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Expert: Outlook for carotid stenting good due to technology, patient selection advances

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HOLLYWOOD, Fla. — While carotid artery stenting is declining in use for treatment of symptomatic and asymptomatic carotid stenosis, there are reasons to be optimistic about its future use, an expert said at the International Symposium on Endovascular Therapy.

The main reason is that technological advances are greatly reducing the risk for stroke in patients undergoing carotid artery stenting (CAS), Frank J. Veith, MD, professor of vascular surgery at NYU School of Medicine and Cleveland Clinic, and the chairman of VEITHsymposium, said here.

He said the decline in use in symptomatic patients is due to registry and population-based studies showing CAS is associated with higher rates of stroke and death compared with carotid endarterectomy, and the decline in use in asymptomatic patients is because “best medical treatment has such low stroke rates that it may make CAS (and carotid endarterectomy) unnecessary.” Those rates have dropped from 3% to 6% per year in 1985 to less than 1% per year in 2017, he said.

Frank J. Veith

However, Veith said, three advances have the potential to decrease strokes associated with CAS: better embolic protection devices, a transcarotid neuroprotective system (Enroute, Silk Road Medical) that enables operators to avoid the aortic arch during the procedure, and new membrane- or mesh-covered stent designs that may prevent delayed strokes.

“If these three advances decrease CAS stroke rates, CAS would be more competitive to [carotid endarterectomy] and would replace [carotid endarterectomy] more widely than it does now,” he said.

Also, there are now better imaging techniques to predict who is at high risk for stroke among patients with asymptomatic carotid stenosis, and researchers have learned that “some asymptomatic patient groups have a more than 12% per year stroke risk, and some have a less than 1% risk,” Veith said.

“However, there is one reservation,” he said. “The efficacy of these methods for decreasing CAS stroke rates and improving asymptomatic patient selection must be proven by appropriate clinical trials. Despite this reservation, I believe the outlook for CAS is bright in the future. All vascular surgeons should prepare for improving CAS results.” – by Erik Swain

Reference:

Veith FJ. Session IV: Advances in carotid stenting: Are we turning a corner on advancing this therapy? Presented at: International Symposium on Endovascular Therapy; Feb. 4-8, 2017; Hollywood, Fla.

Disclosure: Veith reports no relevant financial disclosures.