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Carotid Interventions

2004 Edition, August 30, 2004

Complete Document

Detail Summary

Active, Most Current

Additional Comments:
ISBN: 978-0-8247-5932-2
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Product Details:

  • Revision: 2004 Edition, August 30, 2004
  • Published Date: August 30, 2004
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 345
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


The purpose of this book is to assist the reader in the process of identifying, understanding, and improving the skills needed for incisionless treatment of carotid artery stenoses. Our emphasis is on technique and results but we have included practical advice on topics such as how to get started, what kind of training is needed, and how to safely and efficiently add carotid angioplasty and stenting to your therapeutic offerings.

The developing clinical utility of carotid angioplasty and stenting highlights the importance of a broader issue facing vascular surgery. Will vascular surgeons be able to adapt and retain our role as providers of full-service vascular care? We believe that vascular surgeons are ideally, if not uniquely, qualified to manage patients with extracranial cerebrovascular disease and to assess competing therapies.

Carotid stent placement represents the convergence of multiple factors at a time when we are rethinking our approach to vascular disease. Skills and technology developed in other, more forgiving, vascular beds have improved over the past few years. Carotid bifurcation atherosclerosis is more amenable to endovascular intervention than conventional wisdom would have predicted. Distal protection devices and other technical advances may be able to decrease stroke risk and make the neurological outcome of carotid stent placement competitive with carotid endarterectomy. Specialists in multiple disciplines represent an eager potential workforce ready to participate in the rapid dissemination of carotid stenting to an expanded pool of patients

Among vascular surgeons, the traditional therapists of carotid occlusive disease, many offer only endarterectomy and have yet to perform carotid stent placement as an alternative therapy for their patients. Vascular surgeons who have honed their ability to offer effective therapy for carotid disease via carotid endarterectomy, but who do not have the experience that would allow them to participate in the performance of carotid angioplasty and stenting, are forced to choose between two unappealing alternatives: abdicating their leadership role in the delivery of carotid therapeutics or emphasizing their skepticism and underscoring the flaws inherent to the process of carotid stenting trials conducted by other specialists.

Many cardiologists and radiologists have never managed carotid disease and face the challenges of learning and refining the clinical management paradigms for a complex medical problem. Since they do not have the skills necessary for performing carotid endarterectomy and no practical way of obtaining these skills, their options for treatment of carotid artery disease are limited to catheter interventions, medical management, or referring the patient to a surgeon. They have no reference for the importance of open surgical skills or even intimate clinical knowledge of carotid disease in adding to the effectiveness of a catheter-based interventionalist.

These factors make it difficult to obtain an objective assessment of the relative efficacy of the three competing therapeutic modalities: medical management, carotid angioplasty and stenting, and carotid endarterectomy. I assert that the ideal arbiter of the efficacy of competing treatments is a practitioner, capable of performing each with the highest possible level of skill and who has nothing to gain from the evident superiority of any one treatment. Endovascular surgeons possessing a combination of excellent endovascular skills and open surgical experience are the only specialists ideally positioned to evaluate the currently available carotid treatments.

Carotid stenting will assume a broad role in carotid disease management and is significantly different from other endovascular procedures. The cerebrovasculature is the last vascular bed to be significantly impacted by endovascular intervention. Vascular surgeons know too much; they are eyewitnesses to the friable carotid plaque contents that cause stroke. Carotid stenting is among the most sophisticated endovascular procedures and there is no open component, as there has been with endovascular grafts for aortic aneurysms. Carotid endarterectomy has been one of the most successful vascular procedures offered to patients over the years. For these reasons, vascular surgeons have been slow to adapt and other specialists have been eager to adapt this new technique. Despite the success and efficacy of carotid endarterectomy, further major improvements in the results of open repair are unlikely. In comparison, carotid stent placement is only in its first or second iteration, and is certain to improve with further enhancements in cerebral protection devices, access, miniaturization, and the accumulated knowledge garnered by continued endovascular work within the carotid bed.

We believe that if you are a clinician skilled in the management of carotid disease, you have experience with complex endovascular procedures, and you become an accomplished carotid angiographer, you are well prepared to master the skills of carotid stent placement. The incorporation of carotid stenting into vascular practice poses significant challenges and it is easy to get distracted by the logistics involved and the complexities of protectionism. However, the development of carotid stenting is likely to further the transition of vascular surgery from an open surgical specialty where many useful tools are ignored to a modern specialty where all available modalities are used to benefit the patients and provide a full spectrum of care. Old allegiances and nostalgia aside, carotid stenting is one of the most exciting developments ever in the management of vascular disease.