Objectives: Carotid Artery Stenting (CAS) is being performed more frequently with the recent Center for Medicare Services (CMS) approval of TransCarotid Artery Revascularization (TCAR) for asymptomatic patients. Having identified a number of carotid stent fractures in our practice, we studied the incidence of carotid stent fractures and its impact on CAS durability.
Methods: In this prospective trial, we enrolled 200 patients who underwent carotid artery stenting (CAS) between January 2002 and November 2021. These patients were evaluated for stent fractures by AP and lateral cervical x-rays. The x-rays were independently reviewed by three vascular surgeons and only those patients with consensus fracture by all surgeons were included as definitive stent fractures. A modification to the study allowed for a second x-ray to be obtained at a later date to assess the potential for late fracture development. The primary outcome was the incidence of carotid stent fracture and the secondary outcome was to evaluate any clinical implications associated with carotid stent fracture.
Results: For the 200 patients consented and enrolled, a total of 227 unique stent procedures were performed over the duration of the study. In the first x-rays obtained, 18 stent fractures were identified for a stent fracture rate of 7.9%. Of the total patients enrolled, 103 patients received a second/delayed x-ray. In the 117 total second x-rays obtained, 6 later fractures were identified for a delayed fracture rate of 5.6%. The total number of 24 fractures identified represents a stent fracture rate of 10.6%. Of those with stent fractures, duplex assessment in the follow up period identified only 1 severe recurrent stenosis requiring intervention for a reintervention rate of 4.2%.
Conclusions: Among patients with carotid artery stent placement, we identified a total stent fracture rate of 10.6% with a delayed fracture rate of 5.6%. While we have identified that carotid stent fractures do occur, the follow up duplex examinations revealed minimal restenosis with only one reintervention required. Our study indicates that the CAS fracture rate is approximately 10% and the clinical sequelae appears to be negligent. However, with the increased use of carotid stenting, prospective studies with long-term outcomes are warranted with attention to stent fractures and reintervention rates.