3.3 Carotid Artery Disease: CEA, CAS, TCAR, or Just Pills?

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of the problem or issue

Carotid arterial disease is usually caused by atherosclerosis and it results in narrowing of the arteries in the neck that supply blood to the brain. Unfortunately, carotid disease often does not cause symptoms until the narrowing becomes severe and/or a thromboembolic event occurs. There are several diagnostic tests that can be performed to confirm the diagnosis. Then, the real dilemma becomes: what is the best treatment option. A surgical procedure, carotid endarterectomy (CEA), is the oldest invasive treatment available, and it is relatively safe when performed by experienced surgeons. However, some patients are at high or even prohibitive risk for this surgery. Percutaneous carotid artery stenting (CAS) and transcarotid artery revascularization (TCAR) are alternatives to CEA. Additionally, over the years since the advent of CEA therapy, there have been advances in pharmacology that have expanded medical treatment options, and these possibly may alter the need for invasive approaches.

Gaps in knowledge

What is the most appropriate treatment for each individual patient with carotid disease has not been resolved. Risk stratification for carotid revascularization is at the forefront of the decision-making process for selecting treatment. There is no universally accepted risk stratification schema. Interestingly, the technical abilities required to perform a safe procedure are often overlooked. Data reveal the decreasing incidence of complications over the years as operator experience increases and advances in technology provide operators with better and safer equipment. Trials have been conducted yielding varying results. Comparisons of therapies have been interpreted with divergent conclusions. The role of aggressive medical therapy in lieu of invasive procedures has not been fully evaluated, and yet may be the only treatment necessary in asymptomatic patients despite the degree of carotid stenosis.

Possible solutions and future directions

Limited insurance coverage for CAS began in 2001 for patients who could participate in investigational device exemption (IDE) trials. Medicare (CMS) still does not cover CAS unless patients are symptomatic, are at high surgical risk, and have a high degree of stenosis. Despite numerous registries and randomized trials that have demonstrated its clinical benefit, CAS remains one of the most political issues in medicine. We must push to allow this percutaneous option for our patients and at the same time ensure that procedures are performed by the appropriate physicians. Training in fellowship programs should be comprehensive and provide a level of expertise that can be documented, if a trainee plans to perform these procedures after graduation. We anxiously await the results of the ongoing CREST II trial and encourage industry to continue to explore newer technologies.