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The Current State and Future of Carotid Artery Stenting
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When carotid artery stenting first came on the scene several years ago, there was a great deal of excitement in the endovascular community, which thought that it would, in many circumstances, replace carotid endarterectomy and, furthermore, that there would be greater screening for carotid artery stenosis, resulting in a higher volume of cases in total that might benefit from carotid revascularization. The advent of embolic protection devices and self-expanding stents and delivery systems further fueled the initial period of excitement and growth in carotid artery stenting (CAS).
However, after that initial enthusiasm, a number of trials came out with mixed results. Some studies such as the SAPPHIRE study were very encouraging, while other studies showed that CAS was not superior to carotid endarterectomy and might, in fact, be inferior. Negative studies were predictably criticized and the lack of robust performance of CAS was attributed to operator inexperience, as negative interventional trials are often interpreted. The most recent studies, such as CREST, strongly suggest that carotid endarterectomy and CAS are overall comparable procedures, although carotid endarterectomy does seem to still have a slight edge with respect to stroke, while CAS has an advantage with endpoints such as MI and cranial nerve injury.
Therefore, it seems that, much as is the case with coronary revascularization, carotid revascularization is something that is best individualized based on the patient’s own risks for cerebral and coronary ischemic complications, as well as patient preference. Of course, this evolution in our understanding of the role of CAS is somewhat limited by the bigger issue among most stroke neurologists, which is that they remain highly skeptical that any form of carotid revascularization should occur in asymptomatic patients other than some specific circumstances such as rapid lesion progression. In general, however, most stroke neurologists feel there is too much carotid revascularization going on.
Hopefully, ongoing trials such as CREST-2 will nail down whether asymptomatic carotid stenosis should be treated with a procedure, be it carotid endarterectomy or CAS. This will be the important closing chapter in the saga of the optimal mode of treatment of carotid artery stenosis.
Read more about this topic in the Cover Story.
– Deepak L. Bhatt, MD, MPH
Chief Medical Editor
Cardiology Today’s Intervention