Carotid artery stenting in high-risk patients: midterm mortality analysis.

Carotid artery interventions are predicated on early and late survival to prevent ischemic strokes. The technical feasibility of carotid artery stenting (CAS) has been established. Short-term results have been conflicting. Despite this, many practices have adopted CAS as an alterative to carotid endarterectomy in high-risk patients. Long-term protective benefits, however, are less established in high-risk patients. Midterm results following CAS in our high-risk protocol were analyzed to determine specific and all-cause mortality rates (beyond 30 days). We retrospectively evaluated a prospective carotid artery stent registry from October 2003 to February 2006. Demographics, high-risk indication, presence of carotid symptoms, prior history of cancer, periprocedural success, complications, as well as follow-up including readmission rate as well as specific etiology of death were recorded. Fifty patients with critical carotid stenosis (mean stenosis 90%) underwent CAS. This cohort met high-risk criteria due to physiologic reasons in 26 patients and anatomic factors in 22 cases. Two patients met both criteria. Indications were symptomatic disease in 14 (30%) and asymptomatic in 36 cases. The overall 30-day stroke, myocardial infarction, and death rate was 2%. No minor or major strokes were recorded within 30 days postprocedure. Overall average follow-up was 11-28 months. Stroke-free survival was 94% for all patients. Overall 1-year survival was 75% for all patients, significantly higher for the asymptomatic group (88%) (p < 0.01). Late mortality after 30 days was 11 cases (22%) at an average of 9 months post-CAS, ranging 3-13 months. No late mortality was due to ischemic stroke. Specific etiologies of mortality included end-stage cardiac disease (n = 1), recurrent or metastatic cancer (n = 2), acute cardiac event (n = 1), infectious complications (n = 3), and other (n = 3). Only symptomatic indication was predictive of late mortality. Clinicians may continue to cautiously offer CAS to asymptomatic high-risk patients given their anticipated longevity. Symptomatic patients, despite poor midterm survival, do achieve freedom from neurologic death following CAS.

Pharmacologic risk factor treatment of peripheral arterial disease is lacking and requires vascular surgeon participation.

The pharmacologic treatment of the cardiovascular comorbidities in patients with peripheral arterial disease (PAD) can have a profound effect on the outcomes of these patients. Guidelines for the treatment of hypertension, hyperlipidemia, diabetes, and tobacco use have been published by the American Heart Association and American College of Cardiology (AHA/ACC). Patients with PAD are often under-treated for these conditions. We sought to evaluate the adherence to these established guidelines in all new patients presenting with PAD to a vascular surgery clinic and delineate the opportunity for vascular surgeon involvement in these treatments. Consecutive new patients with symptomatic, objectively proven PAD (ankle-brachial index < 0.9) were evaluated in a vascular surgery clinic by a staff vascular surgeon. PAD risk factors, pre-visit medications, and prior cardiovascular interventions were recorded. Patients were stratified whether they were receiving appropriate preventive pharmacotherapy and whether they were meeting AHA/ACC goals. In patients without prior cardiovascular history, screening for these conditions was performed. One hundred sixty-seven new patients were evaluated over a 1-year period. Objectively diagnosed PAD included intermittent claudication in 115 (69%) and critical limb ischemia in 52 (31%) patients. Average age was 67.8 years, and 73 patients (44%) were current smokers. At initial evaluation, only 115 (69%) patients reported antiplatelet use. Patients with a recorded diagnosis of hypertension met clinical guidelines in 39 instances (71%). Eighteen patients (20%) with diabetes mellitus had poor glycemic control (Hgb-A1C > 7.0%). Seventeen (19%) of 88 patients with a history of hyperlipidemia were not adequately treated. Vascular surgeon medical interventions resulted in 31% of patients being started on antiplatelet therapy, 29% of hypertension therapies were modified, 19% of established lipid therapy was modified, and lipid therapy was initiated in 20%. A new diagnosis of hypertension was made in 10 cases (6%) and hyperlipidemia in 13 cases (7%). Despite clear guidelines for the medical community regarding cardiovascular prevention, a large percentage of patients with symptomatic PAD presenting to the vascular surgery clinic are not receiving appropriate therapy for their comorbidities or are not meeting the established goals. Vascular surgeons have an important role in promoting vascular health through the systemic prevention of ischemic events.