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Carotid Stenting in Neuroradiology

A Short Journey from the Past to Current Debates

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Abstract

After a period of stagnation due to negative results of randomized trials for patients with symptomatic stenosis, the relevance of carotid artery stenting (CAS) is increasing again. CAS has become an important and evidence-based part of interventional stroke treatment. Our ability to manage acute recanalization of carotid occlusions and other niche indications properly led some skeptical neurologists to trust in carotid intervention for elective cases as well. The evolution of CAS from initial euphoria to more realistic views under consideration of trial results and guidelines is reviewed. Quality assurance in Germany proves that CAS complication rates within the carotid endarterectomy (CEA) quality criteria are feasible even with higher proportions of high-risk patients. Recent trial results showed that long-term efficacy of CAS or CEA are not significantly different. Other than in symptomatic stenoses, acute complication rates of both means treatment does not differ in asymptomatic patients, where medical therapy becomes increasingly competitive. Technical issues of CAS like the cell design of stents or the usefulness of embolic protection are still under discussion. We will see whether CAS results will further improve over time. Standardized techniques, proper training, and patient selection are important for acute and elective cases.

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Abbreviations

ACT:

Asymptomatic Carotid Trial

ACST:

Asymptomatic Carotid Surgery Trial

CAS:

Carotid Artery Stenting

CCA:

Common Carotid Artery

CEA:

Carotid Endarterectomy

CREST:

Carotid Revascularization Endarterectomy versus Stenting Trial

DSA:

Digital Subtraction Angiography

DWI:

Diffusion Weighted Imaging

ECA:

External Carotid Artery

EVA-3S:

Endarterectomy versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis trial

ICA:

Internal Carotid Artery

ICSS:

International Carotid Stenting Study

MCA:

Middle Cerebral Artery

MRI:

Magnetic Resonance Imaging

mRS:

modified Rankin Scale

s & d CAS:

stroke and death Carotid Artery Stenting

SPACE:

Stent-Protected Angioplasty versus Carotid Endarterectomy

TIA:

Transitory Ischemic Attack

TTP:

Time to Peak

References

  1. Mathias K. Perkutane Rekanalisation der supraaortalen und zerebralen Arterien. In: Günther RW, Thelen M, editors. Interventionelle Radiologie. Stuttgart: Thieme; 1996. pp. 112–23.

    Google Scholar 

  2. Theron JG, Payelle GG, Coskun O, Huet HF, Guimaraens L. Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. Radiology. 1996;201:627–623.

    Article  CAS  PubMed  Google Scholar 

  3. Roubin GS, Yadav S, Iyer SS, Vitek J. Carotid stent-supported angioplasty: a neurovascular intervention to prevent stroke. Am J Cardiol. 1997;78(3A):8–12.

    Google Scholar 

  4. Wholey MH, Wholey M, Bergeron P, Diethrich EB, Henry M, Laborde JC, Mathias K, Myla S, Roubin GS, Shawl F, Theron JG, Yadav JS, Dorros G, Guimaraens J, Higashida R, Kumar V, Leon M, Lim M, Londero H, Mesa J, Ramee S, Rodriguez A, Rosenfield K, Teitelbaum G, Vozzi C. Current global status of carotid artery stent placement. Cathet Cardiovasc Diagn. 1998;44(1):1–6.

    Article  CAS  PubMed  Google Scholar 

  5. Malek AM, Higashida RT, Phatouros CC, Lempert TE, Meyers PM, Smith WS, Dowd CF, Halbach VV. Stent angioplasty for cervical carotid artery stenosis in high-risk symptomatic NASCET-ineligible patients. Stroke. 2000;31(12):3029–33.

    Article  CAS  PubMed  Google Scholar 

  6. Berkefeld J, Turowski B, Dietz A, Lanfermann H, Sitzer M, Schmitz-Rixen T, Steinmetz H, Zanella FE. Recanalization results after carotid stent placement. AJNR Am J Neuroradiol. 2002;23(1):113–20.

    PubMed  Google Scholar 

  7. Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, Bailey S, Bergeron P, Dorros G, Eles G, Gaines P, Gomez CR, Gray B, Guimaraens J, Higashida R, Ho DS, Katzen B, Kambara A, Kumar V, Laborde JC, Leon M, Lim M, Londero H, Mesa J, Musacchio A, Myla S, Ramee S, Rodriquez A, Rosenfield K, Sakai N, Shawl F, Sievert H, Teitelbaum G, Theron JG, Vaclav P, Vozzi C, Yadav JS, Yoshimura SI. Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv. 2000;50(2):160–7.

    Article  CAS  PubMed  Google Scholar 

  8. Connors JJ 3rd, Seidenwurm D, Wojak JC, Hurst RW, Jensen ME, Wallace R, Tomsick T, Barr J, Kerber C, Russell E, Nesbit GM, Fox AJ, Tsai FY. Treatment of atherosclerotic disease at the cervical carotid bifurcation: current status and review of the literature. AJNR Am J Neuroradiol. 2000;21(3):444–50.

    PubMed  Google Scholar 

  9. Crawley F, Brown MM. Percutaneous transluminal angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev. 2000;2:CD000515.

    Google Scholar 

  10. SPACE Collaborative Group, Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, Hartmann M, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Stingele R, Zeumer H, Hacke W. 30 day results from the SPACE trial of stent-protected angioplasty versus carotidendarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. 2006;368(9543):1239–47.

    Article  Google Scholar 

  11. Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lièvre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viguier A, Piquet P, Garnier P, Viader F, Touzé E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X, EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660–71.

    Article  CAS  PubMed  Google Scholar 

  12. International Carotid Stenting Study investigators, Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, de Borst GJ, Lo TH, Gaines P, Dorman PJ, Macdonald S, Lyrer PA, Hendriks JM, McCollum C, Nederkoorn PJ, Brown MM. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375(9719):985–97.

    Article  PubMed Central  Google Scholar 

  13. Carotid Stenting Trialists’ Collaboration., Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, Fraedrich G, Mali WP, Zeumer H, Brown MM, Mas JL, Ringleb PA. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet. 2010;376(9746):1062–73.

    Article  Google Scholar 

  14. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF, CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Silver FL, Mackey A, Clark WM, Brooks W, Timaran CH, Chiu D, Goldstein LB, Meschia JF, Ferguson RD, Moore WS, Howard G, Brott TG, CREST Investigators. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2011;42:675–80.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, Chiu D, Gonzales NR, Burke JL, Rinaldi M, Elmore JR, Weaver FA, Narins CR, Foster M, Hodgson KJ, Shepard AD, Meschia JF, Bergelin RO, Voeks JH, Howard G, Brott TG, CREST Investigators. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012;11(9):755–63.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bonati LH, Fraedrich G, Carotid Stenting Trialists’ Collaboration. Age modifies the relative risk of stenting versus endarterectomy for symptomatic carotid stenosis – a pooled analysis of EVA-3S, SPACE and ICSS. Eur J Vasc Endovasc Surg. 2011;41:153–8.

    Article  CAS  PubMed  Google Scholar 

  18. Bonati LH, Dobson J, Featherstone RL, Ederle J, van der Worp HB, de Borst GJ, Mali WP, Beard JD, Cleveland T, Engelter ST, Lyrer PA, Ford GA, Dorman PJ, Brown MM, International Carotid Stenting Study investigators. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet. 2015;385:529–38.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, Moore WS, Hill MD, Mantese VA, Clark WM, Timaran CH, Heck D, Leimgruber PP, Sheffet AJ, Howard VJ, Chaturvedi S, Lal BK, Voeks JH, Hobson RW 2nd, CREST Investigators. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374:1021–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Eckstein HH, Kühnl A, Dörfler A, Kopp IB, Lawall H, Ringleb PA. Multidisciplinary German-Austrian guideline based on evidence and consensus. The diagnosis, treatment and follow-up of extracranial carotid stenosis. Dtsch Arztebl Int. 2013;110(27–28):468–76.

    PubMed  PubMed Central  Google Scholar 

  21. American College of Cardiology Foundation/American Heart Association Task Force, American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, Society for Vascular Surgery, American Academy of Neurology, Society of Cardiovascular Computed Tomography, American College of Cardiology Foundation/American Heart Association Task Force, American College of Cardiology Foundation/American Heart Association Task Force, Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. J Neurointerv Surg. 2011;3(2):100–30.

    Article  Google Scholar 

  22. Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein HH, Diaz-Sandoval LJ, Cao L, Fu Q, Wijeratne T, Leung TW, Montero-Baker M, Lee BC, Pircher S, Bosch M, Dennekamp M, Ringleb P. Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke. 2015;46:3288–301.

    Article  PubMed  Google Scholar 

  23. Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W, SPACE 2 Investigators. SPACE-2: a missed opportunity to compare carotid endarterectomy, carotid stenting, and best medical treatment in patients with asymptomatic carotid stenoses. Eur J Vasc Endovasc Surg. 2016;51:761–5.

    Article  PubMed  Google Scholar 

  24. Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, Wechsler L, Jaff MR, Gray W, ACT I Investigators. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374:1011–20.

    Article  CAS  PubMed  Google Scholar 

  25. Hadar N, Raman G, Moorthy D, O’Donnell TF, Thaler DE, Feldmann E, Lau J, Kitsios GD, Dahabreh IJ. Asymptomatic carotid artery stenosis treated with medical therapy alone: temporal trends and implications for risk assessment and the design of future studies. Cerebrovasc Dis. 2014;38:163–73.

    Article  PubMed  Google Scholar 

  26. Warming G, Heinze G, Rasch S, Fachgruppe auf Bundesebene Gefäßchirurgie, IQTIG Institut für Qualitätssicherung und Transparenz im Gesundheitswesen. Qualitätsreport 2015, Berlin 2016:17–24.

  27. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG, HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.

    Article  PubMed  Google Scholar 

  28. Maurer CJ, Joachimski F, Berlis A. Two in one: endovascular treatment of acute tandem occlusions in the anterior circulation. Clin Neuroradiol. 2015;25:397–402.

    Article  CAS  PubMed  Google Scholar 

  29. Sivan-Hoffmann R, Gory B, Armoiry X, Goyal M, Riva R, Labeyrie PE, Lukaszewicz AC, Lehot JJ, Derex L, Turjman F. Stent-retriever thrombectomy for acute anterior Ischemic stroke with tandem occlusion: a systematic review and meta-analysis. Eur Radiol. 2017;27:247–54.

    Article  PubMed  Google Scholar 

  30. Behme D, Mpotsaris A, Zeyen P, Psychogios MN, Kowoll A, Maurer CJ, Joachimski F, Liman J, Wasser K, Kabbasch C, Berlis A, Knauth M, Liebig T, Weber W. Emergency stenting of the extracranial internal carotid artery in combination with anterior circulation thrombectomy in acute Ischemic stroke: a retrospective Multicenter study. AJNR Am J Neuroradiol. 2015;36:2340–5.

    Article  CAS  PubMed  Google Scholar 

  31. Dorado L, Castaño C, Millán M, Aleu A, de la Ossa A, Gomis M, López-Cancio E, Vivas E, Rodriguez-Campello A, Castellanos M, Dávalos A. Hemorrhagic risk of emergent endovascular treatment plus stenting in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis. 2013;22:1326–31.

    Article  PubMed  Google Scholar 

  32. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493–501.

    Article  CAS  PubMed  Google Scholar 

  33. Jalbert JJ, Nguyen LL, Gerhard-Herman MD, Kumamaru H, Chen CY, Williams LA, Liu J, Rothman AT, Jaff MR, Seeger JD, Benenati JF, Schneider PA, Aronow HD, Johnston JA, Brott TG, Tsai TT, White CJ, Setoguchi S. Comparative effectiveness of carotid artery stenting versus carotid endarterectomy among medicare beneficiaries. Circ Cardiovasc Qual Outcomes. 2016;9:275–85.

    Article  PubMed  Google Scholar 

  34. Kedev S, Petkoska D, Zafirovska B, Vasilev I, Bertrand OF. Safety of slender 5 Fr transradial approach for carotid artery stenting with a novel nitinol double-layer micromesh stent. Am J Cardiol. 2015;116:977–81.

    Article  PubMed  Google Scholar 

  35. Wissgott C, Schmidt W, Brandt-Wunderlich C, Behrens P, Andresen R. Clinical results and mechanical properties of the carotid CGUARD double-layered embolic prevention stent. J Endovasc Ther. 2017;24:130–7.

    Article  PubMed  Google Scholar 

  36. Schofer J, Musiałek P, Bijuklic K, Kolvenbach R, Trystula M, Siudak Z, Sievert H. A prospective, multicenter study of a novel mesh-covered carotid Stent: the Cguard CARENET trial (carotid embolic protection using micronet). JACC Cardiovasc Interv. 2015;8:1229–34.

    Article  PubMed  Google Scholar 

  37. Stabile E, Sannino A, Schiattarella GG, Gargiulo G, Toscano E, Brevetti L, Scudiero F, Giugliano G, Perrino C, Trimarco B, Esposito G. Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc Interv. 2014;7:1177–83.

    Article  PubMed  Google Scholar 

  38. Cassese S, Ndrepepa G, King LA, Nerad M, Schunkert H, Kastrati A, Ott I, Fusaro M. Proximal occlusion versus distal filter for cerebral protection during carotid stenting: updated meta-analysis of randomised and observational MRI studies. EuroIntervention. 2015;11:238–46.

    Article  PubMed  Google Scholar 

  39. Bonati LH, Jongen LM, Haller S, Flach HZ, Dobson J, Nederkoorn PJ, Macdonald S, Gaines PA, Waaijer A, Stierli P, Jäger HR, Lyrer PA, Kappelle LJ, Wetzel SG, van der Lugt A, Mali WP, Brown MM, van der Worp HB, Engelter ST; ICSS-MRI study group. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol. 2010;9:353–62.

    Article  PubMed  Google Scholar 

  40. Malas MB, Leal J, Kashyap V, Cambria RP, Kwolek CJ, Criado E. Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system. J Vasc Surg. 2017;65:916–20.

    Article  PubMed  Google Scholar 

  41. Kwolek CJ, Jaff MR, Leal JI, Hopkins LN, Shah RM, Hanover TM, Macdonald S, Cambria RP. Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2015;62:1227–1223.

    Article  PubMed  Google Scholar 

  42. Giri J, Kennedy KF, Weinberg I, Hawkins BM, Press MC, Drachman D, McCormick DJ, Aronow HD, White CJ, Rosenfield K, Yeh RW. Comparative effectiveness of commonly used devices for carotid artery stenting: an NCDR Analysis (National Cardiovascular Data Registry). JACC Cardiovasc Interv. 2014;7:171–7.

    Article  PubMed  Google Scholar 

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  1. Institute of Neuroradiology, University Hospital of Frankfurt am Main, Schleusenweg 2–16, 60528, Frankfurt am Main, Germany

    Joachim Berkefeld, Marlies Wagner & Richard du Mesnil

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  1. Joachim Berkefeld
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Correspondence to Joachim Berkefeld.

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J. Berkefeld, M. Wagner and R. du Mesnil declare that they have no competing interests.

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Berkefeld, J., Wagner, M. & du Mesnil, R. Carotid Stenting in Neuroradiology. Clin Neuroradiol 27, 409–415 (2017). https://doi.org/10.1007/s00062-017-0603-y

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