Interventional procedure overview of transfemoral carotid artery stent placement for asymptomatic extracranial carotid stenosis

'For neurologically symptomatic patients with stenosis less than 50% or asymptomatic patients with stenosis less than 60% diameter reduction, optimal medical therapy is indicated. There are no data to support transfemoral CAS, TCAR, or CEA in this patient group.

Neurologically asymptomatic patients with a 70% or greater diameter stenosis should be considered for CEA, TCAR, or transfemoral CAS for reduction of long-term risk of stroke, provided the patient has a 3- to 5-year life expectancy and perioperative stroke/death rates can be 3% or less. Perhaps future models to help estimate life expectancy based on calculating various physiologic comorbidities such as cardiac, pulmonary, renal, malignancy, will be available in the future. The determination for which technique to use should be based on the presence or absence of high risk criteria for CEA, TCAR, or transfemoral CAS.

Neurologically asymptomatic patients deemed high risk for CEA, TCAR, and transfemoral CAS should be considered for primary medical management. Intervention can be considered in these patients only with evidence that perioperative morbidity and mortality is less than 3%. CAS should not be performed in these patients except as part of an ongoing clinical trial.

There are insufficient data to recommend transfemoral CAS as primary therapy for neurologically asymptomatic patients with 70% to 99% diameter stenosis. Data from CREST, ACT, and the VQI suggest that in properly selected asymptomatic patients, CAS may be equivalent to CEA in the hands of experienced interventionalists. Operators and institutions performing CAS must exhibit expertise sufficient to meet the previously established AHA [American Heart Association] guidelines for treatment of patients with asymptomatic carotid stenosis. Specifically, the combined stroke and death rate must be less than 3% to ensure benefit for the patient.'

'Multidisciplinary team review is recommended to reach consensus decisions regarding the indications for, and treatment of, patients with carotid stenosis regarding carotid endarterectomy, carotid stenting or optimal medical therapy (Class 1, Level C)

For average-surgical-risk patients with an asymptomatic 60-99% stenosis, carotid endarterectomy should be considered in the presence of one or more imaging or clinical characteristics that may be associated with an increased risk of late stroke, provided 30 day stroke/death rates are less than or equal to 3% and patient life expectancy exceeds 5 years (Class 2a, Level B).

For average-surgical-risk patients with an asymptomatic 60-99% stenosis in the presence of one or more imaging or clinical characteristics that may be associated with an increased risk of late stroke, carotid stenting may be an alternative to carotid endarterectomy, provided 30 day stroke/death rates are less than or equal to 3% and patient life expectancy exceeds 5 years (Class 2b, Level B).

For asymptomatic patients deemed by the multidisciplinary team to be 'high risk for surgery' and who have an asymptomatic 60-99% stenosis in the presence of one or more imaging/clinical characteristics that may be associated with an increased risk of late stroke on best medical therapy, carotid stenting may be considered provided anatomy is favourable, 30 day death/stroke rates are less than or equal to 3% and patient life expectancy exceeds 5 years (Class 2b, Level B.

For patients with a 70% to 99% asymptomatic carotid stenosis, carotid interventions are not recommended for the prevention of cognitive impairment until a causal association between severe asymptomatic carotid stenoses and cognitive decline has been established (Class 3, Level B).'

'12/12 experts concluded that in patients with asymptomatic carotid stenosis in whom revascularisation is considered to be appropriate and who are less suitable for surgery, stenting may be suggested. We recommend careful consideration of the risks and benefits at a multidisciplinary team meeting.

12/12 experts concluded that the independently assessed risk of in-hospital stroke or death following endarterectomy or stenting for asymptomatic carotid stenosis should be as low as possible, ideally below 2%.'