Transcervical access, reversal of flow and mesh-covered stents: New options in the armamentarium of carotid artery stenting

Abstract

In the last 25 years, the very existence of carotid artery stenting (CAS) has been threatened on a number of occasions. The initial disappointing results that even lead to the discontinuation of an early randomized controlled trial have improved considerably with time. Novel devices, advanced stent and equipment technology, alternative types of access and several types of filters/emboli protecting devices have been reported to reduce stroke/death rates during/after CAS and improve CAS outcomes. The present review will provide a description of the various technology advances in the field that aim to reduce stroke and death rates associated with CAS. Transcervical access, reversal of flow and mesh-covered stents are currently the most promising tools in the armamentarium of CAS.

One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field

“…Today, with a growing proportion of endovascular-minded surgeons who routinely apply endovascular techniques in their every-day practice to treat common vascular pathologies, and with the advanced stent technologies [ 5 – 7 , 60 – 63 ] that enable sustained embolic prevention [ 60 , 66 ] and improved peri-procedural cerebral protection strategies [ 35 – 38 , 43 – 45 , 65 , 66 , 101 ], the surgical community considers CAS a viable prospective treatment modality in carotid revascularisation [ 93 , 97 ]. Rather than acutely treated (which is generally accepted despite the fact that, for many patients, it comes unfortunately too late to avoid clinically-relevant brain damage [ 3 – 5 ]), carotid stenosis-related strokes should be safely and effectively prevented [ 10 – 12 ].…”

Robotic assisted carotid artery stenting for the treatment of symptomatic carotid disease: technical feasibility and preliminary results

“…Despite the conflicting clinical trial data, the relative performance of CAS in relation to carotid endarterectomy has increased over time and improvements in CAS outcomes have occurred despite increases in vascular risk factors and the proportion of symptomatic patients being treated 8 9. The recent design improvements in stent and embolic protection systems may further reduce treatment risks and increase CAS utilization even further 10. It is likely that robotics will add further advantages to these technological advances.…”

Seeing light and shadows: A commentary on the 2017 European Society for Vascular Surgery carotid guidelines

“…7,8,10,13 Despite this current conclusion, it must be acknowledged that recent promising improvements in CAS (including mesh-covered stents, reversal of flow, cerebral protection, and cervical access) may decrease its stroke/ death risks, improve outcomes, and make CAS a more acceptable alternative. 16 However, such improved outcomes remain to be conclusively documented.…”