Letter by Su et al Regarding Article, “Carotid Stent Fractures Are Not Associated With Adverse Events: Results From the ACT-1 Multicenter Randomized Trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease)”

HomeCirculationVol. 137, No. 24Letter by Su et al Regarding Article, “Carotid Stent Fractures Are Not Associated With Adverse Events: Results From the ACT-1 Multicenter Randomized Trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease)” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Su et al Regarding Article, “Carotid Stent Fractures Are Not Associated With Adverse Events: Results From the ACT-1 Multicenter Randomized Trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease)” Qiang Su, MD, PhD, Ziliang Ye, MD and Lang Li, MD, PhD Qiang SuQiang Su Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China. Search for more papers by this author , Ziliang YeZiliang Ye Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China. Search for more papers by this author and Lang LiLang Li Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China. Search for more papers by this author Originally published12 Jun 2018https://doi.org/10.1161/CIRCULATIONAHA.117.032212Circulation. 2018;137:2674–2675To the Editor:We read with interest the asymptomatic carotid trial1 evaluating the stent fracture rate and its association with in-stent restenosis and adverse outcomes in 1021 patients treated with carotid artery stenting, which demonstrated that the stent fracture rate was low and not associated with major adverse clinical events or in-stent restenosis. After reading this article carefully, we would like to make the following points.First, as the authors described in Tables 1 and 2, there were statistical differences in previous carotid endarterectomy and calcification severe between the 2 groups (P=0.02 and P=0.02, respectively). When the adverse clinical outcomes were compared between the 2 groups, we sincerely advise the authors to use a multivariate logistic regression analysis to adjust confounding factors (such as previous carotid endarterectomy and calcification severe) and then reach an accurate conclusion that can reflect the real world.Second, carotid stent fracture (CSF) is 1 of the uncommon complications in patients with severe asymptomatic carotid artery stenosis treated with carotid artery stenting.2 At present, whether CSF is closely related to the patient’s adverse prognosis remains unknown. Chang et al3 found that neither CSF nor deformation was associated with late stroke or reintervention. However, they also pointed out that the presence of carotid artery calcification plaque is significantly associated with CSF or deformation (P<0.05), and they concluded that larger studies are needed to confirm this conclusion. In our opinion, more studies are still needed to further confirm whether CSF is not associated with major adverse clinical events or in-stent restenosis, especially those studies conducted in other countries or races. As far as we know, China is a country with a population of 1 300 000 000. The difference in genes, races, or diet can influence the prognosis of diseases. For example, we found that nicorandil can reduce myocardial injury and the incidence of adverse reaction caused by percutaneous coronary intervention for Chinese’s population, but it is not obvious for non-Chinese’s population in our previous study.4 Similarly, the subjects of this study were from the US population; therefore, whether this conclusion can be applicable to other populations still needs to be confirmed by subsequent studies, especially those performed in Asia or Europe.Third, Sfyroeras et al5 reviewed the published studies about the clinical relevance of CSF and found that it is mainly reported in self-expandable nitinol stents and was associated with restenosis. The authors hope that larger prospective studies are needed to confirm the optimal time of treatment for CSF. However, as the authors said in the Abstract, carotid artery stenting used in this study was produced by Abbott Vascular. We hypothesize that different stent types may lead to different results. Those results might be consistent with the use of the same carotid stent. In our opinion, the best way to eliminate different outcomes for different carotid stents is to use a variety of different carotid stents in 1 study and then perform a subgroup analysis to obtain an accurate, reliable conclusion.DisclosuresNone.Footnoteshttp://circ.ahajournals.orgReferences1. Weinberg I, Beckman JA, Matsumura JS, Rosenfield K, Ansel GM, Chaturvedi S, Gray W, Metzger DC, Riles T, Shu Y, Wechsler L, Jaff MR. Carotid stent fractures are not associated with adverse events: results from the ACT-1 Multicenter Randomized Trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease).Circulation. 2018; 137:49–56. doi: 10.1161/CIRCULATIONAHA.117.030030.LinkGoogle Scholar2. Garcia-Toca M, Rodriguez HE, Naughton PA, Keeling A, Phade SV, Morasch MD, Kibbe MR, Eskandari MK. Are carotid stent fractures clinically significant?Cardiovasc Intervent Radiol. 2012; 35:263–267. doi: 10.1007/s00270-011-0149-3.CrossrefMedlineGoogle Scholar3. Chang CK, Huded CP, Nolan BW, Powell RJ. Prevalence and clinical significance of stent fracture and deformation following carotid artery stenting.J Vasc Surg. 2009; 49:685–690.CrossrefGoogle Scholar4. Ye Z, Su Q, Li L. The clinical effect of nicorandil on perioperative myocardial protection in patients undergoing elective PCI: a systematic review and meta-analysis.Sci Rep. 2017; 7:45117. doi: 10.1038/srep45117.CrossrefMedlineGoogle Scholar5. Sfyroeras GS, Koutsiaris A, Karathanos C, Giannakopoulos A, Giannoukas AD. Clinical relevance and treatment of carotid stent fractures.J Vasc Surg. 2010; 51:1280–1285. doi: 10.1016/j.jvs.2010.01.050.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails June 12, 2018Vol 137, Issue 24 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.032212PMID: 29891631 Originally publishedJune 12, 2018 PDF download Advertisement SubjectsCerebral AneurysmCerebrovascular Disease/StrokeIschemic StrokeMoyamoya