Carotid Stenting
2006; Lippincott Williams & Wilkins; Volume: 114; Issue: 1 Linguagem: Inglês
10.1161/circulationaha.106.624379
ISSN1524-4539
Autores Tópico(s)Cardiovascular Health and Disease Prevention
ResumoHomeCirculationVol. 114, No. 1Carotid Stenting Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBCarotid Stenting Marco Roffi and Jay S. Yadav Marco RoffiMarco Roffi From the Department of Cardiology, University Hospital, Zurich, Switzerland (M.R.), and the Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio (J.S.Y.). and Jay S. YadavJay S. Yadav From the Department of Cardiology, University Hospital, Zurich, Switzerland (M.R.), and the Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio (J.S.Y.). Originally published4 Jul 2006https://doi.org/10.1161/CIRCULATIONAHA.106.624379Circulation. 2006;114:e1–e4In Western countries, stroke is the third leading cause of death, after heart disease and cancer, and is the most common cause of permanent disability.1 This neurological condition affects &0.2% of the population each year, and the incidence of stroke-related death is expected to double over the next 30 years. The estimated direct and indirect costs of stroke in the United States for the year 2006 are estimated to be $58 billion.1 A stenosis of the internal carotid artery may be responsible for 10% to 20% of all strokes or transient ischemic attacks. Carotid artery stenting (CAS) has emerged as a potential alternative revascularization strategy to carotid endarterectomy (CEA) for patients with carotid stenosis.Case PresentationA 75-year-old man known to have an asymptomatic occlusion of the left internal carotid artery presented with transient left arm weakness. His cardiovascular risk factors included smoking and hyperlipidemia. Because of poor compliance, the patient was on no medication at the time of admission. Urgent computed tomography scan of the brain showed no bleeding or ischemic lesions. Same-day carotid Duplex ultrasound demonstrated a ≥70% stenosis of the right and the previously diagnosed chronic occlusion of the left internal carotid arteries. Aspirin and a statin were administered, and revascularization options were discussed with the patient.Carotid EndarterectomyLarge-scale randomized clinical trials have established the superiority of CEA over medical management in preventing neurological events in patients with high-grade carotid stenosis. A pooled analysis of the randomized data showed that surgery was highly beneficial for individuals with symptomatic stenosis ≥70% and of some benefit for those with 50% to 69% stenosis.2 In asymptomatic patients, surgery has been associated with a small but definite reduction in the risk of stroke in the presence of a stenosis ≥60%.3 The American Heart Association guidelines support CEA for all symptomatic patients with ≥50% internal carotid artery stenosis and for asymptomatic patients with stenosis ≥60%, as long as the estimated perioperative death or stroke rate is 110 000 Medicare beneficiaries showed that although within randomized trials, the perioperative mortality rate for CEA was as low as 0.6% for symptomatic and 0.1% for asymptomatic patients, the overall perioperative mortality rate in the hospitals participating in the trials was 1.4%.5 In addition, the study detected a perioperative mortality rate of 2.5% in low-volume hospitals. Although low operator and hospital volumes are factors that have been repeatedly associated with poor outcomes after CEA, most surgeries are performed in the United States by low-volume surgeons. An analysis that included >136 000 CEAs documented a mean volume per operator of 15 procedures per year, whereas one third of the patients were operated on by surgeons with a mean CEA volume of 5 per year.6 With respect to patient selection, the impact of comorbidities on the outcomes of CEA is recognized. High-risk features, according to the Centers for Medicare and Medicaid Services (CMS), are listed in Table 1, and the advantages and disadvantages of CEA are reported in Table 2. TABLE 1. Main High-Risk Features for CEA According to the CMSNYHA indicates New York Heart Association.Congestive heart failure NYHA class III/IVLeft ventricular ejection fraction <30%Unstable anginaContralateral carotid occlusionRecent myocardial infarctionPrevious endarterectomy with recurrent stenosisEarlier radiation treatment to the neckTABLE 2. Advantages and Disadvantages of Carotid Revascularization ProceduresCEACASProsWidely availableOutcome less influenced by comorbiditiesExcellent results for high-volume surgeons/hospitals in low-risk patientsLocal anesthesiaNo neck incision/scarUsually next-day dischargeConsOutcome influenced by comorbiditiesFewer experienced operatorsFrequently performed under general anesthesiaRisk of the procedure may increase in patients with severe peripheral vascular disease; severely calcified, tortuous/steep aortic arch; severe calcification or tortuosity of cervicocranial vesselsNeck incision/scarFemoral access site complicationsNeck complications, cranial nerve palsiesMay not be performed if aspirin/clopidogrel intoleranceNot suitable for high or low carotid lesionsLonger hospital stayCarotid StentingPercutaneous carotid revascularization with balloon angioplasty was pioneered in the early 1980s. The advent of stent technology in the mid 1990s allowed protection against dissections and a restenosis rate in the single-digit range. Although prospective comparative studies are lacking, stenting has been virtually uniformly embraced as superior to angioplasty in this setting. The introduction of embolic protection devices (EPDs) in the year 2000 made CAS a safer procedure (Figure 1). The need for EPDs came from transcranial Doppler observations that embolization, although in most cases clinically silent, occurred in virtually all cases of both surgical and endovascular carotid revascularization. A broadly shared opinion, although not unanimous, supports the use of EPDs during CAS, despite the lack of randomized data. A systematic review of 2357 patients who underwent CAS without EPD and 839 protected procedures documented 30-day death and stroke rates of 5.5% and 1.8% (P 10 000 CAS procedures, the use of EPDs halved the event rates.8 As a possible confounding factor, the use of an EPD likely occurred at a later stage of the operator's learning curve. Advantages and disadvantages of CAS are listed in Table 2. Download figureDownload PowerPointFigure 1. EPDs. The most widely used type is the filter (top), which allows blood flow and optimal lesion visualization throughout the procedure. Alternative devices include proximal balloon occlusion (middle) and distal balloon occlusion (bottom).Decision Making in Carotid RevascularizationLow-Risk PatientsThe Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) compared CEA and carotid angioplasty in patients at low to moderate risk for surgery.9 A total of 504 patients with symptomatic carotid stenosis were randomized to CEA or angioplasty.9 The incidence of death or stroke at 30 days was 10% in the endovascular group and 9.9% in the surgical group. The outcomes among the 2 groups remained comparable at 3 years. The study was criticized by the interventionalist community for the low stenting rate (26%) and by surgeons for the high event rates in the surgical arm. Currently, several randomized trials are underway that compare CAS and CEA in low-risk patients, including the US National Institutes of Health–sponsored Carotid Revascularization Endarterectomy Versus Stent Trial (CREST). Until these results become available, low-risk patients should be treated with CAS only within studies.High-Risk PatientsThe Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial is the first and currently only randomized trial comparing CEA and CAS with EPD.10 The study focused on patients at high risk for surgery with ≥50% symptomatic or ≥80% asymptomatic carotid stenosis. Among the 334 patients randomized, major adverse events occurred in 12.2% in the stent group and in 20.1% in the CEA group (P=0.053) at 1 year (Figure 2). In addition, the need for repeat carotid revascularization was lower in the CAS group than in the CEA group (0.6% versus 4.3%; P=0.04). For the first time, nonfatal cardiac events were included in the outcome analysis of a carotid revascularization trial. Patients who underwent CAS had significantly fewer myocardial infarctions at 30 days compared with those who were randomized to CEA (1.9% versus 6.6%; P=0.04). Prospective registries including almost 4000 protected CAS procedures, performed mainly in high-risk patients, resulted in 30-day death, myocardial infarction, or stroke rates ranging between 3.4% and 7.8%.11 On the basis of the current evidence, CAS with EPD in the hands of experienced operators should be considered equal if not superior to CEA in this patient population. Download figureDownload PowerPointFigure 2. One-year results of the SAPPHIRE trial. Major adverse events were defined as composite of death, stroke, or myocardial infarction within 30 days or death or ipsilateral stroke between 31 days and 1 year. In the intention-to-treat analysis (A), the rate of event-free survival at 1 year was 87.8% among patients randomly assigned to CAS versus 79.9% among those randomly assigned to CEA (P=0.053). In the actual-treatment analysis (B), the rate of event-free survival at 1 year was 88.0% among patients who received a stent versus 79.9% among those who underwent CEA (P=0.048). I bars represent 1.5 times the standard error. Reproduced from Yadav et al,10 with permission from the Massachusetts Medical Society.Current CMS GuidelinesIn the United States, the CMS has concluded that CAS with EPD is reasonable and appropriate for symptomatic patients with carotid stenosis ≥70% at high risk for surgery (Table 1).12 If performed within clinical trials or CAS postapproval studies, the procedure may be performed in high-risk symptomatic patients with 50% to 70% stenosis and in high-risk asymptomatic individuals with stenosis ≥80%. Carotid stenting is considered appropriate if performed in facilities and by operators complying with the set standards.12 A suggested management strategy for patients with carotid stenosis is illustrated in Figure 3. Download figureDownload PowerPointFigure 3. Management strategy for patients with carotid stenosis. LDL indicates low-density lipoprotein; MR, magnetic resonance; and CT, computed tomography.ConclusionsCAS has emerged as alternative treatment to CEA in patients with carotid stenosis. Current evidence suggests that using an EPD markedly reduces the number of neurological events. In patients at high risk for surgery, the SAPPHIRE trial has shown that protected CAS is equal if not superior to surgery in the hands of experienced operators. Ongoing randomized trials, including CREST, are investigating the role of CAS in low-risk patients. In the United States, CMS guidelines currently support protected CAS for patients at high risk for surgery with symptomatic carotid stenosis ≥70%. Because of the presence of a contralateral carotid occlusion, the patient discussed earlier was considered at high risk for surgery. He was offered both CEA and CAS but preferred the endovascular approach. After clopidogrel loading, he underwent uneventful protected CAS of the right internal carotid artery. At the 1-year follow-up, he was free of recurrent neurological events and restenosis.DisclosuresNone.FootnotesCorrespondence to Jay S. Yadav, MD, Cleveland Clinic Foundation, Department of Cardiovascular Medicine, F25 9500 Euclid Ave, Cleveland, OH 44195. E-mail [email protected] References 1 Heart Disease and Stroke Statistics–2006 Update. Dallas, Tex: American Heart Association; 2006.Google Scholar2 Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJ. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003; 361: 107–116.CrossrefMedlineGoogle Scholar3 Rothwell PM, Goldstein LB. Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke. 2004; 35: 2425–2427.LinkGoogle Scholar4 Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation. 1998; 97: 501–509.CrossrefMedlineGoogle Scholar5 Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE, Fisher ES. Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. JAMA. 1998; 279: 1278–1281.CrossrefMedlineGoogle Scholar6 Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003; 349: 2117–2127.CrossrefMedlineGoogle Scholar7 Kastrup A, Groschel K, Krapf H, Brehm BR, Dichgans J, Schulz JB. Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature. Stroke. 2003; 34: 813–819.LinkGoogle Scholar8 Wholey MH, Al-Mubarek N. Updated review of the global carotid artery stent registry. Catheter Cardiovasc Interv. 2003; 60: 259–266.CrossrefMedlineGoogle Scholar9 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001; 357: 1729–1737.CrossrefMedlineGoogle Scholar10 Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004; 351: 1493–1501.CrossrefMedlineGoogle Scholar11 Wholey MH. History and current status of endovascular management for the extracranial carotid and supra-aortic vessels. J Endovasc Ther. 2004; 11 (suppl 2): II-43–II-61.CrossrefGoogle Scholar12 CMS decision memo for carotid artery stenting (CAG-00085R). Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=157. Accessed December 12, 2005.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Csizmadia S, Kaszás Z, Klucsai R, Bartha É and Vörös E (2021) The correlation between the cardiovascular instability and the size of the developed ischaemic lesions in patients who underwent carotid stenting, The Neuroradiology Journal, 10.1177/1971400920988667, 34:5, (383-391), Online publication date: 1-Oct-2021. Brownson K and Dardik A (2016) Next generation ECM-based vascular biomaterials Extracellular Matrix-derived Implants in Clinical Medicine, 10.1016/B978-0-08-100166-0.00003-7, (19-40), . 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July 4, 2006Vol 114, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.624379PMID: 16818819 Originally publishedJuly 4, 2006 PDF download Advertisement SubjectsCerebrovascular ProceduresPercutaneous Coronary Intervention
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