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3 results

  • Chapter 20 - Carotid and Vertebral Artery Revascularization

  • from Part V - Prevention
  • Edited by Jeffrey L. Saver, Graeme J. Hankey, University of Western Australia, Perth
  • Book:
    Stroke Prevention and Treatment
    Published online:
    15 December 2020
    Print publication:
    10 December 2020, pp 412-449

  • Summary

    With the exception of near-occlusion, CEA is of overall benefit for selected patients with recent symptomatic carotid stenosis =50% (NASCET method), provided surgical stroke/death risk is low. The benefit is greater with greater stenosis, men, the elderly (aged =75y), most recent ischaemic event within 2w, irregular plaque surface, and impaired cerebral perfusion reserve. Patients with recent symptomatic carotid territory ischaemic events should be screened by Doppler ultrasonography, MRA, or CTA, confirming substantial stenosis with a second non-invasive investigation. Catheter angiography may be required to confirm uncertain results. The surgical peri-operative stroke and death rate (7% in RCTs) is higher in women, hypertension, peripheral arterial disease, and occlusion of the contralateral ICA or ipsilateral ECA. The experience of the surgeon and hospital are crucial, and audited peri-operative complication rates should be publically available. Carotid stenting is less invasive than CEA and causes fewer local complications (cranial neuropathy and neck haematoma), but carries a higher procedural risk of stroke. Stenting should be considered in younger patients, or those at increased risk from CEA. While stenting is of high risk for intracranial vertebral artery stenosis, risk is low for extracranial stenosis and should be considered for recurrent symptoms despite optimal medical therapy.

  • 8 - Interventional management of carotid disease

  • from Background
  • Edited by Jonathan Gillard, University of Cambridge, Martin Graves, University of Cambridge, Thomas Hatsukami, University of Washington, Chun Yuan, University of Washington
  • Book:
    Carotid Disease
    Published online:
    03 December 2009
    Print publication:
    07 December 2006, pp 94-104

  • Summary

    The NASCET showed that stroke risk was significantly reduced by carotid surgery in suitable patients with recent symptoms and carotid stenosis narrowing the vessel by more than 70%. For asymptomatic stenosis the risks and benefits of surgery are finely balanced and two recent trials, the asymptomatic carotid atherosclerosis study (ACAS) trial and the recent Medical Research Council (MRC) asymptomatic carotid surgery trial (ACST) have looked at this in great detail. Two new trials are in the process of commencing: the asymptomatic carotid surgery trial II (ACST II), and also the transatlantic asymptomatic carotid interventional trial (TACIT). Data on carotid angioplasty available from several small series show the risks of procedural related stroke or death are similar to those reported in NASCET and ECST. Carotid stenting is now a mature technique and is being rapidly used by many centers as a first-line treatment for symptomatic and asymptomatic carotid stenosis.

  • Cerebral protection devices for use during carotid artery angioplasty with stenting: A health technology assessment

  • Devidas Menon, Tania Stafinski
  • Journal:
    International Journal of Technology Assessment in Health Care / Volume 22 / Issue 1 / January 2006
    Published online by Cambridge University Press:
    27 February 2006, pp. 119-129

  • Objectives: This study sought to examine the safety, efficacy, and economic implications of the use of cerebral protection devices during carotid artery angioplasty and stenting (CAS) in high-risk patients with severe carotid artery disease (CAD).

    Methods: A comprehensive search for peer- and non–peer-reviewed studies that compared carotid endarterectomy (CEA) or CAS without cerebral protection to CAS with cerebral protection and appeared in the English language literature between January 1990 and January 2005 was completed. Information from studies identified was extracted using a common data abstraction form and then critically appraised against published quality assessment criteria.

    Results: Of the eight studies found, six provided information on technical or procedural success rates, with values ranging from 95.6 percent to 100 percent. Three of the four studies comparing groups of patients who received CAS with cerebral protection with those who received only CAS reported a non-statistically significantly higher 30-day incidence of death and stroke (major or minor) in the latter group. None of the three studies comparing CAS with cerebral protection to CEA demonstrated a statistically significant difference in the 30-day incidence of death, major stroke, or myocardial infarction between treatment groups. No economic analyses were found.

    Conclusions: In high-risk patients with severe CAD, the evidence suggests that CAS with cerebral protection may offer a safe and efficacious alternative to CEA, reducing the risk of embolic peri-procedural complications associated with CAS to acceptable levels.