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Carotid Stenting
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Cartotid Stenting is when a stent is inserted into the carotid artery to open the narrowing or ulceration and stabilize the carotid artery.
The Status and Future of Carotid Stenting: Who are the Players and What is at Stake?
The ongoing controversy regarding interventional treatment of carotid stenosis using intravascular stents involves not only identification of the appropriate clinical indications for this procedure, but also the adequacy of the regulatory processes involved with both the FDA approval of this technology and CMS reimbursement for the indicated population. The evolution of carotid stenting in the United States has been influenced by several interested parties, including the medical community, patient population and regulatory agencies, each with their own expectations and challenges. In this article, we describe the FDA approval and CMS coverage processes for carotid stenting with embolic protection, evaluate the effects of off-label use and medical practice on acceptance of this technology, and identify future challenges and approaches for both government and medicine.
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Inaccurate Ultrasound Assessment of Internal Carotid Disease in Patients with Carotid Artery Disease and Aortic Valve Stenosis Candidates to Endovascular Carotid Stenting and Cardiac Surgery
Purpose. The association of internal carotid artery disease (ICAD) with aortic valve stenosis (AVS) constitutes a very high-risk clinical occurrence in which combined surgery may increase the operative risks. Therefore, carotid stenting before or after cardiac surgery may be a valuable option. Unfortunately, in patients with aortic valve stenosis (AVS), the evaluation of carotid arteries by Doppler ultrasound (DUS) may be inaccurate. The present retrospective study is aimed to evaluate the pitfalls of DUS and the role of carotid angiography in evaluating ICAD in patients with AVS. Methods. We analyzed the clinical, hemodynamic and angiographic findings of 200 patients with moderate to severe AVS (5.5% of 3600 patients undewent cardiac catheterization, mean age 68.5 ± 10.6 years) investigated in our institution over the past 2 years. Patients with moderate to severe AVS, candidates for open cardiac surgery, underwent carotid ultrasonography to assess ICAD and complete left and right catheterization with coronary artery angiography. In case of doubtful carotid artery sonography, the patients also underwent carotid artery angiography at the time of complete cardiac catheterization before confirming the indication to carotid stenting or combined surgery. Results. Seventy patients with moderate to severe AVS and doubtful carotid ultrasonography underwent coincident carotid angiography. The use of suboptimal Doppler ultrasonographic examinations are related to the anatomical or difficult evaluation of Doppler flow due to hemodynamic influences of aortic valve stenosis. On carotid angiography, 20 patients (28.5%, male/female: 8/12, mean age 72.1 + 5.1 years) were diagnosed with critical stenosis of one (16 patients) or both (4 patients) internal carotid arteries. In 5 patients, a significant ICAD was not diagnosed by DUS, whereas in 7 patients the stenosis was underestimated by DUS (mean luminal narrowing 58 + 12.7% versus 76.7 + 19.3%, p<0.03), and in the other 8, DUS overestimated ICA
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Embolic Protection ? Its Role in Carotid, Coronary and Renal Intervention
The end-organ consequences of arteriosclerosis, namely heart attack, stroke and renal failure, are the leading cause of mortality and morbidity in the western world. Advances in percutaneous interventional techniques have meant that a fair proportion of this disease burden can be dealt with by percutaneous and nonsurgical options. Coronary angioplasty is an established way of dealing with simple and increasingly complex coronary disease. Carotid and renal stenting are also gaining favor as the preferred treatment options, compared to either medical therapy or surgical treatment. Overall, the endovascular approach to treating increasingly complex arterial atherosclerosis is increasing. As the use of stenting increases, so the drive to reduce potential complications and improve success rates intensifies. Although embolization from local atheroma has long been recognized as a potential complication in vascular surgery, direct evidence of this phenomenon was also observed during saphenous vein graft angioplasty. There is also evidence that similar embolization also occurs during carotid and renal stenting, and in certain native coronary lesions with a high thrombus burden. This review examines the rationale for the use of embolic protection systems during endovascular intervention and the clinical evidence base for their use. We also describe the different types of embolic protection systems currently available, their relative merits and outline recommendations for the current use of these devices.
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A Single Center Clinical Evaluation of Carotid Stenting for the Treatment of Obstructive Carotid Artery Disease: Experience in a Community Hospital
Objectives. Carotid angioplasty and stenting (CAS) is a less invasive alternative to conventional carotid endarterectomy (CEA). We sought to demonstrate that carotid angioplasty and stenting can be accomplished safely and successfully in a community hospital with results comparable to those attained in clinical trials at academic centers. Background. Trials performed in academic centers have concluded that CAS with an embolic protection device is not inferior to carotid endarterectomy in high-risk patients and has been shown to have fewer complications in the short term. Methods. We report prospective data on fifty consecutive cases utilizing a standardized carotid protocol at our institution performed by a single operator. CAS was completed in 48 high-risk patients. The majority (96%) of procedures included embolic protection devices. Neurological examination and duplex scans were performed at baseline and in follow-up (1 month, 6 months, and 1 year). Long-term results were assessed retrospectively by telephone interview and chart review. Results. Angiographic success was obtained in all 50 cases. Neurological complications included one (2%) major stroke and one minor stroke (2%). One mortality occurred (2%) as a result of a major stroke. There was one non-neurologic complication. During 1 year of follow-up, there was one stroke. The reintervention rate at one year was 0%. There were no further strokes and one reintervention with long-term follow-up (average 2.6 years). Conclusions. In comparison to outcomes from academic centers and multi-center trials, our data suggest that carotid angioplasty and stenting with the use of an embolic protection device is safe and effective in high-risk patients when performed in a community hospital.
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Cutting Balloon Angioplasty Facilitates Stenting of Severely Calcified Carotid Lesions
Background. Severe calcification of the carotid artery has been reported as a contraindication to stenting because the calcium prevents complete expansion of the stent. Cutting balloon angioplasty (CBA) may facilitate carotid stenting of severely calcified lesions by altering plaque morphology. We report the first case series of using CBA to facilitate stenting of heavily calcified carotid arteries. Methods. From August 2004?December 2005, 178 patients underwent carotid artery stenting at Baptist Medical Center-Princeton in Birmingham, Alabama. Of these patients, 23 (13%) had heavily calcified arteries, as determined by angiography and form the basis of this report. Mean patient age was 75 ± 18 yrs and 70% were asymptomatic. All patients were high risk for carotid endarterectomy (CEA). Cerebral protection was used in all but one patient (96%), where severe tortuosity precluded delivery of the protection catheter. Results. Quantitative angiographic analysis revealed baseline stenosis of 86 ± 6%. Following pre-dilatation with a cutting balloon, approximately 1?2 mm less than the reference vessel diameter and subsequent carotid artery stenting, angiographic success was achieved in all lesions with a mean residual post-dilatation stenosis of 14 ± 9%. There were no perioperative neurological complications. One perioperative death occurred secondary to severe hemorrhage from the groin site and anemia associated with ventricular fibrillation. Conclusion. Our series demonstrates the feasibility of stenting heavily calcified carotid arteries with this new pre-dilatation strategy. This study broadens the population of high-risk patients suitable for carotid artery stenting. Key words: cutting balloon angioplasty, carotid stenosis, calcium
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Duplex Ultrasound Surveillance after Carotid Stent Angioplasty: When to Follow-up and What to Look for
medical therapy for stroke prevention in patients with severe atherosclerotic ICA stenosis in both the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS),3,4 and is currently being compared to carotid stent-assisted angioplasty (CAS) in the Carotid Revascularization Endovascular Stent Trial (CREST). Angiography confirmed > 75% DR CAS stenosis in all 6 patients, resulting in balloon angioplasty (n = 3), stent angioplasty (...
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Is Endovascular Treatment Going to Put Open Surgery Out of Business?
Endovascular surgery, like other forms of minimally invasive surgery, has developed considerably over the last decade, following the trend set by laparoscopic surgery. Level I evidence to support this surge in interventional techniques has been less convincing. This article reviews the development of stenting and endovascular surgery, drawing comparisons between outcomes following open and endovascular procedures.
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Current developments with Carotid Stenting (CAS): The Perfect Vascular Storm Re-Visited
Current developments with Carotid Stenting (CAS): The Perfect Vascular Storm Re-Visited Editor's Letter: Current developments with Carotid Stenting (CAS): The Perfect Vascular Storm Re-Visited - Frank J. Criado CAS developments were portrayed as ? supported clinical application of CAS for carotid revascularization on symptomatic (>50% stenosis) and asymptomatic (>80%) lesions occurring on patients deemed to be high-risk candidates for CEA because of anatomical factors or severe medical co-...
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Ask the Expert: New Collaborative Multi-Societal Credentialing Guidelines for Carotid Artery Stenting
Dr. Cates? expertise is in interventional techniques for the treatment of coronary artery and vascular disease. He is recognized as a national leader in cardiology, especially in the area of managed care, and led the team that performed the first carotid artery stent procedure in Georgia in 1995. Since then, Dr. Cates has performed hundreds of carotid artery stent procedures and represented the ACC in writing the CPT code for carotid stenting and subsequent CPT approval for the carotid stent code. He is the Director of SCAI?s core curriculum course in carotid stenting.
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Online Training for Carotid Stenting Professionals
Dr. Gray is an Interventional Cardiologist who is the Director of Endovascular Care for Swedish Heart Institute. He is also a principal partner with Swedish Cardiovascular Research, located on Swedish's First Hill Campus. Dr. Gray is board-certified in internal medicine, cardiology and interventional cardiology. He has been on staff at Swedish since 1999. Dr. Gray has been principal investigator for numerous clinical and commercial trials and is routinely asked to speak at national and international conferences. He has also been a consultant and device/procedure proctor for numerous medical corporations and is a journal reviewer for such publications as the Journal of the American Medical Association, Circulation and Annals of Emergency Medicine. Boston Scientific, working with Medsn and four of the leading experts in carotid artery stenting (CAS), has developed an online Carotid Education and Stenting Course featuring a series of modules designed to educate physicians on key learnings needed for CAS. The self-paced modules are a valuable tool to help physicians increase their fund of knowledge as they move along the pathway to CAS.
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