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What Is the Learning Curve for Carotid Artery Stenting With Neuroprotection? Analysis of 200 Consecutive Cases at an Academic Institution

Ruth L. Bush, MD

Eric Peden, MD

Wei Zhou, MD

Panagiotis Kougias, MD

Esteban Henao, MD

Imran Mohiuddin, MD

Alan B. Lumsden, MD

Houston, TX

Carotid artery stenting (CAS) has emerged as an acceptable treatment alternative in high-risk patients with carotid stenosis. This study assessed the effect of the Learning curve on treatment complications and clinical outcome of CAS. Clinical variables and treatment outcomes of 200 consecutive CAS procedures in 182 patients (mean age, 72 years) with carotid stenosis of 70% or greater during a 40-month period were analyzed. Technical success, periprocedural complications, and treatment outcomes were compared in four sequential groups (group 1 1I, Ill, and IV) of 50 consecutive interventions. Treatment indications and relevant risk factors were similar among the four groups. The overall technical success was 98%, and the combined 30-day stroke and death rates was 2.5%. An increase in the technical success rate was noted in the latter three groups compared with group I (P < .05). Total procedural time and contrast volume were significantly higher in group I compared with the latter three groups (P < .05). The intraoperative anticoagulation regimen was changed from an intravenous heparin combination to bivalirudin after the first 54 cases, resulting in reduced bleeding complications in groups Ill and IV (P = .03) compared with group 1. The 30-day stroke and death rate in groups I and 11 was 8% and 2%, which was reduced significantly to 0% in groups Ill and IV (P < .05). A Cox regression model identified procedural volume (P = .03) as a predictor of a reduced complication rate. Carotid artery stenting with neuroprotection can provide excellent treatment outcome. Our experience demonstrates a procedural-associated learning curve, as evidenced by the reduced procedural-related complications, fluoroscopic time, and contrast volume that occurred with an increase in physician experience. The procedural success is also enhanced partly by endovascular device refinement and improved anticoagulation regimen. Successful outcome of CAS can be achieved once physicians overcome the initial procedural-related learning curve.

Key Words: carotid artery stenting • procedural-related learning curve • neuroprotection devices

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