Current Cardiology Reports

, Volume 13, Issue 1, pp 30–37 | Cite as

Interventional Management of Asymptomatic Extracranial Carotid Stenosis

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Abstract

Carotid artery stenosis is a major risk factor for stroke and transient ischemic attack. Although carotid endarterectomy is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS)—proven by large randomized clinical trials and rigorous registries and supported by improving stent designs, embolic protection, and increasing neurointerventionalist experience—is developing into a safer and more efficacious method of stroke prevention. Today, protected CAS is approved for symptomatic and asymptomatic patients with severe carotid stenosis with high surgical risk. We reviewed recently published data regarding new developments in the use of protected CAS, particularly in patients with carotid stenosis who are either asymptomatic or at low surgical risk.

Keywords

Extracranial carotid stenting Asymptomatic carotid stenosis SAPPHIRE CREST Ongoing carotid trials 

Clinical Trial Acronyms

ACAS

Asymptomatic Carotid Atherosclerosis Study

ACST

Asymptomatic Carotid Surgery Trial

ACT-1

Asymptomatic Carotid Stenosis, Stenting Versus Endarterectomy Trial

CABERNET

Carotid Artery Revascularization Using the Boston Scientific FilterWire EX/EZ and the EndoTex NexStent

CAPTURE

Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events

CaRESS

Carotid Revascularization Using Endarterectomy or Stenting Systems

CREST

Carotid Revascularization Endarterectomy Versus Stent

ECST

European Carotid Surgery Trial

EVA-3S

Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis

ICAROS

Imaging in Carotid Angioplasty and Risk of Stroke

ICSS

International Carotid Stenting Study

NASCET

North America Symptomatic Carotid Endarterectomy Trial

SAPPHIRE

Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy

SPACE

Stent-Supported Percutaneous Angioplasty of the Carotid Artery Versus Endarterectomy

TACIT

Transatlantic Asymptomatic Carotid Intervention Trial

References

Papers of particular interest, published recently, have been highlighted as: • Of Importance

  1. 1.
    Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24(1):35–41.PubMedGoogle Scholar
  2. 2.
    Fisher M, Paganini-Hill A, Martin A, et al. Carotid plaque pathology: thrombosis, ulceration, and stroke pathogenesis. Stroke 2005; 36:253–7.CrossRefPubMedGoogle Scholar
  3. 3.
    de Weerd M, Greving JP, de Jong AW, Buskens E, Bots ML. Prevalence of asymptomatic carotid artery stenosis according to age and sex. Systematic review and metaregression analysis. Stroke 2009; 40: 1105–13.CrossRefPubMedGoogle Scholar
  4. 4.
    Goessens BM, Visseren FL, Kappelle LJ, Algra A, van der Graaf Y, for the SMART Study Group. Asymptomatic carotid artery stenosis and the risk of new vascular events in patients with manifest arterial disease, The Smart Study. Stroke 2007; 38:1470–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Dick P, Sherif C, Sabeti S, Amighi J, Minar E, Schillinger M. Gender differences in outcome of conservatively treated patients with asymptomatic high grade carotid stenosis. Stroke 2005; 36:1178–83.CrossRefPubMedGoogle Scholar
  6. 6.
    Inzitari D, Eliasziw M, Gates P, Sharpe BL, Chan RKT, Meldrum HE, et al for the North American Symptomatic Carotid Endarterectomy Trial Collaborators. The causes and risk of stroke in patients with asymptomatic internal carotid artery stenosis. N Engl J Med. 2000; 342: 1693–700.CrossRefPubMedGoogle Scholar
  7. 7.
    The European Carotid Surgery Trialist Collaborative Group. Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995; 345: 209–12.Google Scholar
  8. 8.
    Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for symptomatic carotid artery stenosis. JAMA. 1995; 273: 1421–8.CrossRefGoogle Scholar
  9. 9.
    Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004; 363:1491–502.CrossRefPubMedGoogle Scholar
  10. 10.
    Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006; 37(2):577–617.CrossRefPubMedGoogle Scholar
  11. 11.
    Rothwell PM. ACST: which subgroups will benefit most from carotid endarterectomy? Lancet 2004; 364(9440):1122–3.CrossRefPubMedGoogle Scholar
  12. 12.
    CAPRIE Steering Committee. A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE). Lancet 1996; 348:1329–39.CrossRefGoogle Scholar
  13. 13.
    Gent M, Blakely JA, Easton JD, et al. The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet 1989; 1:1215–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143:1–13.CrossRefPubMedGoogle Scholar
  15. 15.
    Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: cosponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006; 37:577–617.CrossRefPubMedGoogle Scholar
  16. 16.
    Progressive Collaborative Group. Randomized trial of a perindoprilbased blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischemic attack. Lancet 2001; 358:1033–41.CrossRefGoogle Scholar
  17. 17.
    Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560–72.CrossRefPubMedGoogle Scholar
  18. 18.
    Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke 2004; 35:776–85.CrossRefPubMedGoogle Scholar
  19. 19.
    Amarenco P, Bogousslavsky J, Callahan A III, et al., The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355:549–59.CrossRefPubMedGoogle Scholar
  20. 20.
    Amarenco P, Labreuche J, Lavallee P, Touboul PJ. Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis. Stroke 2004; 35:2902–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Collins R, Armitage J, Parish S, Sleight P, Peto R, Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with Simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004; 363:757–67.CrossRefPubMedGoogle Scholar
  22. 22.
    Plehn JF, Davis BR, Sacks FM, et al., CARE Investigators. Reduction of stroke incidence after myocardial infarction with pravastatin: the Cholesterol and Recurrent Events (CARE) study. Circulation 1999; 99:216–23.PubMedGoogle Scholar
  23. 23.
    Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. 2004; 351:1493–501.Google Scholar
  24. 24.
    Gurm HS, Yadav JS, Fayad P et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N. Engl. J. Med. 2008; 358:1572–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Gray WA, Yadav JS, Verta P, et al. The CAPTURE Registry: Results of Carotid Stenting With Embolic Protection in the Post Approval Setting. Catheter Cardiovasc Interv. 2007; 69: 341–48.CrossRefPubMedGoogle Scholar
  26. 26.
    Matsumura JS, Gray W, Chaturvedi S, et al. CAPTURE 2 Risk-Adjusted Stroke Outcome Benchmarks or Carotid Artery Stenting with Distal Embolic Protection. J Vasc Surg. 2010 Abstract.Google Scholar
  27. 27.
    CaRESS Steering Committee. Carotid revascularization using endarterectomy or stenting systems (CARESS): phase I clinical trial. J Endovasc Ther 2003; 10:1021–30.CrossRefGoogle Scholar
  28. 28.
    CaRESS Steering Committee. Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg 2005; 42:213–9.CrossRefGoogle Scholar
  29. 29.
    Wennberg, David E. MD, MPH; Lucas, F. L. PhD; Birkmeyer, John D. MD; Bredenberg, Carl E. MD; Fisher, Elliott S. MD, MPH. Variation in Carotid Endarterectomy Mortality in the Medicare Population: Trial Hospitals, Volume, and Patient Characteristics. JAMA Volume 279(16) April 1998, pp 1278–1281.Google Scholar
  30. 30.
    Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339:1415–25.CrossRefPubMedGoogle Scholar
  31. 31.
    Zarins CK, White RA, Diethrich EB, et al. Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS): 4-year outcomes. J Endovasc Ther. 2009; 16(4): 397–409.CrossRefPubMedGoogle Scholar
  32. 32.
    Hopkins LN, Myla SV, Grube E, et al. Carotid Artery Revascularization in High Surgical Risk Patients with the NexStent and the FilterWire EX/EZ: the CABERNET Trial. Catheter Cardiovasc Interv. 2008; 71(7):950–60.CrossRefPubMedGoogle Scholar
  33. 33.
    Hopkins LN, Myla SV, Grube E, et al. Carotid Artery Revascularization in High-Surgical-Risk Patients with the NexStent and the FilterWire EX/EZ: 3-year Results from the CABERNET Trial. EuroIntervention. 2010; 5(8): 917–24.CrossRefPubMedGoogle Scholar
  34. 34.
    Safian RD, Bresnahan JF, Jaff MR, et al. Protected Carotid Stenting in High-Risk Patients With Severe Carotid Artery Stenosis. J Am Coll Cardiol 2006; 47:2384–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Safian RD, Jaff MR, Bresnahan JF, et al. Protected Carotid Stenting in High-Risk Patients: Results of The SpideRX Arm of the Carotid Revascularization with ev3 Arterial Techonology Evolution Trial. J Interv Cardiol. 2010 Abstract.Google Scholar
  36. 36.
    • Massop D, Dave R, Metzger C, et al. Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy: SAPPHIRE Worldwide Registry first 2,001 Patients. Catheter Cardiovasc Interv. 2009; 73(2): 129–36. The SAPPHIRE Worldwide Registry, requiring a vetting process for inclusion of interventionalists and the same emboli protection device and stent, continued to show the clear noninferiority of CAS to CEA in the first 2001 high surgical risk patients. CrossRefPubMedGoogle Scholar
  37. 37.
    • Brott TG, Hobson RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010; 362(1): 11–23. This NIH-funded, multicenter, randomized trial enrolling standard surgical risk patients with symptomatic and asymptomatic carotid stenosis requiring rigorous vetting of interventionalists and use of the same stent and embolic protection device showed no significant difference in the primary end points between CAS and CEA. CrossRefGoogle Scholar
  38. 38.
    Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lievre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viguier A, Piquet P, Garnier P, Viader F, Touze E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006 October 19;355(16):1660–71.CrossRefPubMedGoogle Scholar
  39. 39.
    Ringleb PA, Allenberg J, Bruckmann 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 carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006 October 7;368(9543):1239–47.CrossRefPubMedGoogle Scholar
  40. 40.
    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. Lancet 2010 Mar 20;375(9719):985–997.CrossRefPubMedGoogle Scholar
  41. 41.
    Bhatt DL, Kapadia SR, Bajzer CT, Chew DP, Ziada KM, Mukherjee D, Roffi M, Topol EJ, Yadav JS. Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol 2001 December;13(12):767–71.PubMedGoogle Scholar
  42. 42.
    Herault JP, Peyrou V, Savi P, Bernat A, Herbert JM. Effect of SR121566A, a potent GP IIb-IIIa antagonist on platelet-mediated thrombin generation in vitro and in vivo. Thromb Haemost 1998; 79(2):383–8.PubMedGoogle Scholar
  43. 43.
    Makkar RR, Eigler NL, Kaul S, et al. Effects of clopidogrel, aspirin and combined therapy in a porcine ex vivo model of high-shear induced stent thrombosis. Eur Heart J 1998; 19(10):1538–46.CrossRefPubMedGoogle Scholar
  44. 44.
    Realizing the Potential of Carotid Artery Stenting: Proposed Paradigms for Patient Selection and Procedural Technique. Roubin, Gary S. MD, PhD; Iyer, Sriram MD; Halkin, Amir MD; Vitek, Jiri MD; Brennan, Christina MD. Circulation Volume 113(16), 25 April 2006, pp 2021–2030.CrossRefPubMedGoogle Scholar
  45. 45.
    Wholey, Michael H. Al-Mubarek, Nadim. Wholey, Mark H. Updated review of the global carotid artery stent registry. Catheterization & Cardiovascular Interventions. 60(2):259–66, 2003 Oct.CrossRefGoogle Scholar
  46. 46.
    Biasi GM. Froio A. Diethrich EB. Deleo G. Galimberti S. Mingazzini P. Nicolaides AN. Griffin M. Raithel D. Reid DB. Valsecchi MG. Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation. 110(6):756–62, 2004 Aug 10.CrossRefPubMedGoogle Scholar
  47. 47.
    Asymptomatic Carotid Surgery Trial-2 (ACST-2): A Large, Simple Randomized Trial to Compare Carotid Endarterectomy versus Carotid Artery Stenting to Prevent Stroke. Assessed at www.acst.org.uk
  48. 48.
    Rundback J. Update on the TACIT trial. Endovascular Today 2006;August: 93–4.Google Scholar
  49. 49.
    Press release (January 18, 2005): Abbott Announces Groundbreaking New Trial in Stroke Prevention. Available at: http://www.abbott.com/global/url/pressRelease/en_US/60.5:5/Press_Release_0227.htm. Accessed October 21, 2007.
  50. 50.
    Carotid Stenting vs. Surgery of Severe Carotid Artery Disease and Stroke Prevention in Asymptomatic Patients (ACT I). Available at http://www.clinicaltrials.gov/ct/show/NCT00106938?order_1. Accessed October 21, 2007.

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Louisville School of MedicineLouisvilleUSA
  2. 2.University of Louisville School of MedicineLouisvilleUSA

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