Carotid stenting

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Carotid stenting (CAS) is a surgical 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, including the Carotid Revsacularization Endarterectomy versus Stenting Trial (CREST)[1] funded by the National Institutes of Health (NIH), the rates of stroke and death have exceeded traditional carotid endarterectomy surgery and have led many to reconsider indications for it's use. In the Carotid Revascularization using Endarterectomy or Stenting Systems (CARESS) uncontrolled phase one clinical trial the 30-day risk of stroke or death following carotid stenting with cerebral protection is 2%, which is equivalent to standard carotid endarterectomy. PMID 14723574 Randomized controlled trials are needed. High risk patients for complications from CAS have been identified as patients older then 70, symptomatic lesions producing strokes or TIA, tight lesions on arteriograms, heavily calcified carotid artery walls, or "soft" and potentially unstable plaques. ^[1]

1 Procedure
2 Indications
3 Contra-indications
4 Complications
5 Reference
6 External links

[edit] 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

[edit] Indications

The aim of CAS is to prevent the adverse sequelae of carotid artery stenosis secondary to atherosclerotic disease, i.e. stroke. As with any prophylactic operation, careful evaluation of the relative benefits and risks of the procedure is required on an individual patient basis. Peri-operative combined mortality and major stroke risk is 2 – 5% in younger patients, but may approach 11% in older,high-risk individuals.

In most institutions, CAS had been considered only in those considered 'high risk' for carotid endarterectomy:

Previous carotid endarterectomy - increased scar tissue with higher risk of operative complications
Previous neck irradiation - as above
Extensive cardio-respiratory illness making anaesthesia high risk

As suggested by the CREST trial, high-risk patients may actually fare worse with CAS versus CEA.

[edit] Contra-indications

Complete internal carotid artery obstruction (because the intraluminal thrombus then extends too far downstream, well into the intracranial portion of the artery, for stenting to be successful).
Previous stroke on the ipsilateral side with heavy sequelae because there is no point in preventing what has already happened.
Unable to obtain vascular access to carotid artery
- Difficult configuration of aortic arch
- Disease within the aorta or iliacs complicating vascular access
- Unable to use access through the arm (brachial artery)
Tortuous or other difficult configurations of the carotids

[edit] Complications

[edit] 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,