Endovascular Treatment of Carotid Disease: Carotid
Angioplasty-Stenting
Endovascular therapy can be defined as the treatment of vascular
pathology accomplished with the percutaneous transvascular passage of a therapeutic
device, such as a catheter, guidewire, or stent. Over the past 2 decades, percutaneous
revascularization techniques have become accepted alternatives to surgical revascularization
of aortoiliac, renal, subclavian, and femoropopliteal lesions. Endovascular treatment
of carotid artery disease is an innovation in evolution for stroke prevention and
involves percutaneous transluminal angioplasty and stenting. Although the use of
carotid angioplasty-stenting is increasing rapidly, the safety and efficacy of this
approach has not been established.[579]
A major
concern is the potential for carotid angioplasty-stenting to produce embolic particles
that may result in neurologic deficit.[705]
Increasing
attention is being focused on cerebral protection devices to prevent embolization
during carotid angioplasty-stenting.[705]
[706]
A survey of major interventional centers worldwide found that
more than 12,000 procedures have been performed, with a technical success rate of
98.9%.[707]
Proponents of carotid angioplasty-stenting
have recommended the procedure as an alternative to endarterectomy, particularly
in specific patient subsets considered to be high risk for open surgery.[578]
[708]
A published consensus statement supports
the
use of carotid angioplasty-stenting in high-risk patients.[709]
However, the concept of the high-risk endarterectomy patient has been questioned,
[572]
[573]
because
no data exist that clearly define any such large group of patients. Randomized trials
[710]
[711]
have
documented combined stroke and death rates of 10% to 12% with carotid angioplasty-stenting,
raising significant safety concerns. A large, multicenter, randomized trial of carotid
angioplasty-stenting versus endarterectomy has begun enrollment.[712]
Randomized trials incorporating cerebral protection devices are underway as well.
Most carotid angioplasty-stenting procedures are performed under
local anesthesia with light or no sedation in specialized endovascular suites. General
anesthesia is used at some centers, particularly in the early phase of program development.
Some degree of bradycardia and hypotension has been reported in 68% of patients
undergoing carotid angioplasty-stenting.[713]
Most
procedures are performed by cardiologists (57%) and radiologists (30%).[714]
