01), and P-EPD were used in 83.1% of procedures involving HR lesions (vs 2.5% for non-HR lesions, p < 0.001). In-hospital complications included 6 (0.55%) deaths, 1 (0.08%) major stroke and 19 (1.61%) minor strokes. No myocardial infarctions (MI) were noted. Among 7 (0.59%) cases of hyperperfusion syndrome, 2 were fatal. Thirty-day complication rate (death/any stroke/MI) was 2.38%. Age > 75 years was a predictor of death (p = 0.015), and prior neurological symptoms were a predictor of death/stroke (p = 0.030). There were 4 cases of periprocedural embolic cerebral artery occlusion, all treated with combined intracranial mechanical and local thrombolytic therapy.
  
  
  CONCLUSIONS
  CAS with EPD and stent type selection on the basis of thorough non-invasive diagnostic work-up (tailored- -CAS) is safe. Advanced age was associated with an increased risk of death and the presence of prior neurological symptoms was a predictor of death/stroke at 30 days. With the tailored-CAS approach, high-risk lesion features (soft/thrombus- -containing/tight/ulcerated) are eliminated as a risk factor. Hyperperfusion syndrome is a severe CAS complication which may lead to intracranial bleeding and death. Acute, iatrogenic embolic cerebral artery occlusion is rare and may be managed by combined intracranial mechanical and local thrombolytic therapy.
authors.affiliation: Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland. kardio@kki.krakow.pl
authors.forename: Piotr
authors.initials: P
authors.lastname: Pieniążek
authors.forename: Lukasz
authors.initials: L
authors.lastname: Tekieli
authors.forename: Piotr
authors.initials: P
authors.lastname: Musiałek
authors.forename: Anna
authors.initials: A
authors.lastname: Kabłak Ziembicka
authors.forename: Tadeusz
authors.initials: T
authors.lastname: Przewłocki
authors.forename: Rafał
authors.initials: R
authors.lastname: Motyl
authors.forename: Karolina
authors.initials: K
authors.lastname: Dzierwa
authors.forename: Piotr
authors.initials: P
authors.lastname: Paluszek
authors.forename: Marta
authors.initials: M
authors.lastname: Hlawaty
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Żmudka
authors.forename: Piotr
authors.initials: P
authors.lastname: Podolec
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D016893:Carotid Stenosis / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D057505:Embolic Protection Devices / Q000009:adverse effects*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000517:prevention & control; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015427:Reperfusion Injury / Q000209:etiology / Q000517:prevention & control; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors