Die Behandlung der Karotisstenose aus der Sicht des Interventionalisten

In the hand of experienced interventionalists carotid stenting is a valuable alternative to endarterectomy for patients with carotid stenosis. Mechanical emboli-protection systems have been a major advance in the field by reducing the incidence of periprocedural neurologic events. The greatest advantage of carotid stenting over endarterectomy is that the outcomes are far less influenced by the comorbidities of the patients. Therefore, the endovascular treatment of carotid disease is particularly suitable for patients at high-risk for surgery. The SAPPHIRE study, which randomised patients at high-risk for surgery to endarterectomy or carotid stenting with filter-emboli protection, demonstrated that patients allocated to carotid stenting had significantly less adverse events. Advantages of carotid stenting over endarterectomy include the reduction of periprocedural myocardial infarctions, the lack of general anesthesia and of neck complications such as cranial nerve lesions. In addition, patients are generally discharged the day following stenting, which leads to a reduction in costs. Patients particularly suitable for carotid stenting are elderly (≥75 years of age), with restenosis following surgery, with stenosis/ occlusion of the contralateral carotid, and those requiring coronary bypass surgery. The only large-scale randomised trial published in non-high risk patients (CAVATAS) showed similar results in patients treated surgically or with balloon angioplasty. The results of ongoing trials should be awaited before expanding the indication of carotid stenting to this patient population off-protocol and in non-specialised centers.