1. LLiimmiittaattiioonnss ooff ccaarroottiidd
sstteennttiinngg
nneeuurroollooggiisstt ppooiinntt ooff vviieeww
Antoni Ferens
Stroke Unit
University Hospital Kraków

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. 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. 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. 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. 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. IInnddiiccaattiioonnss ffoorr rreevvaassccuullaarriizzaattiioonn
ooff ccaarroottiidd aarrtteerryy
 asymptomatic stenosis
 symptomatic stenosis
 emergency revascularisation

8. MMeeddiiccaall lliimmiittaattiioonnss
 general and neurological status
 life expectancy
 comorbidities (renal insufficiency, contralateral
carotid occlusion)
 age
 gender
 compliance !

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. CCeenntteerr lliimmiittaattiioonnss
 operator expirience
 range of available devices
 reimbursement

11. FFiinnaall ddeecciissiioonn
To stent or not to stent?
Carefully weight all pros and cons for every patient

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?