Jiri Vitek - Stent supported Carotid Artery... 5th. International ... - FaC

Jiri Vitek - Stent supported Carotid Artery... 

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Stent supported Carotid Artery 

Angioplasty as Prevention of Stroke 

Jiri Vitek* 

Sriram Iyer, Gary Roubin 

Lenox Hill Heart and Vascular Institute of New York, 

New York, NY, USA 

Carotid artery stenting (CAS) is being investigated as an endovascular alternative to carotid 

endarterectomy (CEA) for the treatment of obstructive carotid stenoses. The goal of both procedures 

is to prevent stroke caused by extracranial carotid disease. CAS offers patients a less invasive and 

less traumatic means of achieving this goal. The efficacy of CAS in preventing stroke depends on the 

ability of the operator to achieve complication-free results by careful consideration of the patients 

selected and meticulous performance of the intervention. The recent application of embolic protection 

devices, designed to capture embolic matter released during the stenting procedure before it reaches 

the brain, has added an important dimension to the performance of safe carotid stenting. This report 

provides a step-by-step approach to the clinical and technical aspects of the carotid stenting 

procedure in an effort to ensure safer outcomes. 

Carotid angioplasty and stenting (CAS) has evolved rapidly over the last decade. Since Dotter, Judkins 

[1,2], and Grüntzig’s [3] pioneering work, few procedures have met with such vigorous scrutiny and 

criticism as carotid stenting. Given the potential for procedural neurological complications and the 

existence of a well-validated surgical approach, caution has always been warranted. In the case of 

carotid stenting, opposition in the U.S. surgical community [4] has delayed the approval of advanced 

devices and techniques, slowed progress in clinical trials, and has created limited access for patients 

who might benefit from the procedure. However, despite resistance, carotid stenting has become 

widely accepted as a viable alternative to carotid endarterectomy (CEA). 

Historical Perspective 

CEA was introduced in the early 1950s for the prevention of embologenic etiology of stroke from 

atherosclerotically narrowed carotid bifurcation and internal carotid artery (ICA). By the early 1990s, 

at least three prospective randomized trials had demonstrated that CEA indeed reduced the risk of 

stroke in patients with carotid stenoses [5–7]. The results of these trials confirmed a large body of 

prospective observational data that suggested a benefit of surgery over medical therapy, depending 

on symptom status and the severity of stenosis. Furthermore, the data confirmed the view that if the 

periprocedural stroke and mortality risks of CEA were low, patients benefited. However, prospective 

trials documented a significant perioperative risk that had not been highlighted by the surgeons. In 

NASCET (North American Symptomatic Endarterectomy Trial), in addition to a 5.8% rate of 

neurological complications, the 30-day adverse events that were associated with the open surgical 

procedure were: 

• Perioperative cranial nerve damage (5.6%). 

• Medical complications (8.1%). 

• Myocardial infarction (MI, 1.2%). 

• Congestive heart failure (CHF, 1.2%). 

(Additionally all patients required general anesthesia.) 

In the 1980s, interventional radiologists started to cautiously approach stenotic afflictions in the 

carotid arteries. In 1977 and 1980, Mathias et al. reported successful results with the use of 

percutaneous angioplasty for carotid stenosis [8, 9]. In the early 1980s, Hasso et al. and Belan et al. 

reported successful ICA angioplasty in fibromuscular dysplasia [10,11], and 1983 saw Bockenheimer et 

al., Wiggli and Gratzl, Tsai et al., and Theron et al. publish their results on carotid angioplasty in 

atherosclerotic disease [12–15]. In 1984, Rabkin et al. reported on the experimental use of 

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intravascular Nitinol stents [16], and Theron et al. [17] began their pivotal work with distal balloon 

protection during carotid bifurcation angioplasty, later supplemented by stents. From a historical 

perspective, the first insertion of a (glass) tubular structure into the blood vessel of an animal was 

reported by Carrel in 1912 [18]. Use of silastic tubes was attempted by Dotter in 1969, but these were 

shown to thrombose and migrate [19]. In 1983, Dotter et al. reported the use of uncoated stainless 

steel or nickel titanium alloy wire coils with more success [20]. In the same year, Cragg et al. [21], and 

1 year later, Maass et al. [22], reported on using nitinol spiral endoprostheses in animal experiments. 

Less known is the fact that, in 1973, Kononov [23] implanted a balloon expandable stent graft into a 

dog’s aorta. After multiple successful experiments, on May 5th, 1979, he obtained a patent on a 

“device for implanting a prosthesis in a tubular organ”. In 1990, Rabkin et al. [24] reported that they 

had been successfully implanting Nitinol self-expandable stents inhuman iliac arteries since 1984. The 

successful placement of an endovascular graft transluminally to treat a patient with iliac artery 

occlusive disease was achieved by Volodos et al. in 1985 [25]. 

As was the case in other arterial sites, the evolution and availability of arterial stents transformed the 

less predictable carotid balloon angioplasty, and by the early 1990s prospective observational studies 

of carotid stenting had been initiated [26–29]. From the outset, carotid stenting performed by 

experienced operators produced acceptable outcomes, with a 1% rate of major complications. Non – 

disabling neurological events (approximately 6%) were found in 

patients with advanced age and more complex, severe stenoses [30]. Given the nature of the carotid 

lesion, the incidence of embolic neurological events was not entirely unexpected, and led to the 

development of embolic protection techniques and devices. In 1983, Vitek et al. reported angioplasty 

of the innominate artery with distal occlusion balloon protection of the common carotid artery (CCA) 

[31]. Henry et al. [32] perfected Theron’s technique [17] with a low profile occlusion balloon system for 

embolic protection. Parodi et al. [33] focused on proximal occlusion devices that facilitated embolic 

protection by temporarily reversing flow in the ICA. Recently, several distal embolic filter devices have 

been developed. As different embolic protection systems became available, a number of single-center 

studies and multicenter registries confirmed the ability of experienced operators to achieve excellent 

results with CAS, with a remarkably low risk of embolic complications [34–37]. Consequently, the 

simplicity of this less invasive approach together with its low morbidity rate has accelerated the 

acceptance of CAS in medical community. 

Indications 

In general, the indications for CAS are similar to those for carotid surgery with respect to symptomatic 

status and severity of carotid stenosis. There are notable exceptions to this therapeutic principle. 

Subsets of patients are emerging as better candidates for CAS, while others appear to be better 

candidates for CEA. Patients who have co-morbid medical conditions that would increase the risk of an 

open surgical procedure or the use of general anesthesia are primary candidates for stenting. Based 

on results from the recent SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High 

Risk for Endarterectomy) trial [38], these conditions include: 

• Age >80 years. 

• CHF and/or severe left ventricular dysfunction. 

• Opened heart surgery needed within 6 weeks. 

• Recent MI. 

• Unstable angina. 

• Severe pulmonary disease. 

In addition, any condition that would increase the risk of surgery represents a probable indication for 

CAS, including: 

• Isolated brain hemisphere by arterial supply. 

• Contralateral occlusion of the ICA. 

• Prior ipsilateral endarterectomy. 

• Prior neck dissection or radiation. 

• High lesions behind the mandible. 

• Low lesions that require thoracic exposure. 

The advantage of an endovascular approach is that the angiographic status (anatomy, collaterals, 

status of circle of Willis, intracranial lesions, and flow characteristics) is usually well defined prior to 

the stenting procedure. Although not emphasized in the carotid surgery trials, the incidence of cranial 

nerve damage, wound hematoma, and infection are also significant and must be considered before 

referring the patient for neck surgery. 

Contraindications 

There is a number of notable relative contraindications to carotid stenting. Patients who are intolerant 



to a combination of antiplatelet agents are more safely managed with CEA. Similarly, CEA may be a 

better option if the patient has a compelling reason to undergo a major surgical procedure within 3–4 

weeks that will require the cessation of antiplatelet therapy. Another relative contraindication to CAS 

is the presence of chronic renal failure, although experienced operators can complete the procedure 

using 50–75 cc of contrast or use Gadolinium contrast. The important relative anatomical 

contraindications that increase the risk of performing CAS are: 

• Severe diffuse atherosclerotic disease, calcifications, elongation, and tortuosity of 

the brachiocephalic vessels and aortic arch, which make access to the carotid 

bifurcation difficult, riskier, and occasionally impossible (Figure 1A and 1B). 

• Severe tortuosity in the region of the carotid bifurcation (Figure 1C). 

• Severe calcification completely surrounding the stenotic segment (Figure 1D). 

Figure 1: Lesions unsuitable for CAS. 

a. Diffuse atherosclerotic disease in the common carotid artery (CCA). 

b. Anatomically unsuitable approach due to the tortuosity of the CCA. 

c. Severe tortuosity of the internal carotid artery (ICA) preventing safe placement of the 

protection device and stent. 

d. Heavy circumferential, concentric calcifications and distal tortuosity. 

Placement of embolic protection systems, guide wires, and stents is much more complicated in such 

anatomical conditions, and the degree of tortuosity can be substantially increased after placement of a 

carotid access sheath (Figure 2). In addition, the presence of a mobile thrombus should be ruled out 

before CAS. 



Figure 2: Kink created (arrow) in the distal segment of the ICA by placement 

of the sheath in the CCA (bifurcation displaced cephalad). 

The conditions that are not define as a contraindications for CAS include intracranial stable 

aneurysms, AVMs, and fistulas. Critical control of hypertension and modulation of anticoagulation is 

mandatory in these conditions. 

Management of the Procedure 

The carotid stenting protocol in the Lenox Hill Heart and Vascular Institute (LHHVI, New York, NY, 

USA) has been described in detail previously [39]. In the pre-procedural management of patients, 

adequate dual antiplatelet therapy is vital. On the day of the procedure, oral antihypertensive therapy 

is withheld and the patient must be well hydrated. Mild sedation may be offered to anxious patients 

prior to the procedure but for the vast majority gentle reassurance combined with local anesthesia is 

all that is necessary. This approach also facilitates continuous, accurate pre-, intra-, and postprocedural 

neurological monitoring. Intra-procedural monitoring can be accomplished by engaging in 

verbal contact with the patient and by having them squeeze a toy placed in the contralateral hand 

after every step of the intervention. Pulse oximetry, intra-arterial pressure and heart rate monitoring, 

and careful control of hemodynamics are essential elements of the procedure. Atropine (0.6–1 mg) 

should be administered after placement of the sheath in the CCA to suppress the baro-receptors. If 

the blood pressure remains elevated after the stenosis has been relieved, it should be rapidly lowered 

using intravenous nitroglycerine, nitroprusside, or another appropriate rapidly acting agent. When an 

occlusion balloon embolic protection system is used, the blood pressure should be lowered before the 

protection balloon is deflated. Occasionally, substantial hypotension is noted after post-dilation of the 

stent, particularly in elderly patients. However, the hypotension is invariably benign and does not 

require aggressive treatment. Patients who have separate critical disease in the intracranial, 

extracranial, or coronary vessels should be treated with intravenous phenylephrine, aggressive 

hydration, and, occasionally, dopamine infusions. Anticoagulation during stenting is critical, but only 

modest anticoagulation levels (activated clotting time [ACT] 200–250 s) are necessary and should be 

monitored during the intervention. Depending on body weight, either heparin (4000 IU) or bivalirudin 

is used. Glycoprotein IIb/IIIa receptor antagonists are not used in our center. 

The current CAS technique requires the use of 6-F femoral access sheaths; femoral closure devices 

are used frequently before the patient leaves the interventional suite. Accordingly, patients can sit up 

and begin to ambulate almost immediately. This allows full neurological assessment, and the 

subsequent natural release of catecholamine counteracts much of the bradycardia and hypotension 

associated with stent placement. Intensive post-procedural care is unnecessary. Instead, patients 

should be managed in a monitored bed with nursing staff who are familiar with post-CAS patient care. 

If the sheath is not removed in the interventional suite with femoral closure systems, it should be 

removed as soon as possible by experienced personnel once the ACT has fallen to


retroperitoneal bleeding, are not overlooked. Patients who have an uncomplicated procedure and 

percutaneous femoral closure device can be discharged on the same day. 

Patients are discharged on a combination of clopidogrel (75 mg) and aspirin (325 mg) for 1 month, 

after which aspirin is continued indefinitely. The exception to this regimen are patients treated for 

post-CEA or post-radiation stenosis in whom the Plavix/aspirin treatment is extended for 

approximately 1 year. Baseline ultrasound duplex studies within 1 month serve as a reference for 

future follow-up evaluations in these patients. Frequently, despite good angiographic results, blood 

velocities within the stent become elevated. However, the evidence to date suggests that this finding 

is not predictive of excessive progression of neointimal proliferation or restenosis [40]. Magnetic 

resonance angiography is not used for follow-up purposes due to signal dropout associated with the 

metallic stent. Computerized tomographic angiography, however, has shown some promise and may 

prove to be the follow-up modality of choice. Significant angiographic restenosis >80% is an 

uncommon finding. Cases of restenosis are seen more commonly in patients with stenosis associated 

with radiation-induced injury and in those treated for post- CEA restenosis. Restenosis occurring after 

stent placement can be managed by repeat balloon dilation and, occasionally, by additional stenting. 

Stenting Technique 

The stenting technique has been covered in detail previously (Figure 3 - 5) [39]. Transcranial Doppler 

studies have shown the importance of performing the intervention with minimum manipulation of the 

lesion. If significant difficulties are encountered during sheath placement or passing the guide wire or 

embolic protection device, the decision to proceed must be reassessed. Few embolic particles are 

generated during careful sheath placement or crossing the lesion with an embolic protection system; a 

modest number of particles is released with pre-dilation, followed by stent deployment; and the 

largest number of particles is released during post-dilation of thestent. 

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Figure 3A: a. Collapsed ICA with 98% ostial stenosis. (Recanalized occlusion?) 

b. Pre-predilatation with 2 x 40 mm balloon over 0.014” Choice PT. 

c. Guard wire occusion balloon advanced into the ICA and deployed.



Figure 3B: a. Pre-dilatation with 4 x 30 balloon. 

b. Stent post-dilatation with 5x20 balloon. 

c.Status post. CAS. 

Figure 4 A: Placement of the (embolic protection device) filter 

with the help of the “buddy wire”. 

a. Symptomatic stenosis with angulation in the left ICA. 

b. Stiffness of the Accunet filter prevents advancement. 

c. 0.014” Stabilizer Plus advanced into the ICA.


Figure 4 B: a. Accunet filter advanced into the ICA. 

b. Accunet filter opened. Stabilizer Plus removed. 

c. Status post CAS. 

Figure 5: Placement of the (protection device) occlusion balloon with the help 

of the “buddy catheter”. 

- 90 degree take-off of the left ICA with 80% angulated stenosis. 

- “Buddy wire” (125 cm JR4 catheter) placed in the ostium of the ICA through the 6F 

sheath. Guard wire with occlusion balloon advanced through the JR4 catheter into the 

ICA. 

- Guard wire balloon inflated. 

- Status post CAS. 

These observations support the view that if an embolic protection system cannot be passed through 

the lesion in a safe expeditious manner before pre-dilation, it can be deployed after mini 2-mm 

balloon pre-dilation (Figure 3) or just before stent post-dilation, which is less efficacious, but still 

useful. 

If available, flow reversal embolic protection systems can be used (Figure 6) in patients who have an 

intact Circle of Willis and thus a good collateral supply in addition to suitable iliac and proximal carotid 

anatomy to facilitate placement of this higher profile device. 



Figure 6: Arteria embolic protection system. 

a. 85% stenosis in proximal ICA. 

b. Stent post-dilatation with embolic protection system in place. 

Occlusion of the CCA (large arrow). Occlusion of the ECA (small arrow). 

c. Status post. CAS. 

Transcranial Doppler studies also demonstrated the importance of minimum manipulation of the lesion 

with balloon dilation and stent placement. Pre-dilation of the lesion with a low-profile 4x40 mm length 

balloon reduces movement of the balloon during inflation. A single brief inflation is all that is required. 

Pre-dilation reduces the risk of embolization when advancing the higher profile stent delivery systems 

across the lesion. The stent should be deployed in one movement and be of sufficient length to cover 

the lesion from normal distal vessel to the CCA. There is no disadvantage in covering the external 

carotid artery (ECA) origin or leaving excess stent in the common carotid. Post-dilation should be 

done with a single well-positioned inflation with a conservatively sized, low-profile balloon ([5 or 5.5 

mm] 20 mm). A second inflation in the same position has the effect of “shearing off” large amounts of 

plaque through the stent struts. Embolic protection systems are effective in abolishing, or markedly 

reducing, the volume of particles reaching the brain, but all of the devices can be overwhelmed by 

suboptimal techniques that release a large volume of debris. 

CAS begins with varying degrees of diagnostic carotid angiography that should be tailored to the 

anatomical information gained from preceding noninvasive studies. It should be performed by 

experienced angiographers who are familiar with use of low profile, atraumatic, and safe 

neuroradiology diagnostic catheters and guide wires. In the LHHVI, we use double-curved 5-F 

catheters (Figure 7) and 0.038-inch angled-tip glide wires [39]. This system enables us (in 98.5% of 

patients) to selectively catheterize the CCA, ICA, and ECA, both subclavian arteries, and at least one 

vertebral artery [40]. The same catheterization technique is used for introducing a 6-F, 90-cm sheath 

into the CCA. The minimum information required for the procedure is the severity and anatomy of the 

bifurcation lesion to be treated, ipsilateral intracranial anatomy, and an assessment of disease and/or 

tortuosity involving the CCA. The latter is important for determining safe access with a guiding sheath. 

If occlusion-type embolic protection systems are to be used, an assessment of collateral supply from 

the contralateral vessel or posterior circulation is mandatory and complete cerebral angiography is 

recommended. 



Figure 7: a. Shapes of available catheters for brachiocephalic angiography. 

b. Double-curved catheter used in the Lenox Hill heart and vascular Institute. 

The stenting procedure itself has four components: 

• The 6-F guiding sheath is placed into the distal CCA. Definitive angiograms 

reassess the lesion anatomy and enhanced tortuosity of the ICA, which is commonly 

encountered due to the cephalad displacement of the bifurcation by the sheath (Figure 

2) 

• The lesion is crossed with an embolic protection device that is deployed in a distal 

segment of the cervical ICA (Figure 3, 4, 5, 9). 

• The lesion is pre-dilated with a single inflation, the stent is placed and post-dilated 

with a conservatively sized, low profile balloon (Figure 3Bb, 6b). 

• The embolic protection system is removed and final extracranial and intracranial 

angiography is performed. Using contemporary, rapid exchange (monorail) filter, 

balloon, and stent systems, the entire process can take as little as 15–20 min. 

Using contemporary, rapid exchange (monorail) filter, balloon, and stent systems, the entire process 

can take as little as 15–20 min. 

Embolic Protection Systems 

Embolic protection devices come in two forms (Figure 8). The first group has “umbrella”- or 

“windsock”-like micropore filters that are compressed in low profile sheaths and deployed distal to the 

lesion. Appropriate sizing and positioning of these devices provides good wall apposition and filtration 

efficiency. Numerous studies have documented the ability of these devices to capture plaque, 

thrombus, and cholesterol crystals that are ≥100 mm in size [32–38]. After post-dilation of the stent, 

they are collapsed and removed from the patient. The advantage of the filters is that they provide 

continuous perfusion to the brain. The disadvantages include a higher profile than distal balloon 

occlusion systems, for some systems difficulty in tracking more angulated bifurcations and tortuous 

vessels, and issue of missing very small particles. Occasionally the “buddy wire” or the “buddy 

catheter” have to use to advance the embolic protection devices into the angulated or tortuous ICA. 

(Figure 4, 5) 



Figure 8: Embolic protection systems. 

Balloon occlusion devices comprise the second group of embolic protection devices and are available 

in two systems. The most commonly used system is a low profile, soft latex balloon that occludes the 

distal ICA below the siphon (Figure 5, 9). Blood containing any debris is aspirated after the stent has 

been dilated, which, theoretically, removes all particles. The balloon is then deflated and removed. 

Compared with filters, this device is easier to track through tortuous vessels (Figure 9). The principle 

disadvantage of the device is that 5–10% of patients do not tolerate ICA occlusion [32]. In addition, 

particles can be diverted up the ECA and reach the cerebral tissue via ophthalmic or vertebral 

collaterals. Retinal infarction has also been noted in these patients. Rarely, significant dissection of the 

distal ICA occurs (Figure 10). 


Figure 9: Distal balloon embolic protection system (Guard wire) in tortuous ICA. 

a. 95% ICA stenosis. Distal ICA tortuosity. 

b. Occlusion balloon in distal ICA (arrow). Post-dilatation of the stent. 

c. Status post CAS.


Figure 10: Dissection of the ICA post. CAS with distal balloon occlusion. 

a. 98% ICA stenosis. 

b. Occlusion balloon in distal ICA (thick arrow). 

c. Status post CAS. Dissection in the ICA (small arrows). 

d. Stat. post stenting of the dissection. 

An alternative proximal occlusion system utilizes a more complicated device that features a cuff 

balloon surrounding the guiding sheath, which occludes the distal CCA. A side port allows placement 

of a balloon that occludes the ECA; thus, the flow in the ICA is reversed as the blood is shunted back 

through the guiding sheath via a filter to the femoral vein (Figure 6 and 8). The theoretical advantage 

of this approach is the removal of all particles, even those that may be produced when crossing the 

lesion. Disadvantages include the large profile of the guiding catheter that necessitates a 10-11-F 

sheath in the femoral artery, and the somewhat more complicated set up procedure. Again, 5–10% of 

patients with “isolated hemispheres” do not have the physiology to promote reversal of flow and do 

not tolerate the absence of cerebral perfusion [32]. 

From a practical perspective, all of the devices described have been studied in well conducted 

prospective trials. When used by experienced operators in the correct anatomical situation, all of the 

embolic protection approaches have demonstrated excellent recovery of debris and excellent 

procedural outcomes. 

The 3% Rule 

As stated above, carotid artery revascularization can be justified in the asymptomatic patient only if 

the procedure can be accomplished with a complication rate >3% [6].With the widespread availability 

of CEA and carotid stenting, candidates for carotid revascularization have generally been selected for 

either procedure on the basis of the presumed surgical risk (the “conventional paradigm,” is presented 

(Figure 11). Low-risk surgical patients would usually be referred for CEA or be enrolled in a 

randomized clinical trial of surgery versus stenting. Patients considered at high risk for open surgery 

were often referred for carotid stenting, arbitrarily considered a low-risk intervention because little 

attention had been given to definition of the risks associated with the latter procedure. However, it is 

of crucial importance to recognize the risks of carotid stenting and to realize that in certain patients 

(easily identified by readily available clinical and angiographic features), particularly those with 

asymptomatic lesions, the risks of procedure-related major adverse events might exceed the longterm 

risk of ipsilateral stroke with medical therapy. We believe that for the full clinical potential of 

carotid stenting to be realized, a paradigm shift needs to be implemented in the process of procedural 

risk stratification and selection of patients for revascularization. This applies both to everyday clinical 

practice and to the design of randomized trials. Clinical decision making that incorporates these 

principles is depicted here. (Figure12). The category of “high risk” patients for CAS should be 

recognized. 



Figure 11: Traditional, conventional paradigm for CAS. 

Figure 12: New proposed paradigm for CAS. 

Implementing the 3% Rule 

In determining the risk of death or stroke associated with carotid stenting, it is of critical importance 

to recognize 4 factors that have been associated with increased procedural complications (Figure 13). 

The most important of these factors is advanced age. In the lead-in phase of the multicenter CREST 

trial, the risk of 30-day stroke or death among 749 patients was directly related to age (80 years, 12.1%; P-0.006) [41]. Although 

the risk attributable to advanced age in this analysis appeared to be independent of other clinical (eg, 

gender or symptom status), angiographic (eg, lesion severity), or procedural (eg, use of distal 

protection devices) factors [41] it is likely that the increasing prevalence of the other factors listed 

(Figure 13) with advanced age accounts, at least in part, for this association. Decreased cerebral 

reserve is another important factor when one considers the risk of carotid stenting. Carotid 

revascularization (carotid stenting or CEA) is usually associated with some degree of cerebral 

embolization that is generally well tolerated in patients with good cerebral reserve; however, patients 

with prior strokes, lacunar infarcts, microangiopathy, or dementia of varying stages are much more 

likely to experience neurological deficits after carotid stenting. This risk is markedly amplified in the 

presence of an isolated hemisphere with lack of good collateral support. Although some lesion 

characteristics (eg, degree of stenosis and length) indicate potential technical difficulties, the 2 most 

important anatomic findings portending an increased procedural risk are vascular tortuosity and heavy 

concentric calcification (Figure 1c, d). Excessive tortuosity is defined as 2 bend points that exceed 

90°, within 5 cm of the lesion, including the takeoff of the ICA from the CCA (Figure 1c, 5a). 

Excessive tortuosity increases the difficulty of access to the lesion, may not permit device delivery, 

and can prevent distal positioning of an EPD with a “landing zone” sufficient for stent placement. 

These factors expose the patient to the risks of atheroembolism excessive contrast administration, 

bifurcation plaque disruption, and ICA dissection. Importantly, tortuosity should be assessed after the 

sheath (or guide catheter) has been placed in the CCA, because forces by the catheter directed 

toward the unyielding base of the cranium tend to exaggerate ICA tortuosity (Figure 2). Finally, heavy 

calcification is an important predictor of complications. This is defined as concentric calcification, 


lesion (Figure 1d). Heavy calcification, especially in combination with arterial tortuosity, causes 

difficulties in tracking devices, lesion dilation, stent positioning, and achieving adequate stent 

expansion. In our experience in more than 1500 cases, the presence of 2 or more of the risk factors 

listed (Figure 12) is an important adverse prognosticator in patients undergoing carotid stenting. 

Although special techniques generally result in a satisfactory angiographic outcome, the risk of 

neurological adverse events exceeds the 3% rule and is thus prohibitive. 

Figure 13: Factors associated with increased CAS procedural complications. 

Results 

Interpreting Outcomes 

Stenting outcomes must be interpreted in an environment of rapidly evolving technology and 

experience. Procedural outcomes documented 5 years ago are not relevant when considering the 

expected outcomes with distal embolic protection systems, enhanced-access sheaths, lower profile, 

more trackable stents, and balloons and adjunctive antiplatelet therapy. 

As with any interventional procedure, outcomes are dependent on operator expertise and experience. 

There is a steep learning curve for physicians beginning carotid stenting. The interventional and 

clinical skills required for optimal results are not found within the confines of any traditional medical 

discipline. Neuroradiologists generally lack experience in large vessel intervention, especially stenting, 

clinical management of patients, and the associated hemodynamic and cardiovascular issues. 

Cardiologists may have this expertise but lack specific neuroradiology and neuroscience backgrounds. 

Vascular surgeons and neurosurgeons generally lack the required interventional skills and 

interventional radiologists often have little experience of carotid vessels and lack the necessary clinical 

skills. However, over the last decade through interdisciplinary collaboration and focused training, 

many physicians from diverse disciplines have gained the experience and skills required to produce 

excellent outcomes from carotid stenting. Choosing an appropriate stenting therapy for each 

individual patient requires an understanding of the outcomes expected from alternative approaches. It 

is important to appreciate how rigorously scrutinized carotid stenting results have been compared with 

surgical therapies. Independent, prospective stroke scale assessment by a neurologist at 24 h was not 

undertaken in any of the surgical trials. An equally important issue has been the inclusion of patients 

in early carotid stent series who had never been subjected to rigorous prospective study in 

endarterectomy trials. The generally low-risk patients studied in NASCET and ACAS (Asymptomatic 

Carotid Atherosclerosis Study) have only recently been studied in carotid stent series. 

Thirty-Day Outcomes 

Two groups have extensive experience with >1000 cases, and examination of their outcomes, 

provides insight into the progress that has been made over the last 10 years, in particular the 

influence of embolic protection devices. 

The LHHVI group reviewed completed >1397 carotid stent procedures in 1268 patients (unpublished 

data). Outcomes were prospectively recorded based on independent neurological examination of the 



cases within 24 h of the stent procedure. The database was maintained as the group moved from the 

University of Alabama (Birmingham, AL, USA) to the LHHVI. This large data set is constantly being 

updated and analyzed to evaluate the outcomes. The data were used to examine the impact of routine 

use of embolic protection devices and the outcomes that might be expected in various populations of 

low- and high-risk patients (unpublished data). In this population o 1268 patients, the mean age was 

71±9 years and 216 (16%) were aged >80 years. Thirty-four percent were female, 62% had severe 

coronary artery disease, 16% had undergone prior CEA, and 45% had bilateral carotid disease. Thirtynine 

percent had prior symptoms of stroke, transient ischemic attacks, or amaurosis fugax and 61% 

had high-grade, asymptomatic lesions. First, outcomes since the availability of embolic protection 

devices in the most recent 551 patients (588 separate vessel–hemispheric interventions) were 

examined (Table 1). There was a significant reduction in the 30-day incidence of stroke and death, 

from 6.2% to 2.4%. The difference was seen in both major and fatal strokes (1.5% to 0.6%) and in 

non-disabling strokes (4.1% to 1.2%). 

Next, the same outcomes were examined in a provocative group of patients aged 380 years who had 

been treated over the same period. Previous analyses have demonstrated an increased incidence of 

neurological events in this group [30]. The use of embolic protection devices in this population of 

patients showed dramatic benefit, with a significant decrease in ischemic complications from 16.5% to 

2.3%. The 30-day outcomes were also examined in a group of ACAS-like asymptomatic, low CEA risk 

patients (Table 2). The current stroke risk in this patient population is 1.1% [6]. Accordingly, when 

counseling such patients on the relative merits of stenting or endarterectomy, it is possible to 

demonstrate a stroke risk of 1% without the operative risks of a surgical procedure. The total 30-day 

rate of stroke and risk from any cause mortality was 1.6%. 

A slight increase was noted in the incidence of retinal embolic events, which were related to the 

dominant use of distal occlusion embolic protection devices and the potential for directing particles to 

the ECA. However, these events have not occurred in recent increasing experiences with distal filter 

systems. Multivariate analysis demonstrated two positive predictors of a procedural stroke during 

stenting: a history of hypertension and age >80 years. A significant negative descriptor was the use 

of an embolic protection system. Embolic protection devices, even in their early stages of 

development, improve outcomes [32–38]. The results are most dramatic in patients at higher risk of 

events, i.e. the elderly, recently symptomatic patients, and those with severe stenoses and long, 

bulky lesions. Compared with historical surgical controls, or even the best results reported from 

endarterectomy, stenting can produce equivalent outcomes without the risk of neck operation, general 



anesthesia, and the associated complications. In patients at higher risk for CEA, the stent procedure is 

clearly a safer option [38]. In low CEA risk patients, the stent procedure is as effective and much more 

acceptable to the patient. 

Mathias et al. conducted another large single-center series that confirmed the LHHVI experience. 

From 1984–98, these authors treated 1222 arteries (hemispheres) with carotid angioplasty and, more 

recently, stenting without embolic protection (K Mathias, personal communication). The minor stroke 

rate in this population was 2.1%, with major stroke and death rates of 1.1% and 0.5%, respectively. 

The total 30-day death and stroke rate was 3.8%. Since 1998, an additional 577 patients have been 

treated with the inclusion of embolic protection devices, demonstrating a minor stroke rate of 0.9%, a 

major stroke rate of 0.4%, and a 30-day mortality rate of 0.2%. Thus, the total 30-day stroke and 

death rate was 1.7%. This group also observed a dramatic reduction in stroke events, from 3.3% to 

1.3%, associated with the introduction of embolic protection systems. Of importance was the 0.35% 

incidence of major disabling stroke in this large series. 

CAVATAS (Carotid and Vertebral Artery Transluminal Angioplasty Study) was the first prospective, 

multicenter, randomized trial comparing carotid endovascular intervention with carotid 

endarterectomy [42]. The interventions were performed by operators in the learning phase of their 

experience, without the use of embolic protection devices, contemporary appreciation for the use of 

aggressive antiplatelet therapy, and state-of-the-art stents and ancillary equipment. Only “bail out” 

stenting was performed (in 26% of patients). While peri-procedural outcomes were higher than would 

be expected today with distal embolic protection and stenting, they were not different from that 

observed in the surgical cohort. 

SAPPHIRE, the first prospective, randomized, multicenter trial using embolic protection devices, 

confirmed the utility of stenting compared with endarterectomy, particularly in 307 patients at 

moderate to high risk from endarterectomy [38]. Severe co-morbidities were common, with 80% 

having coronary disease, approximately one-third having prior coronary artery bypass grafting and 

MI, and 20% having CHF, unstable angina, and prior CEA (Figure 14). This first credible “head to 

head” comparison using contemporary stenting techniques confirmed that for every adverse outcome 

measure, stenting was safer than endarterectomy. Adverse events included death (0.6% vs. 2%), 

stroke (3.8% vs. 5.3%), and major ipsilateral stroke (0% vs. 1.3%). The rate of MI was 2.6% vs. 

7.3% (p=0.07), and the combined predetermined endpoint of death/stroke/MI was 5.8% vs. 12.6% 

(p=0.047). In addition, there was a 5.3% incidence of cranial nerve injury in the surgical group and 

no such injuries in the stent group. 

Figure 14: CAS in post. CEA restenosis. 

a. Post CEA 90% restenosis, proximal and distal. 

b. Status post CAS. 

c. Control in 23 months. 

Late Outcomes 

Late outcomes after carotid stenting have been consistently favorable and competitive, if not superior, 

to CEA. Numerous studies have shown that neurological events are rare once the patient has left the 



procedure room. Rates of late ipsilateral stroke and stroke-related death have been consistent with 

that seen after endarterectomy. In addition, studies have demonstrated low rates of restenosis by 

angiographic definition (80 years. 

Mathias et al. reported 6-month follow-up studies on 1487 treated carotid arteries (K Mathias, 

personal communication), of which 94% were available for follow-up. The all-cause mortality rate in 

these patients was 1.8%, and five patients (0.4%) suffered an ipsilateral stroke. The >50% restenosis 

rate was 4.3%, and, of these patients, 0.5% had complete occlusion. The ipsilateral stroke rate was 

2.3%. Gray et al. followed 136 consecutive stent patients and demonstrated a 6-month angiographic 

restenosis rate of 3.1% and a 100% rate of 2-year freedom from ipsilateral major stroke [46]. Wholey 

et al. followed their large cohort of patients from Pittsburgh (PA, USA) for a period of 21 months 

(range 0–5.6 years) (M Wholey, personal communication). Follow-up data were available in 464 

patients (94%), in whom the cumulative freedom from stroke or neurological death at 3 years was 

96% for self-expanding stents and 95% for balloon expandable stents (early cases), respectively. 

The CAVATAS follow-up study confirmed that endovascular treatment had similar major risks and 

effectiveness at preventing stroke during 3 years compared with CEA [42]. The advantage of 

endovascular treatment was the avoidance of minor complications related to the neck incision (cranial 

nerve palsy, hematoma, infections) and use of general anesthesia. Carotid duplex follow-up studies 

showed more elevated velocities in the non-surgical group, suggesting restenosis. However, 

angiographic correlations were not performed and the relevance of the elevated velocities and the 

prognostic implications have been disputed. 

One-year follow-up of the SAPPHIRE trial data showed significantly lower rates of death (6.8% vs. 

12.6%), major ipsilateral stroke (0% vs. 3.3%), and MI (2.5% vs. 7.9%) without any cranial nerve 

palsies (0% vs. 4.6%) in the endovascular arm (using the modern stenting technique and embolic 

protection) in comparison with CEA, thus confirming the results from CAVATAS. 

Outcome analyses from multicenter studies strongly suggest that these are applicable to clinical 

practice. The German Quality Assurance Program (a prospective registry) is a good example of what 



might be expected with CAS [49]. These data, compiled under the auspices of the German Societies of 

Angiology and Radiology, prospectively audited outcomes from 35 centers in Germany, Austria, and 

Switzerland. During the first 30 months, 2142 planned carotid interventions were registered. Of these, 

57% were symptomatic and 43% asymptomatic. Stents were used in 98% of patients. Embolic 

protection systems were introduced as they became available; they were monitored in the last half of 

the series and were selectively used in 55% of interventions since that time. The overall stroke and 

death rate was 3%. Individual events included a mortality rate of 0.7%, a major stroke rate of 1.4%, 

and a minor stroke rate of 0.8%. The investigators concluded that the outcomes represented a 

realistic view of carotid intervention in the community and suggested that this less traumatic approach 

represented a realistic alternative to CEA. 

Future Developments 

From a technical perspective, carotid stenting is currently in an extremely rapid phase of 

development. The ongoing CREST (Carotid Revascularization Endarterectomy vs. Stent Trial) study 

was initiated with a first-generation embolic protection device, but will soon incorporate second-, 

third-, and fourth-generation devices. The SAPPHIRE trial was completed using a first-generation 

embolic protection device and the outcomes of the stenting cohort in that trial are already being 

questioned given the availability of new technology. Iterative improvements include a lower profile, 

better tracktability, better particle capture efficiency, and increased ease of retrieval. Embolic 

protection devices and stents are evolving to include rapid exchange technology that further expedites 

the procedure. The future will produce carotid stents that contain antiplatelet and antithrombin 

coatings as well as antiproliferative agents. These devices are already available for use in coronary 

arteries; however, much work needs to be done to define the optimal adjunctive antiplatelet and 

anticoagulant therapy for carotid stenting. 

Most importantly, interventional experience and expertise with carotid intervention will grow and, as 

with all medical procedures, the technique will evolve to provide more effective and safer therapy. As 

the medical management of carotid stenosis progresses, the need for re-evaluation of stenting, and 

eventually CEA, in comparison with medical therapy will arise. The next major trial should probably 

compare carotid stenting and CEA with optimal contemporary medical management in asymptomatic 

patients with moderate carotid stenoses (≤80% diameter). Such a trial, however, should await a 

collective community experience with stenting in low-risk patients demonstrating a peri-procedural 

complication rate of ≤2%. There is nothing more important then the proper selection of patients and 

lesions for CAS, to achieve this goal. We have to distinguish groups of patients not only high risk for 

CEA, but also the group of patients with high risk for CAS [Figure 11, 12]. In combination with 

aggressive community based and individual approaches to primary prevention, there is significant 

potential for this emerging technology to have a profound benefit on stroke prevention. The 

availability of a much less invasive, patient friendly, outpatient procedure is likely to gain widespread 

acceptance. 

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CV of the author 

- Presently works at the Lenox Hill Heart and Vascular Institute of New York. 

- Is a neuroradiologist with special expertise in angiography, interventional procedures specialized in carotid 

artery stenting. 

- Was a professor of Radiology, Neurosurgery and Neurology at University of Alabama School of Medicine in 



Birmingham till 1997 when he relocated his practice to Lenox Hill Hospital. 

- A graduate of Charles University School of Medicine in Czech Republic he practiced neurology and neurosurgery 

and in 1976 became board certified in radiology. 

- Published extensively in peer review national and international journals and was invited as a lecturer to multiple 

national and international congresses and courses. 

- Is a member of multiple national and international Radiological and Neuroradiological societies. 

Publication: September 2007 

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