Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Impact of Time Interval between Index Event and Stenting on Periprocedural Risk in Patients with Symptomatic Carotid Stenosis

  • Han, Wonsuck (Department of Neurosurgery, Bundang Jesaeng General Hospital) ;
  • Hwang, Gyojun (Department of Neurosurgery, Bundang Jesaeng General Hospital) ;
  • Oh, Sung Han (Department of Neurosurgery, Bundang Jesaeng General Hospital) ;
  • Lee, Jong Joo (Department of Neurosurgery, Bundang Jesaeng General Hospital) ;
  • Kim, Mi Kyung (Department of Neurosurgery, Bundang Jesaeng General Hospital) ;
  • Chung, Bong Sub (Department of Neurosurgery, Anyang Sam Hospital) ;
  • Rhim, Jong Kook (Department of Neurosurgery, Jeju National University Hospital) ;
  • Sheen, Seung Hun (Department of Neurosurgery, Bundang CHA Medical Center, CHA University) ;
  • Kim, Taehyung (Department of Neurosurgery, Pyeongtaek St. Mary's Hospital)
  • Received : 2020.04.13
  • Accepted : 2020.06.22
  • Published : 2020.09.01
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : The purpose of this study was to evaluate the impact of time interval between index event and stenting on the periprocedural risk of stenting for symptomatic carotid stenosis and to determine the optimal timing of stenting. Methods : This retrospective study included 491 (322 symptomatic [65.6%] and 169 asymptomatic [34.4%]) patients undergoing carotid stenting. The symptomatic patients were categorized into Day 0-3, 4-7, 8-10, 11-14, 15-21, and >21 groups according to the time interval between index event and stenting. Periprocedural (≤30 days) risk for clinical (any neurological deterioration) and radiological (new infarction on postprocedural diffusion-weighted imaging) events of stenting in each time interval versus asymptomatic stenosis was calculated with logistic regression analysis adjusted for confounders, and provided as odds ratio (OR) and 95% confidence interval (CI). Results : Overall clinical event rate (4.3%) of stenting for symptomatic carotid stenosis was higher than that for asymptomatic stenosis (1.2%; OR, 3.979 [95% CI, 1.093-14.489]; p=0.036). Stenting in Day 0-3 (13.2%; OR, 10.997 [95% CI, 2.333-51.826]; p=0.002) and Day 4-7 (8.3%; OR, 6.775 [95% CI, 1.382-33.227]; p=0.018) was associated with high risk for clinical events. However, the clinical event rates in stenting after 7 days from index event (Day 8-10, 1.8%; Day 11-14, 2.5%; Day 15-21, 0%; Day >21, 2.9%) were not different from that in stenting for asymptomatic stenosis. Overall radiological event rate (55.6%) in symptomatic stenosis was also higher than that in asymptomatic stenosis (35.5%; OR, 2.274 [95% CI, 1.553-3.352]; p<0.001). The high risk for radiological events was maintained in all time intervals (Day 0-3 : 55.3%; OR, 2.224 [95% CI, 1.103-4.627]; p=0.026; Day 4-7 : 58.3%; OR, 2.543 [95% CI, 1.329-4.949]; p=0.005; Day 8-10 : 53.6%; OR, 2.096 [95% CI, 1.138-3.889]; p=0.018; Day 11-14 : 57.5%; OR, 2.458 [95% CI, 1.225-5.021]; p=0.012; Day 15-21 : 55.6%; OR, 2.271 [95% CI, 1.099-4.764]; p=0.028; Day >21 : 54.8%; OR, 2.203 [95% CI, 1.342-3.641]; p=0.002). Conclusion : This study showed that as stenting was delayed, the periprocedural risk for clinical events decreased. The clinical event risk was high only in stenting within 7 days and comparable with that for asymptomatic stenosis in stenting after 7 days from index event, although the radiological event risk was not affected by stenting timing. Therefore, our results suggest that delayed stenting after 7 days from symptom onset is a safe strategy for symptomatic stenosis.

Keywords

References

  1. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. : 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/ SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 42 : e464-e540, 2011
  2. de Castro-Afonso LH, Nakiri GS, Monsignore LM, dos Santos AC, Leite JP, Fabio SR, et al. : Early versus late carotid artery stenting for symptomatic carotid stenosis. J Neuroradiol 42 : 169-175, 2015 https://doi.org/10.1016/j.neurad.2015.03.002
  3. Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W, et al. : SPACE-2: a missed opportunity to compare carotid endarterectomy, carotid stenting, and best medical treatment in patients with asymptomatic carotid stenoses. Eur J Vasc Endovasc Surg 51 : 761-765, 2016 https://doi.org/10.1016/j.ejvs.2016.02.005
  4. Geng HH, Wang Q, Li B, Cui BB, Jin YP, Fu RL, et al. : Early neurological deterioration during the acute phase as a predictor of long-term outcome after first-ever ischemic stroke. Medicine (Baltimore) 96 : e9068, 2017 https://doi.org/10.1097/md.0000000000009068
  5. Groschel K, Knauth M, Ernemann U, Pilgram SM, Schnaudigel S, Kastrup A : Early treatment after a symptomatic event is not associated with an increased risk of stroke in patients undergoing carotid stenting. Eur J Neurol 15 : 2-5, 2008 https://doi.org/10.1111/j.1468-1331.2008.02212.x
  6. Jonsson M, Gillgren P, Wanhainen A, Acosta S, Lindstrom D : Periprocedural risk with urgent carotid artery stenting: a population based swedvasc study. Eur J Vasc Endovasc Surg 49 : 506-512, 2015 https://doi.org/10.1016/j.ejvs.2015.01.007
  7. Kim JT, Heo SH, Yoon W, Choi KH, Park MS, Saver JL, et al. : Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration. J Neurointerv Surg 8 : 461-465, 2016 https://doi.org/10.1136/neurintsurg-2015-011690
  8. Kim YD, Song D, Kim EH, Lee KJ, Lee HS, Nam CM, et al. : Long-term mortality according to the characteristics of early neurological deterioration in ischemic stroke patients. Yonsei Med J 55 : 669-675, 2014 https://doi.org/10.3349/ymj.2014.55.3.669
  9. Kwon HM, Lee YS, Bae HJ, Kang DW : Homocysteine as a predictor of early neurological deterioration in acute ischemic stroke. Stroke 45 : 871-873, 2014 https://doi.org/10.1161/STROKEAHA.113.004099
  10. Kwon HM, Lim JS, Park HK, Lee YS : Hypertriglyceridemia as a possible predictor of early neurological deterioration in acute lacunar stroke. J Neurol Sci 309 : 128-130, 2011 https://doi.org/10.1016/j.jns.2011.06.057
  11. Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. : Editor's Choice - management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 55 : 3-81, 2018 https://doi.org/10.1016/j.ejvs.2017.06.021
  12. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. : Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 50 : e344-e418, 2019
  13. Rantner B, Goebel G, Bonati LH, Ringleb PA, Mas JL, Fraedrich G, et al. : The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms. J Vasc Surg 57 : 619-626.e2; discussion 625-626, 2013 https://doi.org/10.1016/j.jvs.2012.08.107
  14. Rantner B, Kollerits B, Roubin GS, Ringleb PA, Jansen O, Howard G, et al. : Early endarterectomy carries a lower procedural risk than early stenting in patients with symptomatic stenosis of the internal carotid artery: results from 4 randomized controlled trials. Stroke 48 : 1580-1587, 2017 https://doi.org/10.1161/STROKEAHA.116.016233
  15. Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. : Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med 374 : 1011-1020, 2016 https://doi.org/10.1056/NEJMoa1515706
  16. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ : Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 35 : 2855-2861, 2004 https://doi.org/10.1161/01.str.0000147040.20446.f6
  17. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ; Carotid Endarterectomy Trialists Collaboration : Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 363 : 915-924, 2004 https://doi.org/10.1016/S0140-6736(04)15785-1
  18. Silver FL, Mackey A, Clark WM, Brooks W, Timaran CH, Chiu D, et al. : Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 42 : 675-680, 2011 https://doi.org/10.1161/strokeaha.110.610212
  19. Song KS, Kwon OK, Hwang G, Bae HJ, Han MK, Kim BJ, et al. : Early carotid artery stenting for symptomatic carotid artery stenosis. Acta Neurochir (Wien) 157 : 1873-1878, 2015 https://doi.org/10.1007/s00701-015-2548-8
  20. Topakian R, Strasak AM, Sonnberger M, Haring HP, Nussbaumer K, Trenkler J, et al. : Timing of stenting of symptomatic carotid stenosis is predictive of 30-day outcome. Eur J Neurol 14 : 672-678, 2007 https://doi.org/10.1111/j.1468-1331.2007.01815.x
  21. Tsantilas P, Kuehnl A, Kallmayer M, Knappich C, Schmid S, Breitkreuz T, et al. : Risk of stroke or death is associated with the timing of carotid artery stenting for symptomatic carotid stenosis: a secondary data analysis of the german statutory quality assurance database. J Am Heart Assoc 7 : e007983, 2018 https://doi.org/10.1161/jaha.117.007983
  22. Wach MM, Dumont TM, Mokin M, Kass-Hout T, Snyder KV, Hopkins LN, et al. : Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis. J Neurointerv Surg 6 : 276-280, 2014 https://doi.org/10.1136/neurintsurg-2013-010744
  23. Yang NR, Jeon P, Kim B, Kim KH, Jo KI : Usefulness of early stenting for symptomatic extracranial carotid stenosis. World Neurosurg 96 : 334-339, 2016 https://doi.org/10.1016/j.wneu.2016.09.027
  24. Zhang X, Sun Z, Ding C, Tang Y, Jiang X, Xie Y, et al. : metabolic syndrome augments the risk of early neurological deterioration in acute ischemic stroke patients independent of inflammatory mediators: a hospital-based prospective study. Oxid Med Cell Longev 2016 : 8346301, 2016