Indications
Carotid stenting is the preferred therapy for patients who are at an increased risk with carotid surgery. High risk factors include medical comorbidities (severe heart disease, heart failure, severe lung disease, age > 75/80, etc.) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that make surgery difficult or risky.
Anatomic high surgical risk: Contralateral carotid occlusion Contralateral laryngeal palsy Post-radiation treatment Previous CEA recurrent stenosis High cervical ICA lesions CCA lesions below the clavicle Severe tandem lesions
Co-morbid high surgical risk: Congestive Heart Failure (Class III/IV), and/or known severe left ventricular dysfunction <30% Open-heart surgery within 6 weeks Recent myocardial infarction (>24 hours and <4 weeks) Unstable angina (CCS class III/IV) Synchronous severe cardiac and carotid disease requiring open heart surgery and carotid revascularization Severe pulmonary disease to include any of the following: Chronic oxygen therapy Resting P02 of < 60 mmHg Baseline hematocrit > 50% FEV1 or DLCO < 50% of normal Abnormal stress test Age greater than 80 years
Using the criteria of successful trials, candidates are either symptomatic (TIA or stroke) patients with >50% stenosis of the carotid artery, or are asymptomatic with >80% stenosis of the internal carotid artery.
Carotid stenting may be considered an alternative to carotid surgery in average surgical risk patients, albeit with a higher risk of death or stroke as seen in the SAPPHIRE and CREST trials.
Features that favor carotid stenting include non-atherosclerotic cause of the stenosis (fibrodysplasia, radiation, early post-surgical stenosis or flap) an experienced center and experienced physician performing the procedure. Features that make stent placement more difficult include significant aortic arch tortuosity, thrombus containing lesions, occluded carotid artery, heavily calcified vessels, symptomatic patients and very tortuous and twisting vessels. None of these affect open, surgical endarterectomy.
Read more about this topic: Carotid Stenting
Famous quotes containing the word indications:
“The indications are that swearing preceded the development of cursing. That is, expletives, maledictions, exclamations, and imprecations of the immediately explosive or vituperative kind preceded the speechmaking and later rituals involved in the deliberate apportioning of the fate of an enemy. Swearing of the former variety is from the lips only, but the latter is from the heart. Damn it! is not that same as Damn you!”
—Ashley Montagu (b. 1905)
“You must labour to acquire that great and uncommon talent of hating with good breeding, and loving with prudence; to make no quarrel irreconcilable by silly and unnecessary indications of anger; and no friendship dangerous, in care it breaks, by a wanton, indiscreet, and unreserved confidence.”
—Philip Dormer Stanhope, 4th Earl Chesterfield (1694–1773)
“It is difficult to write a paradiso when all the superficial indications are that you ought to write an apocalypse. It is obviously much easier to find inhabitants for an inferno or even a purgatorio.”
—Ezra Pound (1885–1972)