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Table of Contents    
COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 6  |  Page : 1429-1430

Carotid Artery Stenting in Occlusive Carotid Artery Disease: An Appraisal


Department of Neurosurgery and Apex Trauma Center, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Kamlesh Singh Bhaisora
Department of Neurosurgery and Apex Trauma Center, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.273616

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How to cite this article:
Singh S, Bhaisora KS, Das KK. Carotid Artery Stenting in Occlusive Carotid Artery Disease: An Appraisal. Neurol India 2019;67:1429-30

How to cite this URL:
Singh S, Bhaisora KS, Das KK. Carotid Artery Stenting in Occlusive Carotid Artery Disease: An Appraisal. Neurol India [serial online] 2019 [cited 2020 Jul 5];67:1429-30. Available from: http://www.neurologyindia.com/text.asp?2019/67/6/1429/273616




The treatment of carotid artery stenosis disease has evolved over the last few decades, and the resultant controversies regarding the best management have culminated in a plethora of more studies. These studies have concluded that carotid artery stenting (CAS) and carotid endarterectomy (CEA) were comparable treatment options for both symptomatic and asymptomatic carotid stenosis disease albeit with higher periprocedural stroke risk in CAS. Altibi et al.,[1] in the study in focus, studied the relation between periprocedural strokes and the 30-day mortality in patients of carotid artery stenosis undergoing CAS. They found that the occurrence of strokes after CAS increased 30-day mortality significantly. This important clinical issue, which had surprisingly gone unreported before, was a major highlight of this study.

Carotid stenosis leads to nearly 20% of all strokes in adults.[2] The treatment for atherosclerotic carotid disease has evolved significantly since the 1950s. Various trials done in the early 1990s have proven the role of CEA vis-à-vis the best medical management. However, medical treatment has also improved significantly since then. First, endovascular angioplasty for carotid stenosis was done in 1970 and ever since, with advancements in the technology of endovascular treatment, CAS has become one of the leading modalities of treatment for carotid stenosis disease. In the early twenty- first century, carotid revascularization endarterectomy versus stenting trial (CREST) concluded that CAS and CEA were comparable treatment options for both symptomatic and asymptomatic carotid stenotic diseases. Still CAS had significantly more risks of periprocedural stroke.[3]

Voeks et al. found similar findings while comparing two different procedures for CAS.[3] The CREST also showed increased periprocedural complications with CAS in the elderly population.[4]

The conclusion by Albiti et al.[1] that periprocedural strokes in CAS increased the risks of 30 days mortality can be an exaggeration in the present scenario, with the advancements in hardware in the endovascular armamentarium, particularly, the availability of various protection devices, seldom used in the earlier studies. In addition, given the fact that this meta-analysis included all retrospective studies until date, this association may not be that relevant in the present times. The cause of stroke in CAS may be hemodynamic insufficiency secondary to the temporary occlusion of flow during the procedure or ischemia because of the dislodgment of embolus during the procedure. The risk of hemodynamic strokes can be there in both the procedures, namely, CEA and CAS.[5] With the widespread use of newer protection devices, this risk of embolic stroke has markedly reduced in CAS, if not completely abolished.[6]

To conclude, CEA and CAS are well-established modalities of treatment for carotid artery disease, as suggested by the large body of literature. The literature has clearly shown that CEA is the best management option for carotid artery stenosis in low surgical risk patients, while it is preferable to go for CAS in high surgical risk patients. We have all the reasons to believe so until compelling new evidence proves otherwise.



 
  References Top

1.
Altibi AM, Saca EE, Dhillon H, Thirumala PD. Perioperative stroke in carotid artery stenting dramatically increases the risk of 30-day mortality in patients with carotid artery stenosis—A systemic review and meta-analysis. Neurol India 2019;67:1423-8.  Back to cited text no. 1
  [Full text]  
2.
Kamalakannan S, Gudlavalleti AS, Gudlavalleti VS, Goenka S, Kuper H. Incidence and prevalence of stroke in India: A systematic review. Indian J Med Res 2017;146:175–85.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Voeks JH, Howard G, Roubin GS, Malas MB, Cohen DJ, Sternbergh WC 3rd, et al. Age and outcomes after carotid stenting and endarterectomy: The carotid revascularization endarterectomy versus stenting trial. Stroke 2011;42:3484-90.  Back to cited text no. 3
    
4.
Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG. CREST Investigators. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): Stenting versus carotid endarterectomy for carotid disease. Stroke 2010;41:S31-4.  Back to cited text no. 4
    
5.
Lai Z, Guo Z, Shao J, Chen Y, Liu X, Liu B, et al. Asystematic review and meta-analysis of results of simultaneous bilateral carotid artery stenting. J Vasc Surg 2019;69:1633-42.e5.  Back to cited text no. 5
    
6.
Farooq MU, Goshgarian C, Min J, Gorelick PB. Pathophysiology and management of reperfusion injury and hyperperfusion syndrome after carotid endarterectomy and carotid artery stenting. Exp Transl Stroke Med 2016;8:7.  Back to cited text no. 6
    




 

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