Carotid Artery Stenting Registry Research Articles

Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting

ObjectiveIt is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort. MethodsData were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events. ResultsA total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001). ConclusionsPatients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

Stroke/Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic Review.

Introduction: Randomized trials have reported contradictory findings regarding outcomes after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of data from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), but also because of improving outcomes in Industry-sponsored ‘high risk for CEA’ CAS Registries. The aim of the current systematic review was to see whether there was a parallel reduction in procedural risk after CAS in contemporary administrative dataset registries. Methods: PubMed/Medline, Embase and Cochrane databases were systematically searched from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS. Results: Twenty-one registries reported outcomes after >1,500,000 procedures. CAS had similar stroke/death rates with CEA in one registry involving ‘average risk’ asymptomatic and in two registries involving ‘average risk’ symptomatic patients. Stroke/death rates after CAS were significantly higher than CEA in 9/15 registries involving ‘average risk’ asymptomatic and in 11/18 registries involving ‘average risk’ symptomatic patients. In five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/15 registries involving ‘average risk’ asymptomatic patients and in 13/18 registries involving ‘average risk’ symptomatic patients. In 5/18 registries, the procedural risk after CAS in ‘average risk’ symptomatic patients exceeded 10%. Conclusion: Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and frequently exceed accepted AHA thresholds. In this systematic review, there was no evidence of a sustained decline in procedural risk after CAS. The extremely high published risks in some symptomatic registries suggest that clinical governance is not being applied.

Fifteen-Year Experience With Carotid Artery Stenting (from the Carotid Artery Stenting—Registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte)

To date only sparse data are available on trends and changes in indications, patient's characteristics, and clinical outcome of patients undergoing carotid artery stenting (CAS) in clinical practice. From February 1996 to December 2010, 6,116 CAS procedures were performed in 5,976 patients at 36 hospitals within the prospective, multicenter CAS registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte. Median age of patients was 71 years, 71.6% were men; a symptomatic stenosis was treated in 50.3% and an embolic protection device (EPD) was used in 82.5% of the patients. The overall hospital mortality or stroke rate was 3.1%. Stroke or in-hospital death occurred in 4.0% in symptomatic patients and in 2.2% in asymptomatic patients. In a logistic regression model, independent predictors of in-hospital death or stroke were heart failure (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.22 to 3.36, p = 0.006), symptomatic stenosis (OR 1.52, 95% CI 1.05 to 2.18, p = 0.03), and age (OR per 10 years 1.46, 95% CI 1.17 to 1.81, p <0.001). The use of an EPD was significantly associated with a lower rate of death or stroke in the registry (OR 0.45, 95% CI 0.26 to 0.78, p = 0.004). From 1996 to 2010, mean age of patients increased by 4.1 years (p <0.001), the proportion of male patients decreased from 82.4% to 70.2% (p = 0.07), the proportion of symptomatic stenoses decreased (84.6% to 24.7%, p <0.001), and the use of EPDs increased from 1.4% to 97.2% (p <0.001). Comparing 2 periods from 1996 to 2003 and 2004 to 2010, a numeric decrease in the in-hospital stroke or death rate was seen in symptomatic (4.7% vs 3.5%, p = 0.11), and in asymptomatic patients (2.9% vs 2.1%, p = 0.27) undergoing CAS, which did not reach statistical significance. In conclusion, the proportion of symptomatic carotid artery stenoses decreased significantly; EPDs established as a standard tool and a numeric decrease of in-hospital stroke or death was seen in asymptomatic and symptomatic patients undergoing CAS in clinical practice over the last 15 years.

Prospective Registry of Carotid Artery Stenting in Japan—Investigation on Device and Antiplatelet for Carotid Artery Stenting

Carotid artery stenting (CAS) is minimally invasive but may cause perioperative cerebral infarction associated with distal embolization. We conducted a multicenter prospective observational study on the onset of vascular events after CAS to find out the efficacy and safety of CAS in Japan and to investigate the effects of antiplatelet drugs administered before and after CAS on efficacy and safety of CAS. A total of 949 patients with cervical carotid artery stenosis were enrolled at 43 institutions in Japan; 934 who had undergone CAS with antiplatelet drugs and followed for 1 year were analyzed. Primary end point was the incidence of the first event of death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, myocardial infarction, or serious hemorrhage within 1 year after enrollment. Comparison of the incidences of events according to antiplatelet drugs was also conducted. The primary end point was observed in 69 patients (7.4%) within 30 days of enrollment and in 40 patients (4.3%) between 31 days and 1 year after enrollment. The incidence of the first event for aspirin+cilostazol was significantly lower than that for aspirin+clopidogrel (P=.01), aspirin+clopidogrel+cilostazol (P=.01), and antiplatelet monotherapy (P<.01). Patient age (P=.01), presence of ischemic cerebrovascular disease (P=.02), presence of antidiabetic drugs (P<.01), femoral artery puncture (P=.02), guiding catheter used (P=.02), and Angioguard XP used (P=.01) were also correlated with the primary end point. Incidences of the primary end point within 30 days and 1 year of enrollment were comparable with previous reports, suggesting that CAS is a useful alternative for carotid endarterectomy in carotid stenosis patients with high risk for carotid endarterectomy. Further randomized controlled studies are needed to determine whether differences in mechanism of action of antiplatelet drugs might have contributed to the results of the present study.

TCT-509 Impact On Outcome Of Different Types Of Carotid Stents: Results From The European Registry Of Carotid Artery Stenting.

TCT-509 Impact On Outcome Of Different Types Of Carotid Stents: Results From The European Registry Of Carotid Artery Stenting.

GeCAS-Register

Clinical registries have become increasingly more important tools for scientists as well as for medical admission boards worldwide during recent years due to the ability to investigate the safety and efficacy of a therapeutic method in the general population under real world conditions. The clinical benefit of current registry data seems to be particularly high in a treatment method, such as carotid artery stenting (CAS) where safety and efficacy, especially in daily clinical practice, could not be totally clarified by several randomized clinical trials (RCT). For this reason the new multidisciplinary, multicenter and prospective German Carotid Artery Registry (GeCAS) was founded in January 2011 for continuing quality control in CAS in clinical practice in Germany. The GeCAS registry is a fusion of two large German CAS registries, the ALKK-CAS registry and the PROCAS registry, which were conducted by cardiologists, angiologists and radiologists and operated from 1996 until December 2010. However, a general duty of documentation (BQS) of every CAS procedure exists throughout Germany since January 2012. In contrast to optional documentation of CAS within the GeCAS registry, the nationwide and obligatory documentation is strictly focused on the main issues, such as indications and between hospital comparisons of outcome of patients. In the GeCAS registry data collection is generally more extensive and also includes a 30-day and 10-year follow-up. Compared to the BQS institute, benchmarking reports of GeCAS are more detailed and are made available to every participating hospital on a biannual basis. This generates an image of the current reality of CAS in Germany in addition to the nationwide obligatory documentation. Furthermore, data of the GeCAS registry is the basis for research work (e.g. publications and presentations), for generating new hypotheses and for technical development in CAS in Germany. Consequently, the existence of a multicenter and multidisciplinary CAS registry, such as the GeCAS registry, is considered necessary and medically useful.

Erratum to: United Kingdom Carotid Artery Stent Registry: Short- and Long-Term Outcomes

Erratum to: United Kingdom Carotid Artery Stent Registry: Short- and Long-Term Outcomes

United Kingdom Carotid Artery Stent Registry: Short- and Long-Term Outcomes

Carotid artery stenting (CAS) has evolved to treat carotid artery disease with the intention of prevent stroke. The British Society of Interventional Radiologists developed a voluntary registry to monitor the practice of this novel procedure. We present the data from the United Kingdom (UK) CAS registry for short and long-term outcomes for symptomatic and asymptomatic carotid disease. The UK CAS registry collected data from 1998 to 2010 from 31 hospitals across the UK for 1,154 patients. All interventions were enrolled in the registry for both asymptomatic and symptomatic patients. Initial entry forms were completed for each patient entered with data including indications, demographic data, CAS data (including stents and protection device details) and 30-day outcomes. Complications were documented. Follow-up data were collected at yearly intervals. Nine hundred fifty-three (83 %) symptomatic and 201 (17 %) asymptomatic patients were enrolled into the registry. The 30-day all stroke and death rates for symptomatic patients were 5.5 and 2.2 % for those with asymptomatic disease. The 30-day mortality rate was 1.7 % for symptomatic and 0.6 % for asymptomatic patients. For symptomatic patients undergoing CAS, the 7-year all-cause mortality rate was 22.2 % and for asymptomatic patients 18.1 %. The 7-year all-cause mortality and disabling stroke rates were 25.3 and 19.4 %, respectively. These data indicate that outside of the tight constraints of a randomised trial, CAS provides effective prophylaxis against stroke and death.

O-007 Carotid stent cell design modified the periprocedural outcomes in the stenting arm of randomized trials of carotid revascularization: a meta-analysis

IntroductionTrials describe a risk of stroke of about 6% following carotid artery stenting (CAS). Stent cell design has been implicated as a potential factor in these risks. The small free...

European registry of carotid artery stenting: Results from a prospective registry of eight high volume EUROPEAN institutions

Carotid endarterectomy (CEA) is the standard revascularization therapy to prevent stroke in patients with carotid artery disease. Carotid artery stenting (CAS) could be considered a potential alternative in patients at high surgical risk. Recent clinical trials have challenged this concept due a relatively high incidence of post-CAS adverse events, which occurred in low volume centers. The aim of this study was to evaluate the outcomes associated with neuroprotected CAS in selected high volume centers. From January 2007 to December 2007, 1,611 patients underwent neuroprotected CAS in eight European Centers. For each patients, clinical, procedural, and one month follow-up data from all patients have been collected. An independent clinical events committee adjudicated the events. Overall in hospital death was 0.06% (one patient), whereas in-hospital stroke was 0.49% (eight patients). Between hospital discharge and 30 days three additional patients died (0.18%) and 10 patients experienced a stroke (0.67%). Overall 30 days mortality was 0.24% (four patients) and stroke incidence 1.12% (18 patients). The 30 day stroke/death rate was 1.36%. CAS is a reasonable alternative to CEA to treat carotid artery atherosclerosis in well-experienced high volume centers. These data suggest that future prospective trials comparing CAS and CEA outcomes should include only centers highly experienced in both treatment modalities.

Carotid Artery Stenting in Clinical Practice: Does Sex Matter? Results From the Carotid Artery Stenting Registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Carotid artery stenting (CAS) is increasingly used for treatment of severe carotid artery stenosis, but only few procedural risk factors for complications of CAS are clearly defined yet. A possible impact of the patient's gender on the outcome of patients undergoing CAS has not been investigated properly and only little information about this topic is available so far. We analysed data of the German prospective, multicenter CAS Registry of the Arbeitsgemeinschaft leitende kardiologische Krankenhausärzte. From July 1996 to May 2009 5130 patients underwent CAS at 35 German hospitals and were enrolled into the prospective ALKK CAS Registry. Therefrom 1443 (28.1%) patients were female. There was no significant time-related difference in the proportion of women undergoing CAS over the years. Women undergoing CAS were significantly older than men (73 years vs. 70 years, p < 0.01) and had a longer in hospital stay in comparison to men (p < 0.01). The majority of patients treated with CAS was between 60 and 80 years of age (∼73%). No significant differences between women and men could be found regarding in-hospital events like death (0.5% vs. 0.5%, p = 0.99), major or minor stroke (1.7% vs. 1.6%, p = 0.97; 1.0% vs. 1.6%, p = 0.12), TIA (2.8% vs. 2.6%, p = 0.64), amaurosis fugax (0.3% vs. 0.5%, p = 0.25) , intracranial bleeding (0.5% vs. 0.3%, p = 0.43), myocardial infarction (0.1% vs. 0.0%, p = 0.48) or all non-fatal strokes and all death (3.0% vs. 3.4%, p = 0.47). 30 day event rates did not show gender related differences in the combined endpoint of the outcome of patients undergoing CAS, as well (♀ n = 31/882 [3.5%] vs. ♂ n = 109/2273 [4.8%], p = 0.12). Our results do not suggest any gender-related differences in success rates and complications in CAS. In clinical practice approximately 30% of patients treated with CAS are women. The institutions and people who participated in the ALKK CAS Registry are listed in Zahn et al.16 The authors have no funding, financial relationships, or conflicts of interest to disclose.

Carotid artery revascularization with distal protection in high‐surgical‐risk patients in routine clinical practice: Rationale and design of the CABANA safety surveillance program

Continuous improvement in carotid artery stenting (CAS) outcomes, especially for periprocedural death and stroke in high-surgical-risk patients, have been seen in recent randomized trials of CAS versus carotid endarterectomy and CAS registries. However, these studies use stringent inclusion/exclusion criteria for patient, institution, and physician selection. The Carotid Stenting Boston Scientific Surveillance Program (CABANA) study was initiated to evaluate periprocedural outcomes with modern versions of the Carotid Wallstent and FilterWire EZ System for operators with a wide range of clinical specialties, CAS experience and training levels, in patients with a broad range of high-surgical-risk conditions and lesion types. This prospective, single-arm study enrolled 1,097 subjects with 1,098 carotid artery lesions at 99 study centers. Investigators were grouped into one of three tiers according to whether they had a high, medium, or low level of previous CAS experience and were also categorized by their CAS-credential-based training requirements for the CABANA study. Follow-up at 30 days includes clinical evaluation and independent neurological and NIH stroke scale assessments. The primary endpoint rate of 30-day composite stroke, death, and MI, as well as the rates of these individual events, will be evaluated across the overall study, by physician experience tier, and by physician training tier. The evaluation of periprocedural CAS safety in a real-world environment with modern devices in high-surgical-risk patients treated by physicians with a broad range of training and experience will better inform treatment decisions in the future.

Carotid artery interventions for restenosis after prior stenting: is it different from interventions of de novo lesions? Results from the carotid artery stent (CAS)—registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

To compare characteristics and outcome of patients with re-stenoses after prior carotid artery stenting (CAS) treated with repeat carotid interventions (Re-CI) with CAS for de novo lesions. The treatment of re-stenosis is a major problem in vascular interventions. Patients with re-stenoses after prior CAS treated with Re-CI are not well defined. We analyzed data from the prospective ALKK CAS Registry. Out of 3,817 CAS procedures 95 were intended in 93 patients (2.5%) for a restenosis after prior CAS and 3,722 CAS in 3,655 patients (97.5%) for a de novo stenosis. There was no difference in age (p = 0.302) or distribution of gender (p = 0.545) between the two groups. Patients treated for a restenosis after CAS were less likely to be treated for a symptomatic lesion (22.7 vs. 40.1%, p = 0.001). Coronary heart disease (p = 0.017), peripheral arterial disease (p < 0.001) as well as diabetes mellitus (p = 0.004) were more prevalent in the restenosis group. Lesions were less complicated in restenosis patients, with less ulcers (7.4 vs. 19.9%, p = 0.003) and less severe calcifications (7.4 vs. 23.6%, p < 0.001). The intended interventions were more often not performed in the Re-CI group (9.5 vs. 3.3%; p = 0.001). In-hospital, the stroke or death rate was 0% in the Re-CI group as compared to 3.1% in the de novo group (p = 0.115). Patients treated with Re-CI for repeat stenoses after prior CAS represent 2.5% of current CAS patients. Although representing a subgroup with more concomitant diseases, Re-CI seems to be associated with lower event rates as compared to CAS for de novo lesions.

Safety, efficacy and long-term durability of endovascular therapy for carotid artery disease: the tailored-Carotid Artery Stenting Experience of a single high-volume centre (tailored-CASE Registry)

We aimed to determine the success, safety and long-term durability of carotid artery stenting (CAS) in stroke prevention for all-comers managed with mandatory neuroprotection and a tailored-approach to intervention. From our CAS registry (beginning July 1997) all procedures up to September 2007 with intention-to-treat by stenting under distal filter or proximal occlusion neuroprotection devices were analysed (N=1523; mean age 72 years [237 >or=80 years, 15.5%]). Indications included symptomatic stenoses >or=50% (366, 24.1%) and asymptomatic stenoses >or=80% (1157, 75.9%). CAS success was 99.6% and the 30-day all-stroke/death rate was 1.5% (minor stroke 11 [0.7%], major stroke 8 [0.5%], death 5 [0.3%]). The risk was 1.2% for asymptomatic patients and 2.7% for symptomatic patients (p=0.042). Regarding octogenarians this risk was 2.1% versus 1.5% for patients <or=79 years (p=0.47). Symptomatic octogenarians had a higher risk than other groups (OR 3.9, 95% CI 1.06 to 14.0): asymptomatic <or=79 1.2%, asymptomatic >or=80 1.2%, symptomatic <or=79 2.3% and symptomatic >or=80 4.5%. The event free survival rates from all strokes or stroke-related deaths at eight years were 96% for asymptomatic and 92% for symptomatic patients. Results from this large cohort show that carotid stenting in a real-world setting is safe and efficacious, and durable in the long-term prevention of stroke.

The impact of timing on outcomes of carotid artery stenting in recently symptomatic patients

ObjectivesWe sought to determine whether the timing of carotid artery stenting (CAS) affects peri-procedural outcomes in recently symptomatic patients.BackgroundEarly carotid endarterectomy following a stroke lowers the risk of recurrent ischemic...

Carotid artery stenting vs. endarterectomy

Randomized clinical trials have demonstrated that carotid endarterectomy (CEA) is superior to medical management for stroke prevention in patients with symptomatic and, to a lesser degree, asymptomatic internal carotid artery stenosis. However, large-scale registries have shown that the adverse event rates following CEA are commonly higher than observed in the trials. In the last decade, carotid artery stenting (CAS) has emerged as a less invasive alternative to surgery. In order to address the efficacy of CAS, we performed a meta-analysis of 10 randomized trials comparing CAS with CEA in 4648 mainly symptomatic patients. The analysis showed that CAS was associated with a statistically significant increased death or stroke rate at 30 days compared with CEA (odds ratio 1.60, 95% confidence interval 1.26-2.02). However, most of the trials had inadequate requirements in terms of endovascular expertise and did not mandate the use of emboli protection devices. Beyond 30 days, long-term follow-up of the trials previously reported suggest that both revascularization techniques are equivalent in terms of stroke prevention. Conversely, large-scale high-quality CAS registries--mostly with independent neurological assessment and clinical event committee adjudication--have reported results in the range of current recommendation for CEA in over 20 000 patients, despite the fact that the majority of patients were at high risk for surgery. Until further data become available, the performance of CAS should be limited to protocols or centres of excellence and targeted especially to patients at high risk for surgery.

Results of cutting balloon angioplasty for carotid artery in-stent restenosis in six patients: description of the technique, long-term outcomes, and review of the literature

Background/purposeThe optimal management of carotid artery in-stent restenosis is not well described. Reported here is experience with cutting balloon angioplasty in six patients with long-term follow-up.MethodsA single-operator, prospective, elective, carotid...

Safety of carotid stenting for stroke prevention: need of an independent outcome assessor

Safety and efficacy of carotid artery stenting have still to be fully established. We propose a standardized registry of carotid artery stenting in use at our hospital to evaluate whether the presence of an independent neurologist performing basal, procedural and post-procedural observation increases the accuracy of outcome assessment. We collected a cohort of patients receiving carotid stenting. An external neurologist supervised the endovascular intervention and monitored the patient's clinical conditions during procedure and follow-up time (12 months). The procedure was carried out successfully in all cases. We registered two intra-procedural strokes and two strokes within 24 h. The risk of major complications in our study was 9.1% at 30 days. Our complication rate is higher than in previous studies. These findings could be partly explained by the unemployment of distal protection devices, but also by the presence of an independent observer that might have increased the accuracy of neurological evaluation.

Carotid Artery Stenting in High-Risk Patients: Midterm Mortality Analysis

Carotid artery interventions are predicated on early and late survival to prevent ischemic strokes. The technical feasibility of carotid artery stenting (CAS) has been established. Short-term results have been conflicting. Despite this, many practices have adopted CAS as an alterative to carotid endarterectomy in high-risk patients. Long-term protective benefits, however, are less established in high-risk patients. Midterm results following CAS in our high-risk protocol were analyzed to determine specific and all-cause mortality rates (beyond 30 days). We retrospectively evaluated a prospective carotid artery stent registry from October 2003 to February 2006. Demographics, high-risk indication, presence of carotid symptoms, prior history of cancer, periprocedural success, complications, as well as follow-up including readmission rate as well as specific etiology of death were recorded. Fifty patients with critical carotid stenosis (mean stenosis 90%) underwent CAS. This cohort met high-risk criteria due to physiologic reasons in 26 patients and anatomic factors in 22 cases. Two patients met both criteria. Indications were symptomatic disease in 14 (30%) and asymptomatic in 36 cases. The overall 30-day stroke, myocardial infarction, and death rate was 2%. No minor or major strokes were recorded within 30 days postprocedure. Overall average follow-up was 11-28 months. Stroke-free survival was 94% for all patients. Overall 1-year survival was 75% for all patients, significantly higher for the asymptomatic group (88%) (p < 0.01). Late mortality after 30 days was 11 cases (22%) at an average of 9 months post-CAS, ranging 3-13 months. No late mortality was due to ischemic stroke. Specific etiologies of mortality included end-stage cardiac disease (n = 1), recurrent or metastatic cancer (n = 2), acute cardiac event (n = 1), infectious complications (n = 3), and other (n = 3). Only symptomatic indication was predictive of late mortality. Clinicians may continue to cautiously offer CAS to asymptomatic high-risk patients given their anticipated longevity. Symptomatic patients, despite poor midterm survival, do achieve freedom from neurologic death following CAS.

Carotid Artery Stenting Will Replace Carotid Endarterectomy

Stroke is the third leading cause of death in the United States. Carotid artery stenosis represents one of the most common etiologies of stroke. The current treatment modalities available for the treatment of carotid artery stenosis are carotid endarterectomy (CEA) and carotid artery stenting (CAS). Several clinical trials comparing CEA with medical management showed superiority of the surgical arm; however, the applicability of these results to the general population is limited by the fact that the patients and surgeons enrolled in these trials were carefully selected, and the optimal medical therapy used does not meet the current treatment standards. Carotid artery stenting has emerged as a treatment alternative to CEA, as shown in randomized trials comparing the 2 treatment modalities. Recent data from large-volume CAS registries indicate that percutaneous treatment of carotid artery stenosis compares favorably to CEA. Furthermore, the CAS trial designs make these results more applicable to the community standards. These data suggest that CAS will become the treatment of choice in patients with carotid artery stenosis.