title: Poststent ballooning is associated with increased periprocedural stroke and death rate in carotid artery stenting.
abstract: BACKGROUND
  Whereas carotid endarterectomy (CEA) remains the "gold standard" treatment, given its low complication rate, carotid artery stenting (CAS) has emerged as a valid alternative in patients with prohibitive surgical risks. However, the application of CAS has been scrutinized, given its increased perioperative risk in comparison to CEA. Operators follow general guidelines in intraoperative techniques in CAS. However, few of those are evidence based. We believe that a specific outcome-driven examination of the effect of pre- and poststent deployment ballooning is warranted. The objective of this study was to analyze the effect of prestent ballooning (pre-SB) and poststent ballooning (post-SB) on hemodynamic depression (HD) and perioperative stroke or death.
  
  
  METHODS
  We performed a retrospective analysis of all patients who had CAS between 2005 and 2014 in the Vascular Quality Initiative database. Logistic regression analyses of the effect of different pre-SB and post-SB combinations on HD and the 30-day stroke and death rate were performed. We excluded patients who had no protection device, those with isolated common carotid artery lesions, and those who had no ballooning at all. The models controlled for patient age, gender, comorbidities, smoking status, symptomatic status, history of previous ipsilateral CEA, preoperative medications, and ipsilateral degree of stenosis.
  
  
  RESULTS
  A total of 3772 patients who underwent CAS were included for analysis. Average age of patients was 69.8 ± 9.6 years, with 63% being male. The overall perioperative stroke and death rate was 3.0%. Compared with pre-SB only technique, the combined pre-SB and post-SB technique had a 2.1-fold increase in HD (odds ratio, 2.13; 95% confidence interval, 1.51-3.01; P < .001) and 2.4-fold increase in perioperative stroke and death rate (odds ratio, 2.37; 95% confidence interval, 1.01-5.62; P < .050).
  
  
  CONCLUSIONS
  Compared with pre-SB alone, the use of post-SB increases the chances of perioperative HD and stroke and death rate in patients undergoing CAS. Post-SB should be used only in those cases with severe residual stenosis.
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Dean J
authors.initials: DJ
authors.lastname: Arnaoutakis
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: James
authors.initials: J
authors.lastname: Black
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
authors.forename: Bruce
authors.initials: B
authors.lastname: Perler
authors.affiliation: Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Malas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult