Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access
Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc
Journal website https://www.cardiologyres.org

Review

Volume 4, Number 1, February 2013, pages 8-14

Carotid Artery Stenting 2013: Thumbs up

Figures

Figure 1.
Figure 1. (a). Common sense analogy from coronary artery revascularisation strategies. Not many sane interventional cardiologists would advocate primary percutaneous treatment for this symptomatic severe left main, left anterior descending, circumflex and intermediate coronary lesion with a collateralised periphery from the right coronary artery. On the other hand, only a few cardiac surgeons would seriously advise bypass grafting as first line treatment for the focal, single vessel lesion depicted in (b).
Figure 3.
Figure 3. Severe calcification of the radial and ulnar artery in an 81-year-old patient with patent radial and ulnar pulse, precluding carotid or coronary intervention using radial access.
Figure 2.
Figure 2. (a). Ulcerated plaque in a 62-year-old patient with contralateral complete chronic occlusion of the internal carotid artery. (b). Result after stenting. The patient is event- and symptom-free, three years after the intervention.
Figure 4.
Figure 4. (a). Symptomatic subacute dissection (thick arrow) of the right internal carotid (thin arrow) in a 64-year-old woman; (b). Repeat angiography one and a half year later, indicated after sonographic diagnosis of severe restenosis, shows only moderate intimal hyperplasia (arrow) and restenosis; (c). Pressure gradient (0.95) measurement across the lesion confirms good functional result. The patient is discharged without undergoing the planned PTA and drug eluting balloon treatment.
Figure 5.
Figure 5. (a). Severe ostial left common carotid stenosis in a 60-year-old patient, heavy smoker, with severe chronic obstructive lung disease and bypass surgery 8 days previously. (b). Result after balloon-expandable stent implantation.
Figure 6.
Figure 6. (a). Severely stenotic lesion of the left internal carotid artery in a 83-year-old patient with recurrent transient ischemic attacks. (b). Result after uneventful stenting. Atrial fibrillation had been treated by pulmonary vein isolation and left atrial appendage occlusion. Critical three-vessel coronary artery disease had been tackled by multivessel-stenting.

Table

Table 1. Anatomic and Clinical Variables Associated With Increased Risk of Periinterventional Stroke (Modified From [7-9])
 
natomic variablesClinical variables
BT: brachiocephalic trunk; CEA: carotid endarterectomy; GFR: glomerular filtration rate; IC: internal carotid artery; LCC: left common carotid artery; SA: subclavian artery; TIA: transient ischemic attack. * Combination of target vessel and lesion variables associated with incremental periinterventional risk. When 2 or more variables are present, the author usually advises CEA as first choice treatment.
Type III aortic arch (elongation and rostral migration of the arch, origin of the BT artery lower than SA by more than 2 diameters of LCC) and/or LCC arising from SA *Previous stroke or TIA (Fig. 6)
Severe tortuosity of target arteries proximal or distal to target lesion*Age > 75 years (Fig. 6)
Severe calcification of target LCC or IC lesion *GFR < 40 mL/min
Stenosis with ulcerated calcified plaque * (Fig. 2a)Smoking
Severe aortic arch calcification *History of atrial fibrillation (Fig. 6)
Tortuous aortic arch, abdominal or thoracic aorta *Dementia
Untreated significant peripheral arterial disease of access arteryPrevious ipsilateral CEA, contralateral total occlusion (Fig. 2)
Calcification of radial or brachial artery when radial or brachial access is considered (Fig. 3)Target lesion symptomatic within 6 months
Visible thrombus present in lesion (contraindication)Urgent cardiac surgery within 30 days (Fig. 5)