Carotid angioplasty and stenting under protection: advantages and drawbacks

Carotid stenosis is responsible for approximately 30% of strokes, and carotid endarterectomy is considered to be the gold-standard treatment. Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery but the risk of neurological complications and brain embolism remains the major drawback to this procedure. Embolic protection devices (EPDs), which retain particles and debris generated during the procedure, have been proposed to reduce the frequency of neurological complications. Three types of EPD have been developed: distal occlusion balloon, distal filters and proximal protection devices. Preliminary clinical results indicate that the routine use of an EPD along with specifically designed flexible stents, increasing skills of the interventionist and appropriate drugs combine to reduce ischemic neurological complications and can achieve similar results to the best surgical series, particularly in high surgical risk patients. Recent prospective, multicenter controlled trials and registries evaluating CAS with EPD have demonstrated that the CAS results are, at least, not inferior to surgery for patients at high risk for surgery (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy study) and in symptomatic patients (Stent Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy study). However, all protection devices are not equivalent and have some drawbacks. Advantages and disadvantages of each EPD will be analyzed in this review, allowing a good choice of the EPD depending on the patient and the lesion. Nevertheless, there is now a consensus among specialists to perform all CAS with EPD. EPDs have become an integral part of CAS and the routine use of EPDs seems beneficial, leading to a 60% reduction of brain embolisms.