Advances in interventional neuroradiology 2007.

T he year 2007 brought further understanding of the risk for subgroups of patients undergoing carotid artery stenting (CAS). For symptomatic patients, both increasing age and treatment within 2 weeks of neurological symptoms were associated with increased risk of perioperative stroke or death. 1 Unfavorable anatomic factors for CAS among octo-genarians included aortic arch elongation, calcification, great vessel origin stenosis, tortuosity, and severity of lesion stenosis, 2 and the combined perioperative stroke/ myocardial infarction/death rate was 10.8% for this group. 2 Diabetic patients Ն75 years undergoing CAS have 4.3ϫ greater risk for any stroke/death and 12.0ϫ greater risk for major stroke/ death, whereas diabetics Ͻ75 years have no increased risk. 3 Increasing age was also associated with higher rates of in-hospital stroke or death. 4 There was no significant difference in periprocedural complications after CAS for patients with previous ipsilateral carotid endarterectomy (CEA). 5 In an attempt to aid decision-making for surgical versus endovascular treatment of carotid artery disease, a single community-based hospital reviewed its contemporary experience with CEAs in 1900 patients. 6 High-surgical-risk patients comprised 54% of the total. The perioperative stroke/ death rate for this cohort was 1.6% compared with 1.3% for all patients. The 30-day stroke/myocardial infarction/death rate was 3.4%. Severe coronary artery disease and previous ipsilateral CEA were associated with increased risk for complications. 6 A prospective randomized trial of CAS versus CEA for symptomatic patients reported that despite increased diffusion-weighted imaging lesions on brain MRI after CAS, similar numbers of patients in each treatment group experienced cognitive changes. 7 A study evaluating brain MRI before and after CAS found diffusion-weighted imaging lesions in 41.5%, with no association between microscopic debris captured in the distal embolic protection device and new lesions on MRI. 8 A pre-/post-MRI study of diffusion-weighted imaging changes after CAS with distal embolic protection device or CEA found lesions in 70% of CAS-distal embolic protection device patients and in none of the CEA patients. 9 Among the CAS patients, diffusion-weighted imaging lesions relative to the vessel treated were either bilateral (36%), ipsilateral (47%), or contralateral (16%), and neurological symptoms lasting Ͼ36 hours occurred in 11%. 9 A protocol for comprehensive blood pressure management initiated in conjunction with CAS was shown to significantly reduce the incidence of intracerebral hemorrhage in all patients and both hyperperfusion syndrome and intracerebral hemorrhage in high-risk patients. 10 A number of industry supported registries continue to supply interesting data. …