Cath Lab Digest

Carotid endarterectomy (CEA) is shown as a very safe and durable procedure for symptomatic carotid artery stenosis >70% and asymptomatic stenosis >60%. The benefits of CEA in patients with symptomatic lesions 50% to 70% and asymptomatic lesions 60% to 80% are marginal. The role of carotid artery stenting per Medicare guidelines includes those patients with symptomatic stenosis >70% and high risk for CEA due to cardiopulmonary and anatomical comorbidities. Patients who are enrolled in FDA-approved clinical trials can receive carotid artery stenting for symptomatic stenosis >50% and asymptomatic stenosis >80% with clinical high-risk criteria for CEA. It is imperative to note that high-risk criteria defined in clinical trials for carotid artery stenting and those governed by Medicare vary.

The role of optimal medical treatment for carotid artery disease using antiplatelet agents, angiotensin-converting enzyme (ACE) inhibitors, statins, and smoking cessation has not been addressed aggressively. Two clinical trials, The North American Symptomatic Carotid Endarterectomy Trial (NASCET)¹ and ACAS,² were aimed to compare medical treatment for carotid artery disease versus surgical revascularization. However, the role of maximal risk factor reduction or the advances in medical treatment were never emphasized.

The recent FDA-approval for carotid artery stent and distal protection devices for low- and high-risk patients with carotid artery stenosis is interesting. Interventionalists are awaiting decisions from payers, mainly Medicare, followed by private insurance companies. We suggest that the role of risk factor reduction addressed as an adjuvant to any carotid revascularization and collaborative work of cardiology, vascular surgery/radiology, and neurology is beneficial. The role of neurology to access patients with carotid artery stenosis before and after revascularization will help us to document the neurological complications in a transparent fashion.

References

1. Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999 Sep;30(9):1751-1758.
2. Baker WH, Howard VJ, Howard G, Toole JF. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators. Stroke 2000 Oct;31(10):2330-2334.

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ARAVINDA NANJUNDAPPA, MD, RVT Dr. Nanjundappa completed medical graduation in Adichunchanagiri Institute of Medical Sciences, India. He is specialist in Internal Medicine and Cardiology. He has certification in Cardiovascular Disease, Internal Medicine and Interventional Cardiology. He has been resident and fellow at Seton Hall University, Shands Hospital, Washington Hospital Center. He has also served as Director of Vascular Medicine and Peripheral Interventions at Pitt County Memorial Hospital, Greenville, North Carolina. At present, he is working as an Associate Professor of Medicine and General Surgery at West Virginia University School of Medicine, Charleston, West Virginia. He is a Board-Certified Cardiologist and Interventionalist.

Recipient of numerous teaching, research awards and grants, Dr. Nanjundappa is author of more than 60 peer-review journal articles and text book chapters. A frequent national and international guest lecturer, he serves on the editorial boards of eight journals including: Angiology; Interventional Cardiology (Associate Editor); and The Internet Journal of Endovascular Medicine (Chief Medical Editor). Dr. Nanjundappa has participated in several important Clinical Trials including: CLEVER, CORAL, CAPTURE, CREST, HERCULES, MOBILITY, and CHOICES.

ROBERT S. DIETER, MD, RVT Dr. Dieter is an interventional cardiologist and vascular medicine specialist. He has completed advanced fellowship in Vascular Medicine and Peripheral Vascular Interventions at Georgetown University/Washington Hospital Center in Washington, D.C.

With a patient care emphasis in Vascular Medicine, he specializes in the management of patients with complex vascular diseases. He manages patients with stroke, TIA, and those at risk for stroke, particularly those with carotid artery blockages requiring angioplasty/stenting or those with PFO. He also specializes in renal artery stenosis. In fact, Dr. Dieter has published on new and potentially safer methods to treat blockages in the renal arteries. Dr. Dieter performs minimally invasive abdominal aortic aneurysm repair (endograft). Dr. Dieter has extensive training in the management of patients with claudication, as well as those with critical limb ischemia and non-healing ulcers — particularly in patients with diabetes. Furthermore, Dr. Dieter is board-certified in interventional cardiology and specializes in angioplasty, stenting and myocardial infarction treatment. Although Dr. Dieter is a vascular medicine specialist and interventional cardiologist, his underlying philosophy is the prevention of disease. He completed an advanced fellowship with renowned experts in Preventive Cardiology. Dr. Dieter actively treats patients with complex dyslipidemias.

Dr. Dieter graduated Alpha Omega Alpha from medical school. He has written over 100 journal articles, eight book chapters, is on the editorial board of several medical journals, and lectures internationally on cardiovascular diseases. He is the editor of two textbooks on vascular disease.