Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis caused by atherosclerosis. The document provides recommendations for treatment of asymptomatic and symptomatic carotid stenosis. It summarizes data from trials comparing outcomes of carotid endarterectomy and stenting to medical management. The risks and benefits of carotid endarterectomy and stenting are discussed, along with indications, contraindications, procedural details, complications, and long-term outcomes of the procedures. Guidelines recommend carotid endarterectomy or stenting only when the risk of perioperative stroke and death is low (<6%).

1. CAROTID ARTERY STENTING –
AN UPDATE ON
ATHEROSCLEROTIC DISEASE
DR. SUMIT KAMBLE
DM RESIDENT
GMC, KOTA

2. Carotid atherosclerosis
• Stroke is fourth leading cause of death.
• Carotid stenosis is important cause of ischemic strokes,
accounting for 20 to 25%.
• Most frequently affected sites - proximal internal carotid artery
and carotid bifurcation.

4. Asymptomatic Carotid Stenosis:
Recommendations
• 1. Patients with asymptomatic carotid stenosis should be
prescribed daily aspirin and a statin. Patients should also be
screened for other treatable risk factors for stroke, and
appropriate medical therapies and lifestyle changes should be
instituted (Class I; Level of Evidence C).
• 2. In patients who are to undergo CEA, aspirin is recommended
perioperatively and postoperatively unless contraindicated
(Class I; Level of Evidence C).

5. • 3. It is reasonable to consider performing CEA in asymptomatic
patients who have >70% stenosis of internal carotid artery if
risk of perioperative stroke, MI, and death is low (<3%).
However, its effectiveness compared with contemporary best
medical management alone is not well established (Class IIa;
Level of Evidence A).
• 4. It is reasonable to repeat duplex ultrasonography annually by
a qualified technologist in a certified laboratory to assess the
progression or regression of disease and response to therapeutic
interventions in patients with atherosclerotic stenosis >50%
(Class IIa; Level of Evidence C)

6. • 5. Prophylactic CAS might be considered in highly selected
patients with asymptomatic carotid stenosis (minimum, 60% by
angiography, 70% by validated Doppler ultrasound), but its
effectiveness compared with medical therapy alone in this
situation is not well established (Class IIb; Level of Evidence
B)

7. • 6. In asymptomatic patients at high risk of complications for
carotid revascularization by either CEA or CAS, the
effectiveness of revascularization versus medical therapy alone
is not well established (Class IIb; Level of Evidence B).
• 7. Screening low-risk populations for asymptomatic carotid
artery stenosis is not recommended (Class III; Level of
Evidence C).

8. Symptomatic Carotid Stenosis:
Recommendations
• 1. For patients with a TIA or ischemic stroke within the past 6
months and ipsilateral severe (70%–99%) carotid artery stenosis
as documented by noninvasive imaging, CEA is recommended
if the perioperative morbidity and mortality risk is estimated to
be <6% (Class I; Level of Evidence A).

9. • 2. For patients with recent TIA or ischemic stroke and ipsilateral
moderate (50%–69%) carotid stenosis as documented by
catheter-based imaging or noninvasive imaging with
corroboration (eg, magnetic resonance angiogram or computed
tomography angiogram), CEA is recommended depending on
patient-specific factors, such as age, sex, and comorbidities, if
the perioperative morbidity and mortality risk is estimated to be
<6%(Class I; Level of Evidence B)

10. • 3. When the degree of stenosis is < 50%, CEA and CAS are not
recommended (Class III; Level of Evidence A).
• 4. When revascularization is indicated for patients with TIA or
minor, nondisabling stroke, it is reasonable to perform the
procedure within 2 weeks of the index event rather than delay
surgery if there are no contraindications to early
revascularization (Class IIa; Level of Evidence B).

11. • 5. CAS is indicated as an alternative to CEA for symptomatic
patients at average or low risk of complications associated with
endovascular intervention when the diameter of the lumen of
the ICA is reduced by >70% by noninvasive imaging or >50%
by catheter-based imaging or noninvasive imaging with
corroboration and the anticipated rate of periprocedural stroke
or death is < 6% (Class IIa; Level of Evidence B).

12. • 6. It is reasonable to consider patient age in choosing between
CAS and CEA. For older patients (ie, older than ≈70 years),
CEA may be associated with improved outcome compared with
CAS, particularly when arterial anatomy is unfavorable for
endovascular intervention. For younger patients, CAS is
equivalent to CEA in terms of risk for periprocedural
complications (ie, stroke, MI, or death) and long-term risk for
ipsilateral stroke (Class IIa; Level of Evidence B).

13. • 7. Among patients with symptomatic severe stenosis (>70%) in
whom anatomic or medical conditions are present that greatly
increase the risk for surgery or when other specific
circumstances exist such as radiation-induced stenosis or
restenosis after CEA, CAS is reasonable (Class IIa; Level of
Evidence B).
• 8. CAS and CEA in the above settings should be performed by
operators with established periprocedural stroke and mortality
rates of < 6% for symptomatic patients, similar to that observed
in trials comparing CEA to medical therapy and more recent
observational studies (Class I; Level of Evidence B).

14. • 9. Routine, long-term follow-up imaging of the extracranial
carotid circulation with carotid duplex ultrasonography is not
recommended (Class III; Level of Evidence B). (New
recommendation)
• 10. For patients with a recent (within 6 months) TIA or ischemic
stroke ipsilateral to a stenosis or occlusion of the middle
cerebral or carotid artery, EC/ IC bypass surgery is not
recommended (Class III; Level of Evidence A).

15. • 11. For patients with recurrent or progressive ischemic
symptoms ipsilateral to a stenosis or occlusion of a distal
(surgically inaccessible) carotid artery, or occlusion of a
midcervical carotid artery after institution of optimal medical
therapy, the usefulness of EC/IC bypass is considered
investigational (Class IIb; Level of Evidence C).
• 12. Optimal medical therapy, which should include antiplatelet
therapy, statin therapy, and risk factor modification, is
recommended for all patients with carotid artery stenosis and a
TIA or stroke, as outlined elsewhere in this guideline (Class I;
Level of Evidence A).

16. SYMPTOMATIC VSASYMPTOMATIC
CAROTIDARTERYSTENOSIS
• Symptomatic - transient or permanent focal neurologic
symptoms related to the ipsilateral retina or cerebral
hemisphere.

17. DIAGNOSIS
CAROTID BRUITS
• Carotid auscultation should be part of the routine physical
examination.
• Specificity lower for greater degrees of stenosis.

18. IMAGING STUDIES
• Cerebral angiography
• Carotid duplex ultrasound
• Magnetic resonance angiography
• Computed tomographic angiography

19. Management ofAsymptomatic carotid
atherosclerotic disease
• Use of statins and antiplatelet agents, along with treatment of
hypertension, cigarette smoking, and diabetes.
• Patients with asymptomatic carotid stenosis should be
prescribed daily aspirin and a statin. Patients should also be
screened for other treatable risk factors for stroke, and
appropriate medical therapies and lifestyle changes should be
instituted (Class I; Level of Evidence C).

20. SMART Study
• 221 patients with >50% carotid stenosis, 5 years treated with
intensive medical management.
• <0.5% stroke risk per year
• Goessens et al. Stroke, 2007
Oxford Vascular Study
• 101 patients with >50% carotid stenosis, 3 years
• <0.5% stroke risk per year
• Marquardt et al. Stroke, 2010

21. CAROTID ENDARTERECTOMY
• It is reasonable to consider performing CEA in asymptomatic
patients who have >70% stenosis of the internal carotid artery if
the risk of perioperative stroke, MI, and death is low (<3%).
However, its effectiveness compared with contemporary best
medical management alone is not well established (Class IIa;
Level of Evidence A).

22. CAROTID STENTING
• Prophylactic CAS might be considered in highly selected
patients with asymptomatic carotid stenosis (minimum, 60% by
angiography, 70% by validated Doppler ultrasound), but its
effectiveness compared with medical therapy alone in this
situation is not well established (Class IIb; Level of Evidence
B).

23. Stenting trials
CREST
• CAS vs. CEA in 2300 patients with symptomatic and
asymptomatic stenosis

24. SAPPHIRE
• Tested the hypothesis that CAS is not inferior to CEA
• There was an almost significant reduction in the primary
composite end point for CAS compared with CEA (12.2 versus
20.1 percent, absolute difference 7.9 percent).

25. Symptomatic carotid atherosclerotic disease
• Symptomatic - transient or permanent focal neurologic
symptoms related to the ipsilateral retina or cerebral
hemisphere.
• For patients with a TIA or ischemic stroke within the past 6
months and ipsilateral severe (70%–99%) carotid artery stenosis
as documented by noninvasive imaging, CEA is recommended
if the perioperative morbidity and mortality risk is estimated to
be <6% (Class I; Level of Evidence A).

26. • For patients with recent TIA or ischemic stroke and ipsilateral
moderate (50%–69%) carotid stenosis as documented by
catheter-based imaging or noninvasive imaging with
corroboration (eg, magnetic resonance angiogram or computed
tomography angiogram), CEA is recommended depending on
patient-specific factors, such as age, sex, and comorbidities, if
the perioperative morbidity and mortality risk is estimated to be
<6%(Class I; Level of Evidence B)

27. • CAS is indicated as an alternative to CEA for symptomatic
patients at average or low risk of complications associated with
endovascular intervention when the diameter of the lumen of
the ICA is reduced by >70% by noninvasive imaging or >50%
by catheter-based imaging or noninvasive imaging with
corroboration and the anticipated rate of periprocedural stroke
or death is < 6% (Class IIa; Level of Evidence B).

28. STUDY DURATI
ON
RISK OF
STROKE/
DEATH
NO. OF
PATIENTS
CONCLU
SION
CAS CEA
ACAS 5 YRS - 5.1%(CEA)
11%(MEDICAL)
1662 CEA>ME
DICAL
NASCET 4YRS
8 YRS
- 6.5%
22.3%
659 CEA>ME
DICAL
ACST-1 10 YRS - 13.4%(CEA)
17.9%(MEDICA
L)
3120 CEA>
MEDICA
L
EVA-3S 4YRS 11.1% 6.2% 527 CEA>CA
S
SPACE 2 YRS 9.5% 8.8% 1214 SAME
(RESTENOSIS
)
ICSS 5 YRS 6.4% 6.5% 1710 SAME

29. Carotid artery angioplasty and stenting (CAS)
• Stenting reduces the risk of embolization, thrombosis, carotid
artery recoil, and long-term restenosis.
• Carotid endarterectomy remains the preferred treatment for
most patients with symptomatic carotid atherosclerosis.
• Only applies when the periprocedural risk of stroke and death
with CAS for the operator or center is <6 percent.

30. INDICATIONS
• CAS rather than CEA, for selected patients with recently
symptomatic carotid stenosis of 70 to 99 percent who have any
of the following conditions:
1. A carotid lesion that is not suitable for surgical access
2. Radiation-induced stenosis
3. Restenosis after endarterectomy
4. Clinically significant cardiac, pulmonary or other disease that
greatly increases the risk of anesthesia and surgery

31. Contraindications
Absolute:
• Visible thrombus within the lesion
• Inability to gain vascular access
• Active infection
Relative:
• Severe plaque calcification, circumferential carotid plaque
• Heavily calcified aortic arch
• Severe carotid tortuosity
• Near occlusion of the carotid artery (ie, string sign)
• Inability to deploy a cerebral protection device
• Age >80

32. RISKASSESSMENT
Many of the risk factors identified for carotid stenting
• Age – ≥80 years old have a significantly higher risk of stroke
and death at 30 days
• Higher incidence of unfavorable arterial factors -- aortic arch
elongation, arch calcification, common carotid and innominate
artery origin stenosis, common and internal carotid artery
tortuosity, and a higher risk of residual stenosis post-stenting
due to underlying vessel calcification

33. • Carotid plaque morphology- – Ulcerated carotid plaque,
increasing degree of carotid stenosis, and longer carotid lesions
are aspects of carotid disease associated with increased risk for
stroke.
• Prior neck irradiation- rate of late carotid restenosis and
occlusion following CAS is higher
• Contralateral disease- presence of contralateral carotid
stenosis ≥50 percent is associated with a higher risk for stroke
after CAS

34. Other risk factors
• Presence of aortic stenosis
• Diabetes mellitus with inadequate glycemic control
(hemoglobin A1C >7 percent)
• Symptomatic compared with asymptomatic ipsilateral carotid
stenosis
• Hemispheric TIA or minor stroke compared with retinal
transient ischemic attack (TIA) or no symptoms
• Chronic renal insufficiency
• Emergency admission

35. PERIOPERATIVEANTIPLATELETTHERAPY
• Treated with aspirin (325 mg twice daily) and clopidogrel (75
mg twice daily) starting at least 48 hours before the CAS
procedure.
• Those scheduled for CAS within 48 hours - aspirin 650 mg and
clopidogrel 450 mg at least four hours before

36. • Following CAS, treatment include aspirin 325 mg once or twice
daily and clopidogrel 75 mg daily (or ticlopidine 250 mg twice
daily) for at least 30 days, with a recommendation to continue
aspirin indefinitely.

37. DiagnosticArteriogram
• Right common femoral artery (CFA) is the preferred access for
CAS.
• Left CFA and the brachial artery are alternative accesses .
• Cervical arch classification.

38. Procedure
• Percutaneous access
• Anticoagulation
• Embolic protection devices
• Stent placement and dilation
• Poststenting angioplasty

40. Embolic Protection Device Placement
Three general types of EPD:
• Distal occlusion balloon
• Distal filter device
• Proximal flow diversion

41. Duplex surveillance
• Three to six weeks following carotid artery stenting to establish
a new baseline for future comparison.
• Duplex surveillance is performed at six months and then
annually.

42. Complications of Carotid Stenting
• Access site complications
• Hypotension/bradycardia
• Dissection
• Distal ICA spasm
• Slow-flow
• Cerebral embolism, stroke
• Hyperperfusion syndrome

43. Hyperperfusion syndrome
• Uncommon sequel of carotid stenting
• Headache ipsilateral to the revascularized internal carotid artery.
• Focal motor seizures and intracerebral hemorrhage may follow.
Myocardial infarction
• 1 to 4 percent
Renal dysfunction
• Contrast-induced nephropathy, renal atheroemboli, or renal
hypoperfusion

44. Carotid thrombosis and restenosis
• In-stent thrombosis reported in 0.5 to 2% of patients.
• Mainly due to neointimal hyperplasia.
• 3 years postprocedure, rate of TVR (target vessel
revascularization) remain lower for CAS compared with
endarterectomy (2.4 versus 5.4 percent).
• Restenosis rate (>50 percent on duplex scan) at 10 years is 6.8
percent

45. Stent fracture
• Detected at a mean radiologic follow-up of 18 months in 29 %
• Risk - presence of arterial calcification in region of the deployed
stent

46. MORBIDITYAND MORTALITY
• Combined 30-day stroke and death rates for symptomatic
patients - 6.3 to 9.6 %

47. THANKYOU

48. REFERENCES
• AHA/ASA Guidelines 2014
• Carotid Artery Stenting: Review of Technique and Update of
Recent Literature Semin Intervent Radiol. 2013 Sep; 30(3):
288–296.
• Carotid Artery Stenting versus Endarterectomy A Systematic
Review Texas Heart Institute Journal
• Carotid Artery Stenting JOU RNAL OF THE AMERICAN
COLLEGE OF CARDIOLOGY 2014
• UPTODATE.COM