Management Of Carotid Disease Research Articles

Prevalence of carotid artery disease in candidates undergoing coronary bypass graft seen at Madras Medical Mission

Background: Significant carotid artery disease in candidates going for coronary artery bypass graft (CABG) increases the risk of developing peri-operative neurologic events. Therefore, a pre-operative carotid Doppler ultrasonography, which is simple, non-invasive, and cheap may be indispensable. In this study, we report the prevalence of carotid disease in candidates for CABG and assessed the correlates between carotid artery disease and coronary artery disease (CAD). Materials and Methods: Seventy three consecutive patients undergoing elective CABG were recruited over 7 months, January to July 2007. All participants underwent pre-operative carotid Doppler assessment for level of stenosis and site of carotid plaque. Using the criteria defined by the Society of Radiologists in the Ultrasound Consensus, the degree of stenosis was stratified into the categories of normal (no stenosis), 50% non-obstructive carotid disease, 50-69% significant stenosis, 70% critical stenosis to near occlusion, near occlusion, and total occlusion. Patients with previous CABG, congestive cardiac failure, and high-risk surgery were excluded. Results: The mean age of patients was 65.0 ± 7.2 years with male-female ratio of 9:1. Twenty one (28.8%) patients had normal carotid arteries 45 (61.6%) had non-obstructive carotid artery disease 4 (5.5%) had significant carotid stenosis and 3 (4.1%) had critical carotid stenosis. Carotid bulb was the most common site of plaque formation while left internal carotid artery was the commonest site of both significant and critical carotid stenosis. Patients with significant carotid artery disease had 3 times the odd of having severe CAD (left main disease/triple vessel disease). However, this was not statistically significant (OR 2.75, P = 0.284). Conclusion: The high frequency of carotid artery disease in this study underscores the need for routine ultrasonic carotid assessment in candidates for CABG to ensure early detection and prompt management of carotid disease in a candidate of CABG which may prevent untoward peri-operative neurologic events.

Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis

Publication of the eagerly anticipated Carotid Revascularization Endarterectomy Versus Stenting Trial in May 2010 was anticipated to engender much activity in the realm of interventions for carotid stenosis. Specifically, a variety of professional societies, including the Society for Vascular Surgery (SVS), published updated practice guidelines in the calendar year 2011, timed to include data from large-scale well-conducted clinical trials comparing carotid endarterectomy with carotid artery stenting (CAS). In anticipation of a renewed application to the Centers for Medicare and Medicaid Services (CMS) to reconsider the national coverage determination for CAS, the SVS Board of Directors voted in June 2011 against any change in the national coverage determination for CAS. CMS convened a Medicare evidence development and coverage advisory committee (MEDCAC) meeting to consider fundamental aspects of the treatment of carotid atherosclerosis on January 25, 2012, to allow an unbiased and current deliberation of the state-of-the-art technology and science referable to the management of carotid atherosclerosis. The MEDCAC differs substantially from a reconsideration of coverage determination and, in this case, was built around seven research questions. The MEDCAC consists of a panel of experts who, after reviewing the literature and submitted comments by interested stakeholders, and after hearing testimony from invited speakers and at-large presentations, held a panel vote on the research questions. Given that management of carotid atherosclerosis is a core element of vascular surgical practice, the SVS had a major presence at the MEDCAC in the form of a comprehensive written document individually considering the research questions and a variety of presentations addressing various aspects in carotid disease management. The purpose of this report is to detail the SVS's position on the MEDCAC research questions referable to the management of carotid atherosclerosis and to otherwise detail the proceedings of the MEDCAC.

Analysis of Florida and New York state hospital discharges suggests that carotid stenting in symptomatic women is associated with significant increase in mortality and perioperative morbidity compared with carotid endarterectomy

Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and, recently, carotid artery stenting (CAS), the under-representation of women in these trials leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we reviewed the hospital outcomes and delineated patient characteristics predicting outcome in women undergoing carotid interventions using New York and Florida statewide hospital discharge databases. We analyzed in-hospital mortality, postoperative stroke, cardiac postoperative complications, and combined postoperative stoke and mortality in 20,613 CEA or CAS hospitalizations for the years 2007 to 2009. Univariate and multiple logistic regression analyses of variables were performed. CEA was performed in 16,576 asymptomatic and 1744 symptomatic women and CAS in 1943 asymptomatic and 350 symptomatic women. Compared with CAS, CEA rates, in asymptomatic vs symptomatic, were significantly lower for in-hospital mortality (0.3% vs 0.8% and 0.4% vs 3.4%), stroke (1.5% vs 2.6% and 3.5% vs 9.4%), and combined stroke/mortality (1.7% vs 3.1% and 3.8% vs 10.9%). In cohorts matched by propensity scores, the same trend favoring CEA remained significant in symptomatic women. There was no difference in cardiac complication rates among asymptomatic women, but among symptomatic woman cardiac complications were more frequent after CAS (10.6% vs 6.5%; P = .0077). Among symptomatic women, the presence of renal disease, coronary artery disease, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women only in those with coronary artery disease or diabetes, there was a statistical difference in the composite mortality/stroke rates favoring CEA (1.9% vs 3.3% and 1.7% vs 3.4%, respectively). After adjusting for relevant clinical and demographic risk factors and hospital annual volume, for CAS vs CEA, the risk of the composite end point of stroke or mortality was 1.7-fold higher in symptomatic and 3.4-fold higher in asymptomatic patients. Medicaid insurance, symptomatic patient, history of cancer, and presence of heart failure on admission were among other strong predictors of composite stroke/mortality outcome. Databases reflecting real-world practice performance and management of carotid disease in women suggest that CEA compared with CAS has overall better perioperative outcomes in women. Importantly, CAS is associated with significantly higher morbidity in certain clinical settings and this should be taken into account when choosing a revascularization procedure.

Carotid Disease and Stroke

Carotid Disease and Stroke. Stroke is a major cause of disability, mortality, dementia, and depression in the world. Carotid atherosclerosis is recognized as an important cause of stroke and a modifiable factor for the risk reduction of subsequent stroke. Randomized clinical trials have shown efficacy of carotid endarterectomy (CEA) in secondary stroke prevention. Carotid stenting has emerged as a new and less invasive alternative to CEA. Continuous advances in medical therapy have made remarkable success in stroke risk reduction. These new treatment modalities were not widely applied in most interventional trials, making extrapolation of an optimal intervention strategy evermore complex in patients with symptomatic and asymptomatic carotid disease. The determination between “symptomatic” and “asymptomatic” carotid stenosis is a pivotal determinant of management of carotid disease. This special issue provides an updated synopsis of risk factors, imaging modalities, and different treatment options of atherosclerotic carotid disease. Some of the highlights are included in the following: In the basic science rat model, the neurotrophic effect of an immunosuppressant agent after transient global cerebral ischemia is presented by Z. N. Sharifi et al. A paper of S. Kovacic and M. Bakran provides a discussion of the main genetic investigations associated with human atherosclerotic vascular diseases. The paper by A. Chatzikonstantinou et al. summarizes the literature of the natural history of the carotid disease and provides evidence that carotid stenosis is a sensitive marker of systemic atherosclerosis. The causal relationship between stroke-free patients with advanced carotid stenosis and cognitive decline is presented in the paper by I. Martinic-Popovic et al. The paper by V. Vukovic-Cvetkovic presents a comprehensive review of (microembolic signal) MES detection and stroke risk by transcranial doppler (TCD)—an important ultrasound technique shown to successfully stratify asymptomatic patients at high risk for future cerebrovascular events. The paper by M. Roje-Bedekovic et al. explores the visual evoked response in patients with severe carotid stenosis, a marker which serves as an important preoperative functional assessment of intracranial circulation. The paper by L. Pedrini et al. discusses near infrared spectroscopy (NIRS) during CEA as a reliable method in detection of clamping ischemia and in the prevention of clamping-related neurologic deficits during CEA. In the paper by H. Koerner et al., periprocedural ischemic lesions on diffusion-weighted imaging (DWI) during stenting procedures of supra-aortal arteries are discussed. The level of platelet inhibition is presented as an intriguing approach to determining the relationship between nonresponders to clopidogrel and clinically silent microembolization. The paper by F. Sallustio et al. presents a case series data suggesting that early carotid artery stenting may be considered as a safe alternative to CEA after IV thrombolysis in selected patients who are at high risk of stroke recurrence. The primary and secondary stroke prevention approaches are exciting clinical topics in evolution with many opportunities and options for both current treatment and future discoveries. Innovations in genetics, pharmacogenomics, and vascular imaging will likely provide specific pathophysiological targets, tailored treatments, and personalized medical management for individuals with atherosclerotic carotid disease. We hope that this special issue will serve as an overview of the accomplishments, current practices, and controversies in the field as well as a useful reference for management of patients with carotid disease and future research opportunities. Arijana Lovrencic-Huzjan Tatjana Rundek Michael J. Katsnelson

Large Artery Revascularization

: Large artery cerebrovascular disease accounts for approximately 20% of ischemic strokes. This review describes anatomic, epidemiologic, imaging, and therapeutic aspects of large vessel obstructive disease, with emphasis on revascularization methods. : Considerable data have accumulated regarding the natural history, diagnosis, and optimal management of carotid disease, and the evidence regarding the optimal management of subclavian/brachiocephalic, vertebral, and intracranial obstructive disease continues to accrue. Advanced vascular imaging modalities have become integral to clinical decision making in the setting of complex cerebrovascular anatomy and physiology. The medical therapy and the surgical techniques have evolved remarkably over the past decades. Novel catheter-based endovascular therapies have rapidly emerged as an alternative or, in some cases, first-line treatment for large artery cerebrovascular disease. : The evidence related to the diagnosis and treatment of large artery cerebrovascular disease has expanded remarkably. Sophisticated imaging protocols have minimized the need for invasive methods, and the efficacy of medical therapy (with newer antiplatelet agents and statins) has improved outcomes related to vascular disease. Endarterectomy and stenting have proven to be effective methods for carotid artery revascularization and stroke prevention. The best approach to patients with severe extracranial vertebral or intracranial stenosis warrants further investigation.

Management of carotid disease in patients undergoing coronary artery bypass surgery

The management of concurrent severe carotid and coronary disease is a subject of ongoing debate in the absence of randomized clinical trials. Amidst the growing controversy, the clinician has to carefully tailor the best strategy for a given patient based on neurologic and cardiac symptoms. This review aims to compile current evidence in this area to help plan strategies for the optimal management of coexisting severe carotid and coronary disease. Carotid revascularization with carotid endarterectomy (CEA) or stenting (CAS) is frequently performed in conjunction with coronary artery bypass surgery (CABG) in the United States for asymptomatic carotid disease. The risk of perioperative stroke with unilateral asymptomatic 70-99% carotid stenosis is likely small based on several observational data. Moreover, the risk associated with both staged and combined CEA-CABG procedures in the asymptomatic population may outweigh any benefit. Carotid artery stenting is an alternative option in patients with severe coronary disease who are considered 'high risk' for CEA. Neurologically symptomatic patients require carotid revascularization prior to or in conjunction with CABG surgery. Ultimately, the choice of carotid revascularization or conservative management will depend on clinical characteristics, anatomy, and local expertise. Severe carotid disease in the CABG population is often unilateral and asymptomatic. Based on the available data, conservative carotid therapy in the low-risk asymptomatic individuals is likely the best treatment option. Carotid revascularization may be justified in symptomatic or high-risk patients such as those with contralateral carotid occlusion or bilateral severe stenosis.

Comparative Analysis of Endarterectomy and Stenting For the Treatment of Carotid Stenosis in Women

Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and stenting (CAS), the under-representation of women leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we delineated patient characteristics predicting outcomes in women undergoing carotid interventions. We analyzed in-hospital mortality, postoperative stroke, and the composite end points of stoke or death in 20,620 hospitalizations in New York and Florida for 2007 to 2009. Univariate and multivariable logistic regression analyses were performed. CEAs were performed in 16,576 asymptomatic and in 1744 symptomatic women and CAS in 1948 asymptomatic and in 352 symptomatic women. Compared with CAS, CEA rates were significantly lower for in-hospital mortality, stroke, and combined stroke/mortality (Table). Cardiac complication rates did not differ among asymptomatic women, but cardiac complications were more frequent among symptomatic women with CAS (10.5% vs 6.5%, P = .008). Among symptomatic women, the presence of renal disease, CAD, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women, only in those with CAD or diabetes, there was a significant difference in the mortality/stroke rates favoring CEA. After adjusting for relevant clinical and demographic risk factors, CAS increased the risk for the composite end point of stoke or death in both symptomatic and asymptomatic patients.TableOutcomeAsymptomaticSymptomaticCEA, %CAS, %PCEA, %CAS, %PMortality0.30.8.00070.43.4<.0001Post-op stroke1.52.6.00043.59.7<.0001Stroke/mortality1.73.1<.00013.811.1<.0001 Open table in a new tab These databases reflect real-world practice performance of the management of carotid disease in women and suggest that CEA has better perioperative outcomes in women. Importantly, CAS is associated with significant morbidity in certain clinical settings, and this should be taken into account when choosing a revascularization procedure.

He Who Pays the Piper…

He Who Pays the Piper…

The Role of Carotid Revascularization in Stroke Prevention

The goal of carotid disease management is prevention of stroke. Many randomized prospective trials of carotid disease management provide level-1 evidence to guide decision making to optimize stroke prevention in patients with carotid disease. Other patients present with clinical scenarios that fall outside the eligibility criteria for these clinical trials, and in these patients, clinical decisions must be based on the best available information on the natural history of each patient's carotid disease and on the clinician's assessment of the risks and benefits of intervention. In this monograph, the author reviews the current clinical data relating to carotid revascularization for asymptomatic carotid disease, for carotid disease with transient ischemic attack or minor stroke, and for carotid disease with acute stroke or stroke in evolution. Relevant clinical trials of carotid endarterectomy and carotid stenting are reviewed in detail. In addition, relevant natural history and risk-benefit data are reviewed to guide clinical decision making in patients whose clinical presentations fall outside the scope of the available clinical trials. The goal of this monograph is to provide the clinician with an evidence basis for clinical decision making in patients with commonly encountered carotid disease-related presentations.

Comparison of SVS and ESVS Carotid Disease Management Guidelines

Comparison of SVS and ESVS Carotid Disease Management Guidelines

Invited commentary

This study, based on an administrative database of >4000 carotid stent procedures, has three major findings: (1) 91% of carotid stents are performed in asymptomatic patients, (2) there is significant regional variation in who is performing carotid stents (46% by vascular surgeons in New York and only 19% by vascular surgeons in Florida), and (3) early outcomes across the three specialties performing carotid stenting are equivalent. The first finding defies rational analysis. It is astonishing that fully 91% of the patients undergoing stenting in New York and Florida in 2005 and 2006 were asymptomatic. There are no level I data supporting carotid stenting as superior to medical management in asymptomatic patients, and the Centers for Medicare and Medicaid Services recently reaffirmed its policy of nonpayment for carotid stenting in asymptomatic patients. So what was the rationale for stenting these patients, and how were those performing the stents reimbursed? The second finding of marked regional variation in provider type may reflect dissimilar referral patterns. Alternatively, such variation might reflect variability in the acceptance of carotid stenting among different provider types in New York and Florida. Regional variation in provider acceptance of carotid stenting likely stems from the absence of high-level data defining the precise role of carotid stenting and from the nonevidence-based and nonclinical drivers of its use. The third major finding is problematic. The statistically equivalent stroke rates of 1.3% for vascular surgeons, 1.1% for interventional cardiologists, and 2.0% for interventional radiologists are lower than those seen in prospectively gathered data sets. The authors attribute these unrealistically low stroke rates to “coding errors” and minimize their significance because they should affect all provider types equally and, therefore, not affect the outcome comparisons. Still, the publication of these stroke rates may result in the misinterpretation that carotid stenting is very safe as performed across the full spectrum of practice settings. Of course, the major flaw in these outcome data is their source. Administrative databases paint with very broad brushstrokes and do not permit an accurate determination of procedure indications, risk stratification, nonlethal complications, and longitudinal follow-up. The real value of this study is its reflection of the current chaos engulfing carotid disease management. The unexplained regional variation in practice patterns results from clinical decisions based on locally prevailing opinion, individual whim, and financial motives. In the absence of widely accepted evidence-based practice standards, such clinical decisions fill the void. An analysis of carotid artery stenting procedures performed in New York and Florida (2005-2006): Procedure indication, stroke rate, and mortality rate are equivalent for vascular surgeons and non-vascular surgeonsJournal of Vascular SurgeryVol. 49Issue 6PreviewCarotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. Unlike CEA, CAS is performed by a wide variety of specialists including vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR). This study compares the indications, in-patient mortality rate, and in-patient stroke rate for patients undergoing CAS, according to operator specialty. Full-Text PDF Open Archive

Analysis of the Evidence Behind the ESVS Guidelines for the Invasive Treatment of Carotid Stenosis

The European Society for Vascular Surgery has recently published updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence (A: randomized controlled trials, B: well-conducted clinical studies, C: expert opinion). The following document summarizes the evidence on which these recommendations were based, in order to keep physicians from various disciplines updated on the advances in the field of the invasive management of carotid disease.

Outcomes of Carotid Revascularization in Patients With Chronic Kidney Disease

Chronic kidney disease (CKD) carries an increased risk for cardiovascular disease (CVD) including cerebrovascular accidents (CVAs). There are multiple etiologies for CVA, and among them extracranial carotid artery disease accounts for approximately 25% of ischemic strokes. It has been shown that carotid revascularization by carotid endarterectomy and carotid artery angioplasty and stenting can decrease the risk of CVA in appropriately selected population with carotid artery disease. Both these techniques of carotid revascularization have been shown to be safe and clinically effective in many large multicentered randomized clinical trials. However, most of these large trials have predominately excluded the patients with kidney failure. Most of the evidence for the management of carotid disease in CKD is based on small clinical trials and expert opinions. There is an urgent need to conduct large clinical trials in patients with CKD to enable better understanding and to improve techniques of various carotid revascularization therapies in CKD patients.

Surgical and Percutaneous Management of Carotid Artery Stenosis

Stroke is one of the leading causes of morbidity and mortality in the United States. Approximately 700,000 Americans suffer from a stroke per year and 270,000 of these patients will die as a result of their stroke. The etiology of cerebrovascular events can be attributed to carotid artery disease in 20-30% of cases. Carotid endarterectomy has been shown to be beneficial in selected patients with symptomatic and asymptomatic carotid artery stenosis. Percutaneous treatment of carotid disease appears to be effective when performed with distal protection by an experienced operator. This review presents the clinical trial data regarding surgical and percutaneous management of carotid disease.

Carotid stenosis: Endarterectomy or angioplasty and stenting?

Atherosclerotic narrowing of the proximal internal carotid artery is an important mechanism in ischemic stroke. Optimal medical management of internal carotid stenosis includes antiplatelet agent and statin administration, blood pressure reduction, weight control, and smoking cessation. Decisions regarding the use of invasive procedures to treat carotid disease--specifically carotid endarterectomy and carotid angioplasty and stenting--must weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks. Clinical trials evaluating the benefits of carotid endarterectomy were conducted before widespread use of statins and newer blood pressure-lowering agents such as angiotensin-receptor blockers; it is unclear what impact this may have had on trial results. Regardless, carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis. Conversely, the benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity. Currently, there is a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease. Selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed may still benefit from endovascular management. However, it is unlikely that asymptomatic patients or symptomatic patients with moderate stenosis considered at high risk for endarterectomy would benefit from any intervention.

What Are the Skills That Prepare Vascular Surgeons for Carotid Stenting?

Although it has been clearly established that in certain groups of patients, such as in patients with symptomatic high-grade carotid stenosis and in selected asymptomatic patients with high-grade stenosis, carotid endarterectomy offers significant protection from stroke compared with medical therapy, the role of carotid stenting in this patients versus carotid endarterectomy is undergoing a rapid evolution. The definitive evidence awaits the results of ongoing prospective, randomized trials such as CREST and others, but it is clear that carotid stenting will increasingly occupy a significant role in the therapy of carotid bifurcation disease. In that context, vascular surgeons, traditionally the experts on the management of this condition, face the specter of other disciplines intervening in its treatment. In addition, if vascular surgeons do not acquire the skills and the expertise necessary to perform carotid stenting, it is self-evident that they run the risk of being spectators rather retaining the mantle of expert in the management of carotid bifurcation disease. As such, it is the duty of vascular surgeons to acquire the skills with which to retain their rightful place in its management and treatment. The purpose of this article is to describe the skills necessary to become competent in the endovascular management of carotid disease, offer some thoughts and strategy by which one can gain experience and develop an armamentarium of skills necessary to perform carotid stenting, and offer a comprehensive array of options of management and treatment to the patient with carotid disease.

Are We Undertreating Carotid Stenoses Diagnosed by Ultrasound Alone?

Clinical management of carotid disease is primarily based on results of national trials (ACAS and NASCET) that used the distal internal carotid artery diameter as a reference. However, commonly accepted ultrasound (US) criteria for carotid stenosis were derived from the correlation of velocity measurements with angiographic bulb diameter reductions (BDR). This study was undertaken to compare the degree of carotid stenosis determined by conventional velocity criteria to the degree of stenosis measured by B-mode (gray scale) diameter at both the carotid bulb and at the distal internal carotid artery, and, second, to evaluate US imaging to derive distal diameter reductions (DDR) noninvasively. During a 3-month period patients referred for carotid US were prospectively analyzed for standard velocity criteria and plaque morphology. Minimum carotid diameter was measured by longitudinal and transverse B-mode measurements and compared to carotid bulb diameter and internal carotid diameter distal to all disease. B-mode diameter reductions were compared to the degree of stenosis determined by velocity criteria and to patient symptoms and the decision for carotid endarterectomy. In total, 131 carotid arteries in 74 patients were evaluated. Based on the University of Washington velocity criteria, lesions were classified as grade I (n = 61, 46%), IIA (n = 58, 44%), IIB (n = 7, 5%), or III (n = 5, 4%). BDR measured by B-mode predicted the grade of disease based on velocity criteria (p < 0.001) with an overall accuracy of 95%. With use of the B-mode for DDR (NASCET style), 18 patients exceeded the 60% threshold for surgical intervention. Of these, only 3 patients were symptomatic and were operated on. An additional 3 operated-on patients had an asymptomatic grade III stenosis, our usual threshold for intervention. Twelve additional patients were appropriate for surgical intervention by B-mode but were not treated based on conventional velocity criteria alone. Bulb diameter reduction by B-mode imaging correlates strongly with diameter reduction determined by velocity criteria, and independently predicts the grade of carotid disease. With this in mind, the accuracy of B-mode imaging may be extended to the measurement of carotid stenosis based on DDR. By B-mode criteria, many patients appropriate for intervention were not offered treatment based on conventional velocity criteria. Modern B-mode imaging provides a noninvasive method to obtain 'arteriographic equivalent'' measurements and should be added as a routine to carotid ultrasound interrogation.

Approval of Virtual Reality Training for Carotid Stenting

PERCUTANEOUS ENDOVASCULAR PROCEDURES CONFER benefits to patients similar to those seen with minimally invasive surgery, such as minimal invasion of the body cavity, reduced pain, shortened recovery time, and more rapid return to work. However, minimally invasive surgery and endovascular procedures also share similar problems. As with minimally invasive surgery, endovascular procedures require physicians to perform invasive procedures guided by 2-dimensional video images while using and manipulating tools with limited degrees of freedom. Endovascular procedures also require the operator to adapt to significantly decreased tactile sensation and overcome similar proprioceptive-visual conflict issues from manipulating long wires or instruments that can fulcrum against the body wall. These hurdles combine to create substantial challenges for physicians training to acquire these skills. The challenge of training physicians for performance of endovascular procedures has been brought to the forefront because of the rapidly expanding application of carotid stenting for treatment of carotid artery stenosis into the broader medical marketplace. Currently, few physicians are experienced in the carotid stenting technique. However, with the recent US Food and Drug Administration (FDA) approval of cartoid stents, many physicians from multiple specialties will want to learn the carotid stenting technique. Traditional training methods for new procedures include performing the procedure on animals, cadavers, or mechanical models or supervised performance of the procedure on patients. Inherent problems with these traditional training strategies include the ethical and anatomical problems of training on animals, risks posed with repeated exposure to radiation, and the expense of consuming real medical devices. However, the majority of procedural training in the United States still occurs on patients with direct mentoring by experienced physicians during an actual clinical procedure. This tradition of training on patients has raised concern among the profession and the public about how physicians will acquire sufficient skill to safely perform new, potentially high-risk, endovascular procedures such as carotid stenting. Because the carotid arteries are the primary blood vessels to the brain, if an embolus of thrombotic plaque dislodges and enters the brain during a carotid stent procedure, the patient could have a stroke or die on the operating table. As with other procedures, carotid stenting has a definite learning curve. However, unlike many other procedures, the risk conferred to the patient in this procedure from the physicians’ learning curve is unacceptably high. Traditionally, it was assumed that if a physician performed a procedure a certain number of times or trained for a period of time then that physician became proficient in the procedure. However, essentially no mechanism for measuring posttraining skill has been used. Both number of procedures and duration of training are, at best, crude surrogate measures of skill and fail to factor in the variability in individual rates of learning. This approach to training produces physicians with considerably variable skills that have been only subjectively assessed by those who trained them. This variation is particularly important with carotid stenting because this procedure crosses multiple clinical specialties with each bringing a different skill set to the training table. For example, a vascular surgeon has a thorough cognitive understanding of vascular anatomy and management of carotid disease but may lack some of the psychomotor technical skills of wire and catheter manipulation and may be unfamiliar with management of the fluoroscope. Conversely, an interventional cardiologist will have the technical skill with catheter-based

Safety and durability of redo carotid operation: an 11-year experience.

With the recent emergence of carotid stenting in the management of carotid disease, the role of surgery has been challenged, particularly for recurrent carotid stenosis. This study was undertaken to determine the safety and durability of redo carotid operation (RCO) for recurrent stenosis. A retrospective review identified 64 consecutive patients who underwent 66 RCOs between 1990 and 2000. There were 33 males (52%) and 31 females, with a mean age of 68.2 years (range, 38-84 years). The mean interval from the primary carotid surgery to RCO was 77.5 months (range, 1-292 months). Operative indications were severe asymptomatic stenosis in 33 cases (50%), transient ischemic attacks (TIA) or amaurosis fugax in 25 (38%), recent stroke in 6 (9%), and nonhemispheric symptoms in 1. Two operations were tertiary carotid reconstructions. A total of 56 (85%) patch angioplasties were performed, 49 with vein and 6 with synthetic material. Primary closure was performed in three cases (5%), whereas interposition grafts were required in eight (12%). Complete follow-up was available in 59 patients (92%) and averaged 4.3 years (range, 0.2-12.9 years); 97% of patients underwent follow-up duplex scanning. There were no operative deaths and only two operative strokes (3.1%). Permanent cranial nerve deficit occurred in one patient (1.5%). Late stroke occurred in five patients: four ipsilateral and one contralateral. Kaplan-Meier estimates for 5- and 10-year stroke-free survival were 92% and 74%, and for overall survival were 72% and 50%. Duplex scanning detected significant recurrent carotid stenosis (>80%) or occlusion in six cases (9%) at a mean follow-up of 4.1 years. Kaplan-Meier estimates for freedom from recurrent stenosis of >80% were 94% and 86% at 5 and 10 years. RCO for recurrent carotid stenosis can be performed safely with excellent protection from stroke and long-term durability. These data provide a standard against which the results of carotid stenting can be compared.

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

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.