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Effects of carotid endarterectomy or stenting on hemodynamic complications in the International Carotid Stenting Study: a randomized comparison

Authors

  • Aysun Altinbas,

    Corresponding author
    1. Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht, The Netherlands
    • Correspondence: Aysun Altinbas, Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, PO Box 85500, G03·228, 3508 GA Utrecht, The Netherlands.

      E-mail: a.altinbas@umcutrecht.nl

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  • Ale Algra,

    1. Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht, The Netherlands
    2. Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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  • Martin M. Brown,

    1. Department of Brain Repair and Rehabilitation, Institute of Neurology, University College, London, UK
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  • Roland L. Featherstone,

    1. Department of Brain Repair and Rehabilitation, Institute of Neurology, University College, London, UK
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  • L. Jaap Kappelle,

    1. Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht, The Netherlands
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  • Gert Jan de Borst,

    1. Vascular Surgery, University Medical Center, Utrecht, The Netherlands
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  • Willem P. Th. M. Mali,

    1. Radiology, University Medical Center, Utrecht, The Netherlands
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  • H. Bart van der Worp,

    1. Utrecht Stroke Center, Departments of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht, The Netherlands
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  • and for the International Carotid Stenting Study Investigators


  • 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.

Abstract

Background

Carotid endarterectomy and carotid artery stenting are frequently complicated by hemodynamic instability.

Aims

The study aims to compare the incidence of hemodynamic complications between carotid artery stenting and carotid endarterectomy in the International Carotid Stenting Study (ISRCTN25337470).

Methods

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.

Results

 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.

Conclusion

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.

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