Strategies for avoidance of nonembolic stroke during carotid artery stenting

Over the last decade many technical and pharmacological advances were made in order to improve the safety profile of carotid artery stenting (CAS). These advances largely addressed the issue of embolic stroke. It is clear, however, that despite each of these advances, which include dedicated carotid stents in place of adapted peripheral or coronary designs, low-profile rapid-exchange 0.014''-compatible equipment, cerebral protection devices and improvements in pharmacological support, there remains a finite risk of stroke and death associated with CAS. For example, the influence of one of these factors, the use of cerebral protection, employed in order to prevent embolic stroke, cannot be seen to be a panacea against procedural stroke. The 30-day results from the randomised trial SPACE, comparing CAS and carotid endarterectomy, indicated that the ipsilateral stroke and death rate was 7.3% in those patients in whom protection had been employed and 6.7% in unprotected patients. Clearly procedural stroke may result from other, nonembolic means such as haemodynamic disturbances and acute carotid occlusions. These factors must be recognised, considered, pre-empted and appropriately managed in order to further impact on the procedural event rate.