Limitations of carotid Limitations of carotid stenting stenting

neurologist point of viewneurologist point of view

Antoni FerensStroke Unit

University Hospital Kraków

StrokeStroke

third leading cause of death most common cause of permanent disability affects 0.2% of the population

(~200/100.000/y) mortality ~50/100.000/y

Carotid stenosisCarotid stenosis

Stenosis of internal carotid artery is responsable for 10-20% of all strokes

Risk of strokeasymptomatic patinents with stenosis >60%~1-3%/ysymptomatic patients with stenosis 50-69% 4.4%/ysymptomatic patients with stenosis >70% 13%/y

Guidelines for carotid stentingGuidelines for carotid stenting

ESO Guidelines 2008

angioplasty and/or stenting (CAS) is only

recommended in selected patients. It should be restricted to the following subgroups of patients with severe symptomatic carotid artery stenosis:

those with contra-indications to CEA,

stenosis at a surgically inaccessible site,

re-stenosis after earlier CEA,

post-radiation stenosis

Guidelines for carotid stentingGuidelines for carotid stenting

Guidelines of AHA/ASA 2011Guidelines of AHA/ASA 2011CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by >70% by noninvasive imaging or >50% by catheter angiography.among patients with symptomatic severe stenosis (>70%) in whom the stenosis is difficult to access surgically, medical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist, such as radiation induced stenosis or restenosis after CEA, CAS may be considered.

Guidelines for carotid stentingGuidelines for carotid stenting

ESC Guidelines eESC Guidelines endorsed by: ESOndorsed by: ESO 2011 2011in asymptomatic patients with an indication for carotid revascularization, CAS may be considered as an alternative to CEA in high-volume centres with documented death or stroke rate <3%.in symptomatic patients requiring carotid evascularization, CAS may be considered as an alternative to CEA in high-volume centres with documented death or stroke rate <6%.

Indications for revascularization Indications for revascularization of carotid arteryof carotid artery

asymptomatic stenosis symptomatic stenosis emergency revascularisation

Medical limitationsMedical limitations

general and neurological status life expectancy comorbidities (renal insufficiency, contralateral

carotid occlusion) age gender compliance !

Anatomical limitationAnatomical limitation inability to obtain femoral access severe atherosclerosis and/or calcification of aortic

arch extreme angulation of great vessel orgins from the aorta severe tortuosity of carotid artery severe calcification of the

target stenosis

Center limitationsCenter limitations

operator expirience range of available devices reimbursement

Final decisionFinal decision

To stent or not to stent?

Carefully weight all pros and cons for every patient

Questions for futureQuestions for future

what is the risk of stroke in carotid artery stenosis ? late complications of stent placement ? when perform revascularization after stroke? who is the most appropriate specialist to qualify

patient?