Carotid angioplasty as an alternative to carotid endarterectomy for management of extracranial atherosclerotic carotid stenosis

Introduction
Endoluminal treatment of carotid stenosis is gaining increasing popularity owing to its perceived less invasiveness. However, the outcome of carotid angioplasty-stenting (CAS) should be verified in each center before considering CAS a valid alternative to carotid endarterectomy (CEA). The aim of this study was to compare the safety and efficacy of CAS and CEA (considered as the gold standard treatment for carotid stenosis) in a concurrent series of patients.
Patients and methods
This is a retrospective study of prospectively collected data comprising all consecutive patients who underwent CAS for atherosclerotic carotid artery stenosis from March 2014 to May 2018 in the Division of Vascular and Endovascular Surgery, University of Perugia, Perugia, Italy, and Department of Vascular and Endovascular Surgery, Assiut University Hospital, Assiut, Egypt. Both asymptomatic and symptomatic patients with carotid artery stenosis were included. Indications for CAS were high-risk patients, recurrent carotid disease, and irradiated neck. All cases of CAS cases were performed under local anesthesia in a hybrid operating room using cerebral protection devices. CEA cases were performed either under local or general anesthesia based on anesthesiologist and patient choice. Transcranial Doppler monitoring was always used when feasible.
Results
Symptomatic stenosis was more frequent in the CEA group (50 vs. 39%, respectively). Severe heart disease was more frequent in the CAS group when compare with the CEA group (62 vs. 30%, respectively). The inability to complete CAS occurred in five (4.2%) patients with immediate conversion to CEA. At 30 days, four major strokes (3.3%; one of them was fatal) occurred in the CAS group, and two (0.6%) major strokes occurred in the CEA group (=0.04; odds ratio=5.9, 95% confidence interval=1.1–31.2). The endovascular group showed a higher incidence of minor neurological complications compared with the CEA group (13/119 vs. 3/344, respectively; <0.0001).
Conclusions
Our early experience showed that CAS has a 30-day neurological outcome worse than CEA. This may be owing to a higher cerebral embolic risk of endovascular procedure. Currently, CEA remains the gold standard for carotid stenosis. CAS should be performed in selected patients.