The Important CAS Technical Issue of Balloon Postdilatation Remains Unresolved

The Society for Cardiovascular Angiography and Interventions (SCAI) presented a substudy of CREST, the Carotid Revascularization Endarterectomy versus Stenting Trial, at the SCAI 2013 meeting in May. The substudy aimed to evaluate whether postdilatation after stent placement increases the risk of complications. Lead investigator Mahmoud B. Malas, MD, associate professor of surgery, director of endovascular surgery, and director of the Vascular and Endovascular Research Center at the Johns Hopkins Bayview Medical Center, made the following comment:

“Carotid stenting is the subject of ongoing research because it provides a less invasive treatment option, which is often necessary for patients who are too sick to undergo surgery… these results show performing balloon angioplasty after stenting significantly reduced the risk of those same arteries narrowing again, but may also increase, though not significantly, the risk of stroke.”

Out of 1,109 patients in CREST who underwent carotid artery stenting, 69 patients underwent balloon angioplasty before the stent was implanted, 344 had ballooning after the stent was implanted, and 696 underwent balloon angioplasty before and after the stent was implanted. The substudy investigators found that the risk of restenosis was reduced by 64% by performing balloon angioplasty after stent deployment as opposed to angioplasty before stent implantation. Importantly, the group having angioplasty after stent placement had a larger number of strokes compared to the group who received angioplasty only before stent placement, but that number was not statistically significant. 

“We actually had too few complications to make any statistically significant assessment about risk of stroke between the different ballooning methods,” Dr. Malas said in the SCAI announcement. 

My own present-day preference – which evolved over the last several years – is to perform predilation routinely and avoid postdilatation in most cases for the sake of safety. But it is true that CAS restenosis (mostly, residual stenosis) occurs more frequently when so doing.