Carotid Artery Stenosis with Acute Ischemic Stroke: Stenting versus Angioplasty

Abstract

Background—When a patient with carotid artery stenosis presents emergently with acute ischemic
stroke, the optimum treatment plan is not clearly defined. If intervention is warranted, and open surgery is
prohibitive, endovascular revascularization may be performed. The use of stents places the patient at additional risk due to their thrombogenic potential. The intent of this study was to compare outcomes following
endovascular approaches (angioplasty alone vs. stent) in the setting of acute stroke.
Methods—We extracted a population from the National Inpatient Sample (2012) and the Nationwide
Inpatient Sample (2003–2011) composed of patients with carotid artery stenosis with infarction that were
admitted nonelectively and received endovascular revascularization. Patients treated with mechanical
thrombectomy or thrombolysis were excluded. Categorical variables were compared between treatment
groups with Chi-squared tests. Binary logistic regression was performed to evaluate mortality and iatrogenic stroke while controlling for age, case severity, and comorbidity burden.
Results—About 6,333 admissions met our criteria. A majority were treated via stenting (89%, n = 5,608).
The angioplasty-alone group had significantly higher mortality (9.0% vs. 3.8%, p < 0.001) and iatrogenic
stroke rate (3.9% vs. 1.9%, p < 0.001) than the stent group. The adjusted odds ratios of mortality and iatrogenic stroke for patients treated with angioplasty alone were 1.953 (p < 0.001) and 1.451 (p = 0.105),
respectively, in comparison to patients treated with carotid stenting.
Conclusion—Multivariate analysis found the risk of mortality to be elevated following angioplasty alone.
This may represent selection bias, but it also may indicate that symptomatic patients with stroke suffer from
severe stenosis and unstable plaques that would benefit from stent placement. These results would caution
angioplasty alone as an arm of a future randomized trial involving this severely burdened patient population
requiring urgent intervention.