Carotid stenting

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Christopher J. White, MD, FACC, FSCAI, FAHA, FESC, Chairman, Department of Cardiovascular Diseases, Ochsner Clinic Foundation

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). 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.

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.)

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

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:

• Patients who are:
  • Symptomatic 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:

• Anatomic:
  • 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 like:
  • 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)..

Patient Selection Warnings:

Lesion Characteristics: Patients with 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. Patients with very tortuous lesions. Patients with total occlusion of the target vessel. Patients with lesions of the ostium of the common carotid. Patients with highly calcified lesions resistant to PTA. Concurrent treatment of bilateral lesions.

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

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 vs Carotid Endarterectomy (CEA)

• 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.
• Stenting may be preferred in patients with high carotid bifurcations where it is hard for surgeons to technically perform the surgery.
• CAS is considered over CEA in patients with neck anatomy unfavorable for arterial surgery(II a, B):
  • Arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis
  • Previous ipsilateral CEA
  • Contralateral vocal cord paralysis
  • Open tracheostomy
  • Radical surgery
  • Irradiation

Shown below is a table comparing carotid endarterectomy versus stenting in symptomatic and asymptomatic patients.

	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

Reference

• 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.
• 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. Full text,

External links

• Carotid endarterectomy (Baylor College of Medicine)
• Carotid Revsacularization Endarterectomy versus Stenting Trial (CREST)