Long-Term Outcomes of Carotid Artery Stenting in a Resource Limited Setting: A Single-Center Experience from a Lower-Middle Income Country

Purpose: To evaluate the safety and long-term outcomes of carotid artery stenting (CAS) in patients with carotid stenosis treated at a resource-limited center in a lower-middle-income country, and to identify predictors of adverse events.

Materials and Methods: We performed a retrospective review of all patients who underwent CAS between December 2017 and August 2024. Demographics, comorbidities, clinical presentation, stenosis severity, procedural details, and outcomes were analyzed. Symptomatic stenosis was defined as ipsilateral ischemic stroke, transient ischemic attack, or amaurosis fugax within six months. Technical success was defined as residual stenosis < 30% with preserved antegrade flow and no major intraprocedural complication. Primary outcomes were 30-day stroke or death and ipsilateral stroke during follow-up. Kaplan–Meier analysis was used to estimate ipsilateral stroke-free survival. Cox proportional hazards regression was performed to assess predictors of long-term stroke, and penalized logistic regression was applied to identify predictors of 30-day adverse outcomes.

Results: A total of 104 patients underwent CAS. The mean age was 68.3 ± 10.4 years; 96 (92.3%) were male. Symptomatic stenosis was present in 88 (84.6%) and asymptomatic stenosis in 16 (15.4%). Mean ipsilateral stenosis severity was 80% ± 10% (median 80%, IQR 80–90%). Technical success was achieved in 104 (100%). Within 30 days, stroke occurred in 10 (9.6%) patients; no deaths occurred. Stroke affected 9 (10.2%) symptomatic versus 1 (6.3%) asymptomatic patient. Median follow-up was 1,096 days (IQR 365–1,765). Ipsilateral stroke occurred in 9 (8.7%) patients. Kaplan–Meier analysis showed stroke-free survival of 92.1% at one year, 88.4% at two years, and 85.2% at three years; three-year survival was 84.5% in symptomatic and 90.6% in asymptomatic patients. Cox regression showed contralateral carotid occlusion increased stroke risk (HR 4.36, 95% CI 0.92–20.6). Logistic regression showed no predictors of 30-day outcomes. Distal filter protection was used in 104 (100%); open-cell stents in 48 (46.2%), dual-layer in 40 (38.5%), and closed-cell in 16 (15.4%).

Conclusion: CAS in a lower-middle-income country achieved 100% technical success, a 30-day stroke/death rate of 9.6%, and durable long-term stroke prevention, with stroke-free survival >85% at three years. Contralateral occlusion may predict late stroke.