Carotid angioplasty with stent placement

Points to remember

• Carotid angioplasty with stent (CAS) placement is appropriate for selected patients with transient ischemic attacks or cerebral infarction and also for certain patients who have severe stenosis of the carotid artery without symptoms.
• The National Institutes of Health selected Mayo Clinic to participate in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). This trial formally evaluated the comparative risks of stroke, myocardial infarction, and other adverse outcomes associated with the 2 procedures.

Carotid angioplasty with stent (CAS) placement is an emerging alternative to carotid endarterectomy for the treatment of patients with carotid artery occlusive disease. Mayo Clinic neuroradiologists began using CAS in 1996 for patients at high risk of surgery.

The cerebrovascular clinic in the Department of Neurology at Mayo Clinic in Rochester, Minnesota, has a multidisciplinary CAS protocol in which a vascular neurologist, an interventionalist (from neuroradiology, neurosurgery, vascular surgery, or cardiology), and a neurosurgeon or vascular surgeon meet with the patient to help clarify the best treatment approach. Cardiology colleagues may also be involved if the patient has cardiac symptoms, which is not uncommon because so many patients with carotid occlusive disease also have coronary artery occlusive disease.

Indications and procedure for CAS placement

Candidates for CAS placement are patients with a severe narrowing of the carotid artery who have had symptoms such as transient ischemic attacks or cerebral infarction. Also candidates are selected patients who have severe narrowing of the carotid artery without symptoms.

Most patients arrive at Mayo Clinic after carotid ultrasonography, magnetic resonance angiography, or computed tomographic angiography has shown narrowing of the carotid artery. After performing a thorough medical history and patient examination, the multidisciplinary team members determine whether CAS placement is the optimal treatment, applying the recently published CREST data and individualizing the management decision.

During the CAS procedure, the patient is sedated but awake, and a small plastic catheter is inserted into a groin artery and tracked through the aorta to the carotid arteries. Next, contrast material is injected through the catheter to delineate the anatomy. If the angiogram confirms severe narrowing that could be best treated with CAS placement, then the procedure begins.

Narrowed carotid artery

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Stent and open artery after CAS

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Before performing the CAS procedure, a protection device may be deployed distally in the carotid artery. This device functions something like a tiny mesh umbrella to catch material that may break free during the angioplasty. Then the angioplasty balloon is advanced across the plaque and inflated to push the plaque aside, thus reducing arterial narrowing. The stent—a small metallic scaffolding device—is put in place to keep the artery open. The procedure ends with withdrawal of the distal protection device and the catheter.

Typically, the patient is hospitalized for 1 day. Aftercare involves taking both clopidogrel and aspirin daily for 1 month to prevent blood clots from forming at the stent site and then aspirin alone indefinitely thereafter. Mayo Clinic specialists follow each patient long term, both to assess durability of the stent and to determine whether narrowing recurs. Follow-up may include intermittent carotid ultrasonography that begins several months after the procedure.

Results, risks, and complications

CAS placement is a logical extension of the balloon stenting used for coronary artery disease. Initially, in the late 1990s, CAS placement was performed on patients who were at high risk of conventional surgery. The outcomes of these early cases were excellent, and the risk of stroke and death was extremely low. Because these measures of success were so similar to those of the standard treatment, carotid endarterectomy, the use of CAS placement was cautiously and carefully expanded.

Since then, Mayo Clinic experience with CAS placement suggests that, when performed by an experienced, multispecialty team on appropriately selected patients, the procedure is approximately equal to carotid endarterectomy in terms of effectiveness, risks, and complications.

Because the procedures require the interventionalist to work within the artery, both carotid endarterectomy and CAS placement carry the risk of stroke during the procedure.

Mayo Clinic's cerebrovascular clinic is a full-time clinic, providing consultations for patients with carotid stenosis and all other types of cerebrovascular disorders. To refer a patient for evaluation, call the cerebrovascular clinic at 507-284-1588.