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Online ISSN 1827-1847
Heyer K. S., Eskandari M. K.
Division of Vascular Surgery Northwestern University Feinberg School of Medicine Chicago, IL, USA
Carotid artery stenting (CAS) has rapidly become an acceptable alternative to carotid endarterectomy (CEA), particularly in patients deemed high risk for surgery. In less than a decade technologic advancements have blossomed dramatically, yet the true clinical impact of these improvements remains unknown. This contemporary review of the literature provides some perspective on available carotid stent systems and the associated neurologic and target lesion outcome. In regards to mechanical embolic protection devices (EPDs), our review shows a slight superiority of those which employ proximal balloon occlusion in reducing the procedural incidence of stroke. Theoretically, this is due to the ability to obtain complete embolic capture prior to crossing the target lesion. However, as with all EPDs there remains a significant and universal stroke risk merely from the maneuvers required to adequately position the guiding catheter or sheath in the common carotid artery. Not surprisingly, stent materials, configurations, and designs have varied clinical implications. Nitinol stents tend to have a slightly lower rate of major stroke as compared to Elgiloy, however the number of cases reviewed did not have the power to tease out a statistically significant difference. Furthermore, data demonstrating differences in restenosis rates among these two stent materials is lacking. Recent data has shown that self-expanding stents possessing a closed cell design have fewer adverse neurological events as compared to open cell stents. The improved flexibility of the open cell stents, however seems best suited for asymptomatic patients with particularly tortuous vessels. Tapered stents may have lower rates of asymptomatic occlusion or restenosis, but perioperatively there is little difference as compared to their nontapered counterparts. Lastly self-expanding stent fracture in the carotid vasculature is relatively unknown; yet two recently published case reports of fractures presenting as early restenotic lesions are discussed in this article.