Outcomes Of Carotid Stenting In Patients With Fibromuscular Dysplasia
Carla K. Scott, MD, Jesus Porras Colon, MD, Alejandro Pizano Umana, MD, Anna L. Driessen, MD, Carlos H. Timaran, MD, John G. Modrall, MD, Shirling Tsai, MD, Melissa L. Kirkwood, MD, Bala Ramanan, MD.
UT Southwestern, Dallas, TX, USA.
BACKGROUND: Fibromuscular dysplasia(FMD) is a noninflammatory arterial disease that affects extracranial carotid arteries in young patients. Ideal treatment of FMD is still debatable and the role of carotid artery stenting(CAS) is controversial. The aim of this study was to assess the feasibility and outcomes of CAS in patients with FMD.METHODS: Retrospective analysis utilizing the Vascular Quality Initiative(VQI) database from December 2012 to May 2021. Out of the 44,558 patients that underwent CAS and 154,861 that underwent carotid endarterectomy, all patients with preoperative FMD were included. Clinical and technical parameters were analyzed and propensity matching (1:1) was performed to derive well-matched comparative cohorts.RESULTS: Fifty-five patients underwent CAS for FMD (mean age 58.7±14years, 62%female, 48%white, mean body mass index 28.1±6kg/m2). Majority of these procedures(71%) were elective. The FMD group had a lower rate of controlled hypertension(44%vs55%,p=0.002), smoking(11%vs47%,p=0.001), diabetes(13%vs40%,p=0.01) and coronary artery disease(9%vs64%,p=0.001) than the non-FMD group. Prior transient ischemic attack was identified in 39(72%) patients and 30(56%) prior stroke in the FMD group. Additionally, 29(53%) patients had anatomic criteria that was high-risk for carotid endarterectomy(CEA) with a high lesion being the most common. The FMD group had a higher rate of procedures for symptomatic stenosis than the non-FMD group(71%vs55% respectively,p=0.008), with a mean stenosis grade of 74%vs84% in the non-FMD group(p=0.001). In the FMD group, transfemoral approach was used in 43(78%) patients with distal embolic protection used in 32 patients and flow reversal used in 2 patients. Transcarotid artery revascularization(TCAR) was performed in 9(16%) patients with flow reversal used in 7 patients. Most cases were performed under local anesthesia(58%). Three patients(5%) in the FMD group had access site complications that were managed non operatively. There were no differences between the FMD and non-FMD groups in perioperative stroke(0%vs0%), TIAs(0%vs0%) or 30-day mortality(0%vs0%). Length of stay was similar between groups and without differences in 1-year survival (100%vs100%). All the patients in the FMD group were discharged without neurological complications and 50 patients(90%) on dual antiplatelet therapy. The mean follow-up was 469±581 days with no mortality or reintervention. In the VQI database, no patients received a carotid endarterectomy or plain balloon angioplasty for FMD.CONCLUSIONS: Carotid artery stenting for fibromuscular dysplasia is a feasible and safe procedure with favorable technical success, low neurological complications and good clinical outcomes at 1-year follow-up.
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