Current Standard of Endovascular Treatment. Indication and Technical Problems of Stent Placement for Cervical Carotid Artery Stenosis.

The gold standard for treating cervical carotid artery stenosis has been carotid endarterectomy (CEA). However, in patients at high risk for surgery, there is no evidence of the risk-benefit ratio of CEA. Carotid stenting (CS) has recently become an alternative treatment in high-risk cases. We discuss our current strategy for cervical carotid artery stenosis, and report our clinical results of CS and some technical contrivances to reduce the procedural risk.We have treated 106 cases involving 116 severe carotid artery stenoses between June 1998 and December 2000. CS was applied to only high-risk cases, while patients at low-risk for surgery were treated with CEA. Lesions with features contraindicating endovascular procedures (tortuous lesion, severe calcification, unstable soft plaque) were also treated by CEA. As a result, 65 of 116 lesions underwent CS mainly with the use of a self-expanding stent, and 51 lesions were treated with CEA. The technical success rate and peri-procedural risk of stent placement were 98.5% and 4.6%, respectively. Diffusion-weighted MR imaging (DWI), which is a useful modality to detect acute cerebral embolism including asymptomatic lesion, demonstrated procedure-related lesions in 32 of 65 CS treated cases (49.2%). Distal protective balloon (dPB) for prevention of distal embolism during stenting was partially effective to reduce the occurrence of procedure-related ischemic lesions on DWI.We concluded that CS and CEA should be complementary treatments of cervical carotid artery stenosis. For establishment of CS procedure as an alternative treatment for carotid stenosis, more effective protective devices and more objective information on the safety and efficacy of CS are required.