New techniques in carotid stenting.

The Nurse Practitioner • April 2008 43 cclusive lesions of the internal carotid artery (ICA) caused by atherosclerosis can cause embolic stroke or cerebral ischemia, which may result in significant morbidity, mortality, and long-term disability. Carotid stenosis can be accurately diagnosed by carotid duplex ultrasound imaging. Specific hemispheric symptoms related to potential embolism from a carotid stenosis include temporary ipsilateral vision loss, contralateral upper or lower extremity weakness or numbness, and speech disturbance (expressive aphasia). Carotid surgery is considered if a patient has had hemispheric symptoms in the past 6 months and more than 50% ICA stenosis, or more than 60% ICA stenosis in an asymptomatic patient. Based on the American Heart Association guidelines, carotid surgery should only be performed if the combined perioperative stroke and death rate is less than 3% in asymptomatic patients and 6% in symptomatic patients with high-grade ICA stenosis. Major landmark clinical trials (North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study) confirmed the superiority of carotid endarterectomy over best medical therapy in preventing stroke. Medical therapy,however,has continued to evolve since these trials. A reduction in stroke risk in patients with atherosclerotic disease has been attributed to the use of new antiplatelet agents, HMG-coenzyme A reductase inhibitors (statins), and more aggressive hypertension control. Studies comparing carotid intervention to the best present-day medical management are lacking, but experts feel carotid repair is still superior to drug therapy. The majority of clinical trials have enrolled only low-risk surgical patients. Higher-risk patients (patients over age 80) were typically excluded. Endovascular techniques continue to evolve in vascular surgery as carotid stenting has moved to the forefront over the last several years. The most significant improvement in carotid stenting safety outcomes has been the development and utilization of embolic protection devices (EPDs). Carotid stenting is emerging as an equivalent alternative to carotid endarterectomy in the management of high-risk surgical patients with carotid occlusive disease, but longO New Techniques in Carotid Stenting