Carotid artery stenting

From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus‐containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra‐indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.© 2013 Wiley Periodicals, Inc.     

Carotid artery stenting with filter protection

BACKGROUND: Neurologic events associated with distal embolization of debris during percutaneous carotid artery stenting complicate the procedure. Filter devices for cerebral protection potentially reduce the risk of embolization and other neurologic events. We studied the feasibility, safety, and efficacy of carotid artery stenting with a filter device. METHODS AND RESULTS: Between January 2002 and January 2003, a total of 22 consecutive patients (30 lesions) who had >70% diameter stenosis of the internal carotid artery underwent carotid artery stenting with filter protection at our institute. The mean age of the patients was 64+/-9 years; 14 were men and 8 women, and 15 had neurologic symptoms. A stent was successfully implanted in 29 lesions. It was possible to position a filter device in all the 29 lesions. Neurologic complications during the procedure, in the hospital, and at 30-day clinical follow-up occurred in 2 patients. One patient suffered a minor stroke that resolved within 24 hours. None of the patients had a major embolic stroke. There was one death from intracerebral hemorrhage related to hyperperfusion and the use of a glycoprotein IIb/IIIa inhibitor. CONCLUSIONS: Filter protection during carotid artery stenting seems technically feasible, safe, and effective. In the present study, the incidence of embolic neurologic events was low.     

Carotid artery in-stent restenosis after carotid artery stenting

Carotid in-stent restenosis is a potential long-term sequela that may occur after carotid artery stenting. We report a single-center experience with this procedure and reviewed the database for individual patient characteristics and possible management options.     

颈动脉内膜剥脱术和支架成形术治疗颈动脉狭窄的临床研究

目的探讨颈动脉内膜剥脱术(CEA)和颈动脉支架成形术(CAS)治疗颈动脉狭窄的临床价值。方法选择颈动脉狭窄患者43例,分为CEA组20例和CAS组23例,分析比较CEA和CAS 2种治疗方法的疗效。结果 CEA组成功率为95%,术后随访2年,再狭窄率为10%;CAS组成功率为100%,术后随访2年,发生再狭窄率为13%,2组的手术成功率和术后再狭窄率比较,差异无统计学意义(P>0.05)。结论 CEA和CAS是治疗颈动脉狭窄的有效方法,两者在安全性和有效性方面相同。     

Carotid artery stenting in surgical high-risk patients.

Recent studies have shown that carotid artery angioplasty and stenting may offer a viable alternative for symptomatic and asymptomatic patients with carotid artery stenosis, especially in high-risk patients. We report the results of a prospective single-center registry designed to evaluate the feasibility and safety of carotid artery angioplasty and stenting with and without distal protection devices in high-risk patients. A total of 116 consecutive patients underwent 126 procedures and 127 stents were deployed successfully in 130 lesions. The majority of patients (63%) had restenosis after a prior carotid endarterectomy; 31% were considered to be ineligible for carotid endarterectomy by both the vascular surgeons and the interventional cardiologist and 9% were considered ineligible for surgery due to hostile neck anatomy. Periprocedural and follow-up evaluation included a thorough independent clinical and neurological assessment. Distal embolic protection devices were used in 44% of all cases. Procedural success was achieved in 122 procedures (97%). The overall rate of in-hospital major adverse cerebrovascular events (death, stroke, and myocardial infarction) was 2.6%. Event rates in patients with prior carotid endarterectomy were comparable to patients with de novo lesions with 5.2% vs. 2.4% death/stroke at 30 days and 8.3% and 6.6% stroke/death rates at 1 year, respectively. When distal protection devices were used, death/stroke rates were 0% as compared to 4.5% when distal protection was not used (P = NS). However, minor embolic phenomena were observed in both primary and secondary lesions independent of the use of distal protection. These results support the use of carotid artery angioplasty and stenting in high-risk patients with significant primary or secondary carotid artery stenosis. In both types of lesions, acceptable results justify its use as a valid revascularization method. While clinical embolic events occur in a minority of patients in both lesion types, they are not entirely prevented by distal protection.     

Carotid artery stenting: acute and long-term results

The objective of this study was to evaluate the safety and efficacy of carotid artery stenting (CAS) in high-risk patients. Carotid endarterectomy (CEA) has been shown to be more effective than medical therapy but has limitations. CAS may be a reasonable alternative, particularly in high-risk patients. The authors evaluated prospectively the safety and efficacy of CAS in 299 consecutive patients who underwent CAS of 343 extracranial carotid arteries. Of the patients enrolled, 210 (70%) would have been excluded from the major trials of CEA, and 84 (28%) were referred by vascular surgeons. This series represents a very high-risk group that included patients with unstable angina, previous ipsilateral CEA, contralateral carotid occlusion, and other severe comorbid illnesses. Seventy-four (25%) patients were aged 80 years or more. All patients had independent neurologic examination before and after the procedure. Three hundred seventy-six stents were deployed in 343 arteries. Procedural success was 99%. Mean stenosis was 75 +/- 12% before and 7 +/- 8% after the procedure. Ninety-two patients had coronary intervention. Only 56 (19%) patients were North American Symptomatic Carotid Endarterectomy Trial (NASCET) eligible. During the initial hospitalization and 30 days post-CAS, there were two (0.6%) major and seven (2.3%) minor strokes. There were no myocardial infarctions or deaths during or within 30 days of CAS. None of the NASCET-eligible patients had a stroke. At a mean follow-up period of 26 +/- 13 months, eight (2.7%) patients had asymptomatic restenosis. No additional major strokes or neurologic deaths occurred. In conclusion, CAS is feasible, can be performed even in high-risk patients, and is associated with a low restenosis rate.     

Carotid artery stenting: state of the art

Carotid artery stenting (CAS) is growing as an alternative to carotid artery endarterectomy. Nowadays, it is performed routinely in many centers worldwide. Still, it is discussed controversially although several clinical trials have shown equivalency or superiority of catheter treatment at least in high-risk patients. What is still missing is a randomized trial in non-high-risk patients. This is an overview about the completed and ongoing trials as well as the current stent and embolic protection technology.     

Carotid artery stenting: utility of cerebral protection devices

Neurologic deficits secondary to embolic events have been the most significant concern regarding carotid bifurcation stenting. Experimental studies utilizing human carotid plaques have shown that embolic particles were released from all specimens. In addition, transcranial Doppler studies have confirmed the fact that multiple emboli are released during each case. Preliminary experiences with the use of cerebral protection devices for carotid stenting have shown encouraging results with embolic particles recovered from each case, although these experiences have also revealed some of the down sides of its use. The present article provides the rationale for routine use of these protection devices and also reviews various protection devices, some of which are currently undergoing clinical trials.     

滤网保护装置在颈动脉和椎动脉狭窄支架置入术中的应用

目的 探讨滤网保护装置在血管内支架治疗颈动脉和椎动脉狭窄中的应用。方法 配合应用滤网保护装置，对颈动脉和椎动脉狭窄患者进行经皮血管内支架成形术36例次(其中颈动脉33例次，椎动脉起始部3例次)，对手术过程、治疗效果和病理学检查结果进行分析。结果全部病例成功应用滤网保护装置进行了支架置入术，手术相关并发症的发生率为O。血管狭窄率由支架前的81．4％下降至支架后的14．1％；病理学检查显示，27例患者保护装置的滤网内有斑块成分，占75％；保护装置捕捉到的有形成分包括纤维蛋白、斑块碎片(坏死组织、胆同醇碎片、钙化成分等)。结论 滤网保护装置可以捕捉到颈动脉和椎动脉狭窄支架成形术中碎解的斑块成分，降低术中栓塞性并发症的发生概率；目前临床治疗中应用的滤网保护装置可以选择性地应用于椎动脉起始部狭窄的支架成形术中；滤网保护装置应进一步向微型化发展，以适应更多部位的血管内支架成形术。     

Carotid stenting

From my point of view, carotid artery stenting, in 2005, is clearly here to stay. "Houston, the Eagle has landed." The rest is up to you and me as we encourage our surgical colleagues and our various medical Societies to embrace this safe, effective, and durable technology and make it available to the patients who will really benefit from it.     

Carotid artery stenting in patients with high neurologic risks

Forty-four patient with high neurologic risks (Mayo class IV) successfully underwent carotid artery stenting with combined major stroke and death rates of 4.5%. Late follow-up at a mean of 23 +/- 1.8 months showed 1 non-neurologic death, but no neurologic events or repeat stenting procedures.     

Pulmonary artery stenting without angiographic imaging.

Pulmonary artery stenosis is a frequent complication seen after surgical repair of tetralogy of Fallot. In this setting, endovascular stent implantation is now accepted as the first-choice therapeutic option. However, angiographic imaging still being held as mandatory to check the stent position before final deployment, this procedure is not considered suitable for patients who cannot be submitted to angiography. In this paper, we report a novel method for the correct implantation of an endovascular stent without angiographic imaging. A 9-year-old boy underwent cardiac catheterization to relieve a severe left pulmonary artery stenosis. A previous attempt had been aborted due to a life-threatening anaphylactic reaction to the contrast medium. To avoid angiography, a contrast medium-filled compliant atrial septal defect sizing balloon (Amplatzer Sizing Balloon, AGA Medical Corporation) was used to image the vessel stenosis and successfully guide stent deployment. After the procedure, the transstenotic pressure gradient disappeared and the left-to-right pulmonary perfusion imbalance almost completely reverted.