ANGIOPLASTY AND STENTING OF THE EXTRACRANIAL CAROTID ARTERIES. PART I

Michel Henry, MD, Max Amor, MD, Isabelle Henry, MD, Isabelle Masson, MD, Kiril Tzvetanov, MD
Polyclinique,
Essey-les-Nancy, France

Cerebro-vascular accidents remain a major public health problem. It is the third leading cause of death accounting for 150,000 strokes per year in France and 500,000 strokes per year in the United States. One third of the patients suffering from an ischemic stroke die and another third are rendered permanently disabled [1]. The incidence of the ischemic origin of stroke increases with age, 33% before the age of 45 and 80% after 50 [2]. Carotid stenoses account for 20 to 30% of all cases [3] and their [4] natural history is related to the severity of the lesions [4]. Indeed, patients who have carotid stenosis greater than 75% have a 2 to 5% risk of suffering an ischemic stroke during the first year [5,6]. Following a transient ischemic attack, the risk for ischemic stroke is 12 to 13% in the first year, and 30 to 37% in the 5 years following the first symptoms [7,8]. In patients who have had a stroke, the risk for subsequent strokes is 5 to 9% per year, and approximately 24 to 45% of them have another stroke within the next 5 years [9]. The presence of ulceration also predicts an increased risk for an ischemic stroke [6,10]. Prospective randomized studies such as NASCET [11], ECST [12] and the ACAS study [13] proved the superiority of carotid endarterectomy over medical treatment for symptomatic stenoses greater than 70% and 60% respectively. However, the inherent risks of surgery limit the application of carotid endarterectomy. The risk of stroke was 5.8% in the NASCET study, 7.5% in the ECST study and 2.3% in the ACAS study. Goldstein [14] reported on 25 surgical studies and estimated the risk of ischemic stroke and death at 30 days to be 3.35% for asymptomatic and 5.18% for symptomatic stenoses. Rothwell [15] studied 50 surgical series and found the risk of cerebro-vascular accidents to be 7.7% in the series followed up by neurologists, and 2.3% in the series with only a surgical follow-up. Roubin [16] also reported a 7.7% incidence of stroke in a review of 126 surgical published series when the follow up was performed by a neurologist. The mortality and morbidity was particularly high (18%) [11,17,18] in the surgical patients who also had significant coronary artery disease. Other complications of the carotid endarterectomy procedure are cranial nerve palsies (7.6 to 27%) [11-19], hematomas (5.5%) [11], and restenoses (5 to 9%) [20,21]. Even though the endarterectomy procedure was performed by well trained surgeons in these series, high risk patients were excluded in the NASCET and ACAS studies because of strict exclusion criteria. Angioplasty has proved to be very effective in coronary and peripheral arteries and therefore may also be considered as an alternative to surgery for carotid stenoses. Long term results – at least 5 years – are expected. Although carotid angioplasty was first performed by Kerber [22] in 1980, it is still not a widely accepted treatment for carotid stenosis. Interventionists have been reluctant due to the potential risks of cerebral embolism, but it is expected in the future cerebral protection methods may limit these risks. We are reporting our personal experience with carotid angioplasty and stenting in a series of 205 arteries (192 patients) and we are describing the different techniques used in our experiment for this procedure.

KEY WORDS: Carotid stenting.

P. 81-92

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