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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article reviews the latest advances in carotid stenting for the management of stroke, including carotid stenting for prevention of ipsilateral stroke, carotid endarterectomy versus carotid artery stenting, and embolic protection and patient selection.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EValvular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECarotid Stenting for Prevention of Ipsilateral Stroke\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EInternal carotid artery stenosis accounts for 20% of all ischemic strokes. Carotid artery stenosis is considered symptomatic in the presence of transient ischemic attack (TIA) or stroke affecting the corresponding territory within the previous 6 months. The North American Symptomatic Carotid Endarterectomy Trial [NASCET] found that the risk of recurrent ipsilateral stroke in patients with symptomatic carotid artery stenosis treated conservatively was 4.4% per year for patients with 50% to 69% stenosis and 13% per year for those with \u0026gt;70% stenosis. The risk of recurrent TIA or stroke is 10% to 30% in the first month [Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EProf. Habib Gamra, MD, Fattouma Bourguiba University Hospital, Monastir, Tunisia, reviewed the latest advances in carotid stenting for the management of stroke. Accurate assessment and revascularization should be undertaken very early after a TIA. The decision to revascularize is based on the presence of signs or symptoms related to the affected carotid artery; the degree of internal carotid artery stenosis; and other factors including patient age, gender, comorbidities, and life expectancy [Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EPatients with carotid artery disease may present with hemispheric ischemia, which manifests as a combination of weakness, paralysis, numbness, and\/or tingling on the side of the body contralateral to the culprit artery. Another possible clinical manifestation is temporary or permanent partial or total blindness in the ipsilateral eye, caused by emboli to the retinal artery. Duplex ultrasound, computed tomography angiography, and\/or magnetic resonance angiography are recommended by the European Society of Cardiology (ESC) for evaluation of carotid artery stenosis and to determine the need for revascularization (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/8\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022ESC Guidelines for Management of Carotid Artery Disease.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1626189615\u0022 data-figure-caption=\u0022ESC Guidelines for Management of Carotid Artery Disease.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/8\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/8\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/8\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12780\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EESC Guidelines for Management of Carotid Artery Disease.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003E*The management of symptomatic carotid artery disease should be decided as soon as possible (\u0026lt;14 days after onset of symptoms); \u2020After multidisciplinary discussion including neurologists; BMT=best medical therapy; CTA=computed tomographic angiography; MRA=magnetic resonance angiography; TIA=transient ischemic attack.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from The European Society of Cardiology.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECarotid Endarterectomy Versus Carotid Artery Stenting\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ECarotid endarterectomy (CEA) was shown to be more effective than medical management for the endpoint of stroke and death rate in NASCET (5.8%) and the Asymptomatic Carotid Atherosclerosis Study [ACAS] (2.7%). Carotid artery stenting (CAS) is less invasive than CEA, is performed under local anesthesia, avoids the risk of peripheral nerve damage associated with neck dissection, and is less painful. The goal of CAS is to lower the risk of ipsilateral carotid, plaque-related stroke.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ESeveral studies have compared CAS with CEA (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). The only current head-to-head trials of CAS versus CEA are the Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS; CAVATAS Investigators. \u003Cem\u003ELancet\u003C\/em\u003E 2001], Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE; Gurm HS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008], and Carotid Revascularization Using Endarterectomy or Stenting Systems [CaRESS; Di Mario C et al. \u003Cem\u003ELancet\u003C\/em\u003E 2008] studies. The 30-day data showed no significant difference in stroke or death rates between CAS and CEA in the CAVATAS (10% vs 10%), SAPPHIRE (4.8% vs 5.6%), and CaRESS studies (2.1% vs 3.6%; \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E). For the endpoint of stroke, death, or myocardial infarction (MI) with CAS vs CEA, there was no significant difference in the CAVATAS (10% vs 11%), CaRESS (2.1% vs 4.4%), and SAPPHIRE (4.8% vs 9.8%) trials, although the difference was close to reaching significance in the SAPPHIRE study (p=0.06).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12781\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12781\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12781\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EStudies of CAS Versus CEA.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12782\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12782\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12782\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003E30-Day Results: CAS Versus CEA.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis [EVA-3S] trial randomized 527 symptomatic patients with stenosis \u226560% to CAS or CEA, with a primary endpoint of the cumulative incidence of any stroke or death within 30 days of treatment [Mas JL et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2006]. The trial was stopped early because of significantly increased event rates in the CAS arm (9.6%) versus the CEA arm (3.9%; RR, 2.5; 95% CI, 1.2 to 5.1; p=0.01).\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe Carotid Revascularization Endarterectomy Versus Stenting Trial [CREST] randomized 2502 asymptomatic and symptomatic patients to CAS versus CEA [Brott TG et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. There was no difference in the primary endpoint of periprocedural stroke, MI, or death, plus ipsilateral stroke at 4 years between CAS (7.2%) and CEA (6.8%; HR for CAS, 1.11; 95% CI, 0.81 to 1.51; p=0.51). However, CAS was more effective than CEA in patients \u0026lt;70 years (p=0.02). Twice as many acute MIs occurred in the CEA group (2.3%) versus the CAS group (1.1%; p=0.03). The difference in overall stroke rate was 4.1% with CAS versus 2.3% with CEA (p=0.01) but there was no difference in major disabling strokes between the 2 groups.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EA meta-analysis of 13 randomized trials (n=7484) found that CAS versus CEA was associated with an increased risk of any stroke (RR, 1.45; 95% CI, 1.06 to 1.99), decreased risk of periprocedural MI (RR, 0.43; 95% CI, 0.26 to 0.71), and a nonsignificant increase in mortality (RR, 1.40; 95% CI, 0.85 to 2.33) [Economopoulos KP et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011; Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEmbolic Protection and Patient Selection\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EEmbolic protection devices (EPDs) are an accepted part of CAS designed to reduce the risk of periprocedural stroke. Several types exist, including temporary occlusion and aspiration devices, filter devices, and flow reversal devices.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EIn the EVA-3S trial, CAS without an EPD was halted because of excessive stroke risk compared with EPD use (OR, 3.9; 95% CI, 0.9 to 16.7) [Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011]. The ESC Guidelines on the diagnosis and treatment of peripheral artery diseases recommend dual antiplatelet therapy with aspirin and clopidogrel for patients undergoing CAS, and the use of EPDs may be considered.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ESelection of patients for CAS is important. High-risk patients include asymptomatic patients \u0026gt;80 years of age, patients with access problems, patients with a large neurologic defect at baseline, patients with marked cerebral atrophy and microangiopathy, and those with dementia. High-risk lesions include those with obvious filling defect or thrombus; vessel occlusion; severe distal loops, kinks, or bends; and heavy concentric calcifications.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EThe ESC Guidelines say CEA should be considered in asymptomatic patients with carotid artery stenosis \u226560% if the perioperative stroke and death rate for procedures performed by the surgical team is \u0026lt;3% and the patient\u0027s life expectancy exceeds 5 years [Tendera M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011]. CAS may be considered as an alternative in high-volume centers with a documented death or stroke rate \u0026lt;3%. In symptomatic patients, CEA is recommended for those with 70% to 99% stenosis and should be considered for those with 50% to 69% stenosis, depending on patient-specific factors. For symptomatic patients at high surgical risk requiring revascularization, the guidelines recommend CAS as an alternative to CEA. In symptomatic patients requiring revascularization, CAS may be considered as an alternative to CEA in high-volume centers with a documented death or stroke rate of \u0026lt;6%.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003ECarotid stenting is an appealing noninvasive procedure with great potential, particularly in the management of stroke. However, the indications for carotid stenting remain limited and patient selection is crucial. Operator expertise is even more important and has been shown to influence outcomes.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/8\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzna41\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzna41\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzna41\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}