Carotid stenting

Carotid artery stenting (CAS) is an endovascular procedure where a stent is deployed within the lumen of the carotid artery to treat narrowing of the carotid artery and decrease the risk of stroke. CAS is used to treat narrowing of the carotid artery in high-risk patients, when carotid endarterectomy is considered too risky.

Carotid stenting
Illustration showing the process of carotid artery stenting
ICD-9-CM00.55, 00.63, 39.90,

Uses

Carotid stenting is used to reduce the risk of stroke associated with carotid artery stenosis. Carotid stenosis can present with no symptoms or with symptoms such as transient ischemic attacks (TIAs) or strokes.

While historically endarterectomy has been the treatment for carotid stenosis, stenting is an alternative intervention for patients who are not candidates for surgery. High risk factors for endarterectomy, which would favor stenting instead, include medical comorbidities (severe heart disease, heart failure, severe lung disease) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that would make surgery difficult and risky.[1]

Reasons to avoid

While rates of stroke and death after both surgery and stenting are low, rates of stroke and death after stenting may be higher than endartererectomy, particularly for transfemoral stenting in patients over age 70.[2]

Procedure

Carotid stenting involves the placement of a stent across the stenosis in the carotid artery. It can be performed under general or local anesthesia.

The stent may be placed from the femoral artery or from the common carotid artery at the base of the neck. Critical steps in both approaches are vascular access, crossing the stenosis with a wire, deploying a stent across the lesion, and removing the vascular access. A number of other steps may or may not be performed, including the use of a cerebral protection device, pre- or post-stent balloon angioplasty and cerebral angiography.

Trans-femoral carotid stenting

The trans-femoral route is the traditional approach to carotid stenting. In this technique, the femoral artery is used to gain access to the arterial system. Wire and sheath are advanced through the aorta to the common carotid artery on the side to be treated. Flow reversal or filter cerebral protection may be used. The procedure is typically performed percutaneously.

Trans-carotid artery revascularization (TCAR)

Trans-cartoid artery stenting involves a surgical incision at the base of the neck over the common carotid artery. Wire access is obtained at that location and used to deliver the stent to the internal carotid artery. Cerebral protection is usually obtained by flow reversal - the common carotid artery is clamped, and arterial blood from the internal carotid is run through a filter and returned to a femoral vein during the highest risk portions of the procedure.

Recovery and Outcomes

Recovery following carotid stenting is simple provided no complications occur. Patients typically leave the hospital in 0–1 days. The blood pressure is kept at a goal below 140 mmHg systolic. Elevated blood pressure in the 2–10 days post-operatively may lead to reperfusion syndrome.

The most feared short-term complication of any stroke prevention procedure on the carotid artery is stroke itself. Patients must be selected for surgery or stenting such that the long-term risk reduction of the procedure is greater than the short term risk assumed with the procedure of causing a stroke at the time of the procedure. Other short term complications include bleeding, infection and heart problems such as myocardial infarction related to anesthesia.

Late complications such as recurrent stenosis may occur, and surveillance with duplex ultrasound or CT-Angiography may be performed.

The risk-reduction from intervention for carotid stenosis (stenting or endarterectomy) is greatest when the indication for intervention is symptoms (i.e., the patient is symptomatic) - typically stroke or TIA.[3] There is insufficient evidence to say that stenting or endarterectomy is better for symptomatic patients.

For patients without symptoms (i.e., patients with a stenosis found on physical exam or screening), the benefit of intervention (beyond therapy with anti-platelet and statin medications) at all is controversial.

References
  1. Gurm, H. S; Yadav, J. S; Fayad, P; Katzen, B. T; Mishkel, G. J; Bajwa, T. K; Ansel, G; Strickman, N. E; Wang, H; Cohen, S. A; Massaro, J. M; Cutlip, D. E (2008). "Long-term results of carotid stenting versus endarterectomy in high-risk patients". New England Journal of Medicine. 358 (15): 1572–9. doi:10.1056/NEJMoa0708028. PMID 18403765.
  2. Bonati, LH; Lyrer, P; Ederle, J; Featherstone, R; Brown, MM (12 September 2012). "Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis". The Cochrane Database of Systematic Reviews (9): CD000515. doi:10.1002/14651858.CD000515.pub4. PMID 22972047.
  3. Paraskevas, KI; Mikhailidis, DP; Veith, FJ (July–August 2009). "Carotid artery stenting may be losing the battle against carotid endarterectomy for the management of symptomatic carotid artery stenosis, but the jury is still out". Vascular. 17 (4): 183–9. doi:10.2310/6670.2009.00039. PMID 19698297. S2CID 30747828.
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