Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3608_Библиотеки_им_академика_М_И_Перельмана

and approved the RX Acculink carotid stent (Abbott Vascular, Santa Clara, Calif.) for use in con­junction with Abbott's embolic protection device (EPD), the Accunet filter. The expanded label as a result of the FDA's approval was for treatment of extracranial carotid stenosis in symptomatic and asymptomatic patients who would otherwise be considered standard risk for surgical carotid endarterectomy (CEA). This was a landmark event because for the first time, carotid stenting, at least in the United States, qualified as a standard-of-care treatment and was no longer investigational or experimental for the majority of patients with carotid artery disease. (Earlier in [2004], the FDA had approved carotid artery stenting [CAS] for high CEA risk patients). This chapter reviews historical aspects and development of CAS, discusses stenting technique in detail, and reviews clinical trial data that support current indications for this procedure.

Endovascular Approaches to Treat Carotid Stenosis

suite. the University of Alabama at Birmingham (UAB) plasty of the innominate artery aided by balloon occlusion pro­tection of the common carotid artery (CCA). This early report represents the first percutaneous intervention performed with the benefit of distal embolic protection. During the 1980s, clinical reports of carotid angioplasty were sporadic and limited to small

confirmed the

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Initial interventions were performed using stand-alone balloon angioplasty (no stents). To maximize the luminal result, a long inflation was performed using a 5-mm over-the-wire balloon; the center port of this balloon could accommodate a 0.035-inch guidewire. Once the balloon was in place, the wire was withdrawn, and oxygenated arterial blood withdrawn from the femoral artery was infused through the center port of the balloon with the help of a special pump device, permitting a long 10-minute balloon infla­tion. The first four patients were treated without complications. Patient #5, a woman with contralateral carotid occlusion, presented with a transient ischemic attack (TIA) related to a high-grade ste­nosis in the index carotid artery and underwent an uncomplicated balloon angioplasty procedure. Despite a perfectly acceptable angio­graphic result, approximately an hour after the procedure, there was acute closure of the angioplastied carotid artery. Although a tech­nically successful, urgent reintervention with recanalization and stenting of the occluded vessel was performed, the patient did not recover from the major stroke related to the acute closure and subse­quently expired. This case triggered the decision by the UAB group to perform elective carotid stenting—irrespective of the angiographic results of balloon angioplasty—and primary stenting became the intervention of choice for treatment of cervical carotid stenosis. The subsequent rapid adoption of this approach by interventional cardi­ologists in particular, and the endovascular interventional commu­nity in general, heralded the modern era of endovascular treatment for extracranial carotid bifurcation disease.