Carotid arterial stenting

Carotid arterial stenting (CAS) is a minimally invasive endovascular interventional procedure that can potentially offer the same advantage as surgery (carotid endarterectomy).

Indications

Indications for carotid stenting are evolving with endarterectomy trials that evaluate the carotid stenosis cutoff values for treatment. The indications include:

• symptomatic patients with ≥70% stenosis (NASCET trial)

• asymptomatic patients with >60% stenosis (ACAS study) 

• symptomatic patients with stenosis of at least 50-69% stenosis

• carotid artery dissection or pseudoaneurysm

Contraindications

• complete carotid occlusion

• major disabling stroke on the ipsilateral side/disabling dementia

• intracranial tumor/hemorrhage

• unstable plaque or thick calcification at the site of carotid stenosis

• extreme tortuosity of the vessel

Complications

• preprocedural cerebrovascular accident (~8%) ³

• recurrent carotid arterial stenosis or in-stent restenosis (~6% at 1 year) ⁴

• hyperperfusion syndrome after carotid artery stenting (1-2%): headache, seizures and intracranial hemorrhage ⁶

Alternative treatment options

• carotid endarterectomy

Outcomes

Operator skills and experience have a profound impact on patient outcomes following CAS. One systematic review and meta-analysis of the literature found ​Carotid Endarectomy (CEA) to be superior to CAS in freedom from stroke/death within 30 days of treatment, with the incidence of stroke/death within 30 days of treatment was 4.7% for CAS and 3.5% for CEA ⁸.

History and etymology

• the first percutaneous transluminal carotid angioplasty (PTA) was performed by Charles Kerber in 1980 ⁵. 

• somewhat surprisingly the word 'stent' is actually an eponym, originally named after Charles Stent (1807-1885), a largely-forgotten British dentist. He invented an improved material for forming dental impressions and set up a company to manufacture it. During the Great War, J F Esser, a Dutch surgeon used a mold of Stent's Compound as a fixative for skin grafting in injured infantrymen. This innovative use was rapidly adopted into practice, and stenting as a concept rapidly segued into multiple specialties ⁷.