Did your competent? doctor tell you about the risks of either?
For me, with no medical background the
best solution is to determine if the Circle of Willis is complete, then
close up the offending artery. Don't listen to me.
Low Stroke Risk in Patients With Asymptomatic Severe Carotid Stenosis
You might want to ask your doctor about this?
New ischemic brain lesions on diffusion-weighted MRI after treatment were found in 51% of cases after stenting. Link here
You might want to prevent stent placement complications per European Society of Cardiology
A - Minor complications
Carotid artery spasm
Sustained hypotension / bradycardia
Carotid artery dissection
Contrast encephalopathy (very rare)
Minor embolic neurological events (TIAs)
B - Major complications
Major embolic stroke
Intracranial hemorrhage
Hyperperfusion syndrome
Carotid perforation (very rare)
Acute stent thrombosis (very rare)
Complications at the site of the vascular access
Ticagrelor Induced Angioedema Following Carotid Artery Stenting
The latest here:
Carotid Artery Stenting Versus Carotid Artery Endarterectomy in Asymptomatic Severe Carotid Stenosis: An Updated Meta-Analysis
Published: December 14, 2023
DOI:
10.7759/cureus.50506
Peer-Reviewed
Cite this article as: Aggarwal A, Whitler C, Jain A, et al. (December 14, 2023) Carotid Artery Stenting Versus Carotid Artery Endarterectomy in Asymptomatic Severe Carotid Stenosis: An Updated Meta-Analysis. Cureus 15(12): e50506. doi:10.7759/cureus.50506
Abstract
Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are revascularization options for the management of severe carotid disease in asymptomatic patients. We aimed to compare the peri-procedural outcomes of the two modalities. A systematic review of the databases PUBMED, EBSCO, and Cochrane Library was performed. All the studies that reported periprocedural outcomes (within 30 days) in asymptomatic carotid stenosis patients were included in the meta-analysis. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) to compare the outcomes. Fifteen studies (including seven randomized controlled trials) met the inclusion criteria. A total of 15251 patients were included, out of which 6419 (42%) underwent CAS and 8832 (57.9%) underwent CEA. There was no statistical difference in the primary composite outcome of death/stroke/myocardial infarction (MI) (RR 1.02, 95% CI [0.69-1.51], p 0.93). No difference was found in the secondary outcome of all-cause mortality. CAS was associated with a slightly lower risk of MI and cranial nerve palsy. CAS was associated with a slightly higher risk of stroke with no difference in the occurrence of disabling stroke or ipsilateral stroke. In general terms, the study confirms equipoise in the two treatment strategies with a higher risk of MI and cranial nerve palsy with CEA and a higher risk of non-disabling stroke with CAS.
Introduction & Background
Stroke is one of the leading causes of mortality and morbidity in the United States and is associated with high morbidity [1]. About 15% of strokes are caused by atherosclerosis of the extracranial carotid artery [2]. Asymptomatic carotid artery stenosis (ACAS) is defined as a ≥50% narrowing of the carotid artery in the absence of retinal or cerebral ischemia in the preceding six months. Based on age and gender, the prevalence of asymptomatic carotid stenosis ranges from 0.5% to 7% in the general population [3]. A recent meta-analysis evaluating the risk of stroke in this population found the incidence of stroke to be as high as 4.3% in patients with high-risk plaque features [4]. Revascularization with either carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) plays an important role in stroke prevention. The most recent 2011 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on Management of Patients with Extracranial Carotid and Vertebral Artery Disease recommends CEA as first-line therapy, with CAS as a reasonable alternative in symptomatic patients [5]. This consensus guideline also states that it is reasonable to perform revascularization in asymptomatic patients who have more than 70% stenosis of the internal carotid artery (ICA) if the risk of perioperative stroke, myocardial infarction (MI), and death is low. They recommend choosing CEA in older patients and CAS when CEA cannot be performed due to unfavorable anatomy [5]. Similarly, the 2017 European Society of Cardiology guidelines recommend CEA to be performed in asymptomatic patients with an increased risk of stroke if the perioperative risk is <3% [6]. Further, they recommend CAS in high-risk (Class IIa) and average-risk patients (Class IIb) when CEA cannot be performed [6].
In recent years, CAS has been proposed as a safer alternative due to the lower risk of cranial nerve palsy and cardiovascular complications. Nevertheless, there is a concern for an increased risk of perioperative stroke with CAS [7]. However, with further advancements including the introduction of embolic protection devices, this risk appears to be significantly reduced. A study by Kastrup et al. showed that the use of an embolic protection device during CAS led to a statistically significant reduction in the occurrence of both major and minor strokes from 1.1% to 0.3% and from 3.7% to 0.5%, respectively [8]. A recent meta-analysis comparing the two modalities showed a lower risk of MI but a non-significant trend toward an increased risk of periprocedural stroke with CAS [9]. Since the publication of this meta-analysis, new data has emerged comparing the safety and efficacy of CAS with CEA. Due to conflicting literature and the emergence of new data in the field, we aimed to perform an updated systematic review and meta-analysis comparing the periprocedural outcomes of the two modalities for the management of asymptomatic severe carotid stenosis.
The preliminary results of our meta-analysis were presented at the 2022 Society for Cardiovascular Angiography & Interventions (SCAI) Annual Meeting on May 19, 2022.
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