Current status in cervical carotid artery stent placement

M H Wholey, W C S Wu
Journal of Cardiovascular Surgery 2009, 50 (1): 29-37
Based upon recent and old medical literature, with the exception of high surgical risk symptomatic patients, there remains much debate on how to manage extracranial carotid arterial disease, whether by surgical or endovascular intervention or by medical therapy alone. A review of the various global current carotid artery stent and endarterectomy registries and trials was performed incorporating more than 14,000 patients who have received carotid stents. There is substantial evidence supporting the benefit of carotid artery stenting (CAS) for the high anatomic risk population. Complication rates with symptomatic patients, including octogenarians, continue to show trend towards improvement as operators gain experience. The results are limited for standard risk carotid stenting for symptomatic patients though results with recent trials are pending but will probably show equivalence with endarterectomy. The asymptomatic patient population remains controversial: there is a small but reproducible benefit for revascularization. Long term (1-3 years) neurological results are now being reported for the major registries and trials. Analysis of target lesion revascularization, stroke and death rates of carotid stenting is comparable or better than rates for endarterectomy. Carotid artery stent placement has met the CMS targets 3% for MAE for asymptomatic patients and 6% for symptomatic patients with numerous registries and trials. CAS has also proven outcomes at 3 years with restenosis rates and stroke-free rates comparable or better than CEA. CAS provides an option for patients not suited for medical therapy and who were high-risk for CEA, especially for those symptomatic patients. It is still controversial with the role of stenting asymptomatic patients as well as for octogenarians. However, forthcoming trials will be helpful in providing more insight. Despite questionable studies and bad press, carotid stenting in the right hands with good patient selection is an excellent procedure. Finally, it is important to remember, carotid stenting is still in its early development and will only get better.

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