title: Understanding risk factors for perioperative ischemic events with carotid stenting: is patient age over 80 years or is unfavorable arch anatomy to blame?
abstract: OBJECTIVE
  Several studies have reported increased perioperative risk after carotid artery stenting (CAS) for patients ≥80 years of age; however, most have not considered unfavorable anatomic features noted more frequently in this population as a confounding variable. The purpose of this study was to show a correlation between poor aortic arch anatomy and perioperative ischemic complications after CAS.
  
  
  METHODS
  Our prospectively maintained database was queried for all CAS procedures performed on symptomatic patients between 2009 and 2011. Retrospective analysis of consecutive CAS procedures was performed. The primary endpoint was perioperative (within 30 days) ischemic events (stroke, transient ischemic attack (TIA)). Event incidence was compared between groups dichotomized by age and anatomical features. Incidence of unfavorable arch (acute angle between aortic arch and treated common carotid artery) was compared between age groups.
  
  
  RESULTS
  Perioperative ischemic events included four ischemic strokes and three TIAs (all events ipsilateral to the treated vessel). Event incidence was more frequent in patients with unfavorable arch anatomy (7.9%) than in those with favorable aortic arch features (0.7%) (p=0.0073). Event incidence in patients ≥80 years of age (4.5%) was not statistically different than that in patients <80 years (2.3%) (p=0.428). Unfavorable aortic arch anatomy was increased in frequency in patients aged 80 years and over (<80 years, 29%; ≥80 years, 52%; p<0.001).
  
  
  CONCLUSIONS
  In the present series, the incidence of perioperative complications was increased in patients with unfavorable aortic arch anatomy but not in patients ≥80 years. CAS represents a revascularization option for patients of all ages; however, patients with unfavorable aortic arch anatomy may represent a group at relatively high risk for periprocedural ischemic events.
authors.affiliation: Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Travis M
authors.initials: TM
authors.lastname: Dumont
authors.forename: Maxim
authors.initials: M
authors.lastname: Mokin
authors.forename: Michael M
authors.initials: MM
authors.lastname: Wach
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Drummond
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.forename: L Nelson
authors.initials: LN
authors.lastname: Hopkins
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000002:abnormalities / Q000033:anatomy & histology*; D002545:Brain Ischemia / Q000453:epidemiology / Q000209:etiology*; D002340:Carotid Artery Diseases / Q000628:therapy*; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology / Q000209:etiology*; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000209:etiology; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects*; D020521:Stroke / Q000453:epidemiology / Q000209:etiology*; D016896:Treatment Outcome
keywords: Artery; Complication; Stent; Stroke