Carotid Artery Stenting: An Update
Carotid Artery Stenting: An Update
Carotid stenting, although it is a mature technique regularly applied with excellent outcomes in high-volume centres by expert operators, is struggling to find the consensus of the scientific community. The initial enthusiasm for CAS as a valuable and less invasive alternative to CEA has been mitigated by the undisputable gap in outcomes between the two strategies observed in randomized clinical trials. Inadequate requirements in terms of endovascular expertise, potentially leading to an increased event rate related to both insufficient technical skills and inadequate patient selection, has been proposed as the main reason for the unfavourable outcomes related to CAS. Despite the fact that high-quality multi-centre registries and high-volume single-centre experiences have consistently described favourable CAS outcomes, the evidence has not been considered sufficient in the neurologist community to recommend CAS. In addition, in some countries including the United States the procedure has been reimbursed only within research protocols. Overall, the number of procedures performed in recent years is stagnant if not decreasing and industry massively reduced funding for research, development, and clinical trials. Unfortunately, in the next years little additional randomized data comparing CAS and CEA are to be expected. The promising technologies described may reverse the currently unfavourable trend for CAS only if they will be given the chance to be tested in adequately powered clinical trials, which require major funding by either industry or private or public entities.
Future Directions
Carotid stenting, although it is a mature technique regularly applied with excellent outcomes in high-volume centres by expert operators, is struggling to find the consensus of the scientific community. The initial enthusiasm for CAS as a valuable and less invasive alternative to CEA has been mitigated by the undisputable gap in outcomes between the two strategies observed in randomized clinical trials. Inadequate requirements in terms of endovascular expertise, potentially leading to an increased event rate related to both insufficient technical skills and inadequate patient selection, has been proposed as the main reason for the unfavourable outcomes related to CAS. Despite the fact that high-quality multi-centre registries and high-volume single-centre experiences have consistently described favourable CAS outcomes, the evidence has not been considered sufficient in the neurologist community to recommend CAS. In addition, in some countries including the United States the procedure has been reimbursed only within research protocols. Overall, the number of procedures performed in recent years is stagnant if not decreasing and industry massively reduced funding for research, development, and clinical trials. Unfortunately, in the next years little additional randomized data comparing CAS and CEA are to be expected. The promising technologies described may reverse the currently unfavourable trend for CAS only if they will be given the chance to be tested in adequately powered clinical trials, which require major funding by either industry or private or public entities.
