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{{CMG}}, Christopher J. White, MD, FACC, FSCAI, FAHA, FESC, Chairman, Department of Cardiovascular Diseases, Ochsner Clinic Foundation
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==Overview==
==Overview==
'''Carotid stenting''' (CAS) is a percutaneous, endovascular procedure available to correct [[carotid stenosis]] (narrowing of the [[carotid artery]] lumen by [[atheroma]]).  Carotid stenosis can present with no symptoms (diagnosed incidentally) or through symptoms such as [[transient ischemic attack]]s (TIAs) or [[cerebrovascular accident]]s (CVAs, strokes).


'''Carotid stenting''' (CAS) is a percutaneous, endovascular procedure available to correct [[carotid stenosis]] (narrowing of the [[carotid artery]] lumen by [[atheroma]]).  Carotid stenosis can present with no symptoms (diagnosed incidentally) or through symptoms such as [[transient ischemic attack]]s (TIAs) or [[cerebrovascular accident]]s (CVAs, strokes). In a number of clinical trials, in patients at increased for carotid surgery, the rates of 30 day stroke and death have been noninferior or as good as  the standard approach, carotid endarterectomy.  Over 14,000 patients have been enrolled in trials to evaluate the results of carotid stenting in patients at increased-risk for surgery.  High-risk characteristics include anatomical or medical co-morbid conditions.  The most significant study to date has been the SAPPHIRE study, which in a randomized controlled study showed carotid stenting to be "noninferior" to endarterectomy in total Major Adverse Event rates, but superior in rates of major procedural stroke, cranial nerve palsy, and myocardial infarction. Yadav et. al."Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients". New England Journal of Medicine. October7, 2004. pp1493-1501.
==Landmark Studies==
In a number of clinical trials, in patients at increased for carotid surgery, the rates of 30 day stroke and death have been noninferior or as good as  the standard approach, carotid endarterectomy.  Over 14,000 patients have been enrolled in trials to evaluate the results of carotid stenting in patients at increased-risk for surgery.  High-risk characteristics include anatomical or medical co-morbid conditions.  The most significant study to date has been the SAPPHIRE study, which in a randomized controlled study showed carotid stenting to be "noninferior" to endarterectomy in total Major Adverse Event rates, but superior in rates of major procedural stroke, cranial nerve palsy, and myocardial infarction. <ref>Yadav et. al."Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients". New England Journal of Medicine. October7, 2004. pp1493-1501.</ref>


The question of carotid stenting in non-hi-risk patients has yet to be answered, with a few trials ongoing, including the ''Carotid Revsacularization Endarterectomy versus Stenting Trial'' ('''CREST''')[http://www.cresttrial.org/] funded by the [[National Institutes of Health]] (NIH.)   
The question of carotid stenting in non-hi-risk patients has yet to be answered, with a few trials ongoing, including the ''Carotid Revsacularization Endarterectomy versus Stenting Trial'' ('''CREST''')[http://www.cresttrial.org/] funded by the [[National Institutes of Health]] (NIH.)   
==Procedure==
*[[Informed consent]] obtained and [[local anaesthetic]] administered
*Preparation of both groins with antiseptic and draped
*Puncture into femoral artery and access through short sheath
*Guidewire passed through [[aorta]] and into arch
*Arch aortogram obtained if not previously performed to confirm suitability to continue
*Carotid and cerebral angiogram performed
*Long access sheath placed after cannulation of common carotid artery (CCA)
*Guidewire passed through area of carotid narrowing
*Placement of embolic protection device above the area of narrowing
*[[Angioplasty]] of carotid narrowing, but more commonly proceed straight to deployment of stent into area of narrowing
*Angioplasty post stent deployment
*Removal of protection device, guidewires and sheath
*Aftercare of groin puncture site


==Indications==
==Indications==
Line 30: Line 17:
Carotid stenting is currently indicated for the following patients:
Carotid stenting is currently indicated for the following patients:


* Patients who are:
Either
** Symptomatic with >50% stenosis
* Symptomatic patients with >50% stenosis
** Asymptomatic with >80% stenosis
 
** At least one anatomic or co-morbid risk factor placing them at high-risk for adverse events from CEA:
OR
 
* Asymptomatic patients with >80% stenosis


* Anatomic:
AND
** Contralateral carotid artery occlusion
** Contralateral [[laryngeal nerve palsy]]
** Scarring of the neck post radiation therapy or following neck surgery
** Recurrent stenosis after prior carotid surgery
** High cervical carotid artery lesions
** Carotid artery stenosis:
*** Below the clavicle
*** Distal to the second cervical vertebra
*** Proximal (intrathoracic) arterial stenosis
** Previous [[carotid endarterectomy]]
** Contralateral vocal cord paralysis
** [[Tracheostomy|Open tracheostomy]]


* Co-morbid conditions like:
* At least one anatomic or co-morbid risk factor placing them at high-risk for adverse events from CEA:
** [[Congestive Heart Failure]] (Class III/IV), and/or known severe [[left ventricular dysfunction]] ≤30%
:'''Anatomic Risk Factors:'''
** [[Open-heart surgery]] needed within 6 weeks
:* Contralateral carotid artery occlusion
** Recent myocardial infarction (>24 hours and <4 weeks)
:* Contralateral [[laryngeal nerve palsy]]
** [[Unstable angina]] (CCS class III/IV)
:* Scarring of the neck post radiation therapy or following neck surgery
** Synchronous severe cardiac and carotid disease requiring open heart surgery and carotid revascularization
:* Recurrent stenosis after prior carotid surgery
** Severe pulmonary disease to include any of the following:
:* High cervical carotid artery lesions
*** Chronic oxygen therapy
:* Carotid artery stenosis:
*** Resting P02 of < 60 mmHg
:** Below the clavicle
*** Baseline hematocrit > 50%
:** Distal to the second cervical vertebra
*** [[FEV1]] or [[DLCO]] < 50% of normal
:** Proximal (intrathoracic) arterial stenosis
** Abnormal [[stress test]]
:* Previous [[carotid endarterectomy]]
** Age greater than 80 years
:* Contralateral vocal cord paralysis
:* [[Tracheostomy|Open tracheostomy]]
:'''Co-Morbid Conditions:'''
:* [[Congestive Heart Failure]] (Class III/IV), and/or known severe [[left ventricular dysfunction]] ≤30%
:* [[Open-heart surgery]] needed within 6 weeks
:* Recent myocardial infarction (>24 hours and <4 weeks)
:* [[Unstable angina]] (CCS class III/IV)
:* Synchronous severe cardiac and carotid disease requiring open heart surgery and carotid revascularization
:* Severe pulmonary disease to include any of the following:
:** Chronic oxygen therapy
:** Resting P02 of < 60 mmHg
:** Baseline hematocrit > 50%
:** [[FEV1]] or [[DLCO]] < 50% of normal
:* Abnormal [[stress test]]
:* Age greater than 80 years


====Carotid Revascularization in Patients Undergoing CABG====
====Carotid Revascularization in Patients Undergoing CABG====
Line 68: Line 59:


=====Asymptomatic Stenosis=====
=====Asymptomatic Stenosis=====
The safety and efficacy of carotid revascularization before or concurrent with myocardial revacularization are not well established (II b, C).<ref name="circulation">ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline.Circulation.2011;124:e54-e130</ref>.
The safety and efficacy of carotid revascularization before or concurrent with myocardial revacularization are not well established (II b, C)<ref name="circulation">ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline.Circulation.2011;124:e54-e130</ref>.


==Patient Selection Warnings:==
==Risk Stratification==
Lesion Characteristics:
===High Risk Lesion Characteristics===
Patients with evidence of intraluminal thrombus thought to increase the risk of plaque fragmentation and distal embolization.
*Evidence of intraluminal thrombus thought to increase the risk of plaque fragmentation and distal embolization
Patients whose lesion(s) may require more than two stents.
*Lesion(s) that may require more than two stents
Patients with very tortuous lesions.
*Very tortuous lesions
Patients with total occlusion of the target vessel.
*Total occlusion of the target vessel
Patients with lesions of the ostium of the common carotid.
*Lesions of the ostium of the common carotid
Patients with highly calcified lesions resistant to PTA.
*Highly calcified lesions resistant to balloon inflation
Concurrent treatment of bilateral lesions.
*Concurrent treatment of bilateral lesions


Access Characteristics:
===High Risk Access Characteristics===
Patients with known peripheral vascular, supra-aortic or internal carotid artery tortuosity that would preclude the use of catheter-based techniques.
*Patients with known peripheral vascular, supra-aortic or internal carotid artery tortuosity that would preclude the use of catheter-based techniques.
Patients in whom femoral or brachial access is not possible
*Patients in whom femoral or brachial access is not possible


Patient Characteristics:
===High Risk Patient Characteristics===
Patients at low-to-moderate risk for adverse events from carotid endarterectomy.
*Patients at low-to-moderate risk for adverse events from carotid endarterectomy.
Patients experiencing acute ischemic neurologic stroke or who experienced a stroke within 48 hours.
*Patients experiencing acute ischemic neurologic stroke or who experienced a stroke within 48 hours.
Patients with an intracranial mass lesion (i.e., abscess, tumor, or infection) or aneurysm (>9mm).
*Patients with an intracranial mass lesion (i.e., abscess, tumor, or infection) or aneurysm (>9mm).
Patients with arterio-venous malformations of the territory of the target carotid artery.   
*Patients with arterio-venous malformations of the territory of the target carotid artery.   
Patients with coagulopathies.
*Patients with coagulopathies.
Patients with poor renal function, who, in the physician’s opinion, may be at high-risk for a reaction to contrast medium.
*Patients with poor renal function, who, in the physician’s opinion, may be at high-risk for a reaction to contrast medium.
Patients with perforated vessels evidenced by extravasation of contrast media.
*Patients with perforated vessels evidenced by extravasation of contrast media.
Patients with aneurysmal dilation immediately proximal or distal to the lesion.
*Patients with aneurysmal dilation immediately proximal or distal to the lesion.
Pregnant patients or patients under the age of 18.
*Pregnant patients or patients under the age of 18.


==Stenting vs Carotid Endarterectomy (CEA)==
==Stenting (CAS) vs Carotid Endarterectomy (CEA)==
===Outcomes===
* The CREST study showed a higher rate of death/MI in patients treated with stenting vs CEA: 6.4% vs 4.7%.
* The CREST study showed a higher rate of death/MI in patients treated with stenting vs CEA: 6.4% vs 4.7%.
* CEA is preferred in patients who impaired renal function who are at risk of [[contrast induced nephropathy]], tortuous calcified aortoas, complex eccentric calcified lesions.
===Scenarios Where Carotid Endarterectomy is Preferred===
* Stenting may be preferred in patients with high carotid bifurcations where it is hard for surgeons to technically perform the surgery.
Carotid endarterectomy is preferred in the setting of:
*CAS is considered over CEA in patients with neck anatomy unfavorable for arterial surgery(II a, B):
*Impaired renal function with increased risk of [[contrast induced nephropathy]]
**Arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis
*A tortuous calcified aortoa
**Previous ipsilateral CEA
*Complex, eccentric, calcified lesions
**Contralateral vocal cord paralysis
 
**Open tracheostomy
===Scenarios Where Carotid Endarterectomy is Preferred===
**Radical surgery
Carotid endarterectomy is preferred in the setting of:
**Irradiation.
*Neck anatomy unfavorable for arterial surgery(II a, B)
*High carotid bifurcations where it is hard for surgeons to technically perform the surgery.
*Arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis
*Previous ipsilateral [[carotid endarterectomy]] [[CEA]]
*Contralateral [[vocal cord paralysis]]
*Open tracheostomy
*History of previous radical neck surgery
*History of [[radiation therapy]]<ref name="circulation">ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline.Circulation.2011;124:e54-e130</ref>


;Shown below is a table comparing carotid endarterectomy versus stenting in symptomatic and asymptomatic patients.
;Shown below is a table comparing carotid endarterectomy versus stenting in symptomatic and asymptomatic patients:<ref name="circulation">ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline.Circulation.2011;124:e54-e130</ref>


<center>
{| border="1" cellpadding="10" style="text-align:center"
{| border="1" cellpadding="10" style="text-align:center"
|-
|-
Line 123: Line 123:
|'''LOE'''||B||B||B
|'''LOE'''||B||B||B
|}
|}
</center>


==Reference==
==Procedure==
* Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L. ''Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association.'' Circulation 1998;97:501-9. PMID 9490248.
*[[Informed consent]] obtained and [[local anaesthetic]] administered
* Golledge J, Mitchell A, Greenhalgh RM, Davies AH. Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease. ''Stroke'' 2000;31:1439-43. PMID 10835469. [http://stroke.ahajournals.org/cgi/content/full/31/6/1439 Full text],
*Preparation of both groins with antiseptic and draped
*Puncture into [[femoral artery]] and access through short sheath
*[[Guidewire]] passed through [[aorta]] and into arch
*Arch aortogram obtained if not previously performed to confirm suitability to continue
*Carotid and cerebral angiogram performed
*Long access sheath placed after cannulation of common carotid artery (CCA)
*Guidewire passed through area of carotid narrowing
*Placement of embolic protection device above the area of narrowing
*[[Angioplasty]] of carotid narrowing, but more commonly proceed straight to deployment of stent into area of narrowing
*Angioplasty post stent deployment
*Removal of protection device, guidewires and sheath
*Aftercare of groin puncture site


==External links==
==External links==
* [http://www.debakeydepartmentofsurgery.org/home/content.cfm?proc_name=Carotid+Endarterectomy&content_id=272 Carotid endarterectomy] (Baylor College of Medicine)
* [http://www.cresttrial.org/ Carotid Revsacularization Endarterectomy versus Stenting Trial (CREST)]
* [http://www.cresttrial.org/ Carotid Revsacularization Endarterectomy versus Stenting Trial (CREST)]


==References==
{{Reflist|2}}


[[Category:Vascular surgery]]
[[Category:Vascular surgery]]
[[Category:Neurosurgery]]
[[Category:Neurosurgery]]
[[Category:Cardiology]]
[[Category:Cardiology board review]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Carotid stenting (CAS) is a percutaneous, endovascular procedure available to correct carotid stenosis (narrowing of the carotid artery lumen by atheroma). Carotid stenosis can present with no symptoms (diagnosed incidentally) or through symptoms such as transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs, strokes).

Landmark Studies

In a number of clinical trials, in patients at increased for carotid surgery, the rates of 30 day stroke and death have been noninferior or as good as the standard approach, carotid endarterectomy. Over 14,000 patients have been enrolled in trials to evaluate the results of carotid stenting in patients at increased-risk for surgery. High-risk characteristics include anatomical or medical co-morbid conditions. The most significant study to date has been the SAPPHIRE study, which in a randomized controlled study showed carotid stenting to be "noninferior" to endarterectomy in total Major Adverse Event rates, but superior in rates of major procedural stroke, cranial nerve palsy, and myocardial infarction. [1]

The question of carotid stenting in non-hi-risk patients has yet to be answered, with a few trials ongoing, including the Carotid Revsacularization Endarterectomy versus Stenting Trial (CREST)[2] funded by the National Institutes of Health (NIH.)

Indications

The aim of CAS is to prevent the adverse sequelae of carotid artery stenosis secondary to atherosclerotic disease, i.e. stroke.

Carotid stenting is currently indicated for the following patients:

Either

  • Symptomatic patients with >50% stenosis

OR

  • Asymptomatic patients with >80% stenosis

AND

  • At least one anatomic or co-morbid risk factor placing them at high-risk for adverse events from CEA:
Anatomic Risk Factors:
  • Contralateral carotid artery occlusion
  • Contralateral laryngeal nerve palsy
  • Scarring of the neck post radiation therapy or following neck surgery
  • Recurrent stenosis after prior carotid surgery
  • High cervical carotid artery lesions
  • Carotid artery stenosis:
    • Below the clavicle
    • Distal to the second cervical vertebra
    • Proximal (intrathoracic) arterial stenosis
  • Previous carotid endarterectomy
  • Contralateral vocal cord paralysis
  • Open tracheostomy
Co-Morbid Conditions:
  • Congestive Heart Failure (Class III/IV), and/or known severe left ventricular dysfunction ≤30%
  • Open-heart surgery needed within 6 weeks
  • Recent myocardial infarction (>24 hours and <4 weeks)
  • Unstable angina (CCS class III/IV)
  • Synchronous severe cardiac and carotid disease requiring open heart surgery and carotid revascularization
  • Severe pulmonary disease to include any of the following:
    • Chronic oxygen therapy
    • Resting P02 of < 60 mmHg
    • Baseline hematocrit > 50%
    • FEV1 or DLCO < 50% of normal
  • Abnormal stress test
  • Age greater than 80 years

Carotid Revascularization in Patients Undergoing CABG

Symptomatic Stenosis

CAS (with embolic protection) before or concurrent with CABG is reasonable in patients with >80% stenosis who have experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months (I,C).

Asymptomatic Stenosis

The safety and efficacy of carotid revascularization before or concurrent with myocardial revacularization are not well established (II b, C)[2].

Risk Stratification

High Risk Lesion Characteristics

  • Evidence of intraluminal thrombus thought to increase the risk of plaque fragmentation and distal embolization
  • Lesion(s) that may require more than two stents
  • Very tortuous lesions
  • Total occlusion of the target vessel
  • Lesions of the ostium of the common carotid
  • Highly calcified lesions resistant to balloon inflation
  • Concurrent treatment of bilateral lesions

High Risk Access Characteristics

  • Patients with known peripheral vascular, supra-aortic or internal carotid artery tortuosity that would preclude the use of catheter-based techniques.
  • Patients in whom femoral or brachial access is not possible

High Risk Patient Characteristics

  • Patients at low-to-moderate risk for adverse events from carotid endarterectomy.
  • Patients experiencing acute ischemic neurologic stroke or who experienced a stroke within 48 hours.
  • Patients with an intracranial mass lesion (i.e., abscess, tumor, or infection) or aneurysm (>9mm).
  • Patients with arterio-venous malformations of the territory of the target carotid artery.
  • Patients with coagulopathies.
  • Patients with poor renal function, who, in the physician’s opinion, may be at high-risk for a reaction to contrast medium.
  • Patients with perforated vessels evidenced by extravasation of contrast media.
  • Patients with aneurysmal dilation immediately proximal or distal to the lesion.
  • Pregnant patients or patients under the age of 18.

Stenting (CAS) vs Carotid Endarterectomy (CEA)

Outcomes

  • The CREST study showed a higher rate of death/MI in patients treated with stenting vs CEA: 6.4% vs 4.7%.

Scenarios Where Carotid Endarterectomy is Preferred

Carotid endarterectomy is preferred in the setting of:

  • Impaired renal function with increased risk of contrast induced nephropathy
  • A tortuous calcified aortoa
  • Complex, eccentric, calcified lesions

Scenarios Where Carotid Endarterectomy is Preferred

Carotid endarterectomy is preferred in the setting of:

  • Neck anatomy unfavorable for arterial surgery(II a, B)
  • High carotid bifurcations where it is hard for surgeons to technically perform the surgery.
  • Arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis
  • Previous ipsilateral carotid endarterectomy CEA
  • Contralateral vocal cord paralysis
  • Open tracheostomy
  • History of previous radical neck surgery
  • History of radiation therapy[2]
Shown below is a table comparing carotid endarterectomy versus stenting in symptomatic and asymptomatic patients
[2]
Symptomatic Patients Asymptomatic Patients
50-69% Stenosis 70-99% Stenosis 70-99% Stenosis
Endarterectomy Class I Class I Class II a
LOE B A A
Stenting Class I Class I Class II b
LOE B B B

Procedure

  • Informed consent obtained and local anaesthetic administered
  • Preparation of both groins with antiseptic and draped
  • Puncture into femoral artery and access through short sheath
  • Guidewire passed through aorta and into arch
  • Arch aortogram obtained if not previously performed to confirm suitability to continue
  • Carotid and cerebral angiogram performed
  • Long access sheath placed after cannulation of common carotid artery (CCA)
  • Guidewire passed through area of carotid narrowing
  • Placement of embolic protection device above the area of narrowing
  • Angioplasty of carotid narrowing, but more commonly proceed straight to deployment of stent into area of narrowing
  • Angioplasty post stent deployment
  • Removal of protection device, guidewires and sheath
  • Aftercare of groin puncture site

External links

References

  1. ↑ Yadav et. al."Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients". New England Journal of Medicine. October7, 2004. pp1493-1501.
  2. ↑ 2.0 2.1 2.2 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline.Circulation.2011;124:e54-e130

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