ABSTRACT

With the introduction of distal embolic protection (DEP) devices and stents designed for the carotid circulation, several clinical studies have demonstrated the morbidity and mortality for carotid angioplasty and stenting (CAS) in high-risk patients with atherosclerotic carotid artery disease to be on a par with or better than for carotid endarterectomy (CEA).1-12 High-risk CAS registries that included the outcome of myocardial infarction (MI), unlike the North American Symptomatic Carotid Endarterectomy Trial (NASCET)13,14 and the Asymptomatic Carotid Atherosclerosis Study (ACAS),15 have reported 30-day rates of MI, stroke, or death ranging from 3.9 to 8.2%.4,5,7,8,10,11,16

The Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) trial had 5.8% 30-day and 12% 1-year event rates, also including MI.12 A review of our series of patients at the University at Buffalo has demonstrated morbidity and mortality rates paralleling those of NASCET and ACAS, even in a group of patients undergoing CAS of whom 78% would not have qualified for enrolment in

these studies due to anatomic or physiologic high-risk profiles.17 Low-risk CAS trials are ongoing. Nevertheless, from femoral artery puncture to DEP device retrieval and final angiography, potential exists for complications during CAS that can be threatening to life, limb, or brain. Management of these complications can take the effort of a team that includes neuroradiologists, cardiologists, neurosurgeons, and vascular surgeons, depending on the clinical and technical skill set of the individual interventionists. Although delayed neurologic, cardiac, and peripheral complications can occur, an acute neurologic event often requires immediate intervention or the hope for meaningful salvage declines precipitously. Unlike CEA, CAS is usually performed while the patient is awake, which allows continuous neurologic and angiographic assessment and prompt recognition of potential problems.