Innovations in Stroke Prevention: Carotid Stenting
Carotid Stenting: Carotid stenting has been performed in the United States for over a decade and has been undergoing pivotal FDA device approval trials since 2000. Since 2004, 6 FDA-approved carotid stents have emerged for the subset of patients with severe carotid artery stenosis for whom endarterectomy, still the standard operation, carries a high surgical risk.
Throughout this period of innovation, the physicians at NewYork-Presbyterian Hospital, representing both Columbia University Medical Center and Weill Cornell Medical Center, have played a major role in the research and development of this technology. Those interested in remaining abreast of the latest developments in carotid stenting should view this webcast, which will show a challenging case and discuss future directions with innovators in the field.
The webcast will feature William A. Gray, MD, an interventional cardiologist and Director of Endovascular Care at NewYork-Presbyterian/Columbia University Medical Center, who was the national Principle Investigator of the ARCHeR (ACCULINK for Revascularization of Carotids in High Risk Patients) trial, proving the efficacy of filtered stenting in high-risk endarterectomy patients and ultimately resulting in the first carotid stent system ever approved in the US. His many research credits in this field include his work on the interventional management committee of the NIH- and NHLBI-sponsored trial, CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial), which will randomize 2500 patients between stenting and endarterectomy in the US and Canada. CREST, which will be concluded sometime in 2008, is studying stenting in patients with standard surgical risk, a population that represents perhaps 70% of those undergoing endarterectomy.
In addition, Dr. Gray is on the interventional management committee for ACT 1 (Asymptomatic Carotid Trial), which is also comparing the less-invasive stenting to endarterectomy; and is the national Principal Investigator for CAPTURE (The Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events), a prospective, multi-center registry that assesses carotid stenting outcomes that has gathered the largest data set of carotid stenting in the world.
In the case of severe carotid stenosis, with or without symptoms, most physicians would recommend endarterectomy provided that the surgery is a good option based on evaluations of risk. Among the patients considered high surgical risk include those with severe heart or lung disease, those who have undergone neck surgery, including tracheotomy or prior endarterectomy, and those who have received radiation to the area. Carotid stenting for patients deemed to be at significant surgical risk has been proved to be as safe as and perhaps safer than endarterectomy, and stenting is also as effective in stroke prevention. To widen the population that might benefit from carotid stenting, however, studies like CREST and ACT 1, on patients who are at average risk for surgery, must be finalized and evaluated.
Y. Pierre Gobin, MD, is the Director of Interventional Neuroradiology at NewYork-Presbyterian/Weill Cornell Medical Center, which, like Columbia, is currently a CREST study site. Dr. Gobin is also extensively involved in endovascular research, and was an investigator in the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) trials that explored the safety and efficacy of a device for mechanical embolectomy in acute ischemic stroke. Dr. Gobin noted that advancements in carotid stenting have meant that the risk of stroke, the principal complication from the procedure, has been greatly reduced, to an incidence of about 2-3%. This improvement has been aided by the use of filters during stenting. Other possible, less-frequent complications of carotid stenting include restenosis, in which the carotid artery experiences a renewed blockage, and dissection, in which the arterial wall is torn.
There are differences in technical preferences among physicians who perform carotid stenting. Dr. Gobin, for instance, is in favor of doing most of the angioplasty before the stent is placed, thus limiting post-stent angioplasty, whereas the majority of operators are in favor of performing most of the angioplasty after placement of the stent. An area of research interest for Dr. Gobin is to explore the efficacy of the antiplatelet therapy used during stenting procedures, since unknown resistance to antiplatelet treatment might have an effect on the risk of complications during and after the procedure.
Overall, carotid stenting has become a mature procedure whose less-invasive approach may well be on the verge of being made available to a wider population. Those interested in seeing a relatively difficult case and hearing commentary from a team of physicians from NewYork-Presbyterian Hospital who are experts in this promising technology should watch this webcast.
William Gray, MD, FACC, FSCAI
Associate Professor of Clinical Medicine, Director, Endovascular Services, Columbia University Medical CenterNew York Presbyterian Hospital
Director of Interventional Neuroradiology at NewYork-Presbyterian/Weill Cornell Medical Center
James Mckinsey, MD
Associate Professor of Surgery, Columbia University College of Physicians and Surgeons Adjunct Associate Professor of Surgery, Weill Cornell Medical College; and Interim Chief of Vascular Surgery at NewYork-Presbyterian/Weill Cornell and NewYork Presbyterian/Columbia