Has carotid artery stenting found its place? A 10-year regional centre perspective

The post-Carotid Revascularization Endarterectomy versus Stenting Trial era has seen a dramatic decline in the practice of carotid artery stenting (CAS). A retrospective review of prospectively collected CAS outcomes over a 10-year period by a single operator was undertaken to determine if this change in practice is justified and to identify the place of carotid stenting in current practice.

One hundred fifty-nine carotid stent procedures were undertaken on 137 patients from 2002 to 2012. Cases were selected for CAS only if they fulfilled the inclusion criteria for the SAPPHIRE trial. Post-procedural outcomes were compared against those of a contemporaneous cohort of patients undergoing carotid endarterectomy (CEA) by the same operator and against published meta-analyses. The measure of CAS durability was need for re-intervention, based on the presence of ultrasound-detected re-stenosis >70%.

No significant difference was identified in 30-days' complication rates between patients undergoing CAS and those having CEA. Compared to published meta-analyses of CAS, our practice was accompanied by a significantly lower rate of peri-procedural stroke (1.26% versus 6%, P = 0.014) while carrying equivalent 30-days' death and myocardial infarction. Four stented arteries had re-intervention, due to asymptomatic in-stent stenosis of >70%. Further intervention was declined in a fifth case. This represents a re-stenosis rate of 3.1% over a mean follow-up of 40.2 ± 27.6 months.

CAS can provide a safe and durable treatment option for selected patients with carotid artery disease, in the hands of appropriately trained proceduralists who meet accepted standards of practice.