Carotid artery stenting is an

endovascular procedure Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs bot ...

where a stent is deployed within the lumen of the

carotid artery Carotid artery may refer to: * Common carotid artery, often "carotids" or "carotid", an artery on each side of the neck which divides into the external carotid artery and internal carotid artery * External carotid artery, an artery on each side of t ...

to treat narrowing of the carotid artery and decrease the risk of

stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...

. It is used to treat narrowing of the carotid artery in high-risk patients, when carotid endarterectomy is considered too risky.

Uses

Carotid stenting is used to reduce the risk of stroke associated with carotid artery stenosis. Carotid stenosis can have no symptoms, or have symptoms such as transient ischemic attacks (TIAs) or

s. While historically

endarterectomy Endarterectomy is a surgical procedure to remove the atheromatous ''plaque'' material, or blockage, in the lining of an artery constricted by the buildup of deposits. It is carried out by separating the plaque from the arterial wall. It was firs ...

has been the treatment for

carotid stenosis Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis. Signs and symptoms The common carotid artery is the large artery whose pulse can be felt on both sides of the neck unde ...

, stenting is an alternative intervention for patients who are not candidates for surgery. High risk factors for endarterectomy, which would favor stenting instead, include medical comorbidities (severe heart disease, heart failure, severe lung disease) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that would make surgery difficult and risky.

Reasons to avoid

While rates of stroke and death after both surgery and stenting are low, rates of stroke and death after stenting may be higher than endartererectomy, particularly for transfemoral stenting in patients over age 70.

Procedure

Carotid stenting involves the placement of a stent across the

stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' ...

in the carotid artery. It can be performed under general or local

anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...

. The stent may be placed from the femoral artery, radial artery, or from the common carotid artery at the base of the neck. Critical steps in both approaches are vascular access, crossing the stenosis with a wire, deploying a stent across the lesion, and removing the vascular access. A number of other steps may or may not be performed, including the use of a cerebral protection device, pre- or post-stent

balloon angioplasty Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclero ...

and cerebral angiography.

Trans-femoral carotid stenting

The trans-femoral route is the traditional approach to carotid stenting. The vast majority of these procedures are performed under local anesthesia. In this technique, puncture of the

common femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fem ...

is used to gain access to the arterial system. Wire and sheath are advanced through the aorta to the common carotid artery on the side to be treated. Flow reversal or filter cerebral protection may be used. The procedure is typically performed percutaneously.

Trans-carotid artery revascularization

Trans-carotid artery stenting involves a surgical incision at the base of the neck over the common carotid artery. It is performed under either local or general anesthesia. Wire access is obtained at that location and used to deliver the stent to the

internal carotid artery The internal carotid artery (Latin: arteria carotis interna) is an artery in the neck which supplies the anterior circulation of the brain. In human anatomy, the internal and external carotids arise from the common carotid arteries, where these b ...

. Cerebral protection is usually obtained by flow reversal - the common carotid artery is clamped, and arterial blood from the internal carotid is run through a filter and returned to a femoral vein during the highest risk portions of the procedure.

Trans-radial carotid stenting

The trans-radial route has been introduced as an alternative in the past few years. The vast majority of these procedures are performed under local anesthesia. In this technique, puncture of the radial artery is used to gain access to the arterial system. Wire and sheath are advanced through the aorta to the common carotid artery on the side to be treated. Flow reversal or filter cerebral protection may be used. The procedure is typically performed percutaneously.

Recovery and outcomes

Recovery after carotid artery stenting depends not only on the presence of complications during the procedure, but also on the presence of symptoms at the time of arrival to the hospital. Asymptomatic patients typically leave the hospital in 0–1 days. The blood pressure is kept at a goal below 140 mmHg systolic. Elevated blood pressure in the 2–10 days post-operatively may lead to reperfusion syndrome. The most feared short-term complication of any stroke prevention procedure on the carotid artery is stroke itself. Patients must still be carefully selected for surgery or stenting in order to reduce the risks related to the procedure and ensure the long-term benefit after such intervention. Other short-term complications might include bleeding, infection and heart problems such as myocardial infarction related to anesthesia. Late complications such as recurrent stenosis may occur, and surveillance with duplex ultrasound or CT-Angiography may be performed. The risk-reduction from intervention for carotid stenosis (stenting or endarterectomy) is greatest when the indication for intervention is symptoms (i.e., the patient is symptomatic) - typically

TIA TIA or Tia may refer to: Aviation * Tampa International Airport, US, IATA code TPA * Texas International Airlines, US, ICAO code * Tirana International Airport Nënë Tereza, Albania, IATA code * Trans International Airlines, former U.S. airl ...

. A new generation of double-layer stents is currently being developed to reduce to reduce the risk of stroke during or after the procedure. There is insufficient evidence to say that stenting or endarterectomy is better for symptomatic patients. Angioplasty and carotid stenting in patients with asymptomatic carotid atherosclerotic stenosis should not be performed except in the context of randomized clinical trials.

References

{{DEFAULTSORT:Carotid Stenting Vascular surgery Neurosurgery de:Stentangioplastie