Carotid Artery Stenting for Primary and Secondary Stroke Prevention
Background
Carotid artery disease is a major cause of the disability and mortality associated with strokes. Ischemic stroke remains the major cause of adult disability and third-leading cause of adult mortality, and carotid revascularization currently remains the principal surgical tool in the prophylaxis of this disease.
Methods
The literature representing the current body of evidence for carotid revascularization and the authors' current practices in the management of this disease are summarized in this review.
Results
We provide an evidence-based narration of the development and current status of carotid artery stenting (CAS) by reviewing 1) the evidence for carotid revascularization from early carotid endarterectomy (CEA) trials; 2) the randomized trials comparing CEA and CAS, with a special emphasis on the recently published results of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which have been a “game-changer,” tipping the balance towards accepting CAS as a safe, equally effective, and durable alternative to CEA for all patients requiring carotid revascularization; and 3) the technical advances in CAS after enrollment of patients in the CREST.
Conclusions
CAS and CEA are complementary procedures. Judicious selection of the procedure is made on a case-by-case basis.
Key words: Carotid endarterectomy , Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) , Carotid stenting , Carotid trials , Embolic protection , Technical advances
Abbreviations and Acronyms: ACAS, Asymptomatic Carotid Atherosclerosis Study, ACSRS, Asymptomatic Carotid Stenosis and Risk of Stroke, ACST, Asymptomatic Carotid Surgery Trial, ACT I, Asymptomatic Carotid Stenosis, Stenting versus Endarterectomy Trial, ALKK, Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte, ARCHeR, ACCULINK for Revascularization of Carotids in High-Risk patients, ARMOUR, ProximAl PRotection with the MO. MA Device DUring CaRotid Stenting, BEACH, Boston Scientific EPI: A Carotid Stenting Trial for High-Risk Surgical Patients, BIC, Belgian-Italian Carotid Registry, CABERNET, Carotid Artery Revascularization using the Boston Scientific FilterWire EX/EZ, CAPTURE, Carotid Acculink/Accunet Post Approval Trial to Uncover Unanticipated or Rare Events, CaRESS, Carotid Revascularization using Endarterectomy or Stenting Systems, CAS, Carotid artery stenting, CASES-PMS, Carotid Artery Stenting with Emboli protection Surveillance–Post Marketing Study, CAVATAS, Carotid and Vertebral Artery Transluminal Angioplasty Study, CCA, Common carotid artery, CEA, Carotid endarterectomy, CI, Confidence interval, CMS, Centers for Medicare & Medicaid Services, CREATE, Carotid Revascularization with ev3 Arterial Technology Evolution, CREST, Carotid Revascularization Endarterectomy versus Stenting Trial, ECST, European Carotid Surgery Trial, EMPiRE, Embolic Protection with Reverse Flow, EPD, Embolic protection device, EPIC, European Study, Evaluating the Use of the FiberNet Embolic Protection System in Carotid Artery Stenting trial, EVA-3S, Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis, FDA, Food and Drug Administration, HR, Hazard ratio, ICA, Internal carotid artery, ICSS, International Carotid Stenting Study, MI, Myocardial infarction, MR, Magnetic resonance, NASCET, North American Symptomatic Carotid Endarterectomy, RR, Relative risk, SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy, SPACE, Stent-Protected Angioplasty versus Carotid Endarterectomy, TACIT, Transatlantic Asymptomatic Carotid Interventional Trial, TIA, Transient ischemic attack
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Conflicts of interest: Dr. L. Nelson Hopkins receives research study grants from Abbott (ACT 1 Choice), Boston Scientific (CABANA), Cordis (SAPPHIRE WW), and ev3/Covidien Vascular Therapies (CREATE) and a research grant from Toshiba (for the Toshiba Stroke Research Center); has an ownership/financial interest in AccessClosure, Boston Scientific, Cordis, Micrus, and Valor Medical; serves on the Abbott Vascular Speakers' Bureau; receives honoraria from Bard, Boston Scientific, Cordis, and from the following for speaking at conferences – Complete Conference Management, Cleveland Clinic, and SCAI; receives royalties from Cordis (for the ANGIOGUARD device); serves as a consultant to or on the advisory board for Abbott, AccessClosure, Bard, Boston Scientific, Cordis, Gore, Lumen Biomedical, Micrus, and Toshiba; and serves as the conference director for Nurcon Conferences/Strategic Medical Seminars LLC. Dr. Elad I. Levy receives research grant support (principal investigator: Stent-Assisted Recanalization in acute Ischemic Stroke, SARIS), other research support (devices), and honoraria from Boston Scientific and research support from Codman & Shurtleff, Inc. and ev3/Covidien Vascular Therapies; has ownership interests in Intratech Medical Ltd. and Mynx/Access Closure; serves as a consultant on the board of Scientific Advisors to Codman & Shurtleff, Inc.; serves as a consultant per project and/or per hour for Codman & Shurtleff, Inc., ev3/Covidien Vascular Therapies, and TheraSyn Sensors, Inc.; and receives fees for carotid stent training from Abbott Vascular and ev3/Covidien Vascular Therapies. Dr. Levy receives no consulting salary arrangements. All consulting is per project and/or per hour. Dr. Sabareesh K. Natarajan is the recipient of the 2010–2011 Cushing Award of the Congress of Neurological Surgeons. Dr. Adnan H. Siddiqui has received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms) and the University at Buffalo (Research Development Award); holds financial interests in Hotspur, Intratech Medical, StimSox, and Valor Medical; serves as a consultant to Codman & Shurtleff, Inc., Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, and Penumbra; belongs to the speakers' bureaus of Codman & Shurtleff, Inc. and Genentech; serves on an advisory board for Codman & Shurtleff; and has received honoraria from Abbott Vascular, American Association of Neurological Surgeons' courses, an emergency medicine conference, Genentech, Neocure Group LLC, an Emergency Medicine Conference, and from Abbott Vascular and Codman & Shurtleff, Inc. for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. Dr. Siddiqui receives no consulting salary arrangements. All consulting is per project and/or per hour.
PII: S1878-8750(11)00754-6
doi:10.1016/j.wneu.2011.06.019
© 2011 Elsevier Inc. All rights reserved.
