New and Important Clues in Carotid Artery Stenting

Abstract

Atherosclerotic narrowing (stenosis) of the internal carotid artery accounts for about 10–15% of ischaemic strokes. Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic stenosis and–to a lesser degree with asymptomatic carotid stenosis. Endovascular treatment including balloon angioplasty and carotid artery stenting (CAS) has emerged as an alternative to CEA to treat carotidstenosis. Carotid artery stenting (CAS) is established as an important minimally invasive treatment modality in primary and secondary stroke prevention in atherosclerotic carotid artery disease. Meta-analyses of large-scale randomized trials of first-generation (single- layer) stent CAS versus surgery (carotid endarterectomy, (carotid endarterectomy, CEA) demonstrated equipoise of the two treatment modalities in long-term outcomes. Single-cohort studies suggest that second- generation stents (SGS; “mesh stents") may improve carotid artery stenting (CAS) outcomes by limiting peri- and postprocedural cerebral embolism. SGS differ in the stent frame construction, mesh material, and design, as well as in mesh-to-frame position (inside/outside). Randomized clinical trials show higher 30-day risk of stroke or death after carotid artery stenting compared with surgery. The 30-day risk of stroke or death did not differ according to operator lifetime carotid artery stenting experience or operator lifetime stenting experience excluding the carotid . In contrast, the 30-day risk of stroke or death was significantly higher in patients treated by operators with low and intermediate annual in- trial volumes compared with patients treated by high annual in-trial volume operators, So carotid stenting should only be performed by operators with annual procedure volume ≥6 cases per year.