A LINC Studio discussion on the current status of carotid interventions took place this morning, forming an introduction to the following session on innovative concepts in carotid revascularisation, which included a live case and a selection of the latest in scientific data.
Alberto Cremonesi, MD, (Cardiology Unit and Cardiovascular Department, Humanitas Gavazzeni Hospital – Bergamo, Italy), who participates in both sessions, joined LINC Today to reflect on carotid interventions today.
Professor Cremonesi began by stating that the previously heated debate on carotid artery stenting (CAS) versus carotid endarterectomy (CEA) is of little relevance today. “In the last ten years CAS has reached a very good position as a natural alternative to CAE. I really don’t care what way the patient is treated: once the right indication is reached for ischemic stroke prevention, either CAS or a surgical approach is perfect for me.”
Just how safe CAS is, however, depends on a diligence towards choices of both stent and embolic protection, with recent technical advancements providing opportunities to overcome its remaining limitations. “We need to solve the problem of embolic protection,” he said, “Not only during the procedure, but over the period until the stent is re-endothelialized – which is more or less one or two months after the procedure.
“Fortunately, today we have technological advancements such as the micromesh double layer stent. And there are also combination strategies; for example, during CAS I use some way to protect the brain and then the stent technology can help to solve the problem of late events. If I go in this direction, CAS is very safe and absolutely comparable to CAE.”
Decision-making around asymptomatic patients remains a hot topic, he noted. “This is a big problem, raised four or five years ago. Today, the problem is not only what I have to do for an asymptomatic patient, but how to identify which of these patients could benefit from CEA or CAS.
“I consider it mandatory to establish in these patients the best medical therapy. But an asymptomatic carotid stenosis might be very stable, or it might be very unstable [and lead to] major stroke. Still today, this is very complex. I may rely on some very advanced evaluation here – transcranial Doppler, OCT, PET-CT, etc. – but these can be complex and cumbersome for the patient as well as for the centre, and they are costly.”
During the session Professor Cremonesi will outline accepted indications for CAS,1 as well as discussing how these interplay with real world practice in carotid interventions. Highlighting that treatment decisions are highly personalised according to operator and centre experience, he continued: “We have many data, but how do we incorporate these data into daily practice? Still today, the evidence is not always our driving factor.”
Asked whether this is likely to change given the complexity of decision-making with individual patients, he said: “I started my interest in carotid interventions in 1999 and I continue to say that CAS is one of the most complex procedures in the peripheral world – not only the procedure itself, but also in recognising what is best for the individual patient. We have so many confounding variables.
“Every time I address a patient with symptomatic or asymptomatic stenosis, my position is that of the vascular team, not my individual decision. I really like to put the question: what is best for that specific patient? I have experienced interventional operators as well as very good vascular surgeons, and we make a team decision.”
1. Aboyans V, Ricco JB, Bartelink MEL, et al; ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9):763-816.