Dual-layer vs. closed-cell devices in carotid artery stenting: The role of plaque morphology on short-term outcomes

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INTRODUCTION: Carotid artery stenting (CAS) is an alternative revascularization method for patients with internal carotid stenosis in whom an endovascular approach is selected instead of carotid endarterectomy. In recent years, dual-layer stents have increasingly been employed due to their better plaque coverage compared to closed-cell stents. The aim of this study was to report the outcomes of these two stent types in a real-world clinical setting. METHODS: Patients with internal carotid artery stenosis who underwent CAS between 2004 and 2023 at two high-volume centers were retrospectively analyzed. Plaques were classified as: type 1(lipid-rich), type 2(fibro lipid) and type 3(calcified). Primary endpoints included technical success (defined as residual stenosis <30% on completion angiography), and the incidence of stroke/death and TIA/stroke within 30 days comparing period of procedures and clinical manifestation (symptomatic and asymptomatic) comparing type of stent and type of plaque. RESULTS: A total of 944 CAS procedures were performed. Most of patients were male (68%) and younger than 80 years (72%). Symptomatic stenosis was present in 236(25%) patients, while 708(75%) were asymptomatic, with calcified plaques being most common (60%). Technical success was achieved in 94% procedures. In 6%, CAS procedure was abandoned due to excessive arch/carotid tortuosity. Before and after 2014 technical success rates were 9.7% and 3.6% (p < 0.001). The overall 30-day TIA/stroke and stroke/death rates were 6.4% and 2.4%, 10% and 4% in symptomatic and 5% and 2% in asymptomatic. Closed-cell stents (Wallstent, Boston Scientific Corporation, Massachusetts, USA) and dual-layer stents (Roadsaver, Terumo Corporation, Tokyo, Japan) were used in 64% and 36% of cases. Stroke/death and TIA/stroke occurred in 2.8%vs.0.8% (p = 0.20) in asymptomatic, and in 14.2%vs.5.4%(p = 0.05) in symptomatic. The 30-day stroke/death rate was 0.7%vs.0.8% (p = 0.80) in asymptomatic, while the 30-day TIA/stroke rate was higher, but not statistically significant, in the Wallstent group (5.9% vs.4.2%p = 0.30) in symptomatic. Patients with type 0-2 plaques treated with dual-layer stents had a significantly lower 30-day TIA/stroke rate (10% vs.3.7%, p = 0.02). Asymptomatic status (OR:0.4,95%CI:0.2-0.8, p = 0.008) and use of dual-layer stents (OR:0.5,95%CI:0.3-1, p = 0.05) are independent protective factors for 30-day TIA/stroke. CONCLUSION: Dual layer devices are associated with a significantly lower 30-day TIA/stroke rate in patients with vulnerable plaque types (1-2). Symptomatic status and stent design both influenced periprocedural outcomes, underscoring the value of tailoring device choice to plaque morphology.

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