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carotid artery stenting (CAS)

Carotid artery angioplasty with stenting is a less invasive alternative to carotid endarterectomy [2] Indications: 1) anatomically high internal carotid artery stenosis 2) carotid artery restenosis following prior carotid endarterectomy (CEA) 3) radiation-induced carotid artery stenosis 4) patients at surgical risk due to severe medical comorbidities 5) elderly (80+ years of age) who would be at higher risk during carotid endarterectomy than younger patients [6] (CONTRAST/CONFLICT, see Contraindications ref [8])* * indications for carotid stenting vs CEA in high-risk patients in need of reconsideration [12] Contraindications: - avoid in patients age 70 years & older [8,14] (contrast with indications ref [6]) - medical therapy under-utilized [9] Complications: 1) embolization of plaque debris into brain* 2) perioperative subclinical cerebral ischemia occurs commonly - cognitive deficits can result [10] 3) risk of major stroke 2% for asymptomatic & 4.6% for symptomatic disease [5] - risk of stroke 1.5% for asymptomatic & 2.2% for symptomatic disease [17 - diminished risk of stroke after carotid endarterectomy (CEA) relative to carotid artery stenting (CAS) in the elderly - 30 day risk for stroke, cardiac event or death 3.2-4.9% for CEA lower than that for CAS 5.6-6.3% [16] 4) intracranial hemorrhage, acute in-stent occlusion, & hypoperfusion syndrome < 2% [17] 5) periprocedureal risk for stroke &/or death in elderly (>= 70 years of age) higher than carotid endarterectomy 12% vs 6% [11,14] 6) mortality 1.8% [5] * A filter basket may be placed distal to the stenosis via a guidewire. After the procedure, the filter & its captured embolic material is removed [2] Notes: Comparison with carotid endarterectomy (CEA): 1) cranial-nerve injury more common with CEA than with stenting (7.7% vs. 1.1%) [4] 2) at 1 & 6 months, CEA with less incidence of any stroke or death than stenting (6.1% vs. 11.7%) [3,4] 3) younger patients may do better with stenting; older patients (> 70 years) may do better with CEA 4) higher volume centers associated with better outcomes [9]

Related

carotid artery disease carotid endarterectomy (CEA)

General

carotid artery revascularization vascular surgery vascular stent/vascular stenting

References

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  2. Journal Watch 24(22):165, 2004 Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004 Oct 7;351(15):1493-501. PMID: 15470212
  3. The SPACE Collaborative Group, 30 day results from the SPACE trial of stent-protected angioplasty vs carotid endarterectomy in symptomatic patients. A randomized non-inferiority trial. Lancet 2006, 368:1239 PMID: 17027729 - Naylor AR SPACE: Not the final frontier Lancet 2006, 368:1215 PMID: 17027708
  4. Mas J-L et al. for the EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006 Oct 19; 355:1660-71 PMID: 17050890 - Furlan AJ. Carotid-artery stenting - Case open or closed? N Engl J Med 2006 Oct 19; 355:1726-9 PMID: 17050898
  5. Fairman R, Gray WA, Scicli AP, Wilburn O, Verta P, Atkinson R, Yadav JS, Wholey M, Hopkins LN, Raabe R, Barnwell S, Green R; for the CAPTURE Trial Collaborators. The CAPTURE registry: analysis of strokes resulting from carotid artery stenting in the post approval setting: timing, location, severity, and type. Ann Surg. 2007 Oct;246(4):551-6; discussion 556-8. PMID: 1789349
  6. Chiam PT et al One-year clinical outcomes, midterm survival, and predictors of mortality after carotid stenting in elderly patients. Circulation 2009 May 5; 119:2343. PMID: 19380623 - Belkin M and Bhatt DL Carotid stenting in the elderly: Is 80 the new 60? Circulation 2009 May 5; 119:2302. PMID: 19414655
  7. Roubin GS et al for the CREST investigators Surgery, stenting to open blocked neck arteries similar in safety, efficacy, but show differences in stroke, heart attack and death rates at certain ages: Abstract 197 American Heart Association/American Stroke Association American Stroke Association late-breaking science report: SAN ANTONIO, Feb. 26, 2010 http://americanheart.mediaroom.com/index.php?s=43&item=971 - International Carotid Stenting Study investigators Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial Lancet 2010 Mar 20; 375:985. PMID: 20189239 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960239-5/abstract - Bonati LH et al New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy the International Carotid Stenting Study (ICSS). Lancet Neurol. 2010 Apr;9(4):353-62 PMID: 20189458 - Rothwell PM. Carotid stenting: More risky than endarterectomy and often no better than medical treatment alone. Lancet 2010 Mar 20; 375:957. PMID: 20304225
  8. Carotid Stenting Trialists Collaboration Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data Lancet 2010 Sep 25; 376:1062. PMID: 20832852 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61009-4/abstract
  9. Journal Watch Neurology, October 18, 2011 Massachusetts Medical Society Carotid Artery Stenting in the Real World http://neurology.jwatch.org/cgi/content/full/2011/1018/2?q=etoc_jwgenmed - Nallamothu BK et al. Operator experience and carotid stenting outcomes in Medicare beneficiaries. JAMA 2011 Sep 28; 306:1338. PMID: 21954477 - Halm EA. Carotid stenting at the crossroads: Practice makes perfect, but some may be practicing too much (and not enough). JAMA 2011 Sep 28; 306:1378. PMID: 21954482
  10. Tulip HH et al. Cerebral embolization in asymptomatic versus symptomatic patients after carotid stenting. J Vasc Surg 2012 Dec; 56:1579 PMID: 23040713
  11. Antoniou GA et al Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly. JAMA Surg. Published online October 23, 2013 PMID: 24154858 http://archsurg.jamanetwork.com/article.aspx?articleid=1757343 - Darling RC Carotid Intervention in the Elderly. Who Is Old and Who Benefits? JAMA Surg. Published online October 23, 2013 PMID: 24154829 http://archsurg.jamanetwork.com/article.aspx?articleid=1757342
  12. Paraskevas KI, Veith FJ. The Indications of Carotid Artery Stenting in Symptomatic Patients May Need To Be Reconsidered. Ann Vasc Surg. 2014 Oct 8. PMID: 25305422
  13. Jalbert JJ et al. Outcomes after carotid artery stenting in Medicare beneficiaries, 2005 to 2009. JAMA Neurol 2015 Mar; 72:276. PMID: 25580726
  14. Howard G et al. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: A meta-analysis of pooled patient data from four randomised trials. Lancet 2016 Feb 12; PMID: 26880122
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  16. Liang P, Solomon Y, Swerdlow NJ et al. In-hospital outcomes alone underestimate rates of 30-day major adverse events after carotid artery stenting. J Vasc Surg 2020 Apr; 71:1233. PMID: 32063441 - Boitano LT, DeCarlo C, Schwartz MR et al. Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1242. PMID: 31831310 - Edla S, Atti V, Kumar V et al. Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1222 PMID: 31564583
  17. Uchida K, Sakakibara F, Sakai N et al. Real-world outcomes of carotid artery stenting in symptomatic and asymptomatic patients with carotid artery stenosis. JACC Cardiovasc Interv 2024 May 13; 17:1148. PMID: 38749596 https://www.sciencedirect.com/science/article/abs/pii/S1936879824005764 - Gurm HS, Naik R, Osborne N. Optimizing carotid care: What is the role for carotid artery stenting in 2024? JACC Cardiovasc Interv 2024 May 13; 17:1160. PMID: 38749597 https://www.sciencedirect.com/science/article/abs/pii/S1936879824006381