Carotid artery stenosis poses a significant risk to cardiovascular health. Traditionally, carotid endarterectomy has been the treatment of choice for these narrowings. However, as technology advances, minimally invasive methods have emerged. One such technique is carotid artery stenting. Less invasive for patients, this method accelerates recovery and offers an alternative to surgery. Innovations in vascular surgery help patients return to their normal lives more quickly.
| What You Need to Know About Treating Carotid (Neck Artery) Stenosis with Stents | |
| Definition | Placement of a stent to widen narrowings in the carotid arteries and improve blood flow. |
| Indications | Symptomatic carotid stenosis; severe (70–99%) asymptomatic stenosis; patients at high surgical risk. |
| Contraindications | Complete arterial occlusion; severe bleeding disorders; allergy risk to contrast agents; active infection. |
| Pre‑procedure Preparation | Blood tests; imaging studies (Doppler ultrasound, MR, CT angiography); initiation of aspirin or anticoagulant; fasting requirement. |
| Procedure Duration | Approximately 30 minutes. |
| Anesthesia Type | Local anesthesia with sedation. |
| Procedure Steps |
1. Advance catheter from groin or arm to carotid artery 2. Dilate narrowing with balloon (balloon angioplasty) 3. Deploy and expand stent 4. Verify blood flow and remove catheter |
| Complications | Stroke; bleeding; stent migration; vessel injury; infection; allergic reaction to contrast agent. |
| Recovery Time | Usually one day; hospital stay may be one day. |
| Success Rate | High; symptom relief in symptomatic patients and reduced stroke risk. |
| Alternative Treatments | Carotid endarterectomy; medical therapy (statins, anticoagulants); lifestyle modifications. |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
What Is Carotid Endarterectomy?
Carotid endarterectomy is the surgical removal of plaque from the carotid arteries, also known as the neck arteries. Through an incision in the neck, the artery is exposed and plaque is removed. This procedure is vital for patients with severe stenosis. It is typically performed under local anesthesia. Advantages include:
- Effective removal of high‑risk plaque,
- Reduction of stroke risk,
- Long‑term preservation of vessel health.
Despite advances in vascular surgery, carotid endarterectomy remains widely used. However, with the rise of minimally invasive techniques like carotid stenting, alternatives are gaining prominence. These methods shorten hospital stays and speed recovery. While endarterectomy remains the gold standard in certain cases, treatment should be tailored to each patient’s situation.
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Anatomy and Clinical Importance of the Carotid Arteries
The carotid arteries are major vessels supplying critical blood flow. The left common carotid artery arises directly from the aortic arch, while the right arises from the brachiocephalic trunk. Each divides into internal and external carotid arteries. The internal carotid arteries supply the brain, and the external supply the face, scalp, and neck. This division underscores their vital functions.
- Internal Carotid Arteries: Carry oxygenated blood to the brain.
- External Carotid Arteries: Supply blood to the face, scalp, and neck.
Collateral vessels at several points provide alternative pathways if one artery is blocked. The aortic arch has three anatomical types, classified by the origin of its major branches:
- Type 1: Branches originate at the highest point of the arch.
- Type 2: Branches align with the second parallel line.
- Type 3: Branches lie within the third parallel line.
These anatomical variations affect procedures like carotid stenting, making detailed pre‑procedure imaging essential for each patient.
When Is Carotid Stenting Appropriate?
Ideal candidates are patients at high surgical risk, including those with:
- Severe pulmonary disease,
- Recent myocardial infarction,
- Unstable angina,
- Advanced heart failure.
Previous interventions and anatomical challenges also favor stenting:
- Prior neck radiation therapy,
- Contralateral vocal cord injury,
- Existing tracheostomy,
- Contralateral carotid occlusion,
- Recurrent stenosis after endarterectomy.
Contraindications to Carotid Stenting
Contraindications include:
- Transfemoral approach hindered by severe aortic arch calcification or Type 3 arch,
- Severe contrast allergy (may pre‑treat to reduce risk),
- Transcarotid approach not feasible if common carotid length < 5 cm below clavicle.
Required Equipment and Uses
Essential equipment includes an ultrasound unit and fluoroscopic imaging system for real‑time guidance, plus lead protection and sterile drapes for safety.
For transfemoral approach:
- Micropuncture kit for femoral artery access,
- 0.035″ and 0.014″ guidewires for stent delivery,
- 6 Fr short and long sheaths for access,
- Angled catheters for lesion access,
- Angioplasty balloons for vessel dilation,
- Embolic protection device or flow reversal system to prevent emboli.
Preparation for Carotid Stenting
Proper preparation is critical. For transfemoral access, position the patient supine with head turned contralaterally. Sterilize and drape the groin. Continuous hemodynamic monitoring and vasoactive drugs should be ready. Sedation with local anesthesia or general anesthesia may be used, particularly if neurological monitoring (EEG or cerebral mapping) is required. Continue pre‑ and post‑procedure medications, and involve anesthesia team for monitoring.
Techniques for Treating Carotid Stenosis with Stents
- Image of carotid artery stenting
Treatment options have diversified, with stenting playing a key role.
Transfemoral approach:
- Access via femoral artery,
- Advance guidewire and catheter to aortic arch and carotid,
- Perform angiographic imaging to locate and cross lesion,
- Deploy embolic protection device,
- Place stent and, if needed, perform balloon angioplasty.
Post‑procedure care is vital for rapid recovery. Continuous hemodynamic monitoring and prompt management of complications are essential. Treatment choice depends on patient anatomy, lesion characteristics, and overall health, guided by advanced imaging.
Potential Risks of Carotid Stenting
Risks include:
- Bleeding at femoral access site,
- Vessel perforation or dissection,
- Thrombosis,
- Distal embolization,
- Stent fracture or malposition.
These complications can impact both procedural success and patient recovery. Patients should be informed of these risks during planning.
Clinical Comparisons
Comparative studies between carotid artery stenting (CAS) and surgical endarterectomy (CEA) show similar restenosis rates. However, myocardial ischemia risk is higher with CEA, while stroke risk is higher with CAS. CAS may be more challenging in:
- Patients over 70 years old,
- Those with extensive white matter lesions.
The transcarotid approach can reduce embolization risk. Ongoing trials continue to clarify the benefits. Hospital stays and long‑term costs are comparable for both methods.
Multidisciplinary Team Enhances Outcomes
Carotid disease is a serious condition often identified in primary care. Pulmonologists and internists refer cases to specialists. Vascular surgeons and interventional radiologists perform stenting, speeding recovery and reducing stroke risk. Post‑procedure, lifestyle changes are crucial:
- Weight management,
- Lipid control,
- Regular exercise.
These measures help prevent atherosclerosis and improve overall cardiovascular health.
Frequently Asked Questions
The most serious complication is embolic debris reaching cerebral vessels, causing transient or permanent stroke. Use of embolic protection filters reduces this risk significantly. With careful technique by neurointerventionalists, stroke risk can be lowered below 1%. Thus, stenting is considered very safe, though all interventions carry inherent risks.
Patients typically resume daily activities within days. Lifelong antiplatelet therapy is prescribed and must be adhered to. Smoking cessation, lipid and glucose control through diet and exercise, and regular follow‑up to monitor stent patency and cardiovascular health are essential.
The procedure generally takes about 30 minutes. Duration may vary with lesion complexity and location, sometimes extending slightly. Most cases are completed within this timeframe.
Additional Resources and Documents
https://ozgurkilickesmez.com/wp-content/uploads/2024/07/white-et-al-2022-carotid-artery-stenting.pdf
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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