An Update on Carotid Stent Trials and Perspectives

2009 ◽  
Vol 4 (1) ◽  
pp. 92
Author(s):  
Stefan Bertog ◽  
Marius Hornung ◽  
Jennifer Franke ◽  
Nina Wunderlich ◽  
Horst Sievert ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
The Elderly ◽  
Symptomatic Carotid ◽  
Stent Restenosis ◽  
Asymptomatic Patients ◽  
Symptomatic Carotid Stenosis ◽  
Increased Risk ◽  
Risk Patients

The presence of carotid artery stenosis is associated with an increased risk of stroke. Carotid endartectomy (CEA) has been demonstrated to reduce the stroke risk in standard-risk patients with symptomatic carotid stenosis as well as in asymptomatic patients, provided that the operative risk is low. The role of percutaneous carotid intervention is less clear. There are no trials that compare percutaneous carotid intervention with medical management. Although trial results comparing CEA with carotid artery stenting (CAS) are variable and/or controversial, some trials have demonstrated promising results and have fostered enthusiasm for the performance of ongoing trials comparing CAS with CEA. This article focuses on the results of completed trials and outlines ongoing and planned trials that aim to clarify the role of CAS in patients with carotid stenosis. In addition, potential unresolved problems associated with CAS, such as CAS in the elderly, in-stent restenosis and distal embolisation, are discussed.

Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis

2008 ◽  
Vol 109 (3) ◽  
pp. 454-460 ◽  
Author(s):  
Miguel Bussière ◽  
David M. Pelz ◽  
Paul Kalapos ◽  
Donald Lee ◽  
Irene Gulka ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Multivariable Analysis ◽  
Balloon Dilation ◽  
Peak Systolic Velocity ◽  
Stent Insertion ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
The Mean

Object Conventional endovascular therapy for carotid stenosis involves placement of an embolic protection device followed by stent insertion and angioplasty. A simpler approach may be placement of a stent alone. The authors determined how often this approach could be used to treat patients with carotid stenosis, and assessed which factors would preclude this approach. Methods Over a period of 6 years, 97 patients with symptomatic carotid stenosis were treated with the intention of using a “stent-only” approach. Arteries in 77 patients (79%) were treated with stents alone, 13 required preinsertion balloon dilation, 6 postinsertion dilation, and 1 both pre- and postinsertion dilation. Results The mean stenosis according to North American Symptomatic Carotid Endarterectomy Trial criteria was reduced from 82 to 40% in the stent-only group and from 89 to 37% in the stent and balloon angioplasty group. The 30-day stroke and death rate was 7.2%. Patients were followed for a mean of 15 months. In the stent-alone group, the mean preoperative Doppler peak systolic velocity (PSV) was 409 cm/second, with an internal carotid artery/common carotid artery (ICA/CCA) ratio of 7.2. At follow-up review, the PSV decreased to 153 cm/second and the ICA/CCA ratio to 2.1. In the angioplasty group the mean preoperative PSV was 496 cm/second and the ICA/CCA ratio was 9.2, decreasing to 163 cm/second and 2, respectfully, at follow-up evaluation. Restenosis occurred in 12.8% of patients at 6 months and in 15.9% at 1 year. One stroke occurred during the follow-up period in each group. Using multivariable analysis, factors precluding the “stent-only” approach were as follows: severity of stenosis, circumferential calcification, and no history of hyperlipidemia. Conclusions Balloons may not be required to treat all patients with carotid stenosis. A stent alone was feasible in 79% of patients, and 79% of patients were alive and free from ipsilateral stroke or restenosis at 1 year. Restenosis rates with this approach are higher than with conventional angioplasty and stent insertion. Carotid arteries with very severe stenoses (> 90%) and circumferential calcification may be more successfully treated with angioplasty combined with stent placement.

Early versus late carotid artery stenting for symptomatic carotid stenosis

2015 ◽  
Vol 42 (3) ◽  
pp. 169-175 ◽  
Author(s):  
Luis Henrique de Castro-Afonso ◽  
Guilherme S. Nakiri ◽  
Lucas M. Monsignore ◽  
Antônio C. Dos Santos ◽  
João Pereira Leite ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

scholarly journals Ultrasound detection of cerebral microembolism in carotid stenoses: progress and perspective (A review of the literature)

2020 ◽  
Vol 31 (1) ◽  
pp. 56-67
Author(s):  
M.V. Globa
Keyword(s):  
Surgical Treatment ◽  
Carotid Artery ◽  
Carotid Stenosis ◽  
Multicenter Study ◽  
Cerebrovascular Disorders ◽  
Transcranial Doppler Sonography ◽  
Vascular Events ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Carotid Stenoses

The review summarizes available information regarding the method of Transcranial doppler sonography (TCD) usage to record microembolism in patients with carotid artery stenosis, search for information was carried out in literature 1997–2020 (PUBMED, MEDLINE).History overview of TCD with embolodetection implementation is presented, as well as ways of its technical and methodological improvement. Evidence-based studies of the method clinical relevance in atherosclerotic carotid stenoses and their surgical treatment are outlined. Observation results of the intraoperative cerebral embolization during carotid endarterectomy and carotid artery stenting are presented along with comparison of TCD-embolodetection data, neuroimaging and clinical outcomes. Individual centres and multicenter study ACES data on prognostic value of registration of embolic signals in asymptomatic carotid stenosis, risk assessment of vascular events in diffe-rent groups of patients and in varying degrees of stenosis of the vessel lumen was analyzed. The role of embolodetection in predicting repeated cerebrovascular disorders in symptomatic carotid stenosis and its importance for monitoring antiplatelet therapy is set out (multicenter study CARESS). The evidence of the reliability of TCD embolodetection as tool for verificarion of at-risk patients with carotid stenosis who may benefit ftom surgical treatment is presented.Recent advances in ultrasound and other imaging techniques for assessing unstable plague are outlined along with prospects for the use of TCD monitoting for cerebrovascular disorders forecasting.

scholarly journals Physician Approaches to Imaging and Revascularization for Acutely Symptomatic Carotid Stenosis: Insights from the Hot Carotid Qualitative Study

2022 ◽  
Vol 2 (1) ◽  
Author(s):  
Aravind Ganesh ◽  
Benjamin Beland ◽  
Gordon A.E. Jewett ◽  
David J.T. Campbell ◽  
Malavika Varma ◽  
...  
Keyword(s):  
Decision Making ◽  
Carotid Artery ◽  
Qualitative Study ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Practice Patterns ◽  
Imaging Modality ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

Background Evidence informing the choice between carotid endarterectomy and carotid artery stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated and does not factor in contemporary therapies or techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis. Methods We used a qualitative descriptive methodology to examine decision‐making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for hot carotids. We conducted semistructured interviews with purposive sampling of 22 stroke physicians from 16 centers in 6 world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons. Results Qualitative analysis revealed several themes regarding clinical decision‐making for hot carotids. Whereas CT angiography was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. Carotid endarterectomy was generally favored over carotid artery stenting, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CT angiography imaging and carotid endarterectomy over carotid artery stenting but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk‐stratification with imaging features other than just degree of stenosis.

scholarly journals Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M35-M42
Author(s):  
Emmanuel Messas ◽  
Guillaume Goudot ◽  
Alison Halliday ◽  
Jonas Sitruk ◽  
Tristan Mirault ◽  
...  
Keyword(s):  
Cardiovascular Risk ◽  
High Risk ◽  
Carotid Stenosis ◽  
Smoking Ban ◽  
First Line ◽  
Symptomatic Carotid ◽  
Therapy Strategy ◽  
Choice Of Procedure ◽  
Asymptomatic Patients ◽  
Symptomatic Carotid Stenosis

Abstract Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.

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