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S. Abisi et al.
are safe in patients with appropriate anatomy (short proximal stenosis or occlusion). The combined stroke and death
rate related to percutaneous intervention to treat upper
extremity disease was 3.6% in one study [28].
Complications include stent thrombosis, restenosis, and
stent fracture [28].
Good outcomes have been reported using endovascular
techniques in the treatment of lesions of the aortic arch (i.e.,
supra-aortic) vessels [29].
Immediate technical success occurs in more than 93% of
patients, with failures usually related to an inability to cross
an occlusive lesion [30]. Five-year primary patency rates are
approximately 85% [30]. Sustained resolution of ischemic
symptoms is observed in most patients (>95%) [30].
Angioplasty alone has inferior outcomes compared with
angioplasty and stenting, particularly when recanalizing
occlusive subclavian lesions [28]. A systematic review and
meta-analysis comparing angioplasty alone with angioplasty
and stenting for subclavian artery stenosis found a signicantly higher risk of subsequent events for angioplasty alone
compared with angioplasty and stenting at 1year (odds ratio
2.37, 95% CI 1.32–4.26) [31]. A retrospective study of 42
patients treated with angioplasty and stenting for coronary
subclavian steal syndrome found that the rate of restenosis
was higher in patients with a continuous (compared with
intermittent) subclavian and coronary steal (41% and 7%)
[32].
Symptoms due to signicant (>70%) recurrent stenosis or
obstruction occur in approximately 10% of patients and are
typically treated with repeat angioplasty; however, surgery
may be required in up to 5% of patients [28]. Some risk factors for subclavian in-stent stenosis include younger age,
smoking with a history of chronic obstructive pulmonary
disease, or baseline vessel diameter ≤7mm [33]. A metaanalysis comparing open surgery with endovascular repair
for subclavian atherosclerotic disease showed favorable
early outcomes for both techniques and no signicant differences in survival [23]. While open repair had a better longterm patency, there were no signicant differences in
symptom recurrence.
Stent-grafting—Open surgery for subclavian artery
aneurysm has been the standard and provides a durable longterm repair. However, as with aneurysms at other sites, endovascular stent-grafting has been increasingly used to exclude
the aneurysm from the circulation. Subclavian artery aneurysms can occur proximally, associated with atherosclerosis,
or more distally due to injury (e.g., repetitive injury as with
thoracic outlet syndrome). Each of these segments has anatomic features that make stent-graft placement challenging,
and motion of the shoulder can lead to graft compression
with the potential for endograft fracture.
Endovascular stent-graft repair has also been applied to
the treatment of penetrating or blunt injuries to the axillary
and distal subclavian arteries with good results. A review of
223 patients with subclavian and axillary injuries from 11
trauma centers showed an excellent limb salvage rate of 97%
but a 10% in-hospital mortality related to cardiac (38%),
brain (21%), hemorrhage (21%), multisystem organ failure
(17%), and drug-related (4%) causes (e.g., balloon occlusion) [34].
Thoracic Endografts
Endovascular repair of thoracic aortic aneurysm is accomplished using a fabric-covered stent, termed an endograft or
stent-graft. Adoption of stent-graft technology by vascular
surgeons has been rapid, primarily related to pre-existing
experience and facilities with the endovascular repair of
abdominal aortic aneurysm.
Although there are variations from device to device, three
components (delivery system, main body, and extensions)
are common to all endograft device systems. Thoracic endograft devices are currently approved for the treatment of
descending thoracic aneurysms, penetrating aortic ulcers,
aortic intramural hematoma, descending (type B) thoracic
aortic dissection, [35] residual descending thoracic aortic
dissections, and traumatic aortic transection in the United
States [36].
Thoracic endovascular devices include TAG and cTAG
GORE, TX2 and Alpha COOK, Valiant Thoracic Stent-Graft
System Medtronic, and Relay BOLTON.
The degree of structural support varies from device to
device. Proponents of designs that have less metallic support
structure claim the device is better able to adapt to changes
in aneurysm conguration over time. On the other hand,
some physicians feel that fully supported endografts are less
prone to kinking and subsequent thrombosis. The curve of
the proximal thoracic aorta adds an additional challenge to
achieving a design with adequate proximal xation and seal.
The amount of radial support, which allows the endograft to
withstand external compression, must be weighed against
the need for enough exibility and conformability within the
device to navigate the proximal aorta and achieve a proper
seal following deployment.
New endograft designs are continually being tested to
enhance performance. Improvements have focused upon
smaller device and delivery proles, more accurate
deployment, improved xation systems, and perhaps most
importantly, exibility in managing challenging anatomy.
These improvements, along with increased operator experience, have led to improvements in the short-term and
long-term results of endovascular aneurysm repair and
have expanded the application of endovascular repair to
many patients whose aortic anatomy was previously
deemed unsuitable.
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245
Advanced Devices
When aortic disease is more extensive and involves branch
vessels, the complexity and risks associated with endovascular repair increase. Approaches to address these issues
include debranching procedures and the use of fenestrated
and branched endografts.
Branched grafts have been used in patients with thoracic
or thoracoabdominal aneurysms or thoracic dissection [35].
Initial experience with branched aortic grafts has shown similar perioperative mortality as conventional endovascular
repair, but the rate of aneurysm repair-related morbidity may
be higher.
Aortic arch branch devices—single- and double-branch
thoracic aortic endografts and fenestrated endografts are
available primarily for investigational use to treat zone 0
(innominate), 1 (left carotid), or 2 (left subclavian). These
include the Cook a-Branch, Cook fenestrated, Gore Thoracic
Branch Endoprosthesis (TBE), Medtronic Valiant Mona
LSA, Bolton ascending thoracic device, and Nexus aortic
arch system. These grafts are intended to preserve ow into
the innominate, carotid, or subclavian artery during thoracic
endograft placement. A separate access is needed to deploy
the branch grafts. None of these devices are approved for use
by the US Food and Drug Administration (FDA). Device
clinical trials evaluating use in treating aortic arch pathology
are anticipated.
Choice ofDevice
No one device is appropriate for all clinical indications or
has been shown to be superior to any other device for the
endovascular repair of the thoracic aorta. Most devices were
originally designed for excluding thoracic aortic aneurysm,
and the evaluation of specic designs to manage acute aortic
syndromes (aortic rupture, aortic dissection) is in early
stages. With time, and with the addition of disease-specic
endografts, a clear preference for one device over another
may emerge.
Management ofIatrogenic Injury toSupraaortic Branches
Injury to a supra-aortic trunk vessel is an uncommon, but
devastating, complication of percutaneous central venous
catheter (CVC) placement. The incidence of carotid artery
injury associated with CVC placement in the internal jugular
vein (IJV) has been reported to be in the range of 1–7 cases
per 1000 [37].
Inadvertent arterial placement of a large-bore catheter can
result in hemorrhage, pseudoaneurysm, stroke, and/or death
[37]. Given the devastating complications associated with
arterial catheterization, the early identication of arterial
trauma and knowledge of the complication prole are imperative to provide prompt management and mitigate risk.
The current management of catheter removal involves one
of three techniques: external manual pressure, open direct
arterial repair, or endovascular techniques, including covered
stents and percutaneous vascular closure devices (VCDs).
Endovascular stent-graft repair of traumatic arterial injury
has been associated with a decrease in the anesthetic requirement and blood loss and a decrease in associated mortality
(22% with open surgical repair vs. 0.9% with carotid artery
stenting) [36] (Table24.2).
Suggested endovascular toolkit for the endovascular management of
arch angioplasty
Manufacturer Size/length
Wires
Any standard access wire
Glidewire Floppy Terumo Radifocus
Glidewire Stiff Terumo Radifocus
Rosen Boston Scientic
Corporation
Lunderquist “extra stiff”
Sheaths
Any standard access
sheath
TriForce crossing system Cook Medical 4 Fr/55–90cm
DrySeal GORE 12–24
Ansel Cook Medical 6–8 Fr/45–55cm
Aptus steerable sheath Medtronic 6.5–8.5
Catheters
C2 Cordis
BER II Cordis
Balloons
CODA Cook Medical 30–36mm
Charger Boston Scientic 10mm × 2mm
Stents
Be-graft Bentley 8–14mm/27–
Closure device
Proglides Abbott
These are only a few suggested options based on the author’s experience and can cover the vast majority of cases
Cook Medical
Any 5–10 Fr/11cm
0.035″/180–
300cm
0.035″/180–
300cm
0.035″/180–
300cm
0.035″/300cm
0.035″/300cm
F/33–65cm
F/55–90cm
0.035″/5
Fr/65–90cm
0.035″/4
Fr/65–90cm
57mm
0.035″
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S. Abisi et al.
Case Presentation
Continued from page 239
The procedure was done in a hybrid theater under
GA.Left common femoral vein antegrade access and pacing
wire advanced in the right ventricle via a 6 Fr sheath. Left
common femoral artery retrograde puncture was done under
ultrasound and X-ray guidance. A 5-French sheath was
inserted standby in case a cardiothoracic conversion would
be needed. Right axillary artery percutaneous retrograde
access was obtained under ultrasound and X-ray guidance.
Two Proglide vascular closure devices inserted. A 10-French
sheath was inserted, and a pig-tail catheter was placed in the
ascending aorta. Right brachial artery retrograde puncture
was carried out under ultrasound and X-ray guidance at the
right antecubital fossa level. A 5-French sheath was inserted.
Right common femoral artery retrograde puncture was performed under ultrasound and X-ray guidance. Two Proglide
vascular closure devices were inserted. TOE was used to
conrm the location of the wire. Guide wire was placed in
the left ventricle through the aortic metallic valve by the side
of the metallic leaets. Arch branch Cook stent-graft device
was inserted through the right common femoral artery. It
measured 40mm proximal diameter/28mm distal diameter
× 243mm total length with three branches.
After the stent-graft device was deployed, one Gore
Excluder iliac limb graft was inserted in the innominate
artery branch and innominate artery, through the right axillary artery access after a 12-French DrySeal sheath was
inserted. It measured 16mm proximal diameter/20mm distal diameter × 9.5cm total length. Postdilated into the branch
with a 12 mm × 20 mm plain balloon. The left common
carotid branch was cannulated next with the help of an
8-French long sheath, from below, after a through-andthrough wire was snared out from the right common femoral
artery 20 Fr DrySeal sheath. Viabahn VBX balloonexpandable covered stent was inserted in the left common
carotid artery branch to bridge it with the left common
carotid artery, measuring 9mm × 79mm. The left subclavian
artery branch was cannulated last, and Viabahn VBX balloonexpandable covered stent was inserted in it, measuring
11mm × 59mm. Because there is an acute angulation from
the LSA branch to the left subclavian artery (LSA), Be-Graft
plus (+) balloon-expandable covered stent was inserted and
relined into the VBX stent, measuring 10 mm × 57 mm.
Postdilated with a balloon-expandable covered stent 12mm
× 20mm in the mid and distal parts of the left subclavian
artery stents.
Thoracic stent-graft device extension done next with a
Cook Alpha thoracic stent-graft, measuring 32mm × 155mm
total length. The false lumen of the aortic dissection was cannulated last at the level of the distal abdominal aorta, close to
the L4 vertebral body level. Cook occlusion “Candy plug”
was inserted in the false lumen, just next to the bottom end of
the Alpha distal thoracic stent-graft, measuring 36 mm ×
54mm. Below the bottom end of the “candy plug” radiopaque
stent there was graft fabric of a length 43mm to provide the
occluding effect. Distal/bottom end diameter of the “candy
plug” fabric was 14mm. Final angiogram was done showing
ow through the innominate artery, left common carotid, and
left subclavian artery with a patent thoracic aortic stent-graft.
The 12 Fr DrySeal sheath was removed from the right axillary artery, and the two Proglide vascular closure devices
were deployed. Hemostasis was achieved, and one Be-Graft
balloon-expandable covered stent was placed in the right axillary artery at the level of the previous puncture. It was postdilated with a 12 mm × 20 mm plain balloon. The Be-Graft
stent was inserted through the right brachial artery 7-French
sheath, which was upsized from the previous 5 Fr sheath.
Right brachial artery 7 Fr sheath was removed, and a StarClose
vascular closure device was deployed. Hemostasis achieved.
Present clinical pulses in the right brachial artery post-StarClose deployment. The right common femoral artery
20-French DrySeal sheath was removed, and the two Proglide
vascular closure devices were deployed. Four more Proglide
vascular closure devices were inserted in the right common
femoral artery, and hemostasis was achieved. Left common
femoral artery 5-French sheath was removed, and Mynx
Control vascular closure device was deployed. Hemostasis
was achieved. Left common femoral vein 6-French sheath
was removed, and manual pressure applied.
The nal angiogram and 2 days of postoperative computed tomography (CT) angiography showed no endoleaks
and patent coronary and supra-aortic vessels.
Echocardiography showed normal function of the aortic
valve after the procedure. No complications occurred in the
postoperative period, and the patient was discharged from
ITU on the third postoperative day. After 6months the patient
returned for follow-up, and the CT scan showed exclusion of
the aneurysm with regression of the sac and thrombosis of
the false lumen. The aortic valve function was not
compromised.
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Carotid Artery Stenting: Studies,
https://t.me/medicina_free
Indications, andPre-interventional
Workup
ElizabethA.Andraska andRabihA.Chaer
25
Background
Stroke continues to be a leading cause of morbidity and mortality worldwide. It is estimated that nearly 800,000 people
in the United States are diagnosed with stroke annually, and
an additional 240,000 patients experience transient ischemic
attacks (TIA) [1]. The nancial burden is also signicant, as
stroke-related costs in the United States were estimated to be
about $53 billion between 2017 and 2018 [2]. Up to 87% of
strokes are ischemic in nature, and about 15% are due to
extracranial carotid disease [3, 4]. Ischemic stroke due to
carotid disease and the subsequent disability that ensues represent a signicant healthcare burden and cost that can be
prevented with appropriate treatments.
Although the surgical management of carotid artery stenosis with carotid endarterectomy is the established gold
standard for carotid revascularization, transfemoralcarotid
artery stenting (TF-CAS) has become an alternative to treating the patient with carotid artery stenosis. Today, approximately 135,000 interventions are performed for carotid
artery stenosis annually in the United States, and up to 60%
are reported to be catheter based [5, 6]. Given the availability of self-expanding stent technologies, lower-prole delivery systems, and embolic protection devices, stenting
became broadly used in carotid artery revascularization.
Initial reports of carotid stenting focused on patients with a
hostile neck, such as patients with restenosis after carotid
endarterectomy, given the risk of cranial nerve injury with
surgical repair of those lesions [7]. Indications for the use of
carotid artery stenting later expanded to use in the medically
and anatomically high-risk patient, given the lower risk of
complications due to the noninvasive nature of the proce-
E. A. Andraska · R. A. Chaer (*)
Division of Vascular Surgery, Department of Surgery, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
e-mail: andraskaea@upmc.edu; chaerra@upmc.edu
dure [8]. With the wider diffusion of TF-CAS, a subset of
patients at high risk for neurologic complications after
TF-CAS were identied, such as patients with symptomatic
stenosis and octogenarians [8]. Currently, the indications,
use, and efcacy of carotid artery stenting continue to
evolve, especially with the introduction of transcarotid
artery revascularization (TCAR) and ongoing trials testing
new technologies for carotid artery stenting. This chapter
will outline the most contemporary and integral studies that
inform the modern carotid proceduralist, as well as the indications for the intervention. Finally, it will highlight key
preprocedural considerations with regard to imaging,
approach, and technique.
Key Trials andIndications
Surgical Risk
The indications for carotid artery stenting (CAS) have
evolved over the years. They are highly dependent on the
severity, symptom status, anatomy, and surgical risk of the
patient. High-risk patients who were initially excluded from
carotid endarterectomy (CEA)studies such as the ACAS and
NASCET trials represented a group of patients who could
potentially benet from revascularization with endovascular
techniques. These high-surgical-risk patients included those
with recurrent stenosis, contralateral occlusion, prior radiation therapy or radical neck dissection, surgically inaccessible lesions, and signicant medical comorbidities: chronic
obstructive lung disease, congestive heart failure, left ventricular ejection fraction <30%, unstable angina, multivessel
coronary artery disease, and dialysis-dependent renal insufciency [9–12]. Age >80 years has been a persistent risk factor in TF-CAS. In fact, in the CREST trial, risk of
postoperative stroke was 12% in octogenarians compared to
only 3% in non-octogenarians [7, 13, 14]. The higher risk of
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_25
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E. A. Andraska and R. A. Chaer
adverse events in octogenarians has been repeated in numerous other studies [9–12]. This ultimately led to a consensus
among providers that younger patients with anatomic criteria
that places them at high riskwould be of most benet for
carotid stenting. This includes patients with radiationinduced carotid stenosis, treatment of restenosis, and lesions
higher than C2 [8, 15, 16].
Asymptomatic Carotid Stenosis
Perhaps the most important contribution to the clinician’s
decision to move forward with TF-CAS over CEA is the
symptom status of the patient. With regard to asymptomatic
disease, the ACT-1 trial reported noninferiority of TF-CAS
to CEA at 1 and 5years with regard to the composite endpoint of periprocedural stroke, death, myocardial infarction,
or ipsilateral stroke at 1year [17]. Based on the randomized
trials to date, Cochrane reported similar efcacy between
TF-CAS and CEA for asymptomatic disease, with the caveat
that compelling data is lacking, and further clinical trials are
required [18]. The more recent ACST-2 trial, published in
2021, studied TF-CAS vs. CEA in a modern era of medical
management, self-expanding stents, and embolic protection
devices. This large, randomized study found similar postprocedural stroke rates at 5years for asymptomatic patients.
They reported a stroke rate of 5.3% following TF-CAS and
4.5% following CEA, and determined that the two approaches
were comparable [19]. The ARCHeR and CAPTURE trials
similarly found TF-CAS to be a safe method of carotid revascularization in high-surgical-risk patients specically, with
the lowest risk in young, asymptomatic patients [11, 15]. It is
important to note that in both of these trials, the use of
embolic protection was employed. The SAPPHIRE trial also
evaluated patients at high risk for surgical treatment and
found TF-CAS to be noninferior to CEA with regard to ipsilateral stroke [20, 21]. When the trial re-evaluated ipsilateral
stroke rates at 10years, the lack of differences persisted [14].
At this point in time, TF-CAS has been shown to be safe and
effective in asymptomatic patients younger than 70years,
especially in patients with high surgical or anatomic risk.
Symptomatic Carotid Stenosis
The results of randomized trials with regard to symptomatic
disease have shown worse outcomes with TF-CAS. The two
initial European randomized control trials comparing
TF-CAS to CEA in symptomatic patients were the EVA-3S
trial and the SPACE trial [22, 23]. The EVA-3S trial was
stopped prematurely due to both safety and futility, as they
found the post-operative stroke rate to be 3.9% after CEA
compared to 9.6% after TF-CAS [22]. On long-term follow-
up of the 527 patients they did enroll prior to study termination, there were no signicant differences in long-term
ipsilateral stroke risk between the two groups, but the authors
did conclude that due to the much higher risk of periprocedural stroke in the TF-CAS population, CEA is still favored
in the symptomatic patient [24]. The EVA-3S study also
found a 2.5-fold increase in restenosis after TF-CAS compared to CEA; however, the implications of this with regard
to reintervention or stroke rate have yet to be claried in
clinical trials [25]. The SPACE trial was another European
randomized control trial comparing TF-CAS to CEA in
symptomatic carotid stenosis, and while the outcomes were
not nearly as pronounced, they were unable to prove noninferiority to CEA due to difculty with study enrollment.
Again, they found the rate of restenosis to be signicantly
higher in the TF-CAS arm [26]. SPACE-2 was initially a
promising three-armed clinical trial comparing best medical
management to TF-CAS and CEA, but was terminated due
to low recruitment [27]. More recently, the ICST trial evaluated 1,713 neurologically symptomatic patients and demonstrated an increased periprocedural stroke risk of 7.7% with
TF-CAS compared to 4.1% with CEA [28].
Future Trial Directions
In the CREST trial, which compared TF-CAS to CEA in
symptomatic and asymptomatic patients, there were no
reported differences in a primary composite outcome of
stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke within
4 years after randomization [13]. This did not differ with
respect to symptomatic status. We are currently awaiting the
CREST-2 and ECST-2 trials to better understand these comparisons in the era of more ubiquitous statin and aspirin
usage [29]. The most recent Cochrane review compiled data
from each of the randomized trials and reported that in symptomatic disease, TF-CAS results in higher rates of postprocedural stroke compared to CEA [18, 30]. This higher
rate of stroke is mostly driven by the risk of small embolic
stroke from procedural manipulation in patients older than
70years [18]. Overall, the symptomatic patient is still much
better suited for CEA over TF-CAS.There are ongoing studies evaluating the role of TF-CAS in these patients, which
may help to clarify the patients in this cohort that would nd
the most benet from TF-CAS.
Transcarotid Artery Revascularization (TCAR)
To this point, this chapter has discussed CAS, primarily
regarding a transfemoral approach. To address the higher
periprocedural risk of embolism with manipulation of the
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aortic archduring TF-CAS, a transcarotid approach is being
increasingly employed. This allows for the avoidance of a
diseased aortic arch as well as tortuous supra-aortic branches,
which reduces the risk of procedural embolic stroke.
Additionally, the concomitant use of ow reversal prior to
lesion crossing protects from embolization during manipulationof the lesion. Transcervical carotid artery revascularization (TCAR) with ow reversal is a safe and effective
alternative and has been shown to be safe for patients older
than 70years—a key group that consequently often carries
both high surgical risk and high embolic risk with transfemoral methods [31]. In a study evaluating diffusion-weighted
magnetic resonance imaging (DW-MRI) images of patients
undergoing TCAR with ow reversal versus TF-CAS, Leal
et al. reported a signicantly reduced rate of new postprocedural infarcts in TCAR patients (12.9%) compared to
TF-CAS patients (33.3%) [32].
The ROADSTER study evaluated the safety and efcacy
of the Silk Road Medical ENROUTE transcarotid system
and found a post-procedural stroke rate of 1.4% lower than
the stroke rates reported for TF-CAS [33, 34]. The subsequent ROADSTER 2 trial evaluated, per protocol, symptomatic patients and reported a combined stroke and death rate
of 0.6% [35]. There have consequently been a number of
cohort studies that have compared TCAR to CAS and shown
improved rates of periprocedural stroke in real-world patient
populations [34, 36], as well as TCAR compared to CEA
showing similar periprocedural outcomes [37, 38]. There has
yet to be a randomized study comparing TCAR to TF-CAS
and CEA, which will be necessary to the eld in order to
make true comparisons.
Current Guidelines
In January 2022, the Society of Vascular Surgery produced
specic guidelines with regard to indications and management of the patient with carotid artery disease [5]. For the
symptomatic patient with >50% stenosis, CAS is not recommended. Similar to the Society of Vascular Surgery, the
American Heart association and American Stroke Association
Council on Stroke report that they continue to recommend
CEA in symptomatic patients [1, 39]. They additionally
report that in symptomatic patients with severe stenosis
(>70%) and high risk for surgery, TF-CAS is not inferior to
CEA and can be considered. High surgical risk includes a
neck which is difcult to access surgically, medical conditions that are present and greatly increase the risk of surgery,
or other miscellaneous circumstances such as radiationinduced stenosis or restenosis after CEA [1, 39]. Multiple
randomized and single-center studies have reported prohibitive risk of stroke with TF-CAS in elderly populations. As
such, TF-CAS is not appropriate in the elderly patient
>70years old. There are not yet clear guidelinerecommendations for the use of TF-CAS in the asymptomatic patient.
Future clinical trials will help to inform guidelines with
regard to the role of optimal medical management in the
treatment of carotid artery stenosis.
Initially, TCAR was recommended for patients with
carotid artery stenosis who carry high surgical risk. TCAR
was therefore reserved for patients who had anatomic or
physiologic criteria that put them at prohibitive surgical risk.
Most recently, the Food and Drug Administration (FDA)
expanded TCAR indications to include patients at standard
risk for surgery. TCAR represents a novel approach to the
patient with carotid artery stenosis with promising early
results. Future randomized trials will help to compare TCAR
head-to-head with TF-CAS and CEA. Given the published
outcomes of TCAR showing a low rate of procedural complications, it has mostly replaced the use of TF-CAS in clinical practice.
Pre-interventional Workup
Pre-interventional Considerations
With regard to pre-operative evaluation of the patient with
carotid artery stenosis, imaging and risk assessment are integral to the decision tree. Duplex ultrasound imaging is usually the initial study of choice for the provider to quantify the
degree of arterial stenosis. Stenosis criteria will vary across
vascular labs, but in general, a severe stenosis (>80%) is an
indication for intervention. Additional noninvasive imaging
of the carotid anatomy with either contrasted tomography
angiography (CTA) or magnetic resonance angiography
(MRA) of the neck with attention to the aortic arch is usually
necessary in order to evaluate key anatomic criteria for both
CAS and TCAR.
Key anatomic criteria to consider when evaluating a
patient for CAS or TCAR include arch anatomy and the
extent of the carotid lesion. The size of the internal and common carotid arteries are also important to note as the vessel
must be between 4 and 9mm in order to successfully deploy
the stent. The interventionalist must also note the tortuosity
of the supra-aortic branches as well as the angulation and
disease present on the aortic arch. For TCAR, the carotid
bifurcation must be at least 5cm from the clavicle to allow
for appropriate support of the device platform, with a relatively healthy proximal common carotid artery. A common
carotid artery of at least 6mm is also required to allow for
safe sheath insertion. Lesion characteristics that are not suitable for CAS and TCAR include lesions with intraluminal
thrombus, lesions that may require two stents, a tortuous
common or internal carotid artery, heavily calcied eccentric
lesions, and lesions with total occlusion of the target vessel.
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Additional anatomic criteria have been identied to be
limitations to TF-CAS.Criteria such as an unfavorable arch,
calcication, vessel tortuosity, long stenotic lesions, and
involvement of the carotid ostium have been associated with
an increased risk of periprocedural stroke [40–44].
There has also been recent emphasis on plaque morphology, suggesting that a soft, echolucent plaque is at higher
risk for neurologic events due to embolization with manipulation [43]. Consistently, an increased plaque burden,
necrotic core, and thrombus in the artery are predictors of
cerebral embolism during CAS [45, 46]. To some degree,
these features can be evaluated on ultrasound, CTA, or MRA,
but there will certainly need to be more studies evaluating
these characteristics and perhaps more novel imaging techniques to truly understand the inuence plaque morphology
has on periprocedural cerebral embolization with TF-CAS
and TCAR.
Plaque morphology may also play an important role in the
identication and treatment of restenosis. Multiple studies
have evaluated the incidence of restenosis in TF-CAS. In
fact, restenosis after CAS is nearly three times more likely
than after CEA [47]. However, 97% of all recurrent ipsilateral strokes after TF-CAS occurred in patients without evidence of signicant restenosis or occlusion [48]. Therefore,
the implications of the increased rate of restenosis are
unknown regarding reintervention or recurrent stroke risk.
Often, these lesions are smoother and less vulnerable to
plaque rupture than primary lesions. This, along with the
evaluation of primary plaque morphology, will be important
to study in the future to determine the true risk of these
lesions.
Pre-interventional Risk Assessment
Post-operative risk assessmentof the patient is imperative to
understanding the safety of treatment. Most guidelines suggest a risk threshold of 6% in the symptomatic patient and
3% in the asymptomatic patient [39]. There have been
numerous studies identifying various risk scoring systems
for the patient undergoing TF-CAS [49–51]. In general,
patients at highest risk for stroke or death following CAS or
TCAR are older, symptomatic, have had a recent myocardial
infarction, requiring dialysis, need for concomitant cardiac
revascularization, long lesion length, Type II or Type III aortic arch, or have a tortuous artery [52]. Patients with more of
these factors have increased overall risk. If the patient has
multiple risk factors, a frank conversation weighing the risks
and benets of revascularization is warranted, especially in
asymptomatic patients. There is rising evidence to suggest
that certain patient populations are at prohibitive risk for a
carotid intervention. For example, Yuo etal. evaluated the
USRDS database to determine the risk of carotid interventions in dialysis patients and found a prohibitively high rate
of morbidity and mortality in asymptomatic patients following CAS [53].
Cognition is a relatively novel topic of research in carotid
artery disease literature. Studying the effects of carotid artery
revascularization on cognition has gained traction. While
certainly no denitive evidence exists, TF-CAS has been
found to improve cognitive processing speed, executive
functioning, and motor function to a higher degree when
compared to CEA [54]. No standardized measure of cognition exists in the carotid revascularization literature, which
makes the results difcult to interpret. In a randomized study
comparing TF-CAS to CEA, there were no differences found
in post-operativecognitive function. However,when imaging these patients on follow-up, new ischemic cerebral
lesions were found twice as often in TF-CAS compared to
CEA [55].The implications of these lesions has yet to be
truly investigated and claried.
Medical Considerations
In symptomatic carotid stenosis, a more extensive workup is
warranted. A thorough cardiac evaluation should be performed to evaluate the etiology of the stroke and rule out
arrhythmias. Blood tests should also be performed, including
an HbA1c, lipid panel, hypercoagulability workup, and creatinine. Imaging of the brain must also be performed to better understand the extent of ischemia and conrm the
diagnosis [1]. The workup should be completed in the rst
48hours after symptom onset [1].
Medical optimization is critical in the patient with carotid
artery disease. Smoking cessation, healthy diet and exercise,
as well as a daily aspirin should be encouraged in all patients
pre-intervention [1]. Once the interventionalist has determined the patient to be a candidate for TF-CAS or TCAR,
the patient should be initiated on dual antiplatelet therapy
(DAPT) and should be dosed with DAPT for at least 72hours
prior to the procedure. This reduces the incidence of periprocedural TIA and stroke. Some have argued aspirin and clopidogrel loading at least 4hours prior to the procedure to be
safe, but this is ultimately per the individual institutions’
safety protocols. Clopidogrel resistance assays should be
evaluated during this time periodprior to intervention.If the
patient is determined to be resistant to clopidogrel, alternative options include ticagrelor or prasugrel. Statins should
also be initiated at least 5 days prior to the intervention.
Statins and antiplatelet agents allow for the stabilization of
the plaque.
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Incorporating Health Disparities andHealth
Literacy
It is important to note the lack of data on carotid revascularization in women and marginalized populations. Women are
at higher risk for having a disability after an ischemic stroke,
as well as a higher risk of mortality after enduring an ischemic stroke [56]. Women are underrepresented in clinical trials, making recommendations for this population difcult.
The current literature from the most recent clinical trials suggests similar risks following carotid interventions for both
men and women [56]. While overall, there is similar risk
across genders with respect to CEA and TCAR, there is
some literature to suggest worse outcomes for women with
TF-CAS.This is likely due to reduced carotid diameters and
must be considered when treating these patients [57].
With respect to racial minority populations, there is a disparity in treatment for carotid artery stenosis. Rates of revascularization for carotid disease are lower in minority-serving
hospitals [58]. Perioperative complications are similar across
racial groups, but 30-day myocardial infarction and ipsilateral stroke are increased among black patients [59, 60].
Identifying the socioeconomic determinants of health is an
imperative adjunct to the workup and treatment of carotid
artery stenosis. As such, risk factors can be mitigated as
much as possible [1]. Health literacy must also be determined and integrated into the care plan in order to optimize
risk factor modication and adherence to care. Further studies are needed to elucidate the reasons for these ndings, but
interventionalists should be aware of the existing disparities
when approaching the treatment of a carotid lesion in these
patients.
Technical Pearls
Technical Considerations inTF-CAS
Cerebral embolic protection devices are a critical component
to TF-CAS.Embolic protection lters allow for a safer procedure and reduces procedure-related strokes. The EVA-3S
investigators compared TF-CAS with embolic protection to
unprotected TF-CAS, and the study had to be terminated
because the 30-day stroke rate was 3.9 times higher in the
unprotected group than that of the TF-CAS arm with cerebral protection [61]. Filter protection has since been conrmed as feasible and safe [65] and has become standard of
care for TF-CAS.Consistently, studies have found that the
incidence of post-procedural neurologic complications is
lower with embolic protection than without [62].
Stent design may also impact outcomes in patients undergoing TF-CAS. Multiple cohort studies have identied
closed-cell stent designs to carry a lower risk of cerebral
embolization compared to open-cell stents [46, 63]. In general, it is imperative to properly size the stent. Overstretching
the stent can cause stroke, pain, and rarely, rupture.
Additionally, all exchanges should be performed carefully to
prevent air embolism or trauma to the artery.
Technical Considerations inTCAR
TCAR has additional unique technical challenges. The Silk
Road Medical ENROUTE system uses an 8Fr transcarotid
sheath and can accommodate stent diameters of 6–10mm
and lengths of 20–40mm. The system works over an0.014″
wire. Flow reversal is established by accessing the contralateral femoral vein for placement of the neuroprotective system. Choice of anesthesia is interventionalist dependent.
General anesthesia has been compared to local/light sedation
with no differences in outcomes [64]. Recommended systolic blood pressures are between 140 and 160 mmHg.
Hypotension and bradycardia should be avoided to optimize
ow reversal. A carotid cutdown can be achieved with a
small ~2 cm supraclavicular transverse incision. After the
platysma is divided with electrocautery, the avascular plane
between the two insertions of the sternocleidomastoid muscle to the sternum and clavicle should be developed.
Prior to access, heparin is administered, and an ACT of
>250s should be targeted to optimize systemic anticoagulation. The artery is then accessed with the specialized micropuncture system provided by Silk Road Medical. The system
includes specialized markings on the access needle, guidewire, and catheters to allow for safer access and condence
in placement. The external carotid artery is then selected, and
the ENROUTE sheath is inserted. ICA engagement is
avoided until ow reversal can be established. The CCA is
then clamped, and ow reversal is initiated and conrmed.
Once the lesion is crossed, the stent can be deployed using a
pin-and-pull technique. Similar to TF-CAS, all exchanges
should be performed carefully with judicious use of pre- and
post-dilation. Studies have shown a risk of TIA and stroke
with post-dilation, so this adjunct should be considered only
in cases of signicant residual stenosis [65]. Flow reversal is
continued momentarily to capture any additional debris.
Antegrade CCA ow is then re-established, and the neck
incision is closed (Figs.25.1 and 25.2).
Conclusions
TCAR has become an established alternative to CEA in
patients with carotid artery disease, and the role of TF-CAS
is currently in evolution. Although CEA continues to be the
current gold standard based on societal guidelines, carotid
stenting is mostly indicated for the asymptomatic patient
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E. A. Andraska and R. A. Chaer
Fig. 25.1 Severe asymptomatic carotid stenosis treated with TCAR
<70years old with high surgical risk. TCAR mitigates much
ofthe risk of cerebral embolization that is seen with TF-CAS.
However, future comparative randomized trials are imperative to evaluate the inuence of modern medical optimization, newer technologies and devices, the role of plaque
morphology in clinical decision making, and head-to-head
evaluations of TCAR, TF-CAS, and CEA.Source of
SupportThis writing was supported in part by grant
T32HL98036 from the National Heart, Lung, and Blood
Institute (Andraska). The University of Pittsburgh holds a
Physician-Scientist Institutional Award from the Burroughs
Wellcome Fund (Andraska).
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