CONCEPTS, INNOVATIONS, AND TECHNIQUES

Sung-Chul Jin, MD
Department of Neurosurgery, Seoul National University, Bundang Hospital, Seongnam, South Korea

O-Ki Kwon, MD
Department of Neurosurgery, Seoul National University, Bundang Hospital, Seongnam, South Korea

A Technical Strategy for Carotid Artery Stenting: Suboptimal Prestent Balloon Angioplasty Without Poststenting Balloon Dilatation
BACKGROUND: Traditional carotid artery stenting (CAS) consists of predilatation, optional deployment of embolic protection devices, stenting, and poststent angioplasty. Each step carries a risk of thromboembolism. OBJECTIVE: To design a new and simplified procedural protocol, suboptimal balloon angioplasty without routine poststenting balloon dilatation, and to describe the efficacy this protocol in terms of procedural risks and angiographic and clinical outcomes. METHODS: Over a period of 6 years, 161 carotid artery stenoses in 156 consecutive patients were treated by CAS with embolic protection devices. Among them, 110 lesions in 107 patients (68.3%) were treated by our simplified method (symptomatic, . 50% stenosis; asymptomatic, . 70% stenosis). Overall, 98 lesions (88.3%) had severe stenosis (. 70%). RESULTS: The mean stenosis was reduced from 77% to 10% after CAS. A persistent neurological deficit developed in 2 patients from thromboembolism. Hemodynamic insufficiency developed in 14 lesions during CAS (12.7%). The ipsilateral stroke and mortality rate was 4.5% within 1 month after CAS (asymptomatic, 3.6%; symptomatic, 4.8%). Over a mean of 19 months of follow-up, additive angioplasty was performed in 2 patients as a result of progressive restenosis ($ 50%). A comparison of the balloon sizes of the prestent angioplasty for group 1 (balloon, # 4 mm) and group 2 (balloon, $ 5 mm) showed no difference in restenosis between the groups at 15 months of follow-up after CAS. CONCLUSION: Our CAS technique with suboptimal prestenting angioplasty without routine use of poststenting dilatation is safe, simple, and efficient with acceptable risks.
KEY WORDS: Balloon angioplasty, Carotid artery stent, Embolic protection device, Thromboembolism
Neurosurgery 67:14381443, 2010
DOI: 10.1227/NEU.0b013e3181f07c97

Chang Wan Oh, MD

Department of Neurosurgery, Seoul National University, Bundang Hospital, Seongnam, South Korea

Cheolkyu Jung, MD
Department of Radiology, Seoul National University, Bundang Hospital, Seongnam, South Korea

Moon Gu Han, MD
Department of Neurology, Seoul National University, Bundang Hospital, Seongnam, South Korea

Hee-Joon Bae, MD
Department of Neurology, Seoul National University, Bundang Hospital, Seongnam, South Korea

Sang Hyung Lee, MD

Department of Neurosurgery, Seoul National University, Boramae Hospital, Seoul, South Korea

Young Sub Jung, MD

Department of Neurosurgery, Seoul National University, Boramae Hospital, Seoul, South Korea

www.neurosurgery-online.com

Moon Hee Han, MD

Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea

Hyun-Seung Kang, MD
Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea

Reprint requests: OKi Kwon, MD, Bundang Hospital, 300 Gumi-dong, Bungdang-gu, Seongnam, Gyeonggi, 463-707, South Korea. E-mail: kwonoki@korea.com Received, October 28, 2009. Accepted, April 12, 2010. Copyright 2010 by the Congress of Neurological Surgeons

arotid artery stenting (CAS) has emerged as a safe and efficient modality for patients with severe carotid artery stenosis at high risk for carotid endarterectomy. However, standardization of CAS procedures has not been established. The traditional CAS technique involves initial dilatation with a small balloon (predilatation) to achieve access for other devices, optional placement of an embolic protection device (EPD), followed by positioning of a stent across the stenosis, and poststenting balloon
ABBREVIATIONS: CAS, carotid artery stenting; CTA, computed tomography angiography; EPD, embolic protection device

dilatation (postdilatation) to achieve maximum vessel expansion after stenting. All procedural steps can hold thromboembolic risks, but poststenting balloon dilatation has been known as the riskiest part.1,2 To minimize procedural thromboembolic complications, several studies have reported the safety and efficacy of stenting alone for carotid artery stenosis.3-5 The rationale for this CAS strategy was that avoiding the use of a balloon and an EPD might reduce the risk of distal embolization, in addition to reducing the complexity and cost of the procedure. However, insufficient dilatation is a weak point of this strategy. Our accumulation of experience with CAS led us to modify traditional CAS methods. Our

1438 | VOLUME 67 | NUMBER 5 | NOVEMBER 2010

www.neurosurgery-online.com

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

CAROTID STENTING WITHOUT POSTDILATATION

strategy for CAS has been as follows: passage of an EPD distal to the stenotic lesion without predilatation, prestenting angioplasty with a balloon approximately 1 mm smaller than normal internal carotid artery diameter, stent deployment, and poststenting angioplasty only for residual stenosis . 30%. The aim of this study was to evaluate the efficacy and safety of our technical strategy for CAS.

PATIENTS AND METHODS

Patient Population
Between July 2003 and December 2008, 156 consecutive patients with 161 carotid artery stenoses underwent CAS with an EPD at Seoul National University, Bundang Hospital. CAS was indicated in symptomatic or asymptomatic patients with carotid artery stenosis of . 50% or . 70%, respectively. Our study included 107 patients with 110 carotid stenoses who underwent CAS with prestenting balloon angioplasty without postdilatation. There were 88 men and 19 women with a mean age of 69.9 years (range, 44-87 years). Ninety-five patients (88.8%) had comorbidity equivalent to the high-risk cohort of patients in the North American Symptomatic Carotid Endarterectomy Trial or the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy Trial for carotid endarterectomy.6,7 Eighty-two lesions (74.5%) were symptomatic and 28 were asymptomatic. All asymptomatic lesions and 70 of 82 symptomatic lesions (88.3%) had . 70% stenosis. The proportion with . 90% stenosis was 25.4%. One patient had radiation-induced stenosis. No patients had restenosis after previous carotid endarterectomy. Definite ulceration of atheromatous plaques was revealed in 27 lesions (24.5%) on conventional angiography. Forty-one stenotic lesions (37.3%) were . 20 mm. Procedural time was defined as the time interval between femoral puncture and immediate angiogram after CAS. Clinical follow-up duration was defined as the interval between admission for intervention and final clinical follow-up. The duration of clinical or radiologic follow-up was calculated up to May 2009. Clinical evaluation of the patient after discharge was undertaken mainly by neurologists (M.G.H., H.J.-B.) independently of the procedure and was performed at 1, 3, and 6 months and at 6-month or 1-year intervals thereafter. The primary endpoint was defined as ipsilateral stroke (either ischemic stroke or intracerebral hemorrhage, with symptoms that lasted for 24 hours) or death resulting from any cause. The secondary endpoint was defined as contralateral stroke or myocardial infarction. Follow-up assessment for restenosis or stent patency was generally carried out by computed tomography angiography (CTA) within 6 months after stent placement or transfemoral catheter angiography 1 year after stent placement and annually thereafter. Restenosis was defined as stenosis . 50% on follow-up CTA or transfemoral catheter angiography.

completed within 1 hour in most cases. An 8F introducer sheath was inserted in the common femoral artery. Activated coagulation time was not checked routinely. A guiding catheter (6F Shuttle; Cook, Bloomington, Indiana) was placed in the common carotid artery. Under roadmap guidance, the stenotic lesion was crossed with a 0.014-in guidewire. This was followed by navigation and positioning of an EPD (Emboshield in 82 arteries [Abbott, Galway, Ireland], Spider in 21 arteries [ev3, Plymouth, Minnesota]) distal to the stenotic lesion. The EPD was advanced without the aid of predilatation in 97 lesions (88.2%). Prestenting dilatation with a balloon was applied subsequently to the stenotic lesion after placement of the EPD. The size of balloon was chosen to be about 1 mm smaller than the normal diameter of the distal internal carotid artery. For patients with heart disease and carotid bulb stenosis, 3-mm balloons were often selected despite larger internal carotid artery size. Patients were subdivided into group 1 (prestenting angioplasty with a 3- or 4-mm diameter balloon; n = 58) and group 2 (prestenting angioplasty with 5- or 6-mm diameter balloons; n = 52) according to the prestenting angioplasty balloon size. We positioned the balloon covering the stenotic segment in a monorailed (# 3-mm balloons) or over-the-wire fashion ($ 4-mm balloons) and inflated the balloon gradually once in most cases while monitoring vital signs. The most commonly used stents were Precise (Cordis, Miami Lakes, Florida) in 97 arteries and Wallstent (Boston Scientific, Natick, Massachusetts) and Pro tege (ev3) in 6 lesions each. Poststenting balloon angioplasty was not performed routinely except when significant residual stenosis (. 30%) was found on immediate poststenting angiography.

Statistical Analysis
Statistical analysis was performed to evaluate the efficacy of our CAS method according to balloon size. Nominal data were analyzed with the Fisher exact test or x2 test. Numerical data were analyzed with the t test for parametric values or Mann Whitney U test for nonparametric values. Values of P , .05 were considered significant.

RESULTS
With our protocol, CAS was performed successfully for all lesions. In 110 of 161 carotid stenotic lesions (68.3%), no poststent balloon dilatation was required. Poststent balloon dilatation was performed in cases of . 30% residual stenosis after stent deployment. Poststent angioplasty was not performed even with . 30% residual stenosis in 7 lesions to avoid repetitive severe hemodynamic instability. Poststent dilatation was performed in 47 lesions (29.2%). In 110 carotid stenotic lesions treated without poststent dilatation, immediate angiographic outcome after CAS with our protocol was as follows: residual stenosis # 10% (n = 83, 75.5%), residual stenosis . 10% and # 30% (n = 20, 18.2%), and residual stenosis . 30% and # 50% (n = 7, 6.4%). Mean procedural time was 29.9 minutes, ranging 10 to 92 minutes (SD, 13.9). Follow-up imaging was performed in 72 of 110 stenotic lesions (65.5%) within 1 year after the procedure mainly with CTA. CTA within 1 year after CAS was not performed in some cases for the following reasons: transfer to other hospitals (n = 6), follow-up loss with no specific reasons given (n = 24), and neurological disability or death (n = 8). Within 1 year after CAS, 1 case of restenosis (. 50%) in asymptomatic lesions occurred. In

Our CAS Techniques

Patients received oral aspirin (100 mg) and clopidogrel (75 mg) for at least 7 days before the procedure. Aspirin and a loading dose of clopidogrel (300 mg) were given in the case of emergency stenting (n = 2). Stent placement was performed under local anesthesia in all patients. For stenotic lesions that involved the carotid bulb, an external pacemaker was attached to the anterior chest as discussed in our previous report.8 At the beginning of the procedure, patients received an intravenous bolus injection of 3000 U heparin. An intermittent bolus of 1000 U heparin was given at 1-hour intervals thereafter, but the whole procedure was

NEUROSURGERY

VOLUME 67 | NUMBER 5 | NOVEMBER 2010 | 1439

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

JIN ET AL

53 cases with follow-up CTA or transfemoral catheter angiography at 1 year after CAS and thereafter, restenosis . 50% was found in 2 patients. One patient with symptomatic lesion had poor compliance with antiplatelet medication. The other patient with asymptomatic restenosis was detected on follow-up radiological images. For these 2 patients, retreatment with balloon angioplasty was performed. Procedural complications included bradycardia or hypotension (n = 14, 12.7%); cerebral thromboembolism, including asymptomatic patients (n = 8, 7.2%) (2 were symptomatic); transient ischemic attack without evidence of thromboembolism in angiography and diffusion magnetic resonance image (n = 1, 0.9%); hyperperfusion-induced intracerebral hemorrhage (n = 1, 0.9%); iatrogenic carotid dissection (n = 1, 0.9%); and femoral artery occlusion by malfunction of closing device (n = 1, 0.9%). Bradycardia or hypotension during CAS occurred in 14 patients (12.7%): bradycardia alone in 7, bradycardia with hypotension in 6, and blood pressure fluctuation with bradycardia in 1. All patients except one recovered spontaneously or with the aid of fluid therapy and vasopressor medication within 1 or 2 days after the procedure. An 85-year-old man with heart disease and symptomatic 80% left carotid artery stenosis did not recover from intractable hypotension and bradycardia. This resulted in pulmonary edema, multiple organ failure, and death. Among the patients with thromboembolic complications, 2 (1.9%) suffered from hemiparesis that developed immediately after the procedure, which was sustained at 15 and 21 months of follow-up, respectively. Other patients with thromboembolic complications remained symptom free. Symptomatic hyperperfusion presented with intracerebral hemorrhage developed in 1 patient (0.9%), who remained severely disabled despite surgical hematoma evacuation. Ipsilateral stroke and mortality rates (primary endpoint) within 1 month after CAS,

including procedure-related symptomatic complications, were 2.7% (asymptomatic, 3.6%; symptomatic, 2.4%) and 1.8% (asymptomatic, 0%; symptomatic 2.4%), respectively. The cause of death in patients with symptomatic lesions included multiple organ failure from intractable hemodynamic instability (n = 1) and abdominal aortic aneurysm rupture (n = 1) in group 2 only. The combined contralateral stroke and myocardial infarction rate (secondary endpoint) within 1 month after the procedure was 0.9% (asymptomatic, 0%; symptomatic, 1.2%). Clinical follow-up data beyond 1 year were available for 67 of 83 lesions (80.7%). The 1-year ipsilateral stroke and mortality rate was 0% (asymptomatic, 0%; symptomatic, 0%) and 3.0% (asymptomatic, 5.3%; symptomatic, 2.1%), respectively. The asymptomatic patient and symptomatic patient in group 1 died of acute myocardial infarction and hepatocellular carcinoma with septic shock, respectively. A comparison of groups 1 and 2 (Table 1) shows that there was no difference in the incidence of thromboembolic complications and hemodynamic instability, but symptomatic thromboembolic complication and intractable hypotension with bradycardia developed more in group 2 patients. The average degree of residual stenosis immediately after the procedure was significantly higher in group 1 (P = .001), but restenosis at the 6-month follow-up or between 6 and 15 months after CAS did not differ between the 2 groups. There was no significant difference in the need for additional angioplasty for restenosis between groups 1 and 2. Poststenting balloon angioplasty was not performed routinely except when significant residual stenosis (. 30%) was found on immediate poststenting angiography (n = 47). Table 2 compares the no poststent balloon angioplasty group and poststent balloon angioplasty group. There were no significant differences in thromboembolic, hemodynamic, angiographic, and clinical results between these groups.

TABLE 1. Comparison of Patients and Angiographic Characteristics, Procedural Outcome, and Angiographic Outcome Between Groups 1 (Prestenting Balloon # 4 mm) and 2 (Prestenting Balloon $ 5 mm) According to Prestenting Balloon Sizea Variable Mean age (SD), y Male patients, n (%) With symptomatic lesions, n (%) With vascular risk factors, n (%) With high risk for carotid endarterectomy, n (%) Mean percent stenosis before procedure (SD) With ulceration (%) Mean percent of residual stenosis immediately after procedure (95% CI) With thromboembolic complication, n (%) With hemodynamic instability, n (%) Mean percent restenosis within 1 y after procedure (95% CI) Mean percent restenosis 1 y after procedure (95% CI)
a

Group 1 (n = 58) 71.7 43 44 50 26 79.9 12 13.6 3 7 4.8 10.3 (7.5) (74.1) (75.8) (86.2) (44.8) (10.5) (20.7) (9.7-17.5) (5.2) (12.1) (0.7-9.0) (4.2-16.3)

Group 2 (n = 52) 68.0 45 38 41 22 73.2 15 5.2 5 8 4.5 5.9 (9.1) (86.5) (73.1) (78.8) (42.3) (11.5) (28.8) (2.8-7.6) (9.6) (15.4) (0.9-8.3) (1.8-10.0)

P .02 .32 .74 .31 .79 .002 .32 .001 .37 .62 .94 .09

SD, standard deviation; CI, confidence interval.

1440 | VOLUME 67 | NUMBER 5 | NOVEMBER 2010

www.neurosurgery-online.com

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

CAROTID STENTING WITHOUT POSTDILATATION

TABLE 2. Comparison of Patients and Angiographic Characteristics, Angiographic Outcome, and Clinical Outcome According to the Performance of Poststent Balloon Angioplastya Variable With symptomatic lesions, n (%) With vascular risk factors, n (%) With high risk for carotid endarterectomy, n (%) Mean percent stenosis before procedure (SD) Mean percent residual stenosis immediately after procedure (95% CI) With thromboembolic complication, n (%) With hemodynamic instability, n (%) Mean percent restenosis within 1 y after procedure (CI) Primary endpoint within 1 mo after CAS (%) Secondary endpoint within 1 mo after CAS, n (%)
a

No Poststent Balloon Angioplasty, n = 110 82 91 48 76.5 9.5 8 15 1.2 5 1 (75.8) (82.7) (43.6) (11.7) (7.1-12.0) (7.3) (13.6) (1.1-1.4) (4.5) (0.9)

Poststent Balloon Angioplasty, n = 47 33 37 22 79.3 11.0 2 8 5.0 (70.2) (78.7) (46.8) (12.5) (7.3-14.6) (4.3) (17.0) (0.7-9.3) 0 2 (4.3)

P .57 .5 .23 .10 .29 .72 .63 .24 .32 .20

SD, standard deviation; CI, confidence interval; CAS, carotid artery stenting.

DISCUSSION
Traditional CAS technique includes initial predilatation with a small balloon by which an EPD or a stent is accessible distal to the stenosis, optional placement of an EPD, followed by deployment of a stent covering the stenosis, and postdilatation to achieve maximum vessel expansion after stent deployment. However, standardization of CAS procedures has not been established, and there are many technical variations across institutions and individual interventionists. Consensus on how much residual stenosis is required for subsequent poststent balloon angioplasty has not been reached. According to our accumulated CAS experience, restoration of flow may be sufficient if residual stenosis is , 30%. Therefore, subsequent poststent balloon angioplasty may not be necessary. Although our criterion (residual stenosis . 30%) for whether poststent balloon angioplasty should be performed cannot be applied to general guidelines for poststent balloon angioplasty, our trial may have clinical significance. First, we questioned whether poststent balloon angioplasty should be performed routinely; second, we suggested a guideline of poststent balloon angioplasty (. 30% residual stenosis). CAS should be performed primarily for restoring carotid lumen and reducing the potential risk of plaque embolism. How large one should dilate the carotid lumen is controversial, but an attempt to achieve perfect restoration of angiographic lumen with a large balloon may produce adverse reactions such as excessive carotid sinus reflex (bradycardia and hypotension) and plaque rupture/embolism. Postdilatation is known as the most emboligenic part of the CAS procedure.1,2 Our simplified CAS protocol began from the question of whether all steps, each with a thromboembolic risk, are really necessary. Conventional predilatation is usually performed by small coronary or peripheral angioplasty balloons to make a stenotic lumen large enough for devices such as EPDs or stents to pass through stenotic segments. In our experience, conventional predilatation

was not necessary in most cases, even with severe stenosis (, 1 mm stenosis). Because of an elastic property of the vessel wall and the tapered tip of most EPDs, we navigated EPDs across the stenosis easily without predilatation. Additionally, placing EPDs through the severe stenosis could have the advantage of luminal occlusion (flow occlusion of the internal carotid artery), which would reduce embolism during device manipulation. Our technique of prestenting dilatation aims to enlarge the stenotic lumen suboptimally with the balloon itself and to reduce the resistance of expansion by producing minimal plaque dissection. We selected a balloon about 1 mm smaller than the distal internal carotid artery lumen for predilatation. With stent deployment, the stenotic lumen was further dilated enough not to require postdilatation in 70% of our patients (# 30% of residual stenosis). In our series, CAS with a 3- or 4-mm-diameter balloon for prestenting angioplasty had no symptomatic thromboembolic complications. Compared with patients treated with 5- or 6-mmdiameter balloons, immediate luminal gain was less but the late restenosis rate was statistically not higher in the patients who underwent predilatation with 3- or 4-mm-diameter balloons. Our series demonstrates that prestenting angioplasty with a 3- or 4-mm-diameter balloon is sufficient in terms of luminal gain and low thromboembolic complication rate. We did not perform poststent balloon dilatation routinely. Hemodynamic insufficiency is seen more frequently in CAS than carotid endarterectomy, primarily with balloon inflation.9-14 Gupta et al11 have reported that hemodynamic depression that required vasopressor support developed in up to 17% of patients. However, most intraprocedural bradycardia or hypotension can be managed conservatively or with intravenous fluid and isotropic or chronotropic agents and does not confer increased periprocedural risks.5,7 The present study showed a similar incidence of hemodynamic insufficiency compared with previous studies. There was a tendency for more hemodynamic insufficiency and intractable hemodynamic insufficiency in group 2 patients who

NEUROSURGERY

VOLUME 67 | NUMBER 5 | NOVEMBER 2010 | 1441

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

JIN ET AL

were treated with 5- or 6-mm balloons despite no statistical difference. Balloon angioplasty with smaller balloons may be beneficial in reducing hemodynamic insufficiency. Several studies reported that restenosis rates with conventional CAS ranged from 0.6% to 11% at 1 year.1520 The restenosis rate of our CAS protocol seems not to be higher than the rate of in-stent restenosis, which was 1.4% (, 1 year) and 3.8% ($ 1 year after CAS). Our study has several limitations. First, this study was observational, not case controlled. Second, we did not use objective tools such as transcranial Doppler sonography, diffusionweighted magnetic resonance imaging, and neurocognitive tests when comparing our CAS protocol group with the poststent dilatation group. Lastly, our study requires a longer radiological and clinical follow-up period for clinical significance. Despite these limitations, our CAS protocol, which is characterized as a simplified method, has benefits in terms of technical ease, short operation time, low cost, and low complication rates with compatible efficacy.

CONCLUSION
Our technical strategy of CAS with prestenting angioplasty with a 3- or 4-mm-diameter balloon without postdilatation resulted in a favorable outcome with acceptable morbidity and mortality, in addition to procedural convenience and reduced time. DISCLOSURE
The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

11. Gupta R, Abou-Chebl A, Bajzer CT, Schumacher HC, Yadav JS. Rate, predictors, and consequences of hemodynamic depression after carotid artery stenting. J Am Coll Cardiol. 2006;47(8):1538-1543. 12. Leisch F, Kerschner K, Hofmann R, et al. Carotid sinus reactions during carotid artery stenting: predictors, incidence, and influence on clinical outcome. Catheter Cardiovasc Interv. 2003;58(4):516-523. 13. Mlekusch W, Schillinger M, Sabeti S, et al. Hypotension and bradycardia after elective carotid stenting: frequency and risk factors. J Endovasc Ther. 2003;10(5):851-859. 14. Qureshi AI, Luft AR, Sharma M, et al. Frequency and determinants of postprocedural hemodynamic instability after carotid angioplasty and stenting. Stroke. 1999;30(10):2086-2093. 15. Goodney PP, Schermerhorn ML, Powell RJ. Current status of carotid artery stenting. J Vasc Surg. 2006;43(2):406-411. 16. Gray WA, Hopkins LN, Yadav S, et al. Protected carotid stenting in high-surgical risk patients: the ARCHeR results. J Vasc Surg. 2006;44(2):258-268. 17. Reimers B, Tu bler T, de Donato G, et al. Endovascular treatment of in-stent restenosis after carotid artery stenting: immediate and midterm results. J Endovasc Ther. 2006;13(4):429-435. 18. Roubin GS, Iyer S, Halkin A, Viteck J, Brennan C. Realizing the potential of carotid artery stenting: proposed paradigms for patient selection and procedural technique. Circulation. 2006;113(16):2021-2030. 19. Skelly CL, Gallagher K, Fairman RM, et al. Risk factors for restenosis after carotid artery angioplasty and stenting. J Vasc Surg. 2006;44(5):1010-1015. 20. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501.

COMMENTS
he authors propose that poststent angioplasty is not necessary unless the degree of residual stenosis after prestent angioplasty is . 30%. They report on 156 patients with 161 stenoses treated by carotid artery stenting (CAS) using a distal protection device. In their series, accumulated over 6 years, 110 cervical carotid stenoses in 107 patients were treated without poststent angioplasty. Ninety-eight of these stenoses were . 70%. Ipsilateral stroke and mortality were within accepted limits for both asymptomatic (3.6%) and symptomatic (4.5%) disease. During the follow-up, 2 patients required repeat angioplasty. There was no difference in restenosis rate or stroke and death rate when subgroup analysis was reported as a function of prestent angioplasty balloon diameter (4 or 5 mm). It is well known that the rate and quantity of embolic events are highest during poststent angioplasty. This was recorded using transcranial Doppler during CAS, monitoring the middle cerebral arteries. This was first reported by Rubin and Vitek.1 Therefore, if this step in the CAS procedure could be eliminated, embolic load would be reduced. In addition, when CAS is performed with nitinol self-expanding stents, carotid lumen diameter continues to increase as the stent continues to apply radial outward force on the vessel wall. This late lumen gain can be enhanced when the self-expanding stent diameter is greater than the native vessel diameter. Poststent angioplasty is also associated with bradycardia and hypotension. In patients with untreated left main coronary artery disease, hypotension during carotid angioplasty and stent can be fatal.2 In carotid lesions that are heavily calcified and located adjacent to the carotid bulb, poststent angioplasty with larger-diameter balloons can induce significant baroreceptor responses, resulting in the need for atropine and inotropic support. Hospital length of stay can increase as a result of poststent balloon angioplasty in this subset of patients. The authors report that in 32% of patients prestent balloon angioplasty resulted in a 30% residual stenosis. In these patients, poststent balloon angioplasty was performed. The lesion characteristics that may

REFERENCES
1. Martin JB, Pache JC, Treggiari-Venzi M, et al. Role of the distal balloon protection technique in the prevention of cerebral embolic events during carotid stent placement. Stroke. 2001;32(2):479-484. 2. Vitek JJ, Roubin GS, Al-Mubarek N, New G, Iyer SS. Carotid artery stenting: technical considerations. AJNR Am J Neuroradiol. 2000;21(9):1736-1743. 3. Bussiere M, Pelz DM, Kalapos P, et al. Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis. J Neurosurg. 2008;109(3):454-460. 4. Lownie SP, Pelz DM, Lee DH, et al. Efficacy of treatment of severe carotid bifurcation stenosis by using self-expanding stents without deliberate use of angioplasty balloons. AJNR Am J Neuroradiol. 2005;26(5):1241-1248. 5. Maynar M, Baldi S, Rostagno R, et al. Carotid stenting without use of balloon angioplasty and distal protection devices: preliminary experience in 100 cases. AJNR Am J Neuroradiol. 2007;28(7):1378-1383. 6. Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade carotid stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991;325(7):445-453. 7. Mozes G, Sullivan TM, Torres-Russotto DR, et al. Carotid endarterectomy in SAPPHIRE-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg. 2004;39(5):958-965. 8. Im SH, Han MH, Kim SH, Kwon BJ. Transcutaneous temporary cardiac pacing in carotid stenting: noninvasive prevention of angioplasty-induced bradycardia and hypotension. J Endovasc Ther. 2008;15(1):110-116. 9. Cayne NS, Faries PL, Trocciola SM, et al. Carotid angioplasty and stent-induced bradycardia and hypotension: impact of prophylactic atropine administration and prior carotid endarterectomy. J Vasc Surg. 2005;41(6):956-961. 10. Dangas G, Laird JR Jr, Satler LF, et al. Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology. 2000;215(3):677-683.

1442 | VOLUME 67 | NUMBER 5 | NOVEMBER 2010

www.neurosurgery-online.com

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

CAROTID STENTING WITHOUT POSTDILATATION

have prompted the need for poststent angioplasty were not reported. In the future, ultrasound may help identify which cervical carotid bifurcation plaques will require poststent angioplasty. If poststent angioplasty can be avoided, the number of embolic events can be reduced. In addition, the bradycardia and hypotension caused by baroreceptor manipulation can be reduced. Lee R. Guterman Frederick Vincent Amherst, New York
1. Crawley F, Stygall J, Lunn S, Harrison M, Brown MM, Newman S. Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke. 2000;31(6):13291344. 2. Lopes DK, Mericle RA, Lanzino G, Wakhloo AK, Guterman LR, Hopkins LN. 3. Stent placement for the treatment of occlusive atherosclerotic carotid artery disease in patients with concomitant coronary artery disease. J Neurosurg. 2002;96(3):490-496.

in et al review the results of their experience over a 6-year period performing 110 carotid revascularization procedures in which they did not perform poststenting angioplasty if the prestent dilatation and stent placement yielded . 70% luminal opening. Both symptomatic (. 50% stenosis) and asymptomatic (. 70%) lesions were treated, of which 88.8% had comorbidities consistent with those in the Stenting and Angioplasty with Protection in Patients at High risk for Endarterectomy trial or the North American Symptomatic Carotid Endarterectomy Trial. An embolic protection device was used in all instances. During the same time period, 47 lesions (29.2%) of all the carotid revascularization procedures at this institution did require poststent dilatation. Carotid stenting was successful in all instances. There was a 4.5% combined rate of ipsilateral stroke and mortality at 1 month. Follow-up imaging was via computed tomography angiography, which was performed on 65.5% of the cohort within 6 months and showed no restenosis. Two of 27 patients imaged this way between 15 and 36 months after the procedure showed $ 50% restenosis and underwent repeat angioplasty. The authors substratified the cohort on the basis of whether a small or larger balloon was used for the prestent dilatation and found a statistically significant increased complication rate with the larger balloon and no decreased restenosis rate. The article raises an important issue, that there is a significant lack of scientific data concerning the optimal radiographic endpoint for carotid angioplasty and stenting (CAS). Unlike with carotid endarterectomy, a , 100% luminal repair with CAS is not uncommon. Interestingly, but not surprisingly, the angiographic results from carotid angioplasty/ stenting have been dichotomized in large trials and published clinical

series. This articles announces what is known but infrequently discussed: that angiographic outcomes after CAS reside on a spectrum. In this regard, the article raises more questions than it answers. When does the risk associated with one more dilatation outweigh the potential longterm benefits in terms of clinical outcome? Is the number of predilatation or postdilatations a significant factor influencing long-term restenosis and/or outcome? The authors have simply shown that there is no shortterm radiographic or clinical downside to not poststent dilating in patients in whom . 70% luminal opening is achieved with prestent dilatation and stent placement. I believe many operators, including myself, currently do hold off on poststent angioplasty if a fairly good dilatation is achieved with predilatation angioplasty and stent placement with the idea that poststent angioplasty carries risk and there are inadequate data suggesting that a very mild residual stenosis is detrimental in the near or distant future. Granted, this has not been rigorously studied. The authors would have buttressed their position quite a bit by using transcranial Doppler, diffusion-weighted magnetic resonance imaging or neurocognitive testing and then compared their own group in which poststent dilatation was used and the cohort in which it was not. One wonders whether the authors were very aggressive with the prestenting dilatation to achieve such good results before stent placement. If so, does this kind of aggressive prestent dilatation offset the benefit of no prestent dilatation? Again, transcranial Doppler and diffusion-weighted magnetic resonance imaging might have helped address this. Jonathan L. Brisman Long Island, New York

wo ongoing practical issues in carotid angioplasty and stenting (CAS) concern the need for prestent deployment angioplasty and the utility of poststent angioplasty. Few published data exist to guide neurointerventionalisits in these matters. The authors have done a retrospective study of their experience with carotid angioplasty and stenting according to 2 technical aspects of the CAS procedure: size of the prestent angioplasty balloon and the presence or absence of pos-stenting angioplasty. They found better results in terms of complications with smaller prestent balloons and no significant differences between patients treated with and those treated without poststent angioplasty. The lesson here is that less is more with CAS and that a minimalist approach (small initial angioplasty balloon, no poststent angioplasty) may be prudent. Mark R. Harrigan Ann Arbor, Michigan

NEUROSURGERY

VOLUME 67 | NUMBER 5 | NOVEMBER 2010 | 1443

Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.