Carotid arterial stenting (CAS) is a minimally invasive endovascular interventional procedure that can potentially offer the same advantage as surgery (carotid endarterectomy).
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Indications
Indications for carotid stenting are evolving with endarterectomy trials that evaluate the carotid stenosis cutoff values for treatment. Currently, the indications include:
- symptomatic patients with ≥70% stenosis (NASCET trial)
- asymptomatic patients with >60% stenosis (ACAS study)
- symptomatic patients with stenosis of at least 50-69% stenosis
- carotid artery dissection or pseudoaneurysm
Contraindications
- complete carotid occlusion
- major disabling stroke on the ipsilateral side/disabling dementia
- intracranial tumor/hemorrhage
- unstable plaque or thick calcification at the site of carotid stenosis
- extreme tortuosity of the vessel
Complications
- preprocedural cerebrovascular accident (~8%) 3
- recurrent carotid arterial stenosis or in-stent restenosis (~6% at 1 year) 4
- hyperperfusion syndrome after carotid artery stenting (1-2%): headache, seizures and intracranial hemorrhage 6
Alternative treatment options
Outcomes
Operator skills and experience have a profound impact on patient outcomes following CAS. One systematic review and meta-analysis of the literature found Carotid Endarectomy (CEA) to be superior to CAS in freedom from stroke/death within 30 days of treatment, with the incidence of stroke/death within 30 days of treatment was 4.7% for CAS and 3.5% for CEA 8.
History and etymology
- the first percutaneous transluminal carotid angioplasty (PTA) was performed by Charles Kerber in 1980 5.
- somewhat surprisingly the word 'stent' is actually an eponym, originally named after Charles Stent (1807-1885), a largely-forgotten British dentist. He invented an improved material for forming dental impressions and set up a company to manufacture it. During the Great War, J F Esser, a Dutch surgeon used a mold of Stent's Compound as a fixative for skin grafting in injured infantrymen. This innovative use was rapidly adopted into practice, and stenting as a concept rapidly segued into multiple specialties 7.