Safety and Efficacy of Carotid Stenting Without Embolic Protection Device in Delayed Window Period: Experience From A Tertiary Care Center

Background and Objectives: Cerebrovascular disease is the fifth leading cause of death in the United States. Ischemic stroke, often due to atherosclerotic carotid artery stenosis, carries a high risk of recurrence. Preventive options for stroke include medical management, carotid endarterectomy (CEA), and carotid artery stenting (CAS). CAS offers comparable safety and efficacy to CEA, but the role of embolic protection devices (EPDs) is still unclear. The study aims to evaluate the safety and efficacy of CAS without EPDs in symptomatic carotid artery stenosis, focusing on periprocedural complications and long-term outcomes. Methods: A retrospective analysis included patients who underwent CAS for symptomatic carotid artery stenosis at a tertiary care center. The primary outcome was 30-day major complications (stroke, myocardial infarction, death). Secondary outcomes were restenosis and modified Rankin Scale (mRS) scores during follow-up. Data was recorded after reviewing of medical records and imaging studies. A P value of less than 0.05 was considered significant. Results: A total of 146 patients underwent 156 CAS without EPDs. The median duration from symptom onset to CAS was 37 days (interquartile range [IQR] =14 days). Ischemic stroke was the most common clinical presentation (56.8%). Bradycardia occurred in 24 (16.44%) patients and periprocedural stroke in 6 (4.11%) patients: 4 (2.7%) ischemic and 2 (1.3%) hemorrhagic. Three ischemic stroke patients became clinically asymptomatic and one progressed from mRS 1 to 2, but both hemorrhagic stroke patients died. Restenosis (>50%) occurred in 8 (5.12%) stents in 30-month follow-up. Conclusions: CAS without EPDs is safe and effective for symptomatic carotid artery stenosis, with low complication and restenosis rates, comparable to CEA and CAS with EPDs. Interval CAS without EPDs (delay >2 weeks) with plaque stabilization can be safe and cost-effective, making it a viable option in resource-limited settings with experienced operators.