Physicians at the Brigham and Women’s Hospital’s (BWH) Cardiovascular Center offer carotid angioplasty with stenting and neuroprotection, an innovative alternative to carotid endarterectomy.
The procedure was FDA-approved in August 2004 for patients with suitable anatomy who are at increased risk of complications from carotid endarterectomy, the traditional standard treatment for carotid occlusive disease. Though endarterectomy has been established for over 50 years as a safe, effective, and well-tolerated treatment for both symptomatic and some asymptomatic patients, it may be contraindicated for patients at high risk for cardiopulmonary and other complications of surgery. Carotid stenting is proving to be a good therapeutic option for this group.
According to Andrew C. Eisenhauer, MD, Director of the Interventional Cardiovascular Medicine Service, “Recent information suggests that the real benefit of carotid stent angioplasty may lie in minimizing the non-neurovascular risk, chiefly heart attack, sometimes associated with surgery.”
Patient selection
Appropriate candidates for carotid stent therapy include those patients with severe (>70%) asymptomatic or moderate (>50%) symptomatic stenoses and:
-
High cardiac and/or pulmonary risk for surgery, or;
-
Previous endarterectomy with restenosis, or;
-
Low-lying common carotid lesions or high-lying cervical carotid lesions, or;
-
Limited neck range-of-motion, a history of radiation therapy to the neck, open tracheostomy or contralateral carotid occlusion.
Procedure
Stent-assisted carotid angioplasty with neuroprotection is performed percutaneously, usually through femoral arterial access. After a diagnostic angiogram, a cerebral embolic protection filter is advanced through the area of narrowing and deployed downstream in the distal internal carotid artery to trap any emboli released during the procedure while allowing continued cerebral perfusion. This differs from the requisite arterial clamping in open endarterectomy. A balloon is then advanced into the narrowed artery to dilate the stenosis, followed by placement of a self-expanding stent to maintain vessel patency.
Edwin C. Gravereaux, MD, Director of Endovascular Surgery and Interventional Therapy for the Division of Vascular Surgery, explains, “In experienced hands, the use of cerebral embolic protection devices has reduced the procedural risk of stroke in carotid stenting to the low levels seen in surgical endarterectomy.”
CREST trial
BWH is also a site for the Carotid Revascularization with Endarterctomy vs. Stenting Trial (CREST). This is a large, multicenter trial, which randomizes non-high risk patients to receive either traditional endarterectomy or stent-assisted carotid angioplasty in order to prevent stroke, myocardial infarction, and death. Also using the first FDA-approved system, stent-assisted cartoid angioplasty is a complex procedure being tested on a general set of patients, who would normally be good candidates for carotid surgery.
BWH clinicians will continue to enroll patients in the CREST trial over the next 18 months. They expect that the results will provide the first good comparison of the relative risks and benefits of the two therapies in a general population.
Patient benefits
Matthew T. Menard, MD, a vascular surgeon on the carotid stent team, says, “Carotid stent technology gives us the ability to offer an effective means of stroke prevention in a less invasive manner, without the risks of surgery.”
“Because our experts offer a full range of therapies for carotid occlusive disease, we are able to customize our treatment to reflect each patient’s individual risk stratification, as well as patient and referring physician preferences,” concludes Dr. Michael Belkin, Chief of Vascular and Endovascular Surgery at Brigham and Women’s Hospital.
This article appeared in BWH's March 2005 Cardiovascular Center Update.
The Cardiovascular Center at BWH
Delivering innovative insights and solutions to even the most complex disorders of the heart, vessels and circulatory system, The Cardiovascular Center leads the way in providing comprehensive care across the full spectrum of cardiovascular disease areas. Many of the innovative therapies and state-of-the-art technologies available at the Center have been developed by the experts of Brigham and Women’s Hospital. We are consistently ranked among the best hospitals in the country in just about every specialty, including cardiac surgery, cardiovascular medicine and vascular surgery.
Send Feedback to: 
