Carotid Artery Stenosis

Treatment Options

Medical

Surgical: Carotid Endarterectomy

Endovascular: Carotid Stenting with CerebralProtection

Treatment Options

Stroke rate: 200 / 100.000 per annum 80% ischemic (20% hemorragic)

50% have a carotid artery stenosis

3rd leading cause of death

Clinical symptoms caused by embolic disease in > 80% of patients (< 20% by hemodynamicimpairment)

Carotid Artery Disease

Stroke Current Status in USA

1.5 deaths per 1000

Ranks 3 in cause of death

> 500,000 strokes per annum in USA

2 million survivors with need for ongoing care

Carotid artery occlusive disease accounts for 20-30 all strokes%

Carotid Artery Disease

Surgical Treatment: Endarterectomy

Carotid EndarterectomyPatch Grafting

Reduced risk of acute thrombosis

Increased incidence of use

Lesser use of vein patch

Carotid Angioplasty:

Kerber et al. 1980

Theron et al. 1987 48 pts, 4.1% serious morbidity

Gil-Peralta et al. 1996 82 pts, 0% mortality, 4.9% morbidity

Endovascular History

Drawbacks:

Vessel wall recoil

Angiographically evident dissection

Plaque dislodgement w/ embolisation

Higher restenosis rates

16%, versus 4% w/ stent (Theron, 1996)

Carotid Angioplasty

Carotid Artery Stenting Success Rate

Technical success > 95%

Proc. related mortality: 0.6 – 4.5%

Major stroke rates : 0 – 4.5%

Minor stroke rates : 0 – 6.5%

6-mo restenosis < 5%

Phatouros et al., Neurol.Med.Chir., 1999, 39:809-827

Angioplasty Technical SuccessN Tech

success

TIA Minor

Stroke

Major

Stroke

Death Restenosis >

50%

Roubin 238 96% 4% 2.3% 0.8% 0.5% 5% (6-mo)

Theron 259 94% 0% 2% 0% 0% 4% (1-yr)

Mathias 428 98% 2.3% 1.2% 0.3% 0.2% 9% (3-yr)

Bergeron 99 97% 4.1% 1% 0% 0% 3% (1yr)

Diethrich 238 91% 4.5% 2% 4.4% 1.5% 8% (2yr)

Gaines 251 96% 3.6% 4% 2.4%

Shawl,2000 170 99% 2.4% 0.5% 0.0% 2% (6-mo)

Peeters 90 96% 2.2% 2.2% 1.1% 2.2% 4% (1yr)

Placement of guiding catheter into CCA

Crossing the lesion

Dilatation of the stenosis

Stent implantation and dilatation

Embolisation May Occur During:

Cerebral Protection

Carotid Artery Stenting

Atherosclerotic lesions

Non-atherosclerotic lesions:

Fibromuscular Dysplasia (FMD)

Infectious disease

Dissection

Radiated neck

Recurrent stenosis after CEA

Restenosis after PTA+stent

Compression & Trauma

Lesion Types

Case 1 - Before dilation

After Stenting

Very calcifiedplaque

Case 2 - Before Dilation

Very calcified plaque

Case 2 – After Stenting & Post Dilation

Carotid Stent Angioplasty

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