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Symptomatic Carotid Artery Disease
Published in James Michael Forsyth, How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
Do you not think carotid stenting is appropriate here?“The pooled results from EVA-3S, SPACE, ICSS and CREST showed that the risk of any stroke or death within 30 days after treatment was higher for the carotid artery stenting compared with carotid endarterectomy (7.3% versus 3.3%). The net conclusion of this paper was that carotid stenting is not as safe as carotid endarterectomy in the treatment of patients with symptomatic stenosis of the ICA irrespective of the timing of treatment. As such, my position is that I would be reluctant offer carotid stenting for this patient. If we were going to offer intervention, I would rather offer carotid endarterectomy.”
Stents
Published in Vikram S. Kashyap, Matthew Janko, Justin A. Smith, Endovascular Tools & Techniques Made Easy, 2020
Complications of stenting are uncommon but are similar to those of angiography and angioplasty. Any endovascular intervention is associated with the risk of infection, bleeding, arterial trauma, and distal embolism. Carotid artery stenting and any aortic arch catheterization and manipulation can lead to stroke. A rare complication with angioplasty and stenting is acute vessel occlusion, which is often due to dissection and/or plaque shift at the end of the stent and requires immediate treatment with thrombolytic therapy, open surgery, or even emergency bypass (3).
Vascular Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Yiu-Che Chan, John Wang, Julian Wong, Edward Choke, Tjun Tang
Carotids: The study of Murad et al.23 included 13 RCTs involving both symptomatic (80%) and asymptomatic patients. It concluded that carotid artery stenting is associated with an increased risk of any stroke and decreased risk of myocardial infarct compared to CEA.ACST-124 assessed the long-term effects of CEA for asymptomatic carotid stenoses. CEA was found to reduce 10-year stroke risks in patients younger than 75 years of age.The ACST-2 trial to compare CEA with carotid artery stenting in the prevention of stroke in patients with asymptomatic carotid stenosis is now open and aims to recruit over 5,000 patients.CREST is a study comparing carotid stenting with protection device and open surgery. However, it doesn't show superiority. Also stroke risk is slightly higher for stenting but MI risk is lower. Although the study claims the outcomes are similar but it you isolate stroke risk alone, it's still inferior. This has generated a lot of discussion both pro and con advice on both treatments.
Management of patients with concomitant coronary and carotid artery disease
Published in Expert Review of Cardiovascular Therapy, 2019
Maria Drakopoulou, Georgios Oikonomou, Stergios Soulaidopoulos, Konstantinos Toutouzas, Dimitrios Tousoulis
Various treatment approaches (staged or synchronous) have been proposed in the setting of CABG surgery to reduce the risk of postoperative neurological complications in patients who require both coronary and carotid revascularization. Carotid artery stenting has emerged as a viable therapeutic alternative for these patient cohorts showing acceptable complication rates and is considered to represent a potential treatment option. In addition to the advances in the endovascular treatment of carotid artery disease, surgical techniques with off-pump CABG have increased the therapeutic armamentarium of patients in need of both coronary and carotid revascularization. Extensive research has been made in the refinement of operative techniques to reduce the risk of embolization during aortic cannulation and cross-clamping, since clinical evidence has suggested that the most important cause of post-CABG stroke is thrombotic embolization from a diseased aortic arch.
Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation?
Published in Expert Review of Cardiovascular Therapy, 2020
Olesia Osipova, Irina Popova, Vladimir Starodubtsev, Savr Bugurov, Andrey Karpenko
The choice of a particular carotid stent design is mainly determined by the anatomy of the vessel. The difference in the effect of stent designs on the rate of embolic complications after carotid artery stenting procedure has not been proved. Moreover, stent is only one of the devices used for carotid artery stenting procedure. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in-stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery. Preoperative assessment of carotid plaque instability and the degree of shaggy aorta is also required.
The role of heparin in preventing the early silent ischemia in carotid stenting
Published in International Journal of Neuroscience, 2022
Dilara Mermi Dibek, Mehmet Fevzi Öztekin, Onur Ergun
Carotid artery stenting was performed in symptomatic cases with more than 50% stenosis and in asymptomatic cases with more than 70% stenosis using NASCET measurement on angiography. In the case of symptomatic stenosis, the stent procedure was performed 4 weeks after the ischemic event if the infarct area observed on MRI was larger than 3 cm. Clopidogrel and acetylsalicylic acid loading were performed at least 3 days before stenting in all cases, followed by drug resistance test and antiaggregant treatment was changed if necessary. The procedure was performed under local anesthesia without intravenous sedation in order to follow up neurological examination. At the beginning of the procedure, 5000 units of heparin were administered as an intravenous bolus. Prior to stenting, two different filters, Emboshield NAV6 (Abbott, Illinois, USA) or SpiderFX (ev3 Inc., Paris, France) were used for cerebral embolic protection in all cases. Controlled predilatation was performed by using 2 or 3 mm diameter balloon catheters in cases where the stent could not pass through the stenotic segment after the filter or filter passed. Xact (Abbott, Illinois, USA) or cobalt Wallstent (Boston Scientific, Massachusetts, USA), nitinol structure and distal taper design, closed cell design as stent, Protege RX (nitinol structure and distal taper design) Ev3 Inc., Paris, France) or Precise Pro RX (Cordis, Florida, USA) in nitinol structure or Cristallo Ideale (Medtronic, Minneapolis, USA) with hybrid cell design and nitinol structure and distal taper design. The structure, design or size of the stent was determined according to the vessel structure, and lesion. After stent placement, stent dilatation was performed by using 5 or 6 mm diameter balloon catheters in all cases in order to fully open the stent in the stenotic section and complete apposition of the stent to the vessel wall. After the procedure, patients were advised to use double antiaggregant for 6 months and lifelong acetylsalicylic acid (100 mg).