In-Hospital Complications and Long-term Outcomes of Carotid Artery Stenting: INCARCERATE Study

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Shishehbor, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1918352/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: One of the most common and treatable causes of stroke is carotid artery stenosis. Carotid artery stenting (CAS) is an option for treating the stenosis, with such notable clinical outcomes as low rates of in-hospital death, stroke, and intracerebral hemorrhage. Methods: All patients who underwent carotid angioplasty between December 2010 and January 2019 in Rajaie Cardiovascular Medical and Research Center were enrolled. The incidence rates of major adverse cardiac and cerebral events (MACCE), defined as a composite of stroke, myocardial infarction, bleeding, and all-cause mortality, both during hospitalization and at long-term follow-up were determined. Results : A total of 380 patients, 264 (69.5%) symptomatic and 116 (30.5%) asymptomatic, were included. The mean age of study population was 68.6 ± 10.6 years. During post-CAS in-hospital course, stroke occurred in 2 (0.5%), intracranial hemorrhage in 4 (1.1%), death in 2 (0.5%) and MACCE in 8 (2.1%) in symptomatic, and stroke in 1 (0.3%), intracranial hemorrhage in 1 (0.3%), death in 1 (0.3%) and MACCE in 3 (0.8%) in asymptomatic patients. Totally, stroke occurred in 3 (0.8%), intracranial hemorrhage in 5 (1.3%), death in 3 (0.8%), and MACCE in 11 (2.89%) patients. Long-term follow-up (40.95 ± 15.81 months) was performed on 295 (77.6%) patients; the results demonstrated a mortality rate of 13.9% (n = 41) which 30 (10.1%) cases belonged to symptomatic and 11 (3.7%) cases were from asymptomatic patients. Stroke happened in 26 (8.8%), that 18 (6.1%) cases were symptomatic and 8 (2.7%) cases were asymptomatic. MACCE rate was 19.3% (n = 57) which 41 (13.8%) cases were symptomatic and 16 (5.4%) were asymptomatic. Age (OR: 1.040, 95% CI: 1.002 to 1.079) was confirmed as a meaningful variable for the occurrence of MACCE. Conclusions: Our results confirm the safety and efficacy of carotid stenting in experienced centers. Age was as an important predictor of all-cause mortality, myocardial infarction, and MACCE. Carotid artery stenting Complications Major adverse cardiac and cerebral events Introduction In Iran, stroke has a high incidence compared with developed countries (1). Carotid artery endarterectomy and carotid artery stenting (CAS) are 2 treatment options for carotid artery stenosis (2). CAS is a less invasive procedure and is deemed an alternative to surgical treatment (3). The efficacy of both of these procedures is unsurprisingly interpreted in light of their respective periprocedural complications; nonetheless, research has shown similar early and 3-year outcomes (4, 5). According to the guidelines of the American Stroke Association, CAS is indicated for symptomatic patients with more than 70% stenosis of the internal carotid artery documented by noninvasive imaging or more than 50% stenosis detected by catheter angiography (6). The most serious long-term outcomes of CAS are stroke, intracranial hemorrhage, and death (7, 8), with less significant complications including carotid perforation, dissection, hematoma, and pseudoaneurysms at the site of catheterization (9). This study aimed to investigate early complications and long-term clinical outcomes in patients who underwent carotid artery angioplasty in Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, between 2010 and 2019. Methods Study Population and Protocol The present retrospective study consecutively recruited all patients who underwent carotid artery angioplasty between December 2010 and January 2019 in Rajaie Cardiovascular Medical and Research Center. Carotid stenting was performed for all asymptomatic patients with 80–99% stenosis and all symptomatic patients with 50–99% stenosis in their internal carotid artery. Symptomatic patients comprised those with a history of stroke and/or transient ischemic attack (TIA). The entire study population underwent preprocedural evaluations, comprised of complete history and physical examinations, and biochemistry laboratory tests for the assessment of cardiovascular risk factors, blood glucose, and the lipid profile. Hypertension was defined as the current consumption of antihypertensive drugs or at least 2 independent measurements of the systolic and diastolic blood pressures exceeding 139 and/or 89 mm Hg, correspondingly; diabetes mellitus as the current use of insulin, oral antidiabetic agents, a minimum hemoglobin A1c level of 6.4%, and a minimum fasting blood sugar level of 125 mg/dL; dyslipidemia as the current consumption of lipid-lowering drugs and a fasting plasma total cholesterol level of 200 mg/dL or greater in 2 independent measurements; stroke as the sudden onset of a neurologic deficit dependent on the affected region of the brain and confirmed by spiral brain computed tomography; and TIA as a focal retinal or hemispheric event resolved within 24 hours. Additionally, acute myocardial infarction (MI) was defined as a rise and/or fall in cardiac troponin levels provided that at least 1 value exceeds the 99th percentile upper reference limit, pathologic Q waves or new ischemic changes in electrocardiography, imaging evidence of new loss of viable myocardium, new wall motion abnormalities, and clinical evidence of acute ischemic myocardial injury (10). The body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Hospital’ records were checked for the patients’ demographic information, cardiovascular risk factors, and revascularization details. All post-CAS in-hospital complications and the immediate outcome were recorded. Following hospital discharge, long-term follow-up was carried out by telephone. The study protocol was approved by the Ethics Committee of Rajaie Cardiovascular Medical and Research Center (ethical code: RHC.AC.IR.REC.1395.56). CAS Techniques Arterial access (femoral {greater extent} or radial {lesser extent}) was obtained for the insertion of a 6-F sheath. A diagnostic catheter was used to access the carotid artery, and the contrast medium was injected for carotid and intra-cranial angiography. For distal protection, a wire was passed through the lesion and the distal protection device was deployed; and for proximal protection, a wire was negotiated through the lesion after the deployment of the proximal protection device. Embolic protection filters were placed distally or proximally to the lesion in order to reduce the risk of embolization. Thereafter, an appropriately sized self-expanding stent was deployed in the lesion and post-dilation was carried out with a balloon. Completion angiography was recorded, and the patient was sent to the recovery room to be monitored. Aspirin (325 mg) and Clopidogrel (300 mg) were ordered for all the patients 1 day before the intervention. Anticoagulation with heparin (80 IU/kg) during the procedure and before passing the guidewire was administered. Dual antiplatelet medication (ASA 80 mg/d and Clopidogrel 75 mg/d) were prescribed for at least 1 month after the angioplasty. High-intensity statin with maximal-tolerated dose was recommended for all patients and ASA (80 mg/d) were continued for life after the discontinuation of P2Y12 inhibitors. Follow-up and Long-term Outcomes The medical records of the study population were checked concerning the occurrence of major adverse cardiac and cerebral events (MACCE), defined as a composite of the occurrence of stroke, MI, bleeding, and all-cause mortality in the long term (mean duration = 40.95 ± 15.81 months; minimum 12 and maximum 108 months). In addition, phone interviews were proceeded with the patients or their family members in order to determine the incidence rate of MACCE. The interviews were aimed at enquiring about the patients’ general condition, subsequent cardiovascular hospitalization, potential cardiovascular or cerebral events, bleeding complication and the cause of death. The percentage of cardiovascular mortality along with all-cause mortality have been investigated. Deaths due to stroke or MI were categorized as cardiovascular and those due to other reasons as non-cardiovascular. Questions were also asked regarding any history of rehospitalization and whether it was because of stroke or MI. Cases of rehospitalization owing to stroke or MI were classified as cardiovascular rehospitalization. Another query was as regards any episode of bleeding, with affirmative answers evaluated subsequently in keeping with the guidelines of International Society on Thrombosis and Hemostasis (ISTH) classification (11, 12). Statistical analysis The descriptive results were presented as numbers (percentages) for the categorical variables and the mean ± the standard deviation for the continuous variables. The continuous and categorical variables were compared between the patients with or without MACCE using the 2-independent-samples test and the χ 2 test, respectively. A multivariate logistic regression model was applied to determine the adjusted associations between MACCE and different predictors thereof. All variables with a P value of less than 0.2 in the univariate analysis were entered into the model. The statistical analyses were carried out using IBM SPSS Statistics 20 for Windows (IBM Co, Armonk, NY, USA). A P value of less than 0.05 was considered statistically significant. Data availability and statement The authors confirm that the data supporting the findings of this study are available within the article. Results A total of 411 CAS procedures were performed on 380 patients. Thirty-one patients underwent bilateral stenting due to severe stenosis in the contralateral artery. The mean age of the study population was 68.6 ± 10.6 years. The baseline characteristics of the patients whom we were able to follow and the frequency of common cardiovascular risk factors such as hypertension, diabetes mellitus, smoking, and coronary artery disease (CAD) are depicted in Table 1. All the patients had embolic protection device (358 [94.2%] patients with distal protection device and 22 [5.7%] patients with proximal protection device). Follow-up (mean duration = 40.95 ± 15.81 months; minimum 12 and maximum 108 months) was performed on 295 (77.6%) patients. The outcomes of angioplasty were divided into in-hospital and long-term (i.e., post-hospital discharge) outcomes, including complications. A total of 380 patients, 264 (69.5%) symptomatic and 116 (30.5%) asymptomatic, were included in our study. The mean age of the study population was 68.6 ± 10.6 years. During the post-CAS in-hospital course, stroke occurred in 2 (0.5%), intracranial hemorrhage in 4 (1.1%), death in 2 (0.5%) and MACCE in 8 (2.1%) in symptomatic patients. In asymptomatic patiets, stroke happened in 1 (0.3%), intracranial hemorrhage in 1 (0.3%), death in 1 (0.3%) and MACCE in 3 (0.8%). Totally there were 380 patients that stroke occurred in 3 (0.8%), intracranial hemorrhage in 5 (1.3%), death in 3 (0.8%), and MACCE in 11 (2.89%) patients. During the long-term follow-up, there were 26 (8.8%) cases of stroke, of which 17 (5.7%) were fatal; 9 (3.1%) cases of MI, of which 8 (2.7%) were fatal; and 57 (19.3%) cases of MACCE, including episodes of bleeding in 6 (2.0%): 3 (1.0%) major and 3 (1.0%) clinically relevant non-major bleeding cases. The mortality rate at long-term follow-up was 41 patients, resulting in a 13.9% all-cause mortality rate (Table 2). The univariate analysis revealed age ( P= 0.008) , the BMI ( P = 0.199), prior MI ( P = 0.172), and contralateral stenting ( P = 0.155) as meaningful variables that could predict the occurrence of MACCE. Table 1 also presents the results of the comparisons of the variables between the 2 groups of patients with and without MCACE. All the meaningful variables for each event in the univariate analysis were entered in the multivariate logistic regression analysis in order that each event could be analyzed separately. Each event is illustrated as an independent model in Table 3. According to the results of this analysis, age, the BMI, and contralateral stenting were meaningful variables for all-cause mortality (Model 1); age and a history of hypertension were correlated with cardiovascular death (Model 2); gender, age, prior cerebrovascular accident, being symptomatic, a history of CAD, dyslipidemia, diabetes mellitus, and contralateral stenting were correlated with the event of cardiovascular rehospitalization (due to MI and stroke) (Model 3); age, the BMI, cerebrovascular accident, and contralateral significant stenosis were meaningful variables for the event of MI (Model 4); gender, a history of CAD, diabetes mellitus, and smoking had significant relationships with the event of stroke (Model 5); and age, the BMI, prior MI, and contralateral stenting were correlated with MACCE (Model 6). Table 3 demonstrates the results of the multivariate logistic regression analysis, according to which age (OR: 1.040, 95% CI: 1.002 to 1.079) was an independent predictor of MACCE. Discussion The SAPPHIRE and CREST trials suggested CAS as an alternative to carotid artery endarterectomy for the prevention of stroke in the long term (13, 14). In the present study, we have reported the in-hospital and long-term outcomes of CAS procedure with a mean follow-up of 40.95 ± 15.81 months in high-volume center in Iran. Post-procedural in-hospital stroke, ICH, MACCE and all-cause mortality occurred in 3 (0.8%), 5 (1.3%), 11 (2.89%) and 3 (0.8%) respectively and these results are in-line with acceptable statistics presented in other publications (6, 15, 16). As we know, the major outcomes of CAS procedure in long-term are stroke and death. Rate of any stroke in CAS patients in CREST study during 4 years follow up is 10.2±1.1 (%±SE) (17). The results of a study conducted by Jonsson et al. showed the mortality rate of CAS procedure was 25.7%, the ipsilateral stroke rate was 9.4% and any stroke or death rate was 34.2% in 4.1-year follow-up duration (18). A study by Rubin et al. showed a 3.2% fatal and non-fatal stroke rate after 5 years follow-up (19). Also, in the study of de Donato et al. with 5 years follow-up, average annual rate of all-cause mortality, stroke-related death and any stroke were 3.43%, 1.31%, 1.9% respectively (20). Of note, we have reported a follow-up rate of 77.6%. Our results revealed a 13.9% rate of all-cause mortality, which varied among different subgroups (e.g., 11.6% in patients with diabetes mellitus and 13.2% in patients with CAD), 8.8% rate of stroke and 19.3% rate of MACCE with mean follow up duration of 40.95 ± 15.81 months; (minimum 12 and maximum 108 months) and our results are in line with the results of above-mentioned studies. We also found that diabetes mellitus was not associated with all-cause mortality, MACCE, and cardiovascular rehospitalization due to MI or stroke. Moreover, gender was not a meaningful variable for the occurrence of MACCE, whereas age was shown to be an independent predictor of all-cause mortality and MACCE. Diabetes mellitus, known as an important risk factor for cardiovascular events such as CAD, MI, ischemic stroke, and death (21), can not only increase atherosclerotic complications by increasing carotid plaque revascularization (22) but also cause carotid plaque instability (23, 24) and augment the thickness of the intima and media layers of the carotid artery, which can be a risk factor for cardiovascular events (25, 26). Hussain et al (27) concluded that the risk of post-angioplasty mortality was higher in patients with diabetes than in patients without it, which does not chime in with our results. The discrepancy may be in consequence of different sample volumes. The NASCET and ACE studies concluded that the risk of post-carotid endarterectomy complications was higher in females (28, 29). This claim can be justified by dissimilarities in the male and female anatomy, rendering the procedure more challenging in women, and the higher risk of postoperative thrombosis in women (30, 31). In contrast, Shobha et al (32) compared the 30-day outcome of carotid angioplasty between women and men and posited that this procedure could be performed as safely in women as in men. In our investigation, in-hospital mortality following angioplasty occurred in 3 patients, all of them female. Additionally, in-hospital stroke occurred in 3 patients, of whom 1 was female; nevertheless, we could not reach the conclusion that the female gender was a meaningful variable for the occurrence of death and stroke during the in-hospital course of care. Our results indicated that while gender was not a meaningful variable for the occurrence of MACCE, the male gender was an independent predictor of the occurrence of stroke. Ahmadi et al (33) concluded that CAS could be performed safely even in elderly patients with some comorbidities and that the age of patients was not a predictor of a poor post-CAS outcome. On the other hand, the results of the CREST clinical trial indicated that while older age was allied to a higher risk of post-CAS stroke, such association was absent in regard to carotid artery endarterectomy inasmuch as the risk of stroke after surgery was similar between old and young patients; accordingly, age is of importance in the selection of the optimal choice for the treatment of carotid artery stenosis (13). The results of our study also showed that age was significantly correlated with all-cause mortality, MI, and MACCE. The results of the current study should be interpreted in light of some of its limitations, first and foremost among which is its retrospective design with its inherent weakness in data gathering. Indeed, it is likely that some important risk factors were not recorded properly in the patients’ records. Another shortcoming of note is our long-term telephone-conducted follow-up of only 77.6% of the study population, with 22.4% being missed to follow-up. Further, despite our efforts to fully extract the patients’ cardiovascular risk factors from their records so as to assess their associations with the occurrence of MACCE, our study’s insufficient sample size and retrospective data precluded us from robustly concluding which risk factors were the predisposing factors for MACCE. Conclusions The results of the current investigation indicated that age was an important predictor of all-cause mortality, MI, and MACCE. There was also no difference in the long-term post-CAS clinical outcome between men and women. Also, current investigation revealed presence or absence of diabetes exerting no impact on long-term clinical outcome. Further prospective studies are needed to prove the predisposing factors for MACCE. Declarations Funding This study has no funding. Competing interests The authors declare that they have no competing interests Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Authors' contributions All authors were involved in all stages of data collection, analysis and interpretation of the results obtained and writing the article. Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Rajaie Cardiovascular Medical and Research Center (ethical code: RHC.AC.IR.REC.1395.56). And we confirm that all methods were carried out in accordance with relevant guidelines and regulations. Also, informed consent was obtained from all the participants in this study to publish information related to the research, without mentioning personal details. Consent for publication Not applicable Acknowledgment The authors express their gratitude to Yousef Rezaei MD and all other participated in the study. References Borhani-Haghighi A, Safari R, Heydari ST, Soleimani F, Sharifian M, Kashkuli SY, et al. Hospital mortality associated with stroke in southern Iran. Iranian journal of medical sciences. 2013;38(4):314. Kojuri J, Ostovan MA, Zamiri N, Asli AZ, Hashemi MAB, Haghighi AB. Procedural outcome and midterm result of carotid stenting in high-risk patients. Asian Cardiovascular and Thoracic Annals. 2008;16(2):93-6. Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, et al. 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Ahmadi R, Schillinger M, Lang W, Mlekusch W, Sabeti S, Minar E. Carotid artery stenting in older patients: is age a risk factor for poor outcome? Journal of Endovascular Therapy. 2002;9(5):559-65. Tables Table 1: Baseline characteristics of the patients and the long-term results of the univariate analysis Characteristic Total (N = 295) Positive MACCE (n = 57) Negative MACCE (n = 238) P value Age 69.03 ± 9.6 72.1 ± 8.1 68.3 ± 10.7 0.008 Male gender 206 (69.8%) 36 (63.2%) 170 (71.4%) 0.222 BMI 27.26 ± 6.4 26.3 ± 6.7 27.5 ± 7.2 0.199 CAD 151 (51.1%) 26 (45.6%) 125 (52.5%) 0.349 History of MI 30 (10.1%) 3 (5.3%) 27 (11.3%) 0.172 Hypertension 227 (76.9%) 41 (71.9%) 186 (78.2%) 0.316 Dyslipidemia 150 (50.8%) 27 (47.4%) 123 (51.7%) 0.559 Diabetes mellitus 138 (46.7%) 25 (43.9%) 113 (47.5%) 0.623 Smoking 65 (22.0%) 13 (22.8%) 52 (21.8%) 0.875 Symptomatic 208 (70.5%) 41 (71.9%) 167 (70.2%) 0.793 TIA 60 (20.3%) 15 (26.3%) 45 (18.9%) 0.212 CVA 168 (56.9%) 32 (56.1%) 136 (57.1%) 0.891 Contralateral significant stenosis 50 (16.9%) 10 (17.5%) 40 (16.8%) 0.894 Contralateral stenting 27 (9.1%) 8 (14.0%) 19 (8.0%) 0.155 Contralateral total occlusion 37 (12.5%) 8 (14.0%) 29 (12.2%) 0.705 All data are presented as mean ± SD or numbers (%). MACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality); BMI, Body mass index; TIA, Transient ischemic attack; CVA, Cerebrovascular accident; CAD, Coronary artery disease; MI, Myocardial infarction Table 2: In-hospital and long-term outcomes of carotid artery stenting Number of Patients Symptomatic asymptomatic In-Hospital outcomes Stroke 3 (0.8%) 2 (0.5%) 1 (0.3%) Intracranial hemorrhage 5 (1.3%) 4 (1.1%) 1 (0.3%) Hematoma at the catheterization site 21 (5.5%) 14 (3.7%) 7 (1.8%) Pseudoaneurysm at the catheterization site 2 (0.5%) 2 (0.5%) 0 (0%) Carotid perforation 1 (0.3%) 1 (0.3%) 0 (0%) Bubble injection 1 (0.3%) 0 (0%) 1 (0.3%) Carotid dissection 4 (1.1%) 4 (1.1%) 0 (0%) Death 3 (0.8%) 2 (0.5%) 1 (0.3%) MACCE 11 (2.89%) 8 (2.1%) 3 (0.8) Long-term Outcomes Followed patients 295 (77.6%) 208 (70.5%) 87 (29.5%) All-cause mortality 41 (13.9%) 11 (3.7%) 30 (10.2%) Cardiovascular death 22 (7.5%) 15 (5.1%) 7 (2.4%) MI 9 (3.1%) 6 (2.0%) 3 (1.0%) Stroke 26 (8.8%) 18 (6.1%) 8 (2.7%) Cardiovascular rehospitalization 46 (15.6%) 24 (8.1%) 22 (7.4%) Bleeding 6 (2.0%) 4 (1.3%) 2 (0.6%) MACCE 57 (19.3%) 41 (13.9%) 16 (5.4%) MI, Myocardial infarction; MACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality) Table 3: Multivariate logistic regression analysis results Odds Ratio Confidence Interval (95%) P value Model 1 Age 0.949 0.908 – 0.992 0.022 BMI 1.063 0.985 – 1.148 0.118 Contralateral stenting 0.372 0.139 – 0.997 0.049 Model 2 Age 1.049 0.997 – 1.102 0.063 History of hypertension 0.473 0.188 – 1.191 0.112 Model 3 Gender 1.738 0.837 – 3.613 0.138 Age 0.983 0.953 – 1.015 0.298 Prior CVA 0.998 0.300 – 3.323 0.998 Symptomatic 0.411 0.123 – 1.372 0.148 History of CAD 1.478 0.708 – 3.086 0.298 History of dyslipidemia 1.220 0.577 – 2.578 0.603 History of diabetes 1.990 0.938 – 4.219 0.073 Contralateral stenting 1.705 0.567 – 5.130 0.343 Model 4 Age 1.120 1.006 – 1.247 0.039 BMI 1.059 0.974 – 1.152 0.176 Prior CVA 0.302 0.054 – 1.679 0.171 Significant stenosis 0.732 0.081 – 6.605 0.781 Model 5 Gender 2.579 1.052 – 6.321 0.038 History of CAD 0.600 0.254 – 1.418 0.245 History of diabetes 1.580 0.647 – 3.858 0.316 History of smoking 0.438 0.095 – 2.017 0.289 Model 6 Age 1.040 1.002 – 1.079 0.036 BMI 0.979 0.926 – 1.034 0.445 Prior MI 0.552 0.157 – 1.945 0.355 Contralateral stenting 2.155 0.860 – 5.398 0.101 BMI, Body mass index; CVA, Cerebrovascular accident; CAD, Coronary artery disease Model 1 = death Model 2 = cardiovascular death Model 3 = cardiovascular rehospitalization Model 4 = MI, myocardial infarction Model 5 = stroke Model 6 = MACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality) Additional Declarations No competing interests reported. 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Shishehbor","email":"","orcid":"","institution":"University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mehdi","middleName":"H.","lastName":"Shishehbor","suffix":""},{"id":131548161,"identity":"0bad79aa-7c2f-402b-9b00-9d9fb97e7c54","order_by":4,"name":"Omid Shafe","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Omid","middleName":"","lastName":"Shafe","suffix":""},{"id":131548162,"identity":"a84f22d5-aa09-4b2c-b539-8718ed180237","order_by":5,"name":"Jamal Moosavi","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jamal","middleName":"","lastName":"Moosavi","suffix":""},{"id":131548163,"identity":"e6d32623-3ad1-4502-8e2a-8827bf09863c","order_by":6,"name":"Parham Sadeghipour","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Parham","middleName":"","lastName":"Sadeghipour","suffix":""},{"id":131548164,"identity":"e82521a8-96c7-4d9a-8225-4d0c8a031ac6","order_by":7,"name":"Gelareh Bani Hashemi","email":"","orcid":"","institution":"Sina Hospital, Tehran University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gelareh","middleName":"Bani","lastName":"Hashemi","suffix":""},{"id":131548165,"identity":"55318a3a-e716-442e-8f2a-a6abc1fa353c","order_by":8,"name":"Reza Zolfaghari","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Reza","middleName":"","lastName":"Zolfaghari","suffix":""},{"id":131548166,"identity":"23be6716-e66a-4692-bce0-323bfc2124bf","order_by":9,"name":"Ata Firouzi","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ata","middleName":"","lastName":"Firouzi","suffix":""},{"id":131548167,"identity":"87fc02d8-948f-48f2-b784-910482c7c05f","order_by":10,"name":"Elyar Sadeghi Hokmabadi","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Elyar","middleName":"Sadeghi","lastName":"Hokmabadi","suffix":""},{"id":131548168,"identity":"f8ee5413-2cf4-4c16-9752-d9724d3cf46b","order_by":11,"name":"Hooman Bakhshandeh","email":"","orcid":"","institution":"Shaheed Rajaei Cardiovascular Medical and Research Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hooman","middleName":"","lastName":"Bakhshandeh","suffix":""},{"id":131548169,"identity":"44e50557-57e7-4560-9e92-9323a3a38e30","order_by":12,"name":"Askar Ghorbani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJACZiBOYGBgbHz8pwLEZW4gWkuzAc8ZEJeRaC0MbAK8bSA+AS38/QeYXxdU3Mvjn93cxiA5rzaavx2o5UfFNpxaJG4ksFnPOFNcLHHnYNsDw23Hc2ccZmxg7DlzG7c1NxjYjHnbEhIbbiS2GyRuO5bbANTCzNiGW4v8+QMQLfNvJLZJHJxzLHc+IS0GBxKYH4O0bABqkWxsqMndQEiLIVAlM8+ZhGIgo9mY4diB3I1ALQfx+UXu/OHDn3kqEvLkbqQ/fMxQU5c77/zhgw9+VODxPgNjmwQS7zCYPIBHPQgwf0Di1BFQPApGwSgYBSMRAAA682CSMBiIvwAAAABJRU5ErkJggg==","orcid":"","institution":"Shariati Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Askar","middleName":"","lastName":"Ghorbani","suffix":""}],"badges":[],"createdAt":"2022-08-01 15:59:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1918352/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1918352/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28085990,"identity":"1e40ee42-70df-48c6-82f7-560754d7ef14","added_by":"auto","created_at":"2022-10-21 11:14:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":372893,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1918352/v1/e84f5b25-f0fe-452a-88b8-cb8dce45f4d9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"In-Hospital Complications and Long-term Outcomes of Carotid Artery Stenting: INCARCERATE Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn Iran, stroke has a high incidence compared with developed countries\u0026nbsp;(1). Carotid artery endarterectomy and carotid artery stenting (CAS) are 2 treatment options for carotid artery stenosis\u0026nbsp;(2). CAS is a less invasive procedure and is deemed an alternative to surgical treatment\u0026nbsp;(3).\u0026nbsp;The efficacy of both of these procedures is unsurprisingly interpreted in light of their respective periprocedural complications; nonetheless, research has shown similar early and 3-year outcomes\u0026nbsp;(4, 5).\u003c/p\u003e\n\u003cp\u003eAccording to the guidelines of the American Stroke Association, CAS is indicated for symptomatic patients with more than 70% stenosis of the internal carotid artery documented by noninvasive imaging or more than 50% stenosis detected by catheter angiography\u0026nbsp;(6).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe most serious long-term outcomes of CAS are stroke, intracranial hemorrhage, and death\u0026nbsp;(7, 8), with less significant complications including carotid perforation, dissection, hematoma, and pseudoaneurysms at the site of catheterization\u0026nbsp;(9).\u003c/p\u003e\n\u003cp\u003eThis study aimed to investigate early complications and long-term clinical outcomes in patients who underwent carotid artery angioplasty in Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, between 2010 and 2019.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population and Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present retrospective study consecutively recruited all patients who underwent carotid artery angioplasty between December 2010 and January 2019 in Rajaie Cardiovascular Medical and Research Center. Carotid stenting was performed for all asymptomatic patients with 80\u0026ndash;99% stenosis and all symptomatic patients with 50\u0026ndash;99% stenosis in their internal carotid artery. Symptomatic patients comprised those with a history of stroke and/or transient ischemic attack (TIA).\u003c/p\u003e\n\u003cp\u003eThe entire study population underwent preprocedural evaluations, comprised of complete history and physical examinations, and biochemistry laboratory tests for the assessment of cardiovascular risk factors, blood glucose, and the lipid profile.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHypertension was defined as the current consumption of antihypertensive drugs or at least 2 independent measurements of the systolic and diastolic blood pressures exceeding 139 and/or 89 mm Hg, correspondingly; diabetes mellitus as the current use of insulin, oral antidiabetic agents, a minimum\u0026nbsp;hemoglobin A1c level of 6.4%, and a minimum fasting blood sugar level of 125 mg/dL; dyslipidemia as the current consumption of lipid-lowering drugs and a fasting plasma total cholesterol level of 200 mg/dL or greater in 2 independent measurements; stroke as the sudden onset of a neurologic deficit dependent on the affected region of the brain and confirmed by spiral brain computed tomography; and TIA as a focal retinal or hemispheric event\u003cbr\u003eresolved within 24 hours.\u0026nbsp;Additionally, acute myocardial infarction (MI) was defined as a rise and/or fall in cardiac troponin levels provided that at least 1 value exceeds the 99th percentile upper reference limit, pathologic Q waves or new ischemic changes in electrocardiography, imaging evidence of new loss of viable myocardium, new wall motion abnormalities, and clinical evidence of acute ischemic myocardial injury\u0026nbsp;(10). The body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared.\u003c/p\u003e\n\u003cp\u003eHospital\u0026rsquo; records were checked for the patients\u0026rsquo; demographic information, cardiovascular risk factors, and revascularization details. All post-CAS in-hospital complications and the immediate outcome were recorded. Following hospital discharge, long-term follow-up was carried out by telephone.\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Rajaie Cardiovascular Medical and Research Center (ethical code: RHC.AC.IR.REC.1395.56).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAS Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArterial access (femoral {greater extent} or radial {lesser extent}) was obtained for the insertion of a 6-F sheath. A diagnostic catheter was used to access the carotid artery, and the contrast medium was injected for carotid and intra-cranial angiography. For distal protection, a wire was passed through the lesion and the distal protection device was deployed; and for proximal protection, a wire was negotiated through the lesion after the deployment of the proximal protection device. Embolic protection filters were placed distally or proximally to the lesion in order to reduce the risk of embolization. Thereafter, an appropriately sized self-expanding stent was deployed in the lesion and post-dilation was carried out with a balloon. Completion angiography was recorded, and the patient was sent to the recovery room to be monitored.\u003c/p\u003e\n\u003cp\u003eAspirin (325 mg) and Clopidogrel (300 mg) were ordered for all the patients 1 day before the intervention. Anticoagulation with heparin (80 IU/kg) during the procedure and before passing the guidewire was administered. Dual antiplatelet medication (ASA 80 mg/d and Clopidogrel\u0026nbsp;75 mg/d) were prescribed for at least 1 month after the angioplasty. High-intensity statin with maximal-tolerated dose was recommended for all patients and ASA (80 mg/d) were continued for life after the discontinuation of P2Y12 inhibitors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up and Long-term Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe medical records of the study population were checked concerning the occurrence of major adverse cardiac and cerebral events (MACCE), defined as a composite of the occurrence of stroke, MI, bleeding, and all-cause mortality in the long term (mean duration = 40.95 \u0026plusmn; 15.81 months; minimum 12 and maximum 108 months).\u0026nbsp;In addition, phone interviews were proceeded with the patients or their family members in order to determine the incidence rate of MACCE. The interviews were aimed at enquiring about the patients\u0026rsquo; general condition, subsequent cardiovascular hospitalization, potential cardiovascular or cerebral events, bleeding complication and the cause of death. The percentage of cardiovascular mortality along with all-cause mortality have been investigated.\u0026nbsp;Deaths due to\u0026nbsp;stroke or MI were categorized as cardiovascular and those due to other reasons as non-cardiovascular. Questions were also asked regarding any history of rehospitalization and whether it was because of stroke or MI. Cases of rehospitalization owing to stroke or MI were classified as cardiovascular rehospitalization. Another query was as regards any episode of bleeding, with affirmative answers evaluated subsequently in keeping with the guidelines of International Society on Thrombosis and Hemostasis (ISTH) classification\u0026nbsp;(11, 12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe descriptive results were presented as numbers (percentages) for the categorical variables and the mean \u0026plusmn; the standard deviation for the continuous variables. The continuous and categorical variables were compared between the patients with or without MACCE using the 2-independent-samples test and the \u0026chi;\u003csup\u003e2\u003c/sup\u003e test, respectively. A\u0026nbsp;multivariate logistic regression model was applied to determine the adjusted associations between MACCE and different predictors thereof. All variables with a \u003cem\u003eP\u003c/em\u003e value of less than 0.2 in the univariate analysis were entered into the model.\u0026nbsp;The statistical analyses were carried out using IBM SPSS Statistics 20 for Windows (IBM Co, Armonk, NY, USA). A \u003cem\u003eP\u003c/em\u003e value of less than 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability and statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 411 CAS procedures were performed on 380 patients. Thirty-one patients underwent bilateral stenting due to severe stenosis in the contralateral artery. The mean age of the study population was 68.6 \u0026plusmn; 10.6 years. The baseline characteristics of the patients whom we were able to follow and the frequency of common cardiovascular risk factors such as hypertension, diabetes mellitus, smoking, and coronary artery disease (CAD) are depicted in Table 1. All the patients had embolic protection device (358 [94.2%] patients with distal protection device and 22 [5.7%] patients with proximal protection device).\u003c/p\u003e\n\u003cp\u003eFollow-up (mean duration = 40.95 \u0026plusmn; 15.81 months; minimum 12 and maximum 108 months)\u0026nbsp;was performed on 295 (77.6%) patients.\u0026nbsp;The outcomes of angioplasty were divided into in-hospital and long-term (i.e., post-hospital discharge) outcomes, including complications.\u003c/p\u003e\n\u003cp\u003eA total of 380 patients, 264 (69.5%) symptomatic and 116 (30.5%) asymptomatic, were included in our study. The mean age of the study population was 68.6 \u0026plusmn; 10.6 years. During the post-CAS in-hospital course, stroke occurred in 2 (0.5%), intracranial hemorrhage in 4 (1.1%), death in 2 (0.5%) and MACCE in 8 (2.1%) in symptomatic patients. In asymptomatic patiets, stroke happened in 1 (0.3%), intracranial hemorrhage in 1 (0.3%), death in 1 (0.3%) and MACCE in 3 (0.8%). Totally there were 380 patients that stroke occurred in 3 (0.8%), intracranial hemorrhage in 5 (1.3%), death in 3 (0.8%), and MACCE in 11 (2.89%) patients.\u003c/p\u003e\n\u003cp\u003eDuring the long-term follow-up, there were 26 (8.8%) cases of stroke, of which 17 (5.7%) were fatal; 9 (3.1%) cases of MI, of which 8 (2.7%) were fatal; and 57 (19.3%) cases of MACCE, including episodes of bleeding in 6 (2.0%): 3 (1.0%) major and 3 (1.0%) clinically relevant non-major bleeding cases. The mortality rate at long-term follow-up was 41 patients, resulting in a 13.9% all-cause mortality rate (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe univariate analysis revealed age (\u003cem\u003eP=\u0026nbsp;\u003c/em\u003e0.008)\u003cem\u003e,\u003c/em\u003e the BMI (\u003cem\u003eP\u003c/em\u003e = 0.199), prior MI (\u003cem\u003eP\u003c/em\u003e = 0.172), and contralateral stenting (\u003cem\u003eP\u003c/em\u003e = 0.155) as meaningful variables that could predict the occurrence of MACCE. Table 1 also presents the results of the comparisons of the variables between the 2 groups of patients with and without MCACE. All the meaningful variables for each event in the univariate analysis were entered in the multivariate logistic regression analysis in order that each event could be analyzed separately. Each event is illustrated as an independent model in Table 3. According to the results of this analysis, age, the BMI, and contralateral stenting were meaningful variables for all-cause mortality (Model 1); age and a history of hypertension were correlated with cardiovascular death (Model 2); gender, age, prior cerebrovascular accident, being symptomatic, a history of CAD, dyslipidemia, diabetes mellitus, and contralateral stenting were correlated with the event of cardiovascular rehospitalization (due to MI and stroke) (Model 3); age, the BMI, cerebrovascular accident, and contralateral significant stenosis were meaningful variables for the event of MI (Model 4); gender, a history of CAD, diabetes mellitus, and smoking had significant relationships with the event of stroke (Model 5); and age, the BMI, prior MI, and contralateral stenting were correlated with MACCE (Model 6). Table 3 demonstrates the results of the multivariate logistic regression analysis, according to which age (OR: 1.040, 95% CI: 1.002 to 1.079) was an independent predictor of MACCE.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe SAPPHIRE and CREST trials suggested\u0026nbsp;CAS\u0026nbsp;as an alternative to carotid artery endarterectomy for the prevention of stroke in the long term\u0026nbsp;(13, 14). In the present study, we have reported the in-hospital and long-term outcomes of CAS procedure with a mean follow-up of 40.95 \u0026plusmn; 15.81 months in high-volume center in Iran.\u0026nbsp;Post-procedural in-hospital stroke, ICH, MACCE and all-cause mortality occurred in 3 (0.8%), 5 (1.3%), 11 (2.89%) and 3 (0.8%) respectively and these results are in-line with acceptable statistics presented in other publications\u0026nbsp;(6, 15, 16).\u003c/p\u003e\n\u003cp\u003eAs we know, the major outcomes of CAS procedure in long-term are stroke and death. Rate of any stroke in CAS patients in CREST study during 4 years follow up is 10.2\u0026plusmn;1.1 (%\u0026plusmn;SE)\u0026nbsp;(17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of a study conducted by Jonsson et al. showed the mortality rate of CAS procedure was 25.7%, the ipsilateral stroke rate was 9.4% and any stroke or death rate was 34.2% in 4.1-year follow-up duration\u0026nbsp;(18). A study by Rubin et al. showed a 3.2% fatal and non-fatal stroke rate after 5 years follow-up\u0026nbsp;(19). Also, in the study of de Donato et al. with 5 years follow-up, average annual rate of all-cause mortality, stroke-related death and any stroke were 3.43%, 1.31%, 1.9% respectively\u0026nbsp;(20). Of note,\u0026nbsp;we have reported a follow-up rate of 77.6%. Our results revealed a 13.9% rate of all-cause mortality, which varied among different subgroups (e.g., 11.6% in patients with diabetes mellitus and 13.2% in patients with CAD), 8.8% rate of stroke and 19.3% rate of MACCE with\u0026nbsp;mean follow up duration of 40.95 \u0026plusmn; 15.81 months; (minimum 12 and maximum 108 months)\u0026nbsp;and our results are in line with the results of above-mentioned studies.\u003c/p\u003e\n\u003cp\u003eWe also found that diabetes mellitus was not associated with all-cause mortality, MACCE, and cardiovascular rehospitalization due to MI or stroke. Moreover, gender was not a meaningful variable for the occurrence of MACCE, whereas age was shown to be an independent predictor of all-cause mortality and MACCE.\u003c/p\u003e\n\u003cp\u003eDiabetes mellitus, known as an important risk factor for cardiovascular events such as CAD, MI, ischemic stroke, and death\u0026nbsp;(21), can not only increase atherosclerotic complications by increasing carotid plaque revascularization\u0026nbsp;(22)\u0026nbsp;but also cause carotid plaque instability\u0026nbsp;(23, 24)\u0026nbsp;and augment the thickness of the intima and media layers of the carotid artery, which can be a risk factor for cardiovascular events\u0026nbsp;(25, 26). Hussain et al\u0026nbsp;(27)\u0026nbsp;concluded that the risk of post-angioplasty mortality was higher in patients with diabetes than in patients without it, which does not chime in with our results. The discrepancy may be in consequence of different sample volumes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe NASCET and ACE studies concluded that the risk of post-carotid endarterectomy complications was higher in females\u0026nbsp;(28, 29). This claim can be justified by dissimilarities in the male and female anatomy, rendering the procedure more challenging in women, and the higher risk of postoperative thrombosis in women\u0026nbsp;(30, 31). In contrast, Shobha et al\u0026nbsp;(32)\u0026nbsp;compared the 30-day outcome of carotid angioplasty between women and men and posited that this procedure could be performed as safely in women as in men. In our investigation, in-hospital mortality following angioplasty occurred in 3 patients, all of them female. Additionally, in-hospital stroke occurred in 3 patients, of whom 1 was female; nevertheless, we could not reach the conclusion that the female gender was a meaningful variable for the occurrence of death and stroke during the in-hospital course of care. Our results indicated that while gender was not a meaningful variable for the occurrence of MACCE, the male gender was an independent predictor of the occurrence of stroke.\u003c/p\u003e\n\u003cp\u003eAhmadi et al\u0026nbsp;(33)\u0026nbsp;concluded that CAS could be performed safely even in elderly patients with some comorbidities and that the age of patients was not a predictor of a poor post-CAS outcome. \u0026nbsp;On the other hand, the results of the CREST clinical trial indicated that while older age was allied to a higher risk of post-CAS stroke, such association was absent in regard to\u0026nbsp;carotid artery endarterectomy\u0026nbsp;inasmuch as the risk of stroke after surgery was similar between old and young patients; accordingly, age is of importance in the selection of the optimal choice for the treatment of carotid artery stenosis\u0026nbsp;(13). The results of our study also showed that age was significantly correlated with all-cause mortality, MI, and MACCE.\u003c/p\u003e\n\u003cp\u003eThe results of the current study should be interpreted in light of some of its limitations, first and foremost among which is its retrospective design with its inherent weakness in data gathering. Indeed, it is likely that some important risk factors were not recorded properly in the patients\u0026rsquo; records. Another shortcoming of note is our long-term telephone-conducted follow-up of only 77.6% of the study population, with 22.4% being missed to follow-up. Further, despite our efforts to fully extract the patients\u0026rsquo; cardiovascular risk factors from their records so as to assess their associations with the occurrence of MACCE, our study\u0026rsquo;s insufficient sample size and retrospective data precluded us from robustly concluding which risk factors were the predisposing factors for MACCE.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of the current investigation indicated that age was an important predictor of all-cause mortality, MI, and MACCE. There was also no difference in the long-term post-CAS clinical outcome between men and women. Also, current investigation revealed presence or absence of diabetes exerting no impact on long-term clinical outcome. Further prospective studies are needed to prove the predisposing factors for MACCE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were involved in all stages of data collection, analysis and interpretation of the results obtained and writing the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Rajaie Cardiovascular Medical and Research Center (ethical code: RHC.AC.IR.REC.1395.56).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnd we\u0026nbsp;confirm that all methods were carried out in accordance with relevant guidelines and regulations.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlso, informed consent was obtained from all the participants in this study to publish information related to the research, without mentioning personal details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to Yousef Rezaei MD and all other participated in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBorhani-Haghighi A, Safari R, Heydari ST, Soleimani F, Sharifian M, Kashkuli SY, et al. 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Fourth universal definition of myocardial infarction (2018). Journal of the American College of Cardiology. 2018;72(18):2231-64.\u003c/li\u003e\n\u003cli\u003eSchulman S, Kearon C. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost. 2005;3(4):692-4.\u003c/li\u003e\n\u003cli\u003eKaatz S, Ahmad D, Spyropoulos A, Schulman S, Anticoagulation SoCo. Definition of clinically relevant non‐major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non‐surgical patients: communication from the SSC of the ISTH. Journal of Thrombosis and Haemostasis. 2015;13(11):2119-26.\u003c/li\u003e\n\u003cli\u003eBrott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010;363(1):11-23.\u003c/li\u003e\n\u003cli\u003eYadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. New England Journal of Medicine. 2004;351(15):1493-501.\u003c/li\u003e\n\u003cli\u003eFurie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(1):227-76.\u003c/li\u003e\n\u003cli\u003eOrganisation EbtES, Members ATF, Tendera M, Aboyans V, Bartelink M-L, Baumgartner I, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries The Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). European heart journal. 2011;32(22):2851-906.\u003c/li\u003e\n\u003cli\u003eMantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. 2010;41(10 Suppl):S31-4.\u003c/li\u003e\n\u003cli\u003eJonsson M, Lindstr\u0026ouml;m D, Gillgren P, Wanhainen A, Malmstedt J. Long-Term Outcome After Carotid Artery Stenting: A Population-Based Matched Cohort Study. Stroke. 2016;47(8):2083-9.\u003c/li\u003e\n\u003cli\u003eRoubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW, et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation. 2001;103(4):532-7.\u003c/li\u003e\n\u003cli\u003ede Donato G, Setacci C, Deloose K, Peeters P, Cremonesi A, Bosiers M. Long-term results of carotid artery stenting. J Vasc Surg. 2008;48(6):1431-40; discussion 40-1.\u003c/li\u003e\n\u003cli\u003eCollaboration ERF. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. The Lancet. 2010;375(9733):2215-22.\u003c/li\u003e\n\u003cli\u003eOlson FJ, Str\u0026ouml;mberg S, Hjelmgren O, Kjelldahl J, Fagerberg B, Bergstr\u0026ouml;m GM. Increased vascularization of shoulder regions of carotid atherosclerotic plaques from patients with diabetes. Journal of vascular surgery. 2011;54(5):1324-31. e5.\u003c/li\u003e\n\u003cli\u003eCipollone F, Iezzi A, Fazia M, Zucchelli M, Pini B, Cuccurullo C, et al. The receptor RAGE as a progression factor amplifying arachidonate-dependent inflammatory and proteolytic response in human atherosclerotic plaques: role of glycemic control. Circulation. 2003;108(9):1070-7.\u003c/li\u003e\n\u003cli\u003eRedgrave J, Lovett J, Syed A, Rothwell P. Histological features of symptomatic carotid plaques in patients with impaired glucose tolerance and diabetes (oxford plaque study). Cerebrovascular diseases. 2008;26(1):79-86.\u003c/li\u003e\n\u003cli\u003eBrohall G, Oden A, Fagerberg B. Carotid artery intima‐media thickness in patients with Type 2 diabetes mellitus and impaired glucose tolerance: a systematic review. Diabetic medicine. 2006;23(6):609-16.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson Jr SK. Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. New England Journal of Medicine. 1999;340(1):14-22.\u003c/li\u003e\n\u003cli\u003eHussain MA, Bin-Ayeed SA, Saeed OQ, Verma S, Al-Omran M. Impact of diabetes on carotid artery revascularization. Journal of vascular surgery. 2016;63(4):1099-107. e4.\u003c/li\u003e\n\u003cli\u003eAlamowitch S, Eliasziw M, Barnett HJ. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke. 2005;36(1):27-31.\u003c/li\u003e\n\u003cli\u003eSarac TP, Hertzer NR, Mascha EJ, O\u0026apos;Hara PJ, Krajewski LP, Clair DG, et al. Gender as a primary predictor of outcome after carotid endarterectomy. Journal of vascular surgery. 2002;35(4):748-53.\u003c/li\u003e\n\u003cli\u003eHansen F, Mangell P, Sonesson B, L\u0026auml;nne T. Diameter and compliance in the human common carotid artery\u0026mdash;variations with age and sex. Ultrasound in Medicine and Biology. 1995;21(1):1-9.\u003c/li\u003e\n\u003cli\u003eSchulz UG, Rothwell PM. Sex differences in carotid bifurcation anatomy and the distribution of atherosclerotic plaque. Stroke. 2001;32(7):1525-31.\u003c/li\u003e\n\u003cli\u003eShobha N, Almekhlafi M, Pandya A, Couillard P, Morrish W, Wong J, et al. Carotid Angioplasty and Stenting Is Safe in Women. Can Assoc Radiol J. 2010.\u003c/li\u003e\n\u003cli\u003eAhmadi R, Schillinger M, Lang W, Mlekusch W, Sabeti S, Minar E. Carotid artery stenting in older patients: is age a risk factor for poor outcome? Journal of Endovascular Therapy. 2002;9(5):559-65.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Baseline characteristics of the patients and the long-term results of the univariate analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable align=\"left\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N = 295)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003ePositive MACCE\u003c/p\u003e\n \u003cp\u003e(n = 57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003eNegative MACCE\u003c/p\u003e\n \u003cp\u003e(n = 238)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e69.03 \u0026plusmn; 9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e72.1 \u0026plusmn; 8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e68.3 \u0026plusmn; 10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e206 (69.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e36 (63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e170 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e27.26 \u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e26.3 \u0026plusmn; 6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e27.5 \u0026plusmn; 7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eCAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e151 (51.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e26 (45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e125 (52.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eHistory of MI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e30 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e3 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e27 (11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e227 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e41 (71.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e186 (78.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e150 (50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e27 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e123 (51.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.559\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e138 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e25 (43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e113 (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.623\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e65 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e13 (22.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e52 (21.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eSymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e208 (70.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e41 (71.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e167 (70.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eTIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e60 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e15 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e45 (18.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e168 (56.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e32 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e136 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eContralateral significant stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e50 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e10 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e40 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.894\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eContralateral stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e27 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e8 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e19 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.884615384615383%\"\u003e\n \u003cp\u003eContralateral total occlusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.192307692307693%\"\u003e\n \u003cp\u003e37 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.192307692307693%\"\u003e\n \u003cp\u003e8 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.23076923076923%\"\u003e\n \u003cp\u003e29 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e0.705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAll data are presented as mean \u0026plusmn; SD or numbers (%).\u003c/p\u003e\n\u003cp\u003eMACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality); BMI, Body mass index; TIA, Transient ischemic attack; CVA, Cerebrovascular accident; CAD, Coronary artery disease; MI, Myocardial infarction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: In-hospital and long-term outcomes of carotid artery stenting\u003c/strong\u003e\u003c/p\u003e\n\u003ctable align=\"left\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003eNumber of Patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003eSymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003easymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-Hospital outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e3 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eIntracranial hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e5 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eHematoma at the catheterization site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e21 (5.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e14 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e7 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003ePseudoaneurysm at the catheterization site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eCarotid perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eBubble injection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eCarotid dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e3 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e2 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e1 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eMACCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e11 (2.89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e8 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e3 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLong-term Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eFollowed patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e295 (77.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e208 (70.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e87 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eAll-cause mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e41 (13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e11 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e30 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eCardiovascular death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e22 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e15 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e7 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e9 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e6 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e3 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e26 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e18 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e8 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eCardiovascular rehospitalization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e46 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e24 (8.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e22 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e6 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e4 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e2 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89547038327526%\"\u003e\n \u003cp\u003eMACCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.56445993031359%\"\u003e\n \u003cp\u003e57 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.421602787456447%\"\u003e\n \u003cp\u003e41 (13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.118466898954704%\"\u003e\n \u003cp\u003e16 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMI, Myocardial infarction; MACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Multivariate logistic regression analysis results \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.234726688102894%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003eConfidence Interval (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e0.908 \u0026ndash; 0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.985 \u0026ndash; 1.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eContralateral stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.139 \u0026ndash; 0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e1.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e0.997 \u0026ndash; 1.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.188 \u0026ndash; 1.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e1.738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e0.837 \u0026ndash; 3.613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.953 \u0026ndash; 1.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003ePrior CVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.300 \u0026ndash; 3.323\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eSymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.123 \u0026ndash; 1.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of CAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.708 \u0026ndash; 3.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of dyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.577 \u0026ndash; 2.578\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.603\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.990\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.938 \u0026ndash; 4.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eContralateral stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.705\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.567 \u0026ndash; 5.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e1.120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e1.006 \u0026ndash; 1.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.974 \u0026ndash; 1.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003ePrior CVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.054 \u0026ndash; 1.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eSignificant stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.081 \u0026ndash; 6.605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.781\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e2.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e1.052 \u0026ndash; 6.321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of CAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.254 \u0026ndash; 1.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of diabetes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e1.580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.647 \u0026ndash; 3.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eHistory of smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.095 \u0026ndash; 2.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.289\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" width=\"7.234726688102894%\"\u003e\n \u003cp\u003eModel 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.437299035369776%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.774919614147908%\"\u003e\n \u003cp\u003e1.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.366559485530548%\"\u003e\n \u003cp\u003e1.002 \u0026ndash; 1.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.186495176848876%\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.926 \u0026ndash; 1.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.445\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003ePrior MI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.157 \u0026ndash; 1.945\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.34315424610052%\"\u003e\n \u003cp\u003eContralateral stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.317157712305026%\"\u003e\n \u003cp\u003e2.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.422876949740036%\"\u003e\n \u003cp\u003e0.860 \u0026ndash; 5.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91681109185442%\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, Body mass index; CVA, Cerebrovascular accident; CAD, Coronary artery disease\u003c/p\u003e\n\u003cp\u003eModel 1 = death\u003c/p\u003e\n\u003cp\u003eModel 2 = cardiovascular death\u003c/p\u003e\n\u003cp\u003eModel 3 = cardiovascular rehospitalization\u003c/p\u003e\n\u003cp\u003eModel 4 = MI, myocardial infarction\u003c/p\u003e\n\u003cp\u003eModel 5 = stroke\u003c/p\u003e\n\u003cp\u003eModel 6 = MACCE, Major adverse cardiac and cerebral events (defined as a composite of stroke, MI, bleeding, and all-cause mortality)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Carotid artery stenting, Complications, Major adverse cardiac and cerebral events","lastPublishedDoi":"10.21203/rs.3.rs-1918352/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1918352/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e One of the most common and treatable causes of stroke is carotid artery stenosis. Carotid artery stenting (CAS) is an option for treating the stenosis, with such notable clinical outcomes as low rates of in-hospital death, stroke, and intracerebral hemorrhage.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eAll patients who underwent carotid angioplasty between December 2010 and January 2019 in Rajaie Cardiovascular Medical and Research Center were enrolled. The incidence rates of major adverse cardiac and cerebral events (MACCE), defined as a composite of stroke, myocardial infarction, bleeding, and all-cause mortality, both during hospitalization and at long-term follow-up were determined. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 380 patients, 264 (69.5%) symptomatic and 116 (30.5%) asymptomatic, were included. The mean age of study population was 68.6 ± 10.6 years. During post-CAS in-hospital course, stroke occurred in 2 (0.5%), intracranial hemorrhage in 4 (1.1%), death in 2 (0.5%) and MACCE in 8 (2.1%) in symptomatic, and stroke in 1 (0.3%), intracranial hemorrhage in 1 (0.3%), death in 1 (0.3%) and MACCE in 3 (0.8%) in asymptomatic patients. Totally, stroke occurred in 3 (0.8%), intracranial hemorrhage in 5 (1.3%), death in 3 (0.8%), and MACCE in 11 (2.89%) patients.\u003c/p\u003e\u003cp\u003eLong-term follow-up (40.95 ± 15.81 months) was performed on 295 (77.6%) patients; the results demonstrated a mortality rate of 13.9% (n = 41) which 30 (10.1%) cases belonged to symptomatic and 11 (3.7%) cases were from asymptomatic patients. Stroke happened in 26 (8.8%), that 18 (6.1%) cases were symptomatic and 8 (2.7%) cases were asymptomatic. MACCE rate was 19.3% (n = 57) which 41 (13.8%) cases were symptomatic and 16 (5.4%) were asymptomatic. Age (OR: 1.040, 95% CI: 1.002 to 1.079) was confirmed as a meaningful variable for the occurrence of MACCE. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eOur results confirm the safety and efficacy of carotid stenting in experienced centers. Age was as an important predictor of all-cause mortality, myocardial infarction, and MACCE.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"In-Hospital Complications and Long-term Outcomes of Carotid Artery Stenting: INCARCERATE Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-29 16:51:43","doi":"10.21203/rs.3.rs-1918352/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50ddad8c-dcb1-4494-b9b7-d72ed4d0c53f","owner":[],"postedDate":"August 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-21T11:14:28+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-29 16:51:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1918352","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1918352","identity":"rs-1918352","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}