Target lesion ulceration and arch calcification are associated with increased incidence of carotid stenting-associated ischemic lesions in octogenarians

Purpose: Although evidence is accumulating that advanced age is a risk factor for carotid angioplasty and stenting (CAS), the reason for this finding is incompletely understood. The aims of this study were to compare the prevalence of anatomic risk factors in patients < 80 years with those in patients >= 80 years and to determine the effect of these risk factors on the incidence of new lesions seen on diffusion-weighted imaging (DWI) after protected CAS as surrogate markers for stroke. Methods: Various potential anatomic risk factors for CAS were analyzed in 62 symptomatic patients (49 aged < 80 years; 13 aged >= 80 years) by using preprocedural digital subtraction angiograms and extracranial contrast-enhanced magnetic resonance angiographies. DWI was performed immediately before and <= 48 hours after the procedure. Clinical outcome measures were stroke and death <= 30 days. Results. The octogenarians had a significantly higher incidence of severe aortic arch calcification (54% vs 14%, P < .01) and ulcerated stenoses (69% vs 22%, P < .01), but no statistically significant differences were found between treatment groups in elongation of the aortic arch, common or internal artery tortuousities, degree of stenosis, or length of the stenosis. Although the differences in clinical outcome between the treatment groups (4% aged < 80 years vs 8% >= 80 years) were not significant, the proportion of patients with any new ipsilateral DWI lesions, as well as the total number of these lesions, was higher in octogenarians than in patients aged < 80 years (85% vs 47%, P < .05), with a median of 2 (interquartile range [IQR], 1 to 5) vs 0 (IQR, 0 to 3; P = .07). Similarly, the proportion of patients with any new DWI lesions outside the vascular territory of the target vessel as well as the total number of these lesions was significantly higher in octogenarians compared with patients aged < 80 years (54% vs 10%, P < .01), with a median of 1.5 (IQR, 0.25 to 10.75) vs 0 (IQR, 0 to 1; P < .05). The presence of an ulcerated lesion was an independent predictor of any new ipsilateral DWI lesion (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.06 to 17.1; P < .05), whereas a severe aortic arch calcification tended to be a predictor of new DWI lesions outside the territory of the treated artery (OR, 1.8; 95% CI, 0.99 to 3335; P = .05). Conclusions. Increased prevalences of severe aortic arch calcifications and target lesion ulceration are associated with an increased risk for magnetic resonance DWI-detected embolic events during CAS. Because in our study arch calcification and target lesion ulceration were more prevalent in octogenarians, this association may explain the increased risk of CAS in the elderly.