Conflicts of interests: Dr Altinbas has received research support from the Dutch Heart Foundation (2005B027). Dr Algra serves on the speakers' bureau for Boehringer Ingelheim and receives research support from the Dutch Heart Foundation. Dr Brown serves on a scientific advisory board for Bayer Schering Pharma and has received honoraria from AGA Medical Corporation and ICON for the work required as a member of two Trial End Point Committees. Dr Brown's Chair in Stroke Medicine is supported by the Reta Lila Weston Trust for Medical Research. This work was partly done at University College London Hospital and University College London, who received a proportion of funding from the Department of Health's National Institute for Health Research Biomedical Research Centres funding schemes. Dr Featherstone was supported by a grant from the Medical Research Council. Dr de Borst reports no disclosures. Dr Kappelle has received honoraria from serving on the scientific advisory boards of Boehringer Ingelheim and Bayer HealthCare Pharmaceuticals, serves on the editorial board of Cerebrovascular Diseases, and receives research support from the Dutch Heart Foundation and the Dutch Brain Foundation. Dr Mali reports no disclosures. Dr van der Worp has received speaker honoraria from GlaxoSmithKline and receives research support from the Dutch Heart Foundation (2010T075). ICSS was funded by the Medical Research Council (and managed by NIHR on behalf of the MRC-NIHR partnership), the Stroke Association, Sanofi-Synthélabo, and the European Union.
Effects of carotid endarterectomy or stenting on hemodynamic complications in the International Carotid Stenting Study: a randomized comparison
Article first published online: 9 JUL 2013
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
International Journal of Stroke
Volume 9, Issue 3, pages 284–290, April 2014
How to Cite
Altinbas, A., Algra, A., Brown, M. M., Featherstone, R. L., Kappelle, L. J., de Borst, G. J., Mali, W. P. Th. M., van der Worp, H. B. and International Carotid Stenting Study Investigators (2014), Effects of carotid endarterectomy or stenting on hemodynamic complications in the International Carotid Stenting Study: a randomized comparison. International Journal of Stroke, 9: 284–290. doi: 10.1111/ijs.12089
- Issue published online: 17 MAR 2014
- Article first published online: 9 JUL 2013
- Manuscript Accepted: 20 NOV 2012
- Manuscript Received: 7 JUL 2012
- angioplasty and stenting;
- carotid endarterectomy;
- carotid stenosis;
- hemodynamic complications;
- stroke prevention
Carotid endarterectomy and carotid artery stenting are frequently complicated by hemodynamic instability.
The study aims to compare the incidence of hemodynamic complications between carotid artery stenting and carotid endarterectomy in the International Carotid Stenting Study (ISRCTN25337470).
Patients with symptomatic carotid stenosis were randomly allocated to carotid artery stenting or carotid endarterectomy. The occurrence of peri-procedural hemodynamic depression (severe bradycardia, asystole, or hypotension requiring treatment) and hypertension requiring treatment was assessed in a per-protocol analysis. We compared the rate of hemodynamic complications, determined independent predictors thereof, and assessed their relation with the composite outcome of all-cause death, stroke, and myocardial infarction within 30 days of treatment.
A number of 766 carotid artery stenting and 819 carotid endarterectomy patients had a single completed intervention. Hemodynamic depression occurred in 13·8% after carotid artery stenting and in 7·2% after carotid endarterectomy (relative risk 1·9, 95% confidence interval 1·4–2·6, P < 0·0001). Hypertension requiring treatment occurred less often after carotid artery stenting than after carotid endarterectomy (relative risk 0·2, 95% confidence interval, 0·1–0·4, P < 0·0001). In carotid artery stenting patients, a history of cardiac failure was the strongest independent predictor of hemodynamic depression (relative risk 2·4, 95% confidence interval 1·3–4·8, P = 0·009). There was no statistically significant association between hemodynamic complications and the occurrence of the composite outcome.
Hemodynamic depression occurs more often after carotid artery stenting and severe hypertension more often after carotid endarterectomy, but these complications are not responsible for the excess of major perioperative events after carotid artery stenting.