CAS and Anatomic Factors: a Correlation with Age and Events

Stephanie C. Lin, MD, Weill Cornell Medical Center, Vascular Surgery, New York Presbyterian Hospital, New York, NY; Susan M. Trocciola, MD, New York, NY; Rabih Chaer, MD, New York, NY; James F. McKinsey, MD, New York, NY; K. Craig Kent, MD, New York, NY; Peter L. Faries, MD, New York, NY;

Purpose: Current evaluations of carotid artery angioplasty and stenting (CAS) have suggested non-inferiority compared to carotid endarterectomy (CEA). However, in older patients, the incidence of stroke and death with CAS may be higher than with CEA. We assessed the anatomic characteristics of patients undergoing CAS and compared them based on age greater or less than 75 years. The incidence of post-operative complications was also determined.
Methods: From February 2003 to April 2005, 134 patients underwent carotid artery angioplasty and stenting. Digital subtraction angiograms of 110 patients were available for analysis. Each patient was evaluated by two independent observers blinded to patient indentifiers. The following anatomic characteristics were assessed on a 3-point scale for anatomic and procedural complexity: aortic arch elongation, arch calcification, arch vessel origin stenosis, common carotid tortuosity, index lesion stenosis, lesion calcification, lesion length and internal carotid tortuosity. Post-operative events were defined as myocardial infarction, stroke and death. Chi-square analysis was used to determine statistical significance (p<0.05).
Results: Of the 110 patients, 69 (63%) were male and 41 (37%) female. 48 (44%) were older than 75 years of age. In these elderly patients, moderate and severe classifications were present more often for arch elongation (p=0.02), arch calcification (p=0.006), common carotid or innominate artery origin stenosis (p=0.02), common carotid tortuosity (p=0.02) and internal carotid tortuosity (p=0.0005). No statistically significant difference was found for index lesion stenosis, calcification or length. Post-operative stroke occurred in 4 patients (3%, 3 minor, 1 major), myocardial infarction in 3 patients (2.2%), and death in 1 patient (0.7%) who also suffered a hemorrhagic stroke. All complications occurred in patients older than 75 years.
Conclusions: Elderly patients, defined as age greater than 75 years, have a higher incidence of both complex anatomy and complications with CAS. Although the small number of post-operative events does not allow for determination of a direct relationship to specific anatomic characteristics, there are clearly certain anatomic factors which may pose significant risk of adverse events and therefore warrant serious consideration of CEA.