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270
What was
unique about
the design of the
CREST (Carotid
Revascularization
Endarterectomy
Versus Stenting
Trial-2010) trial,
and what were its
findings?
Design:
RCT comparing outcomes of CAS with EPD
to CEA in both symptomatic patients with
>50% stenosis and asymptomatic patients
with >60% stenosis at standard surgical risk
Findings:
CEA arm: significantly higher risk of
periprocedural MI
CAS arm: significantly higher risk of
periprocedural minor/non-disabling stroke
Of note, as study continued rates of
periprocedural events in CAS arm declined
significantly, suggesting a learning curve (no
similar change in CEA).
At 4years there was no significant difference
in mortality or overall stroke rate:
Higher rate of stroke in asymptomatic
patients at 4years in CAS group
No difference in stroke rate at 4years in
symptomatic patients
Like SPACE, CAS better for patients
<70years old, and CEA better for patients
>70years old
What are the
overall current
findings of pooled
research (per a
meta-analysis)
comparing CEA
and CAS?
At 30days (peri-procedurally):
CAS associated with a significantly elevated
risk of stroke and death
CEA associated with a significantly elevated
risk of MI and cranial nerve injuries
Beyond 30days (long-term), comparable
findings
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271
What trials are
ongoing?
SPACE-2: Two parallel arms of asymptomatic
patients with severe stenosis
CEA and medical therapy vs medical
therapy alone.
CAS and medical therapy vs medical
therapy alone.
Trial currently stopped due to slow
recruitment, but data on previously recruited
patients (n=513) continuing to be collected.
ACST-2: RCT of asymptomatic patients with
severe stenosis comparing CEA vs CAS
CREST-2: Two parallel arms of asymptomatic
patients with severe stenosis
CEA and medical therapy vs medical
therapy alone
CAS and medical therapy vs medical
therapy
What are the
overall findings
from research
at this point,
informing
the above
recommendations
and guidelines?
Both CAS and CEA can be done with low risk
by experienced operators.
Long-term outcomes might be the same.
CAS better for those with cardiac issues peri-
procedurally.
While risk of MI is higher in CEA than in
CAS, the higher stroke rate in CAS seems to
be more detrimental to overall health.
CEA favored for more elderly patients.
More research needs to be done with uniform
use of EPDs, with best medical therapy, and
in symptomatic patients with experience CAS
and CEA operators.
Common Questions
Overall, when is carotid
revascularization
(by CEA or CAS)
indicated?
Symptomatic patients with >70%
stenosis
Patients with <6% risk of
perioperative stroke or mortality
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Carotid Artery Stenosis
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272
When does a patient
qualify as “symptomatic”
from carotid artery
stenosis?
History of non-disabling stroke, TIA,
or amaurosis fugax within the past
6months with ipsilateral carotid artery
stenosis
Generally, when is CAS
indicated over CEA?
In patients with:
Significant cardiac history
Anatomic contraindications to
surgery, such as prior neck surgery
or radiation
What are the major
complications of CAS?
Puncture site trauma
Overall higher risk of periprocedural
stroke than CEA
What is the best
screening and follow-up
test?
Carotid duplex ultrasonography
*Classification of recommendations
and level of evidence guide:
Class I: Benefit >> risk. Procedure
should be performed.
Class IIa: Benefit > risk. It is
reasonable to perform procedure.
Class IIb: Benefit >= risk. Procedure
may be considered.
Class III: No benefit, or there is harm.
Procedure is not helpful or may be
harmful.
Level A: Data from multiple RCTs or
meta-analyses.
Level B: Data from one RCT or from
non-randomized studies.
Level C: Limited data, only case
studies or expert opinion.
Further Reading
Bonati LH, Dobson J, Featherstone RL, etal. Long-term outcomes
after stenting versus endarterectomy for treatment of symptom-
atic carotid stenosis: the International Carotid Stenting Study
(ICSS) randomised trial. Lancet. 2015;385:529–38.
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273
Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/
AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/
SVS guideline on the Management of Patients with Extracranial
Carotid and Vertebral Artery Disease: executive summary: a
report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines,
and the American Stroke Association, American Association
of Neuroscience Nurses, American Association of Neurological
Surgeons, American College of Radiology, American Society
of Neuroradiology, Congress of Neurological Surgeons,
Society of Atherosclerosis Imaging and Prevention, Society
for Cardiovascular Angiography and Interventions, Society
of Interventional Radiology, Society of NeuroInterventional
Surgery, Society for Vascular Medicine, and Society for Vascular
Surgery. Developed in collaboration with the American
Academy of Neurology and Society of Cardiovascular Computed
Tomography. J Am Coll Cardiol. 2011;57:1002–44.
Bulbulia R, Halliday A.The Asymptomatic Carotid Surgery Trial-2
(ACST-2): an ongoing randomised controlled trial comparing
carotid endarterectomy with carotid artery stenting to prevent
stroke. Health Technol Assess. 2017;21:1–40.
Cline J, Hong MJ. Carotid artery stenosis & management RFS
pre IR rotation module. In: Common IR procedures. http://rfs.
sirweb.org/medical-
student- section/introduction- to- ir/common-
ir- procedures/. Oct 2018.
CREST-2: Medical study to prevent stroke caused by plaque buildup
in carotid arteries. In: CREST-2: Medical study to prevent stroke
caused by plaque buildup in carotid arteries. http://www.crest-
2trial.org/. Accessed Oct 2018.
Eckstein H-H, Reiff T, Ringleb P, et al. SPACE-2: a missed oppor-
tunity to compare carotid endarterectomy, carotid stenting, and
best medical treatment in patients with asymptomatic carotid
Stenoses. Eur J Vasc Endovasc Surg. 2016;51:761–5.
Eckstein H-H, Ringleb P, Allenberg J-R, etal. Results of the Stent-
Protected Angioplasty versus Carotid Endarterectomy (SPACE)
study to treat symptomatic stenoses at 2 years: a multinational,
prospective, randomised trial. Lancet Neurol. 2008;7:893–902.
Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD,
Stefanadis C. Carotid artery stenting versus carotid endarter-
ectomy: a comprehensive meta-analysis of short-term and long-
term outcomes. Stroke. 2011;42:687–92.
25 Carotid Artery Stenosis
https://t.me/med1917
274
Ederle J, Bonati LH, Dobson J, etal. Endovascular treatment with
angioplasty or stenting versus endarterectomy in patients with
carotid artery stenosis in the Carotid And Vertebral Artery
Transluminal Angioplasty Study (CAVATAS): long-term follow-
up of a randomised trial. Lancet Neurol. 2009;8:898–907.
Ederle J, Dobson J, Featherstone RL, et al. Carotid artery stent-
ing compared with endarterectomy in patients with symptom-
atic carotid stenosis (International Carotid Stenting Study):
an interim analysis of a randomised controlled trial. Lancet.
2010;375:985–97.
European Carotid Surgery Trialists' Collaborative Group.
Randomised trial of endarterectomy for recently symptomatic
carotid stenosis: final results of the MRC European Carotid
Surgery Trial (ECST). Lancet. 1998;351:1379–87.
Ferral H, Lorenz J.Radcases interventional radiology. New York:
Thieme; 2018.
Halliday A, Harrison M, Hayter E, et al. 10-year stroke preven-
tion after successful carotid endarterectomy for asymptomatic
stenosis (ACST-1): a multicentre randomised trial. Lancet.
2010;376:1074–84.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. Philadelphia: Lippincott Williams &
Wilkins; 2016.
Lefevre ML. Screening for asymptomatic carotid artery stenosis:
U.S.Preventive Services Task Force recommendation statement.
Ann Intern Med. 2014;161:356.
Long A, Lepoutre A. Corbillon, Branchereau A. Critical review
of non- or minimally invasive methods (Duplex ultrasonogra-
phy, MR- and CT-angiography) for evaluating stenosis of the
proximal internal carotid artery. Eur J Vasc Endovasc Surg.
2002;24:43–52.
Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG.The Carotid
Revascularization Endarterectomy Versus Stenting Trial
(CREST): stenting versus carotid endarterectomy for carotid dis-
ease. Stroke. 2010; https://doi.org/10.1161/strokeaha.110.595330.
Mas J-L, Trinquart L, Leys D, etal. Endarterectomy versus angio-
plasty in patients with symptomatic severe carotid stenosis
(EVA-3S) trial: results up to 4 years from a randomised, multi-
centre trial. Lancet Neurol. 2008;7:885–92.
Massop D, Dave R, Metzger C, Bachinsky W, Solis M, Shah R,
Schultz G, Schreiber T, Ashchi M, Hibbard R. Stenting and
angioplasty with protection in patients at high-risk for endar-
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275
terectomy: SAPPHIRE worldwide registry first 2,001 patients.
Catheter Cardiovasc Interv. 2009;73:129–36.
North American Symptomatic Carotid Endarterectomy Trial
(NASCET) Collaborators. Beneficial effect of carotid endarter-
ectomy in symptomatic patients with high-grade carotid stenosis.
N Engl J Med. 1991;325:445–53.
Walker MD, Marler JR, Goldstein M, et al. Endarterectomy for
asymptomatic carotid artery stenosis. Executive Committee
for the Asymptomatic Carotid Atherosclerosis Study. JAMA.
1995;273:1421–8.
25 Carotid Artery Stenosis
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277© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_26
Evaluating Patient
When should renovascular
hypertension (RVH) be
suspected?
In patients with:
Refractory hypertension under
age 30
New onset of severe/refractory
hypertension after age 50
Abrupt worsening of controlled
hypertension
Hypertension with progressive
renal failure
Creatinine (Cr) rise over 20%
with ACE inhibitors (AKI when
put on ACE-I)
Secondary hyperaldosteronism
and resulting hypokalemia
Flash pulmonary edema in
patients with preserved LVEF
Unilateral small kidney with
difference >1.5cm
Chapter 26
Renovascular Hypertension
GauravGadodia
G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: ggadodia.md@gmail.com
(continued)
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What is the definition of
refractory hypertension?
Poorly controlled hypertension
even on optimal medical
management with three
antihypertensive medications
What is the main underlying
cause of RVH?
Renal artery stenosis (RAS)
due to atherosclerosis (90%) or
fibromuscular dysplasia (FMD)
(10%)
How do patients with RAS
usually present?
Asymptomatic, with RAS
incidentally detected during
unrelated angiographic imaging
What physical exam finding
may be found in RAS?
Flank or abdominal bruit
What is a possible severe
acute presentation of RAS?
Flash pulmonary edema
What is the best initial/
screening imaging study for
evaluation of RAS?
Doppler ultrasonography (AHA/
ACC class I, LOE: B)
What are direct signs of RAS
on Doppler?
Peak systolic velocity (PSV)
> 180cm/s
Post-stenotic turbulence/bruit
Renal artery PSV to aortic
velocity ratio > 3.5
What are indirect signs of
RAS on Doppler?
Tardus et parvus waveform distal
to the stenotic lesion
Prolonged acceleration time
(> 0.07seconds)
Loss of early systolic peak distal
to the lesion
Discrepancy in resistive index
(RI) before/after the lesion > 0.05
What is another noninvasive
imaging modality that can
help evaluate RVH when US
findings are equivocal?
Computed tomographic
angiography (CTA) (I, B)
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What is a disadvantage
of CTA (especially in this
population), and what is an
alternative test?
Disadvantage: Contrast-induced
nephropathy in patient population
with a high prevalence of ischemic
nephropathy from stenosis
Alternative: Magnetic resonance
angiography (MRA) (I, B)
What is the gold-standard
test for diagnosing RVH?
Digital subtraction angiography
(DSA) (I, B)
What are other described
diagnostic methods, and their
AHA/ACC recommendation
class/level of evidence?
Captopril renal scintigraphy (III,
C)
Selective renal vein renin
sampling (III, B)
Plasma renin activity (III, B)
Captopril stimulation test (III, B)
High Yield History
About what percentage
of patients with HTN
have underlying RAS?
5% (0.5–10%)
What is the underlying
pathophysiology of
RAS causing RVH?
Decreased renal perfusion ➔ renin
release by juxtaglomerular cells ➔
activates angiotensin II, causing:
Efferent arteriole constriction to
increase renal perfusion
Systemic hypertension
Aldosterone elevation leading to
sodium/water retention and diastolic
dysfunction
What is the definition
of hemodynamically
significant RAS (ACC/
AHA and ACR/SIR)?
10% or greater mean translesional
pressure gradient (and/or SBP gradient
> 20mmHg or > 10mmHg mean
gradient difference)
(continued)
26 Renovascular Hypertension
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280
What lab abnormality
is associated with a
worse prognosis in
RVH?
Creatinine > 3.0
What are the
demographics of
RAS caused by
atherosclerosis?
Older men
What are the
demographics of
FMD?
Women aged 30–50years old
What subtype of FMD
is associated with
HTN?
Medial subtype, with intimal and
adventitial subtypes being much less
likely to cause HTN (< 15% combined)
What is the
characteristic
appearance of FMD?
“Beading” of the artery due to
alternating stenoses and aneurysms
What findings are
associated with FMD?
True and dissecting aneurysms
Arteriovenous fistulas
What is another
differential for RAS?
Noninflammatory vasculitis
What is the
most common
noninflammatory
vasculitis subtype?
Medial fibroplasia
How is this treated? Balloon angioplasty. Only pursue
stenting if angioplasty fails or there are
complications.
What are uncommon
etiologies for RVH?
Renal artery aneurysm, Takayasu
arteritis, neurofibromatosis, Iatrogenic
or traumatic injury causing dissection,
vessel injury damaging the intima
causing thrombosis, retroperitoneal
tumor encasement/compression,
Williams syndrome, segmental arterial
mediolysis, and midaortic syndrome
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