Carotid Artery Stenting: Second Consensus Document of the ICCS/ISO-SPREAD Joint Committee (original) (raw)
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Carotid Artery Stenting: First Consensus Document of the ICCS-SPREAD Joint Committee
Stroke, 2006
Background and Purpose— The prevention of stroke and the correct treatment of carotid artery stenosis represent today a major debate in cardiovascular medicine. Beside carotid endarterectomy, carotid angioplasty and stenting is becoming more widely performed for the treatment of severe carotid obstructive disease, and is now accepted as a less invasive technique that may provide an alternative for selected patients, particularly those with significant comorbidities. An Italian multidisciplinary task force, in which converged the most representative scientific societies involved in carotid treatment, was created to provide neurologists, radiologist, cardiologists, vascular surgeons, and all those involved in prevention and treatment of carotid disease with a simple, clear and updated evidence-based consensus document. Summary of Review— This First Consensus Document of the ICCS (Italian Consensus Carotid Stenting)/SPREAD group addressed the main issues related to methodology, definit...
Carotid artery stenting: Rationale, technique, and current concepts
European Journal of Radiology, 2010
Carotid stenosis is a major risk factor for stroke. With the aging of the general population and the availability of non-invasive vascular imaging studies, the diagnosis of a carotid plaque is commonly made in medical practice. Asymptomatic and symptomatic carotid stenoses need to be considered separately because their natural history is different. Two large randomized controlled trials (RCTs) showed the effectiveness of carotid endarterectomy (CEA) in preventing ipsilateral ischemic events in patients with symptomatic severe stenosis. The benefit of surgery is much less for moderate stenosis and harmful in patients with stenosis less than 50%. Surgery has a marginal benefit in patients with asymptomatic stenosis. Improvements in medical treatment must be taken into consideration when interpreting the results of these previous trials which compared surgery against medical treatment available at the time the trials were conducted. Carotid artery stenting (CAS) might avoid the risks associated with surgery, including cranial nerve palsy, myocardial infarction, or pulmonary embolism. Therefore and additionally to wellestablished indications of CAS, this endovascular approach might be a valid alternative particularly in patients at high surgical risk. However, trials of endovascular treatment of carotid stenosis have failed to provide enough evidence to justify routine CAS as an alternative to CEA in patients suitable for surgery. More data from ongoing randomized trials of CEA versus CAS will be soon available. These results will help determining the role of CAS in the management of patients with carotid artery stenosis.
Eight-year institutional review of carotid artery stenting
Journal of Vascular Surgery, 2010
Objectives: Vascular surgeons have increasingly become proficient in carotid artery stenting (CAS) as an alternative treatment modality for cervical carotid artery occlusive disease. We analyzed our early and late outcomes of CAS over the last 8 years. Methods: We report a single-center retrospective review of 388 carotid bifurcation lesions treated with CAS using cerebral embolic protection from May 2001 to July 2009. Data analysis includes demographics, procedural records, duplex exams, arteriograms, and two-view plain radiographs over a mean follow-up time of 23.0 months (interquartile range, 10.9-35.4). Results: At the time of treatment, the mean age of the entire cohort (76% men and 24% women) is 71 years; 13% were >80 years of age, and 31% had a prior history of either carotid endarterectomy (CEA) and/or external beam neck irradiation (XRT). The mean carotid stenosis is 80%, and asymptomatic lesions represent 69% of the group. Overall 30-day rates of death, stroke, and myocardial infarction are 0.5%, 1.8%, and 0.8%, respectively. The combined death/stroke rate at 30 days is 2.3%. The 30-day major/minor stroke rates for analyzed subgroups are statistically significant only for XRT/recurrent stenosis vs de novo lesions, 0% and 2.6% (P ؍ .03), but not for asymptomatic vs symptomatic patients, 1.9% and 1.7% (P ؍ .91) and age <80 vs >80, 2.0% and 1.8% (P ؍ .52), respectively. At long-term, the freedom from all strokes at 12, 24, 36, and 48 months was 99.2%, 97.6%, 96.7%, and 96.7%, respectively. At late follow-up, the restenosis rate is 3.5%. Restenosis rates for recurrent stenosis/XRT vs de novo lesions are 2.7% and 3.4% (P ؍ .39). Among the restenotic lesions were two associated type III stent fractures in de novo lesions, both of which were closed-cell stents. An additional two other type I fractures have been identified, yielding a stent fracture rate of 5.5%. The late death rate for the entire group is 16.8%, with one stent-related death secondary to ipsilateral stroke at 20 months (0.3% death rate). Conclusions: Vascular surgeons performing CAS with embolic protection can achieve good early and late outcomes that are comparable to CEA benchmarks. Late stent failures (stroke, restenosis, and/or stent fatigue), while uncommon, are a recognized delayed problem.
Carotid artery stenting: results and long-term follow-up
2006
Background and Purpose: The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy in the treatment of for symptomatic carotid artery stenosis is investigated. Materials and Methods: Forty-seven patients underwent CAS over 10-year period. Forty-nine vessels were treated. Stenosis quantification was done using North American symptomatic carotid endarterectomy trial method. The mean follow-up period by clinical and Duplex examination ranged is 5.6 years. Results: The technical success rate was 100%. There were four deaths (8.1%) and two (4.1%) minor strokes within thirty days of procedure. There was no major strokes. All patients with minor stroke achieved complete recovery at 1-month follow up. Two deaths occurred probably due to hyperperfusion syndrome (HS) and two due to cardiac arrest. Conclusion: CAS is an effective treatment modality of symptomatic carotid artery disease but should be carefully done in high risk groups having severe medical ailments and those having severe bilateral stenosis of the carotid arteries.
ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting
Journal of the American College of Cardiology, 2007
atic high-risk patients to determine the relative merits of CAS compared with best medical therapy. Training and Credentialing Operators should previously have achieved a high level of proficiency in catheter-based intervention, complete dedicated training in CAS, and be credentialed at their hospital. Detailed clinical documents on training and credentialing for CAS have been published by 2 multispecialty consensus groups. The elements for competency include requirements for cognitive, technical, and clinical skills, including cervicocerebral angiography and CAS. Hospitals are required to maintain independent oversight of CAS outcomes by a hospital-based oversight committee. The CMS has created facility credentialing requirements for CAS reimbursement. Individual operators and institutions are required by CMS to track their outcomes and to make their data available for submission to a national database.
Tips and techniques in carotid artery stenting
Journal of Vascular Surgery, 2009
Significant technical advances have made carotid artery stenting an option for high-risk patients. These advances bring forth new challenges that must be overcome. Preprocedural planning is essential for optimal outcome for every patient given the high risk for significant neurologic complications. In this article we describe a standard approach for performing carotid artery stenting and techniques used to circumvent challenges that may be encountered. In addition, implementation of modifications and advanced techniques in challenging cases may allow successful treatment of carotid stenosis. Maintenance of proficiency in carotid artery stenting requires significant and ongoing experience. ( J Vasc Surg 2009;50: 216-20.)
Technical aspects and current results of carotid stenting
Journal of Vascular Surgery, 2001
Purpose: We reviewed our experience with carotid stenting (CS), focusing on technical evolution and results. Methods: From September 1995 to February 2000, 77 patients with 83 internal (n = 68) and common carotid artery lesions (n = 15) were selected for CS. This patient population was categorized into three consecutive periods based on patient selection, material, and technical skills. For internal carotid artery lesions, period I included 11 patients treated by means of direct carotid puncture with balloon expandable stents; period II included 42 patients treated by means of a femoral approach with self-expandable stents; and period III included 15 patients in whom monorail system and cerebral protection devices were used. Common carotid artery lesions were treated by means of carotid puncture in five patients and by means of a femoral approach in 10 patients. In only two of the latter cases, cerebral protection devices were used. Results: The overall immediate success rate, defined as successfully treated stenosis with no neurological events, was 89.7% for internal carotid artery lesions and 100% for common carotid artery lesions. All neurological events, which consisted of reversible events (4.4%), minor stroke (1.5%), and major stroke (2.9%), occurred during periods I and II. In periods I, II, and III, the rate of surgical conversion was 18%, 9.5%, and 0%, respectively, the rate of transient ischemic attack and reversible ischemic neurologic deficit was 0%, 7%, and 0%, respectively, and the rate of minor and major stroke was 0%, 7%, and 0%, respectively. All major strokes were cleared with intra-arterial thrombolysis. At discharge, the success rates defined by means of the absence of conversion and neurological events were 82% during period I, 76% during period II, and 100% during period III. The freedom from neurological deficits rates were 100%, 97.6%, and 100%, respectively. During follow-up, six significant asymptomatic restenoses were detected with duplex scanning; however, only one patient required reintervention. Conclusion: Technical skills and technological improvement, including low-profile balloon and catheter, cerebral protection device, and intra-arterial rescue techniques, may reduce the rate of neurological events associated with CS. Technical improvements should be given careful consideration before the initiation of randomized trials comparing CS and carotid endarterectomy. (J Vasc Surg 2001;33:1001-7.)
Carotid Artery Stenting in Patients with Carotid Artery Stenosis
Journal of Rawalpindi …, 2012
Background: To evaluate the effectiveness of carotid artery stenting in patients with carotid artery stenosis Methods: In this descriptive study rail roading technique was used for carotid artery stenosis. An 8F multipurpose guide was mounted over a 5F JB3 diagnostic ...
Circulation, 1998
C arotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials, 1-3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%. 3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference. 3 In patients with or without symptoms who have a stenosis Յ60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with Ͻ30% stenosis, medical therapy is superior to surgical therapy. 2 Studies attempting to define the benefit of therapy in symptomatic patients with Ͻ60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses Ն70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated. In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis Ն60%, but the significance of this finding has been debated. Although mortality associated with conventional antiplatelet therapy has been minimal, 7 surgery clearly has significant perioperative morbidity and mortality. This risk varies as a function of the skill and experience of the surgeon and ancillary personnel. In one large study of symptomatic patients, 3 surgical complication rates were 0.6% mortality; 5.5% perioperative cerebrovascular events; and 2.1% major stroke. By contrast, over the same 32-day observation period, patients treated medically had a 0.3% fatality rate, a 3.3% risk of a cerebrovascular event, and a 0.9% risk of a major event. In a recent review of the published literature, risk of stroke and/or death following carotid endarterectomy in symptomatic patients was found to be 5.6%, although there was substantial variation in incidence as a function of the type of study and the nature of postoperative evaluation and surveillance. 8 Surgery, then, in this symptomatic group of patients with significant carotid artery stenosis has a low but significant incidence of periprocedural complications. More importantly, however, according to actuarial analysis, by 2 years the risk of an ipsilateral stroke was 9% for surgical patients and 26% for medically treated patients, a 17% reduction in absolute risk with surgery. Since its development by Gruentzig 9 in the early 1970s, use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses has gained wide acceptance. In many trials involving many organ systems, percutaneous transluminal angioplasty (PTA) has been shown to be effective. Despite several large studies, however, there is still debate about its relative efficacy and applicability compared with surgery, primarily because long-term patency after PTA is limited by restenosis as well documented in coronary, renal, and peripheral applications. Vascular stents have gained wide popularity over the last several years. There are many types with different characteristics, in different stages of clinical use and FDA approval. More "Carotid Stenting and Angioplasty" was approved by the American