Treatment of carotid artery stenosis: medical therapy, surgery, or stenting?

Abstract

With the aging of the general population and the availability of noninvasive imaging studies, carotid artery stenosis is a disease commonly seen in general medical practice. Differentiation between symptomatic and asymptomatic disease is critical to the treatment course because the natural history differs markedly between them. Antiplatelet therapy and aggressive treatment of vascular risk factors are the mainstays of medical therapy. Class I evidence shows that carotid endarterectomy (CEA) is effective in preventing ipsilateral ischemic events in patients with symptomatic moderate- and high-grade stenosis. The procedure is also effective in selected patients with asymptomatic stenosis, but the benefit is marginal. In the past decade, carotid angioplasty and stenting has been proposed as a valid alternative to CEA. Currently, it is unclear whether carotid angioplasty and stenting is as safe as CEA in patients with carotid artery stenosis who need invasive treatment. Large clinical trials are under way to answer this question.

FIGURE.

Carotid angioplasty and stenting. A, Large catheter (guide catheter, not shown) is placed in the common carotid artery proximal to the stenosis. Through this catheter, a filter wire is used to cross the stenosis and deploy a filter (distal protection) in the internal carotid artery distal to the plaque. The filter captures emboli dislodged during the procedure. B, Angioplasty (predilatation) of the plaque is performed with an angioplasty balloon, followed by stent deployment (C). Occasionally, angioplasty may be necessary after stenting to further dilate residual stenosis. D, The filter is “captured” and withdrawn into the guide catheter. The procedure is done with full heparinization. Patients receive maintenance dual antiplatelet therapy, usually aspirin plus clopidogrel, for at least 4 to 6 weeks.