Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital.

OBJECTIVES: The goal of this study was to determine whether carotid angioplasty and stenting (CAS) is equivalent to carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis >70% by a randomized, controlled trial in a community hospital. BACKGROUND: Carotid angioplasty and stenting has been suggested to be as effective as CEA for treatment of symptomatic carotid artery stenosis. METHODS: A total of 104 patients presenting with cerebrovascular ischemia ipsilateral to carotid stenosis were selected randomly for CEA or carotid stenting and followed for two years. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique as determined by sequential ultrasound. One death occurred in the CEA group (1/51); one transient ischemic attack occurred in the CAS group (1/53); no individual sustained a stroke. The perception of procedurally related pain/discomfort was similar. Hospital stay was similar, although the CAS group tended to be discharged earlier (mean = 1.8 days vs. 2.7 days). Complications associated with CAS prolonged hospitalization when compared with those sustaining a CEA-related complication (mean = 5.6 days vs. 3.8 days). Return to full activity was achieved within one week by 80% of the CAS group and 67% of the patients receiving CEA. Hospital charges were slightly higher for CAS. CONCLUSIONS: Carotid stenting is equivalent to CEA in reducing carotid stenosis without increased risk for major complications of death/stroke. Because of shortened hospitalization and convalescence, CAS challenges CEA as the preferred treatment of symptomatic carotid stenosis if a reduction in costs can be achieved.     

Management of carotid artery stenosis: Comparing endarterectomy and stenting

Stroke ranks as the third leading cause of death, behind diseases of the heart and cancer. It is also the most important cause of disability. Approximately 750,000 people experience a stroke annually, costing an estimated $40 billion in direct and indirect costs. Approximately 25% of these ischemic events are related to occlusive disease of the cervical internal carotid artery. Carotid atherovascular stenosis increases the risk of ischemic stroke by acting as an embolic source, and causing hypoperfusion of the ipsilateral cerebral hemisphere. With some limitations, the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trialists' Collaborative Group (ECST), and Asymptomatic Carotid Atherosclerosis Study (ACAS) have shown that carotid endarterectomy (CEA) substantially reduces the risk of stroke associated with certain grades of carotid stenosis. During the past few years, carotid angioplasty and stenting (CAS) has evolved as an alternative to CEA, particularly in patients who are known to have a higher complication rate with CEA.     

Carotid angioplasty and stenting under protection. State of the art

A carotid stenosis is responsible for about 30% of strokes occurring. Carotid endarterectomy (CEA) is considered to be the gold standard treatment of a carotid stenosis. Carotid angioplasty and stenting (CAS) is emerging as a new alternative treatment for a carotid artery stenosis, but the risk of neurological complications and brain embolism remain the major drawback to this procedure. So as to reduce the risk, we need: good indications, good patient and lesion selection; correct techniques; brain protection devices (cerebral protection devices should be routinely used and are mandatory for any procedure. Three types of protection devices are available: filters are the most commonly used. Nevertheless, all protection devices have limitations and cannot prevent from embolic events. However neurological complications can be reduced by 60%. New protection devices will be discussed); good choice of the stent and correct implantation (all stents are not equivalent and have different geometrical effects); pharmacological adjuncts; good team. Indications are well accepted for high-risk patients and recent studies have shown that CAS has superior short-term outcomes than CEA in this group of patients. Indications for low-risk and asymptomatic patients are controversial. New selection criteria have to be discussed. But there are enough reported data to conclude that CAS is also not inferior to CEA in low-risk and asymptomatic patients. In our series of 844 procedures, without protection (n = 187) 30-day death and stroke rate was 3.7% and with protection (n = 657) 1% (1.3% for symptomatic patients, 0.9% for asymptomatic patients, 1.4% in high-risk patients, 0.4% in low-risk patients). CAS under protection is the standard of care and is maybe becoming the gold standard treatment of a carotid stenosis at least in some subgroups of patients.     

Comparison of in-hospital outcomes of patients with versus without previous carotid endarterectomy undergoing carotid stenting (from the German ALKK CAS Registry)

Repeat carotid endarterectomy (CEA) for recurrent stenosis remains a challenging treatment option associated with high morbidity and mortality. Carotid artery stenting (CAS) is an attractive alternative management option for these patients. However, data about the effectiveness and safety of CAS in a large number of unselected patients are less known. We evaluated 3,070 patients who underwent CAS enrolled in a German registry from 1996 to 2006 at 31 sites. We compared clinical and angiographic features and in-hospital outcomes of patients with and without previous CEA who underwent CAS. Of 3,070 patients in the registry, 223 (7.3%) underwent CAS for restenosis after previous CEA. Median age was similar in patients with and without previous CEA (70 years, interquartile range 64 to 76 vs 71 years, interquartile range 65 to 76). Ipsilateral neurologic symptoms occurred in approximately 1/2 the patients in both groups. Other co-morbid conditions and angiographic or procedural factors did not differ between the 2 groups. In-hospital events including death (0% vs 0.4%), ipsilateral major stroke (1.4% vs 1.5%), death or major ipsilateral stroke (1.4% vs 1.7%), ipsilateral transient ischemic attack (1.9% vs 2.8%), myocardial infarction (0.4% vs 0.1%), and reintervention (0.7% vs 0.4%) were all low and not significantly different between those with and without previous CEA (p >0.05 for all comparisons). In conclusion, our data for a large number of patients who underwent CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events in patients with recurrent stenosis after previous CEA. This low risk along with the less invasive nature of the procedure should make CAS an attractive and perhaps preferred option for the treatment of these patients.     

Symptomatic carotid artery stenosis: what is the preferred treatment?

Stroke is a major cause of mortality, morbidity, and disability. Carotid artery disease is the etiology for 15% to 20% of stroke. Carotid endarterectomy (CEA) reduces the risk of ipsilateral stroke and death in symptomatic patients with 50% to 99% carotid artery stenosis when the operative risk of stroke or death is less than 6%. Treatment benefit is greater with earlier surgery, more severe stenoses, and older age. Recently, carotid artery stenting (CAS) has emerged as a treatment option, especially in patients with high surgical risk due to anatomic or clinical variables. Nondisabling stroke risk may be higher with CAS than CEA, but the difference is narrowed with the use of embolic protection devices. The risk for myocardial infarction is lower with CAS than CEA. There is no difference in risk for disabling stroke or death. Worse results with new or low-volume CAS operators is a concern. CEA and CAS are complementary revascularization strategies. CEA may be preferred in older patients with complex anatomy or bulky plaques. CAS may be preferred in younger patients and those with restenosis, history of neck radiation, surgical contraindications, or surgically inaccessible lesions. The role for optimal medical therapy as an alternative treatment strategy remains to be defined. Nevertheless, all patients should be treated with lifestyle interventions and secondary risk factor control to target levels to reduce the risk of subsequent atherosclerotic events.     

Early and late outcomes of percutaneous transluminal angioplasty of cephalad arteries

BACKGROUND: Efficacy of carotid endarterectomy (CEA) in prevention of stroke in patients with carotid artery stenosis has been confirmed in randomised trials. Carotid artery stenting (CAS) is a routine clinical practice and recent results of CAS are not worse than CEA. Moreover, percutaneous transluminal angioplasty (PTA) techniques allow other cephalad arteries to be dilated. AIM: To assess early and long-term outcome of PTA of cephalad arteries and to determine risk factors of early and late major adverse cardiovascular and cerebral events (MACCE). METHODS: The study group consisted of 223 consecutive patients (151 males, 67.7%, mean age 65.3+/-8.6) in whom 256 PTA procedures of cephalad arteries were performed. Two hundred and forty-two internal carotid, 7 common carotid and 15 vertebral arteries were dilated. Thirty-four patients underwent one-stage carotid and coronary procedures, while in 46 patients one-stage carotid and peripheral procedures were performed. Neuroprotection with a distal protection device was used in 51.5% of cases. The procedures were divided into two groups: with high (n=181) and low (n=75) risk of cardiovascular events. Early and late events were recorded and analysed subsequently. RESULTS: In hospital 30-day MACCE occurred in 12 (4.6%) patients, including 7 (2.7%) strokes, 3 (1.1%) myocardial infarctions and two (0.8%) deaths. Transient ischaemic attacks were observed in 8 patients, pulmonary oedema in 3 cases, as well as a single episode of retinal artery embolisation and acute renal insufficiency. The incidence of 30-day MACCE was not significantly higher in the high-risk group (6.07 vs. 1.33%; NS), but the risk of any adverse event was significantly higher (p=0.03). There was no difference in stroke incidence between procedures with or without neuroprotection (2.27 vs. 3.22%; NS). There was no difference in risk of MACCE between angioplasty of cephalad artery and one-stage cephalad and coronary artery angioplasty procedure (3.6 vs. 5.5%; NS). During 50.3+/-20 months of follow-up there were 16 (7.1%) deaths, 9 (3.5%) strokes and 6 (2.3%) re-stenoses confirmed angiographically. One-year total survival and one-year MACCE-free survival rates according to the Kaplan-Meier analysis were 94.9% and 89.0%, showing a trend towards better outcome in the low-risk group (F-Cox=2.46; p=0.19 and F-Cox=2.17; p=0.09 respectively). CONCLUSIONS: Percutaneous transluminal angioplasty of cephalad arteries is safe and feasible, with a low periprocedural complication rate and good late outcome. Carotid artery stenting is an alternative method to CEA.     

Feasibility and efficacy of balloon-based neuroprotection during carotid artery stenting in a single-center setting

We sought to prospectively assess the feasibility and in-hospital efficacy of the PercuSurge GuardWire temporary balloon-occlusive system for neuroprotection during carotid angioplasty and stenting (CAS).Carotid angioplasty and stenting harbors a risk of distal embolization. Cerebral protection devices are currently under clinical investigation.Ninety-six consecutive patients with carotid bifurcation disease underwent a total of 102 CAS procedures with the intention to use the GuardWire for neuroprotection.GuardWire deployment was achieved in 99 procedures performed in 93 patients (97%). Device failure (n = 3) and severe neurologic responses to balloon occlusion of the targeted carotid artery (n = 2) accounted for five additional procedures that were essentially concluded without neuroprotection, for a total of 94 procedures completed as intended in 88 patients (92% procedural feasibility rate). Carotid angioplasty and stenting was performed successfully in 94 patients (100 procedures). There were no in-hospital deaths; but three patients (3.1%) sustained strokes, and two patients experienced transient ischemic attacks, for a total periprocedural complication rate of 5.2%. One major stroke occurred with the GuardWire in place, whereas two minor strokes were observed in patients in whom the device could not be deployed. Thus, successful neuroprotected CAS without major neurologic events was achieved in 87 patients (91%).The GuardWire temporary balloon-occlusive system is feasible as an adjunct to CAS in the majority of patients. It is associated with a 3.1% rate of major periprocedural neurologic complications. Adverse neurologic reactions to balloon occlusion may prohibit effective use of the system in about 2% of patients.     

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.     

Multidisciplinary approach to carotid stenting

Background: Stroke neurologists, vascular surgeons, interventional neuroradiologists and interventional cardiologists have embraced carotid angioplasty and stenting (CAS) because of potential advantages over carotid endarterectomy (CEA). At Austin Health, a multidisciplinary neuro‐interventional group was formed to standardise indications and facilitate training. The aims of this study were to describe our organisational model and to determine whether 30‐day complications and early outcomes were similar to those of major trials. Methods: A clinical protocol was developed to ensure optimal management. CAS was performed on patients with high medical risk for CEA, with technically difficult anatomy for CEA, or who were randomised to CAS in a trial. Results: From October 2003 to May 2008, 47 patients (34 male, mean age 71.5) underwent CAS of 50 carotid arteries. Forty‐three cases had ipsilateral carotid territory symptoms within the previous 12 months. The main indications for CAS were high risk for CEA (n= 17) and randomised to CAS (n= 21). Interventionists were proctored in 27 cases. The procedural success rate was 94% with two cases abandoned because of anatomical problems and one because of on‐table angina. Hypotension requiring vasopressor therapy occurred in 12 cases (24%). The duration of follow up was one to 44 months (mean 6.8 months). The 30‐day rate of peri‐procedural stroke or death was 6% and the one‐year rate of peri‐procedural stroke or death or subsequent ipsilateral stroke was 10.6%. Restenosis occurred in 13% (all asymptomatic). Conclusion: A multidisciplinary approach is a useful strategy for initiating and sustaining a CAS programme.     

Safety and efficacy of carotid stenting in the very elderly

Background : Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (≥80‐year‐old) are one subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% was reported in very elderly patients during the roll‐in phase of Carotid Revascularization Endarterectomy versus Stent Trial (CREST). We are reporting on a large clinical series of CAS with independent neurological assessment in the very elderly. Methods : Between 1994 and 2008, a consecutive series of 418 CAS patients (≥80‐year‐old) were treated at four high‐volume centers with extensive CAS experience. Independent neurologic assessment was performed after CAS procedures. Thirty‐day follow‐up information was available in 389 patients. Results : The average age was 83.2 ± 2.8 years. Most patients were male (63.2%), and the target lesion carotid stenosis was asymptomatic in two‐thirds (68.2%) of patients. The majority of patients treated with CAS had a history of coronary artery disease (74.4%), hypertension (87.8%), and dyslipidemia (71.1%). One third (30.1%) were diabetic and more than half (56.5%) were current or former smokers. Embolic protection devices (EPD) were used in 78.7% of cases with the CAS procedure being performed before EPD availability being the most common reason for not using them. The overall 30‐day incidence of stroke and death was 2.8% (11/389). The cumulative incidence of major cardiovascular events (stroke, death, or myocardial infarction) during that time period was 3.3% (13/389). Conclusions : This large series of CAS with independent neurologic assessment is convincing evidence that the very elderly (≥80 years) can safely undergo CAS with stroke and death rates comparable to younger patients. The key to obtaining these excellent results is that CAS be performed by high volume, experienced operators who exercise restraint regarding patient selection. © 2009 Wiley‐Liss, Inc.     

Rate, predictors, and consequences of hemodynamic depression after carotid artery stenting.

OBJECTIVES: We sought to determine the frequency, predictors, and consequences of hemodynamic depression (HD) after carotid artery stenting (CAS). BACKGROUND: Hemodynamic depression has been reported after carotid artery stenting CAS and carotid endarterectomy (CEA). METHODS: We retrospectively analyzed data on 500 consecutive CAS procedures performed over a 5-year period. Hemodynamic depression was defined as periprocedural hypotension (systolic blood pressure <90 mm Hg) or bradycardia (heart rate <60 beats/s). Univariate and multivariate binary logistic regression models were used to determine the predictors and consequences of HD and persistent HD. RESULTS: The mean age of the patients was 70.5 +/- 10 years, and 69% were men. Hemodynamic depression occurred during 210 procedures (42%), whereas persistent HD developed in 84 procedures (17%). Features that independently predicted HD included lesions involving the carotid bulb (odds ratio [OR] 2.18 [range 1.46 to 3.26], p < 0.0001) or the presence of a calcified plaque (OR 1.89 [range 1.25 to 2.84], p < 0.002). Prior ipsilateral CEA was associated with reduced risk of HD (OR 0.35 [range 0.20 to 0.60], p < 0.0001). Patients who developed persistent HD were at a significantly increased risk of a periprocedural major adverse clinical event (OR 3.05 [range 1.35 to 5.23], p < 0.02) or stroke (OR 3.34 [range 1.13 to 9.90], p < 0.03). CONCLUSIONS: Hemodynamic depression is common after CAS, particularly in patients with a calcified plaque in the carotid bulb, but is easily treated with conventional methods. Patients who develop persistent HD are at an increased risk of periprocedural major adverse clinical events and stroke.     

MO.MA -- a new cerebral stroke protection system during carotid artery stenting

BACKGROUND: Carotid angioplasty and stenting (CAS) has been introduced as an alternative to carotid endarterectomy for the treatment of carotid atherosclerosis. Due to the risk of embolisation during CAS, the usage of cerebral protection devices is obligatory. AIM: To assess the safety and efficacy of the novel cerebral protection device -- the MO.MA system. METHODS: Twenty one patients selected for carotid stenting were included into the study. We estimated the deliverability of the device to the target site, procedural success rate and the incidence of adverse events. RESULTS: All performed procedures were successful without major cerebro-vascular complications during both 30-day and 6-month follow-up periods. CONCLUSIONS: The MO.MA system is safe and effective in preventing stroke during CAS.     

颈动脉狭窄患者的脑功能储备评价

颈动脉支架置入术（CAS）和颈动脉内膜切除术（QEA）是目前颈动脉狭窄患者最主要的非药物治疗方法。评价颈动脉狭窄患者的脑功能储备,不仅能筛选出近期可能面临卒中的高危患者,而且还能对无症状颈动脉狭窄患者行CEA和CAS的纳入标准进行修正,从而为患者提供最佳的治疗方案。文章对颈动脉狭窄患者的脑功能储备评价和MRI在其中的应用做了综述。     

The treatment of carotid artery bifurcation stenoses with systematic stenting: experience of first 100 consecutive cardiological procedures

Carotid endarterectomy still represents the gold standard treatment of carotid artery bifurcation stenosis but percutaneous angioplasty with stenting is rapidly growing as a non-invasive alternative. In this paper we report the results of systematic application of carotid stenting performed in a cardiological setting, particularly as regards clinical management of patients and technical approach. One-hundred (100) procedures of carotid artery stenting (CAS) on 94 consecutive patients, both symptomatic and asymptomatic, with a carotid stenosis > 70%, were performed over a period of 30 months. The technical approach was directly derived from coronary angioplasty with use of large lumen guiding catheters, 0.014 in. intravascular guidewires and distal protection devices usually employed in coronary interventions. In 3 cases, a post-carotid endarterectomy restenosis and in 97 cases, a de-novo lesion, were treated respectively; in 71 cases, the degree of stenosis was 71-89% and in 29 cases, 90-99%. Cerebral protection was obtained with a distal to the lesion endovascular filter in 63 cases. Immediate technical success, i.e. residual stenosis of the treated vessel < 30% and no significant pathologic acceleration of blood flow (< 1.5 m/sec) at the Doppler ultrasound evaluation, was achieved in all procedures (100%). Ninety-six (96) procedures were totally uncomplicated; in-hospital cerebral complications were 1 TIA, 2 minor and 1 major strokes; at 30-day follow-up one additional major stroke occurred. Despite a particularly high incidence of comorbidities, neither unfavorable cardiological complications nor neurologic deaths were reported. Systematic CAS is a feasible treatment of the carotid artery bifurcation stenosis with high procedural success and low perioperative and short term complications. Its performance in a cardiological setting can combine satisfying procedural results and potentially successful handling of cardiovascular complications.     

Carotid artery disease: Stenting versus endarterectomy

Atherosclerotic carotid artery stenosis is a major cause of disabling stroke or death. Although carotid endarterectomy (CEA) is currently considered to be the standard of care for patients with a severe symptomatic stenosis and selected patients with an asymptomatic carotid stenosis, carotid angioplasty and stenting (CAS) is increasingly being used as an alternative treatment modality. This article briefly summarizes the current trial data on CEA and CAS. More importantly, potential risk factors for CEA and CAS are reviewed and the complementary role of these techniques in the management of the individual patient is discussed.     

Carotid artery stenting: a therapeutic alternative in subtotal internal carotid artery occlusions

Carotid artery stenting (CAS) is emerging as a less invasive modality for treating atherosclerotic occlusive disease of the internal carotid artery (ICA). Randomized trials like the SAPPHIRE trial have demonstrated that CAS is not inferior to carotid endarterectomy (CEA) in the treatment of carotid artery stenosis, and maybe even superior in high-risk symptomatic patients. However, patients with subtotal ICA occlusions with thrombus are excluded from randomized CAS trials and CAS registries. To our knowledge, carotid angioplasty with stenting has not been attempted in these cases. We present three cases of symptomatic subtotal ICA occlusions successfully treated with CAS without any periprocedural complications. With careful patient selection and technical expertise, endovascular management could be considered as a treatment option in subtotal carotid occlusions.     

Carotid angioplasty with stenting in post-carotid endarterectomy restenosis

Recurrent stenosis post-carotid endarterectomy (CEA) is not a solitary or unusual phenomenon. Compared to the initial CEA, the reoperation is often more technically challenging and frequently results in local and neurological complications. Carotid artery angioplasty with stenting (CAS) is currently being investigated as an alternative to carotid endarterectomy. In our study, ninety-nine patients underwent CAS in 110 arteries. Procedural success was 99% (109/110). Our results show that CAS treatment in post-CEA restenosis, especially with improved technique and distal protection, is safe with a low neurological complication rate, without any "local" complications and without any cranial nerve palsies. This study suggests that the future primary mode of treatment of post-CEA restenosis might be carotid stenting rather than surgery.     

Interventional Management of Asymptomatic Extracranial Carotid Stenosis

Carotid artery stenosis is a major risk factor for stroke and transient ischemic attack. Although carotid endarterectomy is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS)—proven by large randomized clinical trials and rigorous registries and supported by improving stent designs, embolic protection, and increasing neurointerventionalist experience—is developing into a safer and more efficacious method of stroke prevention. Today, protected CAS is approved for symptomatic and asymptomatic patients with severe carotid stenosis with high surgical risk. We reviewed recently published data regarding new developments in the use of protected CAS, particularly in patients with carotid stenosis who are either asymptomatic or at low surgical risk.     

Carotid Artery Stenting for Stroke Prevention

Stroke is a global epidemic with a significant economic burden to patients, families, and societies at large. In the industrialized world, stroke is the third most common cause of death, the second most common cause of dementia, and the most common reason for acquired disability in adulthood. Overall, 20%-30% of ischemic strokes are related to extracranial carotid artery stenosis. Revascularization with carotid endarterectomy (CEA) is the gold-standard treatment for patients with significant carotid stenosis. Carotid artery stenting (CAS) has become an accepted alternative to CEA over the past decade for patients at high surgical risk, and has progressively evolved into an elegant procedure over the past 3 decades, with dedicated equipment including proximal embolic occlusion devices that have minimized procedural strokes. High–surgical-risk CAS registries have established this procedure as an alternative to CEA for high-risk patients. The Carotid Revascularization Endarterectomy vs Stent Trial (CREST) has shown similar outcomes with CAS and CEA for patients at standard risk, although CAS is associated with higher minor stroke events and CEA is associated with higher myocardial infarction (MI) events. However, CAS is technically challenging and requires a meticulous approach, with a protracted learning curve that should involve experience with > 70 cases. Careful patient selection is instrumental in avoiding procedural complications, and the procedure should be avoided in patients with prohibitive anatomy. This article reviews the use of CAS for extracranial carotid artery stenosis, considering technical aspects, registry and clinical trial outcomes data, determinants of success, and contemporary guidelines.     

Carotid artery stenting with distal filter protection: single-center experience in high-surgical-risk patients

Carotid artery stenting (CAS) is an efficient alternative procedure for the treatment of high-surgical-risk patients with symptomatic and asymptomatic carotid stenosis. The use of cerebral protection systems might decrease procedural risk of stroke and death. We report our initial experience with protected carotid stenting in high-risk patients with severe carotid artery disease. From January 2006 until July 2008 we routinely performed CAS using a distal filter protection device in 65 consecutive high-surgical-risk patients with 72 high-grade carotid stenoses. Technical success rate was 97.2%. Neurologic periprocedural complications included two transient ischemic attacks and one major stroke. Three filter-related complications were managed without negative results to the patients. The overall in-hospital and 30-days MACE rate was 1.5%, 3.6% in symptomatic patients and 0% in asymptomatic patients. In our series of high-risk patients, CAS with the use of a distal filter protection system was safe and effective with a low incidence of periprocedural complications.