Carotid artery stenting: technical issues and role of operators' experience

Major criticism of randomized clinical trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) focused on the incomplete learning curve of interventionists and the inadequate and outdated technology employed, which might have contributed to the high stroke and death rates in the CAS arm. The effect of the learning curve related to technical expertise and patient selection strongly influences the results of CAS. Due to the devastating potential complications when compared with other endovascular minimally invasive procedures, CAS requires a more strict analysis of operator training and outcome, because improvement in the learning curve is accompanied by a comparative reduction in complication rates. Today, there is a general agreement that requirements for training in CAS are higher than in other fields. In contrast to many endovascular peripheral arterial interventions, CAS represents a more challenging procedure because it involves complex catheter-based skills. Training experience attempts to sensibly reduce strokes that may occur during the unprotected phases of catheterization/approach to the target vessel and the protected phase of ballooning/stenting and cerebral protection device retrieval. Mandatory training, familiarity with the indications and contraindications, and knowledge of the technology and devices are paramount for the success of CAS, and preprocedure, intraprocedure, and postprocedure patient management is essential for reducing morbidity and mortality. These prerequisites are essential to allow CAS to be accepted as a potential alternative to CEA.