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Limitations of carotid stenting - dr Antoni Ferens

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Limitations of carotid stenting - dr Antoni Ferens

  1. 1. LLiimmiittaattiioonnss ooff ccaarroottiidd sstteennttiinngg nneeuurroollooggiisstt ppooiinntt ooff vviieeww Antoni Ferens Stroke Unit University Hospital Kraków
  2. 2. SSttrrookkee  third leading cause of death  most common cause of permanent disability  affects 0.2% of the population (~200/100.000/y)  mortality ~50/100.000/y
  3. 3. CCaarroottiidd sstteennoossiiss Stenosis of internal carotid artery is responsable for 10-20% of all strokes Risk of stroke asymptomatic patinents with stenosis >60%~1-3%/y symptomatic patients with stenosis 50-69% 4.4%/y symptomatic patients with stenosis >70% 13%/y
  4. 4. GGuuiiddeelliinneess ffoorr ccaarroottiidd sstteennttiinngg ESO Guidelines 2008 angioplasty and/or stenting (CAS) is only recommended in selected patients. It should be restricted to the following subgroups of patients with severe symptomatic carotid artery stenosis: those with contra-indications to CEA, stenosis at a surgically inaccessible site, re-stenosis after earlier CEA, post-radiation stenosis
  5. 5. GGuuiiddeelliinneess ffoorr ccaarroottiidd sstteennttiinngg GGuuiiddeelliinneess ooff AAHHAA//AASSAA 22001111 CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by >70% by noninvasive imaging or >50% by catheter angiography. among patients with symptomatic severe stenosis (>70%) in whom the stenosis is difficult to access surgically, medical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist, such as radiation induced stenosis or restenosis after CEA, CAS may be considered.
  6. 6. GGuuiiddeelliinneess ffoorr ccaarroottiidd sstteennttiinngg EESSCC GGuuiiddeelliinneess eennddoorrsseedd bbyy:: EESSOO 22001111 in asymptomatic patients with an indication for carotid revascularization, CAS may be considered as an alternative to CEA in high-volume centres with documented death or stroke rate <3%. in symptomatic patients requiring carotid evascularization, CAS may be considered as an alternative to CEA in high-volume centres with documented death or stroke rate <6%.
  7. 7. IInnddiiccaattiioonnss ffoorr rreevvaassccuullaarriizzaattiioonn ooff ccaarroottiidd aarrtteerryy  asymptomatic stenosis  symptomatic stenosis  emergency revascularisation
  8. 8. MMeeddiiccaall lliimmiittaattiioonnss  general and neurological status  life expectancy  comorbidities (renal insufficiency, contralateral carotid occlusion)  age  gender  compliance !
  9. 9. AAnnaattoommiiccaall lliimmiittaattiioonn  inability to obtain femoral access  severe atherosclerosis and/or calcification of aortic arch  extreme angulation of great vessel orgins from the aorta  severe tortuosity of carotid artery  severe calcification of the target stenosis
  10. 10. CCeenntteerr lliimmiittaattiioonnss  operator expirience  range of available devices  reimbursement
  11. 11. FFiinnaall ddeecciissiioonn To stent or not to stent? Carefully weight all pros and cons for every patient
  12. 12. QQuueessttiioonnss ffoorr ffuuttuurree  what is the risk of stroke in carotid artery stenosis ?  late complications of stent placement ?  when perform revascularization after stroke?  who is the most appropriate specialist to qualify patient?

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