Simultaneous Bilateral Carotid Artery Stenting on Elderly Patients

By Sisi Zhao, Pengfei Hu, Lingtao Tang

Affiliations

1. Department of Neurology, Xingtai Third Hospital, Xingtai, China

doi: 10.29271/jcpsp.2025.08.1075

Sir,

Stroke has always had a high incidence in elderly individuals. Up to 12% of strokes are caused by carotid artery stenosis, and bilateral carotid artery stenosis accounts for 8-39% of symptomatic carotid stenosis according to a single-centre study on simultaneous bilateral angioplasty and stenting.¹ Carotid endarterectomy (CEA) is an effective intervention for carotid artery stenosis. Currently, carotid artery stenting (CAS) has gradually become an alternative option for high-risk patients with CEA.² The safety of simultaneous bilateral carotid artery stenting (BCAS) has been confirmed in several studies,^3,4 but no age-specific studies have been conducted. Carotid artery stenosis is highly prevalent in elderly individuals. This study aimed to investigate the efficacy and safety of simultaneous BCAS for elderly patients.

Clinical data of 19 patients with simultaneous BCAS were analysed. All participants in the study were aged 65 years or older (mean 68.63 ± 2.93 years) and were observed for pre- and post-operative stenosis rates, collateral circulation, and complications within 6 months post-operatively. The Ethics Committee of the Xingtai Third Hospital approved the study (Approval No: 2022-KY-22).

SPSS version 27.0 software was used for data analysis. When the data conformed to a continuous variable and a normal distribution, they were represented as the mean ± standard. The median was used to describe non-normally distributed data. Frequencies and percentages were used to present categorical data, and the Chi-square test was used to compare groups. A p-value of less than 0.05 indicated statistical significance.

A total of 38 stents were implanted in this group the relevant surgical information is shown in Table I.

Resolving 38 stenoses in this group, the percentage of good collateral circulation (n = 27, 71.1%, grades 3-4) was significantly greater than preoperatively (n = 13, 34.2%, p <0.050).

Table  I:  Information  about  the  surgery.

Variables	RICA	LICA
Stents type
Acculink, n (%)	17 (89.5%)	17 (89.5%)
XACT, n	1	1
EV3, n	1	1
Preoperative median stenosis (%)	80.0%	80.0%
Postoperative median stenosis (%)	10.0%	10.0%
Predilation, n (%)	19 (100%)	18 (94.7%)
Postdilation, n (%)	8 (42.1%)	6 (31.6%)
Atropine, n (%)	7 (36.8%)	5 (26.3%)
RICA: Right internal carotid artery; LICA: Left internal carotid artery.

Postoperative haemodynamic depression (HD) occurred in 9 (47.4%) patients including bradycardia in 1 (5.3%), patient persistent hypotension in 4 (21.1%) patients and hypotension combined with bradycardia in 4 (21.1%) patients. Eight patients experienced no obvious discomfort after timely medicine treatment. One patient with bradycardia had no clinical symptoms and was not treated, and his heart rate returned to the preoperative level after 4 days. Two (10.5%) patients experienced headaches immediately after surgery, which was considered cerebral hyperperfusion syndrome (HPS). No haemorrhage was found after re-examination via brain CT. One (5.3%) patient experienced a non-disabling haemorrhage 10 days after the operation. In-stent restenosis occurred in 2 (10.5%) patients within 3 months after surgery. No new complications occurred 6 months after the operation.

At present, there are no guidelines for BCAS. Most studies believe that CAS performed in stages is safer than simultaneously on both carotid arteries.⁵ However, patients who undergo secondary surgery might face increased treatment costs, prolonged hospitalisation, recurrent stroke, untreated carotid artery occlusion, and delayed treatment of other major diseases. Elderly individuals are at high risk for carotid artery stenosis and stroke. This study, which focused on elderly individuals, should provide valuable guidance for clinical practice. In addition, this study compared the improvement in collateral circulation in the affected vascular area before and after surgery, which confirmed the effect of surgery at the vascular level.

The overall incidence of HD in this group was 47.4%, which was similar to that of 46.12% reported in the bilateral CAS meta- analysis conducted by Lai et al.³ There were two cases of headache in this group, which were relieved by strict control of blood pressure and intravenous mannitol. In-stent restenosis occurred in two patients who had Diabetes mellitus and poor postoperative blood glucose. All patients had good outcomes (mRs ≤2) 6 months after the operation.

Simultaneous BCAS in elderly patients has a high success rate, low complication rate, and good prognosis. This procedure may be a feasible, safe, and effective treatment for elderly patients.

ETHICAL   APPROVAL:
Ethical approval was obtained from the Institutional Ethics Committee of the Xingtai Third Hospital, Xingtai, China (No: 2022-KY-22).

COMPETING   INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’   CONTRIBUTION:
SZ: Concept of the study, design, data analysis, and manu-script  writing.
PH:  Editing  of  the  manuscript.
LT:  Data  collection.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Shchehlov DV, Svyrydiuk OY, Vyval MB, Sydorenko OF, Nosenko NM, Gudym MS. Simultaneous bilateral angioplasty and stenting for carotid stenosis - a single centre experience. J Med Life 2022; 15(2):252-7. doi: 10. 25122/jml-2021-0274.
2. AbuRahma AF, Mousa AY. Current status of carotid stenting versus endarterectomy. Adv Surg 2016; 50(1):235-56. doi: 10.1016/j.yasu.2016.04.004.
3. Lai Z, Guo Z, Shao J, Chen Y, Liu X, Liu B, et al. A syste-matic review and meta-analysis of results of simultaneous bilateral carotid artery stenting. J Vasc Surg 2019; 69(5):1633-42.e5. doi: 10.1016/j.jvs.2018.09.033.
4. Li Y, Sun W, Yin Q, Wang Y, Cai Q, Sun W, et al. Safety and efficacy of simultaneous bilateral carotid angioplasty and stenting. J Thromb Thrombolysis 2014; 37(2):202-9. doi: 10.1007/s11239-013-0920-1.
5. Diehm N, Katzen BT, Iyer SS, White CJ, Hopkins LN, Kelley L, et al. Staged bilateral carotid stenting, an effective strategy in high-risk patients - insights from a prospective multicentre trial. J Vasc Surg 2008; 47(6):1227-34. doi: 10.1016/j.jvs.2008.01.035.