General description of procedure, equipment, technique
Carotid stenting is an effective therapy for patients with symptomatic and asymptomatic carotid atherosclerotic disease. Early results of endovascular treatment of carotid disease were limited by high risk of embolic stroke but ongoing improvement in technology (emboli protection devices and self-expanding stents), use of dual antiplatelet therapy, and improved operator experience, have made it a safe and effective procedure in carefully selected
Carotid stenting should be considered as an alternative to carotid endarterectomy (CEA) in patients with symptomatic or asymptomatic carotid artery disease based on patient risk with either treatment. In general, randomized data have demonstrated a higher risk of periprocedural stroke with carotid artery stenting, while the risk of periprocedural myocardial infarction is higher in patients undergoing carotid endarterectomy.
The increased risk of periprocedural stroke with carotid artery stenting appears to be particularly relevant in older patents and those undergoing treatment for symptomatic disease, although this has not been a consistent finding in most of the recent studies.
Current guidelines support the use of carotid revascularization in patients with symptomatic carotid artery disease (defined as nondisabling hemispheric stroke or transient ischemic attack in the prior 6 months), a greater than 50% stenosis, and an anticipated procedural stroke or mortality risk of <6%. In asymptomatic patients, carotid revascularization is advised for patients with a stenosis >70%, a procedural risk of stroke or death of <3%, and a life expectancy of at least 5 years.
Carotid artery stenting (CAS) is favored in patients whose anatomy or comorbidities increase the risk of CEA. Anatomic features that make CEA higher risk are stenosis that is located higher than the second vertebral body, intrathoracic stenosis, prior CEA, contralateral vocal cord paralysis, open tracheostomy, prior radical neck surgery, or prior neck radiation.