CAROTID STENT/ANGIOPLASTY

Carotid angioplasty involves dilating the narrowed channel through atherosclerotic plaque by expanding a balloon at the end of a catheter and then holding the artery open with a metallic frame called a stent. Stent/angioplasty is a technique that is widely employed in other blood vessels such as the coronary arteries of the heart, the arteries to the kidneys, and the arteries supplying blood to the legs. The possibility of employing this technique to the carotid arteries has been undergoing evaluation for the past fifteen years. The technique involves the introduction of a balloon catheter delivery system through an artery in the groin, under local anesthesia, and advancing it to the carotid artery under fluoroscopic control. Once a guide wire has crossed the narrowing in the plaque, an anti-embolism protection device is advanced beyond the plaque as a means of catching debris that is released from the plaque during its dilatation with the balloon catheter which also carries the stent. The artery is then dilated leaving a stent in place to hold the channel open.

Carotid angioplasty(CAS) has been compared to carotid endarterectomy(CEA) in several prospective randomized clinical trials; one in France(EVA-3S), one in the German speaking countries(SPACE), one international trial(ICSS), and one in the United States(CREST). In general all trials have shown that the current risk of stroke following CAS is twice as high as the risk following CEA. This was also true in the CREST trial but it was also shown that the risk of myocardial infarction was higher following CEA than was the case following CAS. However, from the patients perspective, the greatest adverse effect on quality of life occurred with stroke and not myocardial infarction. Therefore, for the patient who is at average risk for surgery, CEA is still preferred over CAS. In time, there will probably be improvements in the safety of CAS. Also, the risk of myocardial infarction following CEA will be reduced due to better pre-operative medical management.