Carotid Artery Stenting Periprocedural Care
- Author: Faisal Aziz, MD; Chief Editor: Karlheinz Peter, MD, PhD more...
Listed below are the standard equipment and materials needed for carotid artery stenting (CAS). All interventionalists who are performing percutaneous carotid interventions should choose their equipment in accordance with their personal preferences and with the local availability of specific materials and devices.
Access can be obtained using a micropuncture kit (Cook, Inc). This kit consists of a 21-gauge needle for obtaining access to the vessel, Torq-Flex® wire, and a coaxial catheter.
The following two wires can be used:
0.035-in. hydrophilic guide wire (Terumo) to access the aortic arch
0.014-in. hydrophilic guide wire (Spartacore) to cross the lesion
A 6-French access sheath can be used initially, then a 6-French long guiding sheath system.
To gain access to the aortic arch and advance the guide wire through the carotid lesion, complex catheter manipulations may be required, especially if the patient has a tortuous anatomy. Catheters with varying degrees of angulation assist in minimally traumatic catheter passage. Available catheters include the following:
JB-2 catheter (Cook, Inc)
SIM 1 catheter (Cook, Inc)
SIM 2 catheter (Cook, Inc)
H1 catheter (Cook, Inc)
VTK catheter (Terumo)
Glide vertebral catheter
There are two main types of balloon systems: coaxial and monorail. For carotid interventions, monorail balloons can be used, with predilation of the lesion with a 2- or 3-mm balloon.
The balloon length is chosen according to the length of the stenotic lesion. To reduce the risk of atheroembolization, poststent dilation is generally avoided. If such dilation is required, a 5- or 6-mm balloon is used, depending on the diameter of the stent and the diameter of the stenotic lesion.
Stents (balloon-expandable and self-expanding)
There are two basic types of stents: balloon-expandable and self-expanding.
Balloon-expandable stents are mounted on a balloon catheter and passively enlarged to the desired diameter at the implantation site by dilating the balloon. They are better suited for proximal carotid artery and innominate artery lesions and offer greater precision during CAS. Their collapsed diameter is slightly larger than that of self-expanding stents; therefore, it is often difficult to cross a lesion with them unless the stenosis is predilated. The Express® stent (Boston Scientific) is the available balloon-mounted stent for carotid artery lesions.
Self-expanding carotid stents are used as a minimally invasive alternative to carotid endarterectomy (CEA). They open actively after being released from the delivery system. Their self-expanding character depends either on the braiding structure or on the type of alloy (usually nitinol or stainless steel). Commercially available self-expanding stents include the following:
Carotid WALLSTENT ® (Boston Scientific)
Nexstent ® (Boston Scientific)
Precise ® (Cordis)
Protege ® (ev3)
Xact ® (Abbott)
Cerebral protection devices
The purpose of cerebral protection devices (CPDs) is to capture atherosclerotic emboli during catheter manipulation, angioplasty, and stenting. The risk of atheroembolization is greatest during balloon angioplasty of the stenosis and when the lesion is crossed by a wire. Different types of CPDs are commercially available, as follows:
GuardWire ® temporary occlusion and aspiration system (Medtronic) - This is available in two balloon sizes, 2.5-5 mm and 3-6 mm, on a 0.014-in. wire system
GORE Neuro Protection System (W. L. Gore & Associates; previously called Parodi Anti-Embolic System) - This system, based on the hemodynamic principle of reversal of internal carotid artery blood flow with common carotid artery occlusion, comes with a set of two balloons, one placed in the external carotid artery and the other in the common carotid artery; when both balloons are inflated, backbleeding generally occurs from the internal carotid artery
Filterwire EZ ® embolic protection system (Boston Scientific) - The basic mechanism is filter-based; it is based on a 0.014-in. wire system
Angioguard RX ® emboli capture guide wire system (Cordis)
RX Accunet ® embolic protection system (Abbott)
Emboshield NAV6 ® embolic protection system (Abbott)
Spider FX ® embolic protection device (ev3)
Conscious sedation and local anesthesia are preferred so as to permit continuous monitoring of the patient’s neurologic status. During balloon inflation, bradycardia and hypotension may occur; therefore, continuous cardiac monitoring and intra-arterial blood pressure monitoring are performed in all patients who undergo CAS.
Carotid stenting procedures are performed in a hybrid, fixed C-arm operating room where multiplanar views are easily obtained. The patient is supine, with the head turned toward the opposite side. The operating surgeon usually stands on the patient's right side. Extra table length is added at the foot of the table to ensure that all wire lengths can be handled easily in a sterile field.
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991 Aug 15. 325(7):445-53. [Medline].
Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998 Nov 12. 339(20):1415-25. [Medline].
Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995 May 10. 273(18):1421-8. [Medline].
MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet. 1991 May 25. 337(8752):1235-43. [Medline].
Aronow HD, Collins TJ, Gray WA, Jaff MR, Kluck BW, Patel RA, et al. SCAI/SVM expert consensus statement on Carotid Stenting: Training and credentialing for Carotid Stenting. Catheter Cardiovasc Interv. 2016 Feb 1. 87 (2):188-99. [Medline].
Naylor AR, Bolia A, Abbott RJ, Pye IF, Smith J, Lennard N. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg. 1998 Aug. 28(2):326-34. [Medline].
Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol. 2001 Nov 15. 38(6):1589-95. [Medline].
Brooks WH, Jones MR, Gisler P, McClure RR, Coleman TC, Breathitt L, et al. Carotid angioplasty with stenting versus endarterectomy: 10-year randomized trial in a community hospital. JACC Cardiovasc Interv. 2014 Feb. 7(2):163-8. [Medline].
Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001 Jun 2. 357(9270):1729-37. [Medline].
Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004 Oct 7. 351(15):1493-501. [Medline].
Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012 Sep. 11(9):755-63. [Medline]. [Full Text].
Chang CK, Huded CP, Nolan BW, Powell RJ. Prevalence and clinical significance of stent fracture and deformation following carotid artery stenting. J Vasc Surg. 2011 Sep. 54(3):685-90. [Medline].
[Guideline] Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neuro... Circulation. 2011 Jul 26. 124(4):e54-130. [Medline].
[Guideline] Bates ER, Babb JD, Casey DE Jr, Cates CU, Duckwiler GR, Feldman TE, et al. ACCF/SCAI/SVMB/SIR/ASITN 2007 clinical expert consensus document on carotid stenting: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Committee on Carotid Stenting). J Am Coll Cardiol. 2007 Jan 2. 49(1):126-70. [Medline].