Managing Extracranial Carotid and Vertebral Artery Disease

New practice guidelines released today are an important step forward for patients with carotid artery disease. The guidelines, sponsored by 14 organizations, including the Society for Cardiovascular Angiography and Interventions (SCAI), reinforce the safety and efficacy of carotid artery stenting (CAS) as an option for patients in need of revascularization.

Support for broadened access to carotid artery stenting continues to gain momentum after a recommendation last week by the FDA Circulatory System Devices Advisory Panel to expand the availability of carotid artery stenting to patients at standard risk for surgical complications.

The findings of the CREST trial (Carotid Revascularization Endarterectomy vs. Stenting Trial; New England Journal of Medicine), offer the latest scientific evidence in support of carotid artery stenting. The largest and most rigorous randomized stroke prevention trial ever undertaken, CREST found carotid artery stenting was equally safe and effective as the surgical procedure carotid endarterectomy (CEA) for stroke prevention, including four-year follow-up, according to a statement from SCAI.

The guidelines published today state that carotid artery stenting is a safe and effective alternative option in symptomatic patients (transient ischemic attack [TIA] or non-disabling stroke within six months) with neck arteries more than 50% blocked, and stenting could be considered for asymptomatic patients with 60% or greater blockages in their neck arteries.

These guidelines, in conjunction with the FDA panel recommendation and CREST data, demonstrate mounting support for carotid artery stenting across physician specialties.

Further support for carotid artery stenting is shown in another set of recently updated guidelines for secondary stroke prevention by the American Heart Association and American Stroke Association, which is consistent with the new guidelines in recommending CAS be considered in a broader population of patients than those currently covered by Medicare.

In light of these developments, SCAI said that it hopes the Centers for Medicare and Medicaid Services will widen its current “highly restrictive” coverage policy on carotid artery stenting and allow patients and physicians to decide what the best form of treatment for individuals is.

Currently, Medicare and most insurers in the United States cover carotid artery stenting only for symptomatic patients at increased surgical risk and those enrolled in clinical trials, barring many patients who could benefit from the minimally invasive stenting procedure from receiving it.

Patients who cannot afford to pay for the carotid artery stenting procedure by themselves or who do not benefit from medication alone, typically undergo the much more invasive CEA procedure, where a surgeon makes an incision in the patient's neck to remove the plaque blockage in the carotid artery.