What's New in Stroke? The Top 10 for 2004/05
Carotid Angioplasty/Stenting
Endovascular techniques for treating carotid stenosis have been developed over recent years. The advantages include avoiding general anesthesia in selected patients (because carotid surgery can be performed under local anesthesia), an incision in the neck, and the risk of cranial and cutaneous nerve damage from the surgical incision. Concern about distal embolization of debris during carotid artery angioplasty/stenting has led to the introduction and increasing use of cerebral protection devices,[13] although the endovascular procedure also carries risk of stroke and death, averaging about 6% in the initial 30 days.
A recently published randomized trial that compared carotid surgery with angioplasty/stenting using a cerebral protection device, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy, enrolled 334 patients with cervical carotid occlusive disease and included patients at high risk for carotid surgery.[14] All participants were given aspirin; in addition, those undergoing stenting received clopidogrel for the first 30 days. The main reasons for being considered "high risk" and hence eligible to participate were manifest coronary artery disease and age of 80 and older. The rate of periprocedural stroke was essentially equivalent, but early MI was lower in the stenting group than the endarterectomy group. In short, angioplasty/stenting resulted in lower risk of periprocedural MI than carotid endarterectomy in patients selected because of high cardiac risk for carotid endarterectomy. Although angioplasty/stenting is a reasonable option for such patients requiring carotid revascularization, the long-term durability of angioplasty/stenting, compared with that of endarterectomy, has not been established. Several large ongoing trials are addressing this issue.
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