Device selection for carotid stenting: reviewing the evidence

Abstract

Carotid artery stenting (CAS) has recently changed the status in the treatment of the extracranial carotid atheromasic disease. In recent years, evolution in both stents and protection devices as well as in carotid stenting techniques, has resulted in an important reduction in the rate of stroke in patients undergoing CAS procedures. Areas covered: The purpose of this article is reviewing the literature and summarizing the current evidence of the new available materials to underline the importance of the correct choice of the devices during the procedure. Expert commentary: Certainly a key issue in order to limit the periprocedural events to the lowest possible, is to select the appropriate device for the appropriate patient anatomy and clinical syndrome, the so called 'tailored approach'.

Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience

“…The recognition of high-risk cases for CAS depends primarily on the skill of the interventional vascular specialist, a factor that is substantially more relevant in the field of CAS than other areas of percutaneous intervention. 34…”

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…Additional challenges exist in so-called vulnerable plaque morphologies [25,27,42,52]. The Stary classification divides plaque grading into six categories, with type V (fibroatheroma) and VI (complicated) lesions considered vulnerable [91][92][93][94]. Histopathologically vulnerable features have included the presence of intraplaque hemorrhage, a necrotic lipid-rich core, and ruptured fibrous caps [93], all of which are correlated with increased T1 and T2 weight MRI signal intensity ratios (SIR) on multivariate analysis [93].…”

“…Modalities range from anchoring techniques [28], the use of dedicated guide catheters [55], and alternative access sites [30]. Advances in stent design have allowed for flexible systems with combined closed and open cell features and improvements in CEUS and angioscopy allow for timely recognition and management of impending thrombogenic events [91,92]. In patients in which proximal endovascular CCA access is unobtainable, several centers report series using open transcervical approaches versus percutaneous access with an extravascular arteriotomy closure device for direct CCA puncture [31,39] with very low rates of morbidity and mortality on short-term follow-up [39].…”

Introduction: Carotid endarterectomy versus carotid stenting—A never-ending story

“…In fact, because embolization through the stent struts is the primary suspected cause of early postoperative neurologic complications, surgical technology has focused on the production of a new generation of stents with a double layer of mesh to reduce the "free area" of the cells, and new embolic protection devices to reduce the risk of intraprocedural embolization to the brain. So although there is still the need for level I evidence from RCTs testing these new tools, we believe that new materials in the hand of skilled operators who are able to choose the appropriate carotid stent and protection device based on the plaque morphology and patient's anatomical characteristics may definitively fill the gap of CAS in comparison to CEA [20][21][22][23]. There is great interest in the possibility of learning additional details regarding the interaction between a carotid plaque and a stent by optical coherence tomography, considering that plaque prolapse through the cell stents has been suggested as one of the major causes of post-procedural complications after CAS, and that available intraprocedural imaging systems (eg, angiography, intravascular ultrasound, and duplex ultrasound) may not be able to detect these intravascular microdefects.…”