Carotid endovascular interventions: patient selection, devices, techniques and tips

Area of Science:

• Vascular Surgery
• Interventional Cardiology
• Medical Device Technology

Background:

• The optimal treatment for carotid artery disease (CAD) remains a subject of debate, with choices including carotid endarterectomy (CEA), carotid artery stenting (CAS), and medical therapy.
• While recent trials (EVA-3S, SPACE) questioned CAS non-inferiority to CEA, ongoing advancements in CAS technology and operator experience suggest potential for safe and efficient application.
• The efficacy of CAS is influenced by operator skill, experience, and crucially, the appropriate selection of carotid stents and cerebral protection devices.

Purpose of the Study:

• To review patient selection principles for contemporary carotid artery stenting (CAS) practice.
• To discuss device selection strategies for carotid artery stenting (CAS), considering the wide array of available stents and cerebral protection devices.
• To provide guidance for CAS practitioners facing challenges in generalizing treatment strategies due to diverse patient profiles and device characteristics.

Main Methods:

• Review of current literature and clinical practice guidelines regarding carotid artery disease (CAD) treatment.
• Analysis of data from major randomized trials (EVA-3S, SPACE) comparing CEA and CAS.
• Discussion of technological advancements in CAS devices, including stents and embolic protection systems.
• Examination of factors influencing patient and device selection in CAS.

Main Results:

• Recent randomized trials have not established the non-inferiority of CAS compared to CEA.
• Growing evidence suggests that CAS can be performed safely and effectively with increasing operator experience and improved dedicated technology.
• The success of CAS is highly dependent on the careful selection of both the patient and the specific devices (stents and cerebral protection) used.

Conclusions:

• Selecting the appropriate treatment for carotid artery disease (CAD) requires a personalized risk assessment.
• While CEA remains a standard, CAS offers a viable alternative when specific patient factors and optimal device selection are considered.
• Further research and standardized guidelines are needed to refine patient and device selection criteria for maximizing the benefits of CAS in treating carotid artery disease.