Carotid Artery Stenting - The Interventional Cardiologist's Role in Stroke Prevention

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Citation
US Cardiology 2006;2005:2(1):1-6

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More than three-quarters of a million Americans will suffer a stroke this year. Stroke ranks as the third most common cause of death after heart disease and cancer. It is the number one cause of disability among adults and the main reason for rehabilitation. Many, but not all, strokes are related to atherosclerosisÔÇöthe same disease that causes heart attacks. Blockage of one of the two main arteries to the brain, the carotid arteries, is a preventable cause of stroke. These blockages can be detected by an ultrasound test and are confirmed by angiography. The conventional treatment for these blockages is a surgical operation, but a non-surgical treatment, carotid stenting, has recently been approved for use in patients at high surgical risk and is being tested as an alternative procedure to surgery for routine patients.

Introduction

Catheter-based therapies, such as stents, have been used in both peripheral and coronary arteries to great success, and in many circumstances have largely replaced surgical therapy as the standard treatment of blocked arteries. The use of carotid artery stents (CAS) to prevent strokes began in Europe.1,2 In a worldwide survey of carotid intervention published in 1998, the specialty of cardiology was dominant, responsible for more than 60% of all the reported cases of CAS.3 Cardiologists have continued to lead this field with the development of embolic protection devices (EPDs) used to trap debris released from the plaque.4

Pathophysiology

The majority of cerebral ischemic events are a focal manifestation of a systemic diseaseÔÇöatherosclerosis. There are two main types of stroke: ischemic and hemorrhagic. Ischemic stroke results from a reduction of blood flow due to emboli, thrombosis, or hypoperfusion. Hemorrhagic stroke includes primary cerebral hemorrhages or hemorrhage secondary to an ischemic event. Atherosclerotic carotid artery stenoses most often cause symptoms due to emboli events. Anatomically, the two internal carotid arteries and two vertebral arteries come together at the base of the skull to form an ideal anastomotic network, the Circle of Willis. In theory, a single vessel could supply the circulatory needs of the entire brain.

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References
  1. Mathias K,A new catheter system for percutaneous transluminal angioplasty (PTA) of carotid artery stenoses, Fortschr. Med. (1977);95(15): pp. 1,007-1,011.
    PubMed
  2. Kerber C W, Cromwell L D, Loehden O L, Catheter dilatation of proximal carotid stenosis during distal bifurcation endarterectomy, AJNR (1980);1(4): pp. 348-349.
    Crossref | PubMed
  3. Wholey M H,Wholey M, Bergeron P et al., Current global status of carotid artery stent placement, Cathet. Cardiovasc. Diagn. (1998);44(1): pp. 1-6.
    Crossref | PubMed
  4. Al-Mubarak N, Roubin G S,Vitek J J et al., Effect of the distal-balloon protection system on microembolization during carotid stenting, Circulation (2001);104(17): pp. 1,999-2,002.
    Crossref | PubMed
  5. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients, Br. Med. J. (2002);324(7329): pp. 71-86.
    Crossref | PubMed
  6. Albers G W,Amarenco P, Easton J D, Sacco R L,Teal P,Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy, Chest (2004);126(3 suppl.): pp. 483S-512S.
    Crossref | PubMed
  7. Taylor D W, Barnett H J, Haynes R B et al., Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. ASA and Carotid Endarterectomy (ACE) Trial Collaborators, Lancet (1999);353(9171): pp. 2,179-2,184.
    Crossref | PubMed
  8. CAPRIE Steering Committee, A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE), Lancet (1996);348(9038): pp. 1,329-1,339.
    Crossref | PubMed
  9. Diener H C, Cunha L, Forbes C et al., European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke, J. Neurol. Sci. (1996);143(1-2): pp. 1-13.
    Crossref | PubMed
  10. Mohr J P,Thompson J L, Lazar R M et al.,A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke, N. Engl. J. Med. (2001);345(20): pp. 1,444-1,451.
    Crossref | PubMed
  11. Law M R,Wald N J, Rudnicka A R,Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis, BMJ (2003);326(7404): p. 1,423.
    Crossref | PubMed
  12. Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S), Lancet (1994);344(8934): pp. 1,383-1,389.
  13. Sacks F M, Pfeffer M A, Moye L A et al., The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators, N. Engl. J. Med. (1996);335(14): pp. 1,001-1,009.
    Crossref | PubMed
  14. European Carotid Surgery Trialists' Collaborative Group, Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST), Lancet (1998);351: pp. 1,379-1,387.
    Crossref | PubMed
  15. North American Symptomatic Carotid Endarterectomy Trial Collaborators, Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis,N. Engl. J. Med. (1991);325(7): pp. 445-453.
    Crossref | PubMed
  16. Barnett H J,Taylor D W, Eliasziw M et al., Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators, N. Engl. J. Med. (1998);339(20): pp. 1,415-1,425.
    Crossref | PubMed
  17. Halliday A, Mansfield A, Marro J et al.,Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial, Lancet (2004);363(9420): pp. 1,491-1,502.
    Crossref | PubMed
  18. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (ACAS), Endarterectomy for asymptomatic carotid artery stenosis, JAMA (1995);273: pp. 1,421-1,428.
    Crossref | PubMed
  19. Wennberg D, Lucas F, Birkmeyer J, Bredenberg C, Fisher E, Variation in carotid endarterectomy mortality in the Medicare population, JAMA (1998);279: pp. 1,278-1,281.
    Crossref | PubMed
  20. Rothwell P M, Slattery J,Warlow C P,A systematic review of the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis, Stroke (1996);27(2): pp. 260-265.
    Crossref | PubMed
  21. Biller J, Feinberg W M, Castaldo J E et al., Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council,American Heart Association, Circulation (1998);97(5): pp. 501-509.
    Crossref | PubMed
  22. Bockenheimer S A, Mathias K,Percutaneous transluminal angioplasty in arteriosclerotic internal carotid artery stenosis,AJNR (1983);4(3): pp. 791-792.
    PubMed
  23. Theron J, Raymond J, Casasco A, Courtheoux F, Percutaneous angioplasty of atherosclerotic and postsurgical stenosis of carotid arteries, AJNR (1987);8(3): pp. 495-500.
    PubMed
  24. White C J, Gomez C R, Iyer S S,Wholey M,Yadav J S,Carotid stent placement for extracranial carotid artery disease: current state of the art, Catheter Cardiovasc. Interv. (2000);51(3): pp. 339-346.
    Crossref | PubMed
  25. Theron J G, Payelle G G, Coskun O, Huet H F, Guimaraens L, Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement [see comments], Radiology (1996);201(3): pp. 627-636.
    Crossref | PubMed
  26. Henry M, Amor M, Henry I et al., Carotid stenting with cerebral protection: first clinical experience using the PercuSurge GuardWire system, J Endovasc. Surg. (1999);6(4): pp. 321-331.
    Crossref | PubMed
  27. Grunwald I Q, Dorenbeck U,Axmann C, Roth C, Struffert T, Reith W,Proximal protection systems using carotid artery stent, Radiologe (2004);44(10): pp. 998-1,003.
    Crossref | PubMed
  28. Muller-Hulsbeck S, Jahnke T, Liess C et al., Comparison of various cerebral protection devices used for carotid artery stent placement: an in vitro experiment, J.Vasc. Interv. Radiol. (2003);14(5): pp. 613-620.
    Crossref | PubMed
  29. Gray W A,A cardiologist in the carotids, J.Am. Coll. Cardiol. 2004;43(9):1602-5.
    Crossref | PubMed
  30. Gray W, Two-year composite end-point results for the Archer Trials: Acculink for revascularization of carotids in high risk patients, Am. J. Cardiol. (2004);94(suppl 6A):62E.
  31. White C J, for the Beach Investigators, BEACH Trial: 30 day outcomes of carotid wallstent and filterwire EX/EZ distal protectioin system placement for treatment of high surgical risk patients, J.Am. Coll. Cardiol. (2005);45(suppl.A):28A.
  32. The SECuRITY trial: More good data for protected carotid stenting in high-risk surgical patients (2003) Accessed at http://www.medscape.com/viewarticle/461721_print
  33. Ramee S, Higashida R,Evaluation of the Medtronic self-expanding carotid stent system with distal protection in the treatment of carotid artery stenosis, Am. J. Cardiol. (2004);94(suppl 6A):61E.
  34. Theiss W, Hermanek P, Mathias K et al., Pro-CAS: a prospective registry of carotid angioplasty and stenting, Stroke (2004);35(9): pp. 2,134-2,139.
    Crossref | PubMed
  35. CAVATAS Investigators,Endovascular versus surgical treatment in patients with carotid stenosis in the carotid and vertebral artery transluminal angioplasty study (CAVATAS): a randomized study, Lancet (2001);357: pp. 1,729-1,737.
    Crossref | PubMed
  36. Yadav J, SAPPHIRE Investigators, Stenting and angioplasty with protection in patients at high risk for endarterectomy: the SAPPHIRE study, Circulation (2002);106:2,986a.
  37. Yadav J S,Wholey M H, Kuntz R E et al., Protected carotid-artery stenting versus endarterectomy in high-risk patients, N. Engl. J. Med. (2004);351(15): pp. 1,493-1,501.
    Crossref | PubMed
  38. Mas J L, Chatellier G, Beyssen B, Carotid angioplasty and stenting with and without cerebral protection: clinical alert from the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial, Stroke (2004);35(1):e18-20.
    Crossref | PubMed
  39. Brown M M, Featherstone R L, Coward L J, Carotid artery stenting with and without cerebral protection, Stroke (2004);35(11): pp. 2,434-2,435.
    Crossref | PubMed
  40. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial, Lancet (2001);357(9270): pp. 1,729-1,737.
    Crossref | PubMed
  41. Coward L J, Featherstone R L, Brown M M, Safety and Efficacy of Endovascular Treatment of Carotid Artery Stenosis Compared With Carotid Endarterectomy.A Cochrane Systematic Review of the Randomized Evidence, Stroke (2005).