Carotid artery stenting stenosis

FIGURE 9.1 Triage of patients with asymptomatic carotid artery stenosis to carotid endarterectomy (CEA) versus carotid artery stenting. (Adapted from Ref. 8, with permission.)... 

The standard antiplatelet regimen for patients undergoing carotid artery stenting include aspirin 325 mg a day and clopidogrel 75 mg a day for at least one week prior to the procedure. Currently, there is no role for elective use of glycoprotein Ilb-IIIa receptor antagonists. All patients should be adequately hydrated to reduce the incidence and severity of intraprocedural hypotension. Traditionally, all antihypertensive medications are withheld on the day of the procedure. This is done to avoid excessive hypotension after CAS, particularly in patients with known severe coronary artery disease or critical aortic stenosis. 

Roubin GS, New G, Iyer SS et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis a 5-year prospective analysis. Circulation 2001 Jan 30 103(4) 532-7. 

At their origins, the internal carotid and coronary arteries are susceptible to atheromatous plaque formation, which is liable to lead to clinically significant stenosis and possible lethal cerebral or cardiac thrombosis (Figure 11.41). While such constrictions can be opened, for example, by insertion of a stent into stenotic carotid artery [carotid artery stent (CAS)], there is a high risk of restenosis... 

One randomized trial of stenting for vertebral artery disease was started (Coward et al. 2005). The Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) included both carotid and vertebral stenosis. However, only 16 patients were randomized between vertebral angioplasty or stenting and best medical treatment. Therefore, there are no robust data from randomized trials providing data on the safety and efficacy of vertebral artery stenting. 

In secondary prevention, carotid endarterectomy of an ulcerated and/or stenotic carotid artery is a very effective way to reduce stroke incidence and recurrence in appropriate patients and in centers where the operative morbidity and mortality are low. In fact, in ischemic stroke patients with 70% to 99% stenosis of an ipsilateral internal carotid artery, recurrent stroke risk can be reduced by up to 48% compared with medical therapy alone when combined with aspirin 325 mg daily. In patients in whom the risk of endarterectomy is thought to be excessive, carotid stenting may be effective in reducing recurrent stroke risk but is less invasive. Carotid stenting is still considered investigational, however, and issues remain regarding the optimal methods and patients for this procedure. 

Hanel RA, Xavier AR, Kirmani IF, et al. Management of carotid artery stenosis Comparing endarterectomy and stenting. Curr Cardiol Rep 2003 5 153-159. 

Consider terminating infusion of thrombolytic by 8 h in anterior circulation stroke. Consider early angioplasty stenting for severe stenosis or occlusion of the extracranial carotid artery. 

Atherosclerotic vascular disease is more frequent in elderly patients and may be associated with more tortuous vessel anatomy. Superselective catheterizations of distal cerebral vessels might thus become technically more difficult. Atherosclerotic carotid bifurcation disease is frequently associated in patients with advanced age and might increase the risk of thromboembolic complications. In selected cases, a combined approach, first stenting of the carotid artery stenosis and subsequently coil embolization of the ruptured aneurysm might be a therapeutic option. 

FIGURE 11.41 Left, Carotid bifurcation with severe stenosis at the origin of the internal carotid artery (arrow). Middle, Balloon catheter inserted in stenotic artery to enlarge the constriction. Right, After enlargement, a stent is implanted to prevent early restenosis. CCA, common carotid artery ICA, internal carotid artery ECA, external carotid artery. 

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