Carotid Stent-Assisted Angioplasty: The Newest Addition to the Surgeons' Armamentarium in the Management of Carotid Occlusive Disease

Abstract

Carotid artery angioplasty and stenting (CAS) has been accomplished in multiple centers with short-term and midterm results similar to carotid endarterectomy (CEA). Until completion of multicentered prospective evaluation of the benefit of CAS versus established therapy (CEA) clinical judgment must be used to determine whether an individual patient with unusual technical challenges and/or risks might be best suited for CEA or CAS. We report our experience with 41 CAS procedures in 39 patients treated from November 1996 through November 2001. Six patients had primary lesions (three symptomatic and three asymptomatic). Thirty-three patients had 35 procedures for recurrent carotid stenosis (11 symptomatic and 24 asymptomatic). Technical success was achieved in 40 of 41 procedures. No deaths occurred. The 30-day major stroke rate was one in 41 (2.4%), and the overall 30-day stroke/transient ischemic attack rate was three in 41 (7.3%). No recurrence or late neurologic events were seen in patients treated for primary carotid stenosis. A 23 per cent recurrence rate was observed in patients treated for recurrent carotid stenosis, after one or more CEAs, with mean follow-up of 18 +/- 14 months. Recurrence requiring operative correction with carotid resection and interposition grafts occurred in three patients treated with CAS in this group. Late deaths occurred in six patients; one of these was due to stroke. Overall freedom from late stroke and/or need for reintervention (by Kaplan-Meier analysis) was 64 +/- 13 per cent at 48 months in the group treated by CAS for post-CEA recurrence. CAS represents a technically simplistic means of providing carotid revascularization. However, its role remains undefined and benefits unproven. Surgical revascularization remains appropriate for patients with operable carotid lesions. However, surgical revascularization is not always an ideal option when we are faced with difficult carotid lesions and risks. For this reason we advocate that all surgeons who intend to remain specialists in the management of carotid disease should attain, master, and maintain the skills necessary for CAS.