Outcomes after Carotid Artery Stenting in Patients with Normal Neck Anatomy and Hostile Neck Anatomy Are Comparable

Carotid artery stenting (CAS) in patients with hostile neck anatomy (prior radiation therapy [XRT] and carotid endarterectomy [CEA]) is safe and effective, but concern remains for higher restenosis and differences in postoperative neurologic events. Our objective was to determine whether periprocedural and long-term outcomes of CAS performed in patients who have had prior XRT or CEA are comparable to those of patients with normal neck anatomy (NL). All patients who underwent CAS from January 2005 to September 2018 at our institution were included. Demographic data, procedural characteristics, and 30-day and long-term outcomes were collected. End points included stroke, death, in-stent restenosis >50%, and reintervention. There were 199 patients included: 114 patients with NL, 42 patients with prior CEA, and 43 patients with prior XRT. Demographic data are listed in Table I. CAS was more commonly performed in men, and age was similar across all groups. The overwhelming majority had >70% stenosis. XRT patients were healthier overall. Neurologic events occurred ≤30 days in four NL patients (3.7%), two CEA patients (4.9%), and one XRT patient (2.4%; all not significant), and all except one occurred in the perioperative period. At ≤30 days, there was one death in the NL group and one in the CEA group (not significant) and no myocardial infarctions or access site complications. Long-term outcomes are listed in Table II. Restenosis >70%, need for reintervention after CAS, and long-term stroke were low and similar between groups. Survival at 3 years ranged from 67.3% to 81.0% in all groups and was not significantly different. The occurrence of myocardial infarction during the course of follow-up was higher in prior CEA vs NL groups. CAS is safe and effective for patients with hostile neck anatomy, given the overall low periprocedural and long-term stroke events as well as observed restenosis rates. A higher long-term myocardial infarction rate in patients with prior CEA may reflect a higher overall burden of cardiovascular disease in this group. Patients with prior CEA and with prior XRT for head and neck cancer can be treated similar to patients with normal anatomy should CAS be necessary.Table IDemographics of patients with normal neck anatomy (NL) compared with patients with prior carotid endarterectomy (CEA) and prior radiation therapy (XRT)DemographicsNL (n = 114)Prior CEA (n = 42)P value (NL vs CEA)Prior XRT (n = 43)P value (NL vs XRT)Sex, male78 (68.4)22 (52.4).1035 (81.4).16Average age, years69.667.3–65.65–Presentation: symptomatic34 (29.8)7 (16.7).1515 (34.9).068Hypertension97 (85.1)37 (88.1).9229 (67.4).02Diabetes mellitus56 (49.1)11 (26.2).027 (16.3)<.01Hyperlipidemia96 (84.2)38 (90.5).5325 (58.1)<.01Coronary artery disease77 (67.5)28 (66.7).9615 (34.9)<.01Dialysis1 (0.9)0 (0)10 (0)1COPD43 (37.7)13 (31).5110 (23.3).11Never smokers16 (14)5 (11.9).589 (18.6).69COPD, Chronic obstructive pulmonary disease.Categorical variables are presented as number (%). Boldface entries indicate statistical significance (P < .05). Open table in a new tab Table IILong-term outcomes of patients with normal neck anatomy (NL) compared with patients with prior carotid endarterectomy (CEA) and prior radiation therapy (XRT)NL (n = 114)Prior CEA (n = 42)P value (NL vs CEA)Prior XRT (n = 43)P value (NL vs XRT)Restenosis >50%4 (3.51)3 (6.82).742 (4.65)1 >70%4 (3.51)0 (0).442 (4.65)1Reintervention4 (3.51)0 (0).501 (2.33)1MI3 (2.63)6 (13.6).021 (2.33)1Death (end of study)39 (34.2)15 (34.1).2015 (34.9).37Ipsilateral ischemic stroke2 (1.75)2 (4.55).742 (4.65).68Contralateral TIA/stroke2 (1.75)4 (9.09).122 (4.65).68Average length of follow-up, months23.0146.8–32.4–Average length of survival, months31.2646.8–39.07–Follow up at 1 year49 (42.98)35 (83.33)<.0126 (60.47).08Survival at 1 year87 (76.32)38 (90.48).0834 (79.07).88Follow up at 3 years23 (20.17)25 (59.52)<.0115 (34.88).09Survival at 3 years79 (69.30)34 (80.95).2133 (76.74).47MI, Myocardial infarction; TIA, transient ischemic attack.Categorical variables are presented as number (%). Boldface entries indicate statistical significance (P < .05). Open table in a new tab