ABSTRACT
SPECIAL ISSUES OR CONSIDERATION There are three groups of patients at high risk for whom the best approach (CAS vs. CEA) remains to be determined. The first group includes patients with evidence of thrombus in a symptomatic carotid lesion. On angiography thrombus appears as intraluminal filling defect, although the differentiation with a severe but focal calcification or a ruptured eccentric plaque may not always be possible. In the North American Symptomatic Carotid Endarterectomy Trial (NASCET), these patients carried an 18% to 22% risk of perioperative stroke. With respect to CAS, such patients have been excluded from the trials, but it is generally agreed that the stroke risk is also high with the endovascular treatment. In these patients, a short period of anticoagulation in addition to aspirin may be considered, followed by CEA or CAS once the thrombus resolves. In patients experiencing ongoing ischemia despite anticoagulation, endovascular therapy may be an option if it can be performed with flow reversal/blockage to prevent embolization during EPD placement.
