Carotid Stenting and Angioplasty

Abstract

C arotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials, 1-3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%. 3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference. 3 In patients with or without symptoms who have a stenosis Յ60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with Ͻ30% stenosis, medical therapy is superior to surgical therapy. 2 Studies attempting to define the benefit of therapy in symptomatic patients with Ͻ60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses Ն70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated. 4 In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis Ն60%, but the significance of this finding has been debated. 5,6 Although mortality associated with conventional antiplatelet therapy has been minimal, 7 surgery clearly has significant perioperative morbidity and mortality. This risk varies as a function of the skill and experience of the surgeon and ancillary personnel. In one large study of symptomatic patients, 3 surgical complication rates were 0.6% mortality; 5.5% perioperative cerebrovascular events; and 2.1% major stroke. By contrast, over the same 32-day observation period, patients treated medically had a 0.3% fatality rate, a 3.3% risk of a cerebrovascular event, and a 0.9% risk of a major event. In a recent review of the published literature, risk of stroke and/or death following carotid endarterectomy in symptomatic patients was found to be 5.6%, although there was substantial variation in incidence as a function of the type of study and the nature of postoperative evaluation and surveillance. 8 Surgery, then, in this symptomatic group of patients with significant carotid artery stenosis has a low but significant incidence of periprocedural complications. More importantly, however, according to actuarial analysis, by 2 years the risk of an ipsilateral stroke was 9% for su...

Pro-CAS

“…Although it has been claimed that during this period, patients should only be treated within trials, 9 the promising results reported by the majority of authors involved in CAS are leading to its increased use in everyday practice in many parts of the world. In view of this situation, the German Society of Angiology and the German Society of Radiology decided to install a registry of CAS as a measure of quality assurance and control against unrestricted use of the method.…”

Carotid Artery Stenting Protected With an Emboli Containment System

“…[11][12][13][14][15][16] However, fear of distal embolization of plaque fragments to the brain has generated concern regarding the safety and wisdom of this approach, especially considering the established low risk and durability of endarterectomy. 17,18 The incidence of stroke generally reported with carotid stenting is 5% to 10%, [11][12][13][14][15][16] although 1 center reported stroke in 71% of an early series. 19 Transcranial Doppler studies suggest the universal occurrence of emboli associated with this procedure.…”

Influência dos sintomas pré-procedimento na evolução hospitalar e tardia das angioplastias carotídeas com implante de stent e sistemas de proteção cerebral

“…Os pacientes com antecedente de AVC isquêmico apresentaram risco elevado de sofrer novo evento cerebrovascular da ordem de 30% a 50% em cinco anos. As diretrizes vigentes [21][22][23] recomendam a realização de ICP nos centros com índices de eventos combinados inferiores a 3% em pacientes assintomáticos (baseado no estudo Asymptomatic Carotid Surgery -ACAS 24 ) e inferiores a 6% em pacientes sintomáticos (baseado no estudo NASCET) 10 .…”