Carotid artery stenting for primary and secondary stroke prevention
Adnan H Siddiqui1, Sabareesh K Natarajan, L Nelson Hopkins
1Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA. asiddiqui@ubns.com
Insights
Carotid artery stenting (CAS) is now a safe and effective alternative to carotid endarterectomy (CEA) for preventing strokes. The choice between CAS and CEA depends on individual patient needs.
Area of Science:
- Vascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Carotid artery disease is a significant cause of stroke-related disability and mortality.
- Ischemic stroke is a leading cause of adult disability and mortality.
- Carotid revascularization is a primary surgical intervention for stroke prevention.
Purpose of the Study:
- To review the evidence for carotid revascularization.
- To summarize current practices in managing carotid artery disease.
- To evaluate the role of carotid artery stenting (CAS) versus carotid endarterectomy (CEA).
Main Methods:
- Literature review of carotid revascularization evidence.
- Analysis of randomized trials comparing CAS and CEA.
- Emphasis on the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) results.
Main Results:
- Early trials established carotid endarterectomy (CEA).
- The CREST trial demonstrated CAS as a safe, effective, and durable alternative to CEA.
- Technical advancements in CAS have occurred post-CREST.
Conclusions:
- Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are complementary procedures.
- Patient-specific factors guide the selection between CAS and CEA.
- Judicious procedural choice ensures optimal patient outcomes.
Background:
Carotid artery disease is a major cause of the disability and mortality associated with strokes. Ischemic stroke remains the major cause of adult disability and third-leading cause of adult mortality, and carotid revascularization currently remains the principal surgical tool in the prophylaxis of this disease.
Methods:
The literature representing the current body of evidence for carotid revascularization and the authors' current practices in the management of this disease are summarized in this review.
Results:
We provide an evidence-based narration of the development and current status of carotid artery stenting (CAS) by reviewing 1) the evidence for carotid revascularization from early carotid endarterectomy (CEA) trials; 2) the randomized trials comparing CEA and CAS, with a special emphasis on the recently published results of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which have been a "game-changer," tipping the balance towards accepting CAS as a safe, equally effective, and durable alternative to CEA for all patients requiring carotid revascularization; and 3) the technical advances in CAS after enrollment of patients in the CREST.
Conclusions:
CAS and CEA are complementary procedures. Judicious selection of the procedure is made on a case-by-case basis.
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