Endarterectomy and Stenting for Asymptomatic Carotid Stenosis

Abstract

Abstract-Atherosclerotic carotid stenosis has been recognized for the past several decades as being responsible for a significant portion of ischemic stroke, particularly the major and disabling ones. This category of stroke distinguished itself as being one of the first ones to have an effective preventive treatment in carotid endarterectomy. It took over 4 decades before major randomized, controlled trials were completed in North America and Europe to provide enough definitive information about its effectiveness, risks, limitations, and categories of patients that most benefit from it. Just like any invasive surgery, endarterectomy is being challenged by minimally invasive stenting, which has already made major technologic leaps and rapid clinical inroads. Stenting has started by tackling patient populations like surgical high-risk patients who were largely avoided in the endarterectomy trials and demonstrated equivalence to it in such populations. The broader applicability of the technique, however, has not been yet adequately investigated. The results so far are greatly reassuring and encouraging to enroll patients in the ongoing randomized trials that will hopefully provide more definitive answers to this issue. Key Words: angioplasty and stenting Ⅲ asymptomatic carotid stenosis Ⅲ carotid endarterectomy Ⅲ carotid stenosis Ⅲ prevention T he first comprehensive description of the relationship between occlusive carotid artery disease and ischemic brain symptoms in 1955 1 by Fisher triggered a momentum in furthering clinical descriptive, experimental, diagnostic, and therapeutic efforts that continue to transform our understanding and management of carotid disease. It took over 40 years for carotid endarterectomy (CEA) to demonstrate its effectiveness and limitations through major randomized trials. Despite these advances and efforts, there remains a lot of uncertainties about many aspects of risks, prognosis, and treatment of carotid stenosis in certain populations and circumstances. Similar to any new technology, the introduction of carotid artery stenting (CAS) as a potential alternative to CEA brought new challenges, questions, and issues. I review the clinical evidence and its limitations including CEA trials and comparisons to published and presented clinical information about CAS. Carotid AtherosclerosisCarotid atherosclerotic disease is a continuum of stages spanning the spectrum from intima-media thickening, to asymptomatic carotid plaque, and to symptomatic carotid disease. Various factors and triggers determine the transformation and evolution from one stage to another. Increasing degrees of atherosclerosis develop in the carotid arteries with older age. The Framingham Heart Study 2 suggests that by the age of 50, less than 1% of the population have carotid stenosis of 50% or greater, but by the age of 75, 9% to 7% of the population will develop a 50% or greater stenosis. Carotid intima-media thickness as measured by ultrasound is rapidly becoming a surrogate marker for systemic atherosclerosis and c...

Coexistence of Internal Carotid Artery Stenosis in Patients with Abdominal Aortic Aneurysm

“…Fayad20) analyzed three major studies of asymptomatic carotid stenosis. The ACAS and ACST and Veterans Affairs Cooperative Study Group trial concluded that carotid endarterectomy reduces the absolute risk of stroke by 5.4-5.9% for 5 years, and at the same time, the preoperative risk of stroke and death was 2.3-4.7%.…”

Cerebral Intolerance During Flow Arrested Carotid Angioplasty

“…These devices can also be used with any 0.014 00 wire system rather than the dedicated wire systems required by carotid stent manufactuers. 2 In addition, the wire only needs to be advanced to just above the target lesion, thus, making ICA tortuosity less of a technical limitation for the CAS procedure. However, there are some unfavorable aspects of the Mo.Ma device.…”

Aktuelles zur Diagnostik und Therapie der asymptomatischen Karotisstenose

“…In einer aktuellen prospektiven Untersuchung bei Patienten mit mittelgradiger asymptomatischer Karotisstenose waren der MRT-Nachweis einer nur dünnen oder rupturierten fibrösen Kappe (Hazard ratio, HR 17) bzw. der Nachweis von Plaqueeinblutungen (HR 5,2) über einen [11,19].…”