Determining Patient Preference for Treatment of Extracranial Carotid Artery Stenosis: Carotid Angioplasty and Stenting versus Carotid Endarterectomy

Revascularization of extracranial carotid artery stenosis (ECAS) continues to be the subject of spirited academic debate. Conflicting studies in the literature have fostered uncertainty among patients choosing between CEA and CAS. We obtained preference-based utilities from prospective patients being evaluated for ECAS and incorporated them into a decision analytic model. Patients being evaluated for ECAS in an outpatient setting were interviewed prior to their initial visit with a vascular surgeon. Patient preference data were elicited using probability trade-off (PTO) assessment and time trade-off (TTO) method. Decision analysis was performed to compare CEA with CAS. Morbidity and mortality rates were obtained from recent literature reports from the same institution. Our results showed that when patients are informed, they prefer and will more often choose CEA over CAS for revascularization of ECAS. Among patients preferring CAS, they expect no more than a 46% increase in the rate of stroke and/or death. Future clinical studies on true stroke rates for CAS will be required to further refine this analysis.     

Surgery and Stenting As Combined Treatment of a Symptomatic Tandem Stenosis of the Carotid Artery

International co-operative studies have demonstrated a benefit from surgery for symptomatic and asymptomatic patients affected by internal carotid artery stenosis of 60-70%. The presence of a tandem lesion, intracranial or extracranial, may annul the benefit of surgery. Such patients may thus represent a challenging problem for management if age, good general conditions and a normal neurological status favour a therapy. A 54-year-old man developed transient ischaemic attacks of the left hemisphere; his general condition was good, and neurological status was normal. Angiography showed a tight stenosis at the left common carotid artery near the ostium and at the homolateral carotid bifurcation. At first, a self-expanding wall stent was placed at the level of the common carotid artery stenosis, and immediately after a standard endarterectomy under general anaesthesia was performed. The postoperative course was normal and was complicated only by the presence of a mild deficit of the hypoglossal nerve due to the presence of a high bifurcation. The early and late outcome of our case suggests that stenosis of the proximal common carotid artery may be successfully treated by stenting. While awaiting additional data about this new technology, endovascular techniques and surgery may be complementary in the management of patients suffering from such tandem lesions.     

Stenting of Atherosclerotic Stenoses of the Extracranial Carotid Artery

Summary. Summary. Background: Percutaneous transluminal angioplasty (PTA) and stenting seems to be, at present, the treatment of choice for early restenosis after endarterectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of symptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation is still debated. Methods: The present study comprises 27 consecutive cases of atherosclerotic lesions of the carotid bifurcation treated with PTA and stenting. All patients were symptomatic, except for 2 suffering from asymptomatic stenosis with contralateral carotid occlusion. There were 23 stenoses occluding 70% or more of the lumen according to the NASCET criteria and 4 mild stenoses (50–60% of the lumen) with large type C ulcers. Criteria for exclusion from surgery in these cases were aged >79 years, previous neck surgery for laryngeal cancer, carotid bifurcation at C2, association with intracranial aneurysms, occlusion of the contralateral carotid artery, and heart, lung and kidney diseases. All procedures were performed under local anaesthesia associated with mild sedation in a few cases. In all cases, self-expandable stents (Wallstent) were used. Follow-up ranged from 6 to 37 months. Findings: Transient neurological deficit occurred in 3 cases (11%). One case (3.7%) experienced a minor stroke at three months. Asymptomatic tight restenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries there was some loss of contact of the stent with the wall of the common carotid artery in the late follow-up. One case (3.7%) experienced severe and prolonged hypotension and bradycardia during the release of the stent. Interpretation: From literature data and our results it emerges that periprocedural catastrophic embolism is unlikely to occur. The best results are undoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre, as occurs at the carotid bifurcation, is not yet available. The problem of periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking.     

Carotid Artery Stenting in a Community Setting: Experience Outside of a Clinical Trial

Carotid artery angioplasty and stenting (CAS) currently represents a less invasive percutaneous alternative to conventional endarterectomy for the treatment of carotid occlusive disease. We report here the results and complication rates of CAS performed by a team of interventionalists at a non-clinical trial center utilizing a standardized CAS protocol. CAS was attempted in 51 arteries in 48 patients (mean age 71 ± 9 years, range 53-90). Fifteen (29%) of 48 patients were symptomatic. Indications for CAS were previous ipsilateral endarterectomy (15/51, 29%), previous neck radiation therapy (1/51, 2%), or significant coronary artery disease (30/51, 59%). SMART^® stents were deployed via percutaneous femoral artery access, with anticoagulation (heparin, abciximab, aspirin, clopidogrel) and temporary transvenous cardiac pacemakers employed in all patients. Neuroprotection was not used. Neurological examination and duplex scans were performed in follow-up. CAS was successfully performed in 96% of cases (49 lesions/46 patients) with angiographic stenoses of 88 ± 8%. Neurological complications included one (2%) minor stroke that occurred 12 hr after CAS. There were no periprocedural mortalities. Clinically significant bradycardia or asystole occurred in 11/49 (22%) procedures, necessitating short-term ventricular pacing. All stented vessels remained patent during 12.2 ± 10.1 (range 1-37) months follow-up period. One asymptomatic restenosis (>70%) occurred at 3 months, which was successfully reangioplastied; we thus had 1-year angiographic restenosis rate of 2%. Patients selected for CAS may represent a subset of patients with carotid disease who have considerable comorbidities or unfavorable anatomy compared to those undergoing conventional endarterectomy. CAS may be performed safely outside of a clinical trial with results similar to those of published series from trial centers using a standardized protocol. Presented at the Thirteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, January 31-February 2, 2003.     

Analysis of Surgical Treatment of Patients with Carotid Artery Stenosis Endarterectomy Versus Stenting

The aim of this paper is to characterize a group of patients with internal carotid artery stenosis and to analyze the outcome of internal carotid artery stenosis treatment. The outcome of treatment of 230 patients with internal carotid artery stenosis hospitalized from 1^st January 2004 to 31^st August 2006 was analyzed. Twenty nine percent of the patients were selected for medical treatment, 70.4% received surgical or endovascular treatment (83.3% of all invasive procedures were endarterectomies, versus 16.7% stenting). The peri-procedural stroke-death rate was 4.9% of patients [3.7% after CEA and 11.1% after CAS (N.S.)]. Statistical analysis disclosed that endarterectomy was associated with a longer in-hospital stay (p < 0.001). In conclusion: Both surgical methods, endarterectomy and stenting are equivalent in safety and present comparable clinical outcomes in selected subgroups of patients (classified to the specific procedure on the basis of the type of atherosclerotic plaque).     

Intracranial Stenting Using a Drug-Eluting Stent for Moyamoya Disease Involving Supraclinoid Internal Carotid Artery: A Case Report

A 43-year-old woman was diagnosed with moyamoya disease (MMD) and underwent right-side bypass surgery. After surgery, previous symptoms disappeared. One month later, transient right hemiparetic attacks and motor dysphasia developed. Angiography revealed progressive severe stenosis of left supraclinoid segment of internal carotid artery. Angioplasty using a drug-eluting stent (DES) was performed. For 18 months, she presented no ischemic symptom and no in-stent stenosis was observed in follow-up angiography. This is the first case report about effect of DES use for MMD. Considering that intimal hyperplasia is a pathophysiology of stenosis, DES may have a role in reducing progression of stenosis in selected moyamoya patients.     

The Nature and Management of Complications in Carotid Artery Stenting

Intussusception is rare in adults and it can be a challenge to diagnose on admission. Non-specific and variable signs and symptoms, frequently only occurring episodically, may cause a considerable delay before treatment. However, in 90% a predisposing organic cause can be found in adults.

A case is presented of small bowel intussusception secondary to a lipoma in a 54-year-old man in whom diagnosis was suggested by CT-scan. The patient was treated with a laparoscopic-assisted reduction and extracorporeal partial small bowel resection, followed by a latero-lateral anastomosis.

This case serves as the basis of a review of small bowel intussusception in adults secondary to lipomas. It focuses on the rarity of the disease, but stresses the need for early referral and investigation in middle-aged patients with recurrent abdominal symptoms.     

Protected Carotid Artery Stenting (PCAS): a short medical technology assessment

After a period of experimenting with angioplasty and stenting, carotid artery stenting under embolic protection (PCAS) is becoming a viable alternative for carotid endarterectomy (CEA).

A standard literature review showed that, at January 2005, there was no evidence that PCAS is more effective than CEA. The high costs of stent and protection device makes PCAS then inferior to CEA. PCAS may be the sole possible option in patients with symptomatic carotid artery stenosis unfit for surgery, where the high risk of stroke overrides uncertainty about health effects and overrides cost-effectiveness. These are a few patients per year in Belgium. Several randomised controlled trials comparing PCAS and CEA are now recruiting patients. To have answers on key questions of cost-effectiveness, it is of paramount importance that these trials recruit and publish rapidly. The KCE (Belgian HealthCare Knowledge Center/Centre Fédéral d’Expertise des Soins de Santé/Federaal Kenniscentrum voor de Gezondheidszorg) therefore advises cooperation with these trials. Outside these trials and compassionate use in the few symptomatic patients unfit for CEA, the use of PCAS raises serious ethical questions.