Objectives: Cerebral hyperperfusion syndrome is a fatal complication that can occur after stent angioplasty in patients with severe carotid artery stenosis. Staged angioplasty can prevent cerebral hyperperfusion syndrome. Conventional staged angioplasty consists of small balloon angioplasty in the first stage and carotid artery stenting in the second stage two to four weeks later. Sometimes, antegrade flow during stage 1 could hardly be maintained and stent will be needed. Solitaire stents were used in some patients in our center. This study aimed to examine the safety and effectiveness of Solitaire stents in staged angioplasty.
Methods: A retrospective analysis was performed on patients with severe carotid artery stenosis and preoperative computed tomography perfusion indicating risk of cerebral hyperperfusion syndrome from 2011 to 2018. Small balloon angioplasty (<3 mm in diameter) only was performed in stage 1 (group 1). If antegrade flow during stage 1 is compromised, then a solitaire stent is deployed (group 2). After two to four weeks, cerebral angiography was undertaken in both groups to determine whether to perform stage 2. If the residual stenosis was more than 50%, carotid artery stenting was deployed. Angiographic results, clinical results, and follow-up results were collected and analyzed.
Results: Twenty-five patients were included in the study (group 1, n = 19; group 2, n = 6). After stage 1, no patient in group 2 and two patients in group 1 developed new symptomatic cerebral infarction (0.0% vs. 10.5%, p = 1.000). One patient in group 2 and three patients in group 1 (16.7% vs. 15.8%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome. One patient in group 2 (n = 4) and three patients in group 1 (n = 12) (25% vs. 25%, p = 1.000) developed hyperperfusion phenomenon. Two patients in group 2 and five patients in group 1 (33.3% vs. 26.3%, p = 1.000) developed symptomatic cerebral hyperperfusion syndrome or hyperperfusion phenomenon. One patient in group 1 developed symptomatic cerebral hyperperfusion syndrome and hyperperfusion phenomenon. After stage 2, no new cerebral infarction occurred in both groups. No patient in group 2 (n = 3) and one patient in group 1 (n = 17) developed symptomatic cerebral hyperperfusion syndrome (0.0% vs. 5.9%, p = 1.000). In the combined analysis of both stages, two patients (10.5%) developed new symptomatic cerebral infarction and four patients (21.1%) developed symptomatic cerebral hyperperfusion syndrome in group 1, no patient (0.0%) developed symptomatic cerebral infarction and one patient (16.7%) developed symptomatic cerebral hyperperfusion syndrome in group 2. There was no significant difference in symptomatic cerebral infarction and symptomatic cerebral hyperperfusion syndrome between the two groups (p = 1.000; p = 1.000). Three patients in group 2 and 17 patients in group 1 (50% vs. 89.5%, p = 0.070) underwent stage 2 angioplasty. No cerebral hemorrhage or cerebral infarction occurred in the Solitaire group during the one-year follow-up period.
Conclusions: Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis.
Keywords: Cerebral hyperperfusion syndrome; Solitaire stents; ischemic events; severe carotid artery stenosis; staged angioplasty.