Advances in interventional neuroradiology 2005.

In the wake of the SAPPHIRE trial1 and subsequent approval of carotid stenting (CAS) devices by the Food and Drug Administration (FDA) in the United States, CAS is poised to explode in the frequency of its application in North America. Although the results of the Carotid Revascularization Stenting versus Endarterectomy Trial (CREST), the largest randomized controlled trial comparing carotid endarterectomy to CAS, are years away, many practitioners in multiple disciplines have already entered the competition for patients and remuneration. Despite the absence of evidence to support CAS over carotid endarterectomy2,3 and the need to continue recruiting patients to CREST,4 cardiologists, vascular surgeons, neurologists, neurosurgeons, general interventional and neurointerventional radiologists are all vying to treat carotid stenoses, many of which are 70% in severity, and asymptomatic.2,5,6 Attempts are being made to establish training, competency and credentialing standards for performance of CAS, and they vary widely between specialties.7,8,9 Computer simulations are playing a larger role in this process10 and may help to address the mismatch between training opportunities and interested practitioners. There have been concerns about the SAPPHIRE trial11 and the incidence of restenosis in previous case series.3,12 The techniques of CAS are still variable, with some operators advocating the use of cerebral protection devices,13 whereas others found that distal emboli might be more common with their usage.14 Although abnormalities on diffusion-weighted MRI after CAS are not uncommon (up to 30% of patients), most of these are asymptomatic.15 Patient related risk factors might be important determinants of complication rates after CAS, with those presenting with hemispheric strokes at particularly high risk.16 There may be a role for preoperative ultrasound in the identification of friable plaque, which may be more likely to generate distal emboli during CAS procedures.17