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Guidelines for patient selection and performance of carotid artery stenting

Authors

  • The Carotid Stenting Guidelines Committee

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      The Carotid Stenting Guidelines Committee: Members: Christopher Bladin, Brian Chambers, Denis Crimmins, Stephen Davis, Geoff Donnan, Judy Frayne and Chris Levi, Royal Australasian College of Physicians, Sydney, Australia, and Stroke Society of Australasia, Sydney, Australia, and Australian and New Zealand Association of Neurologists; David Muller and Gishel New, Royal Australasian College of Physicians, Sydney, Australia, and Cardiac Society of Australia and New Zealand, Sydney, Australia; Michael Denton and Michael Lawrence-Brown, Royal Australasian College of Surgeons, Melbourne, Australia, and Australian and New Zealand Society of Vascular Surgeons, Sydney, Australia; and Constantine Phatouros, Rebecca Scroop and Tim Harrington, Royal Australian and New Zealand College of Radiologists, Sydney, Australia.


  • C Bladin MBBS, MD, FRACP; B Chambers MBBS, MD, FRACP; D Crimmins MBBS, FRACP; S Davis MBBS, MD, FRACP; G Donnan MBBS, MD, FRACP; J Frayne MBBS, FRACP; C Levi BMedSci, MBBS, FRACP; D Muller MBBS, MD, FRACP; G New MBBS, PhD, FRACP; M Denton MBBS, FRACS; M Lawrence-Brown MBBS, FRACS; C Phatouros MBBS, FRANZCR;
    R Scroop MBBS, FRANZCR; T Harrington MBBS, FRANZCR.

  • Conflicts of interest: None

Prof. Christopher Bladin, Department of Neurosciences, Box Hill Hospital (Monash University), Nelson Road Box Hill, Vic. 3128, Australia.
Email: chris.bladin@easternhealth.org.au

Summary

The endovascular treatment of carotid atherosclerosis with carotid artery stenting (CAS) remains controversial. Carotid endarterectomy (CEA) remains the benchmark in terms of procedural mortality and morbidity. Consensus Australasian guidelines for the safe performance of CAS were developed using the modified Delphi consensus method of iterative consultation.

Selection of patients suitable for CAS needs careful consideration of clinical and patho-anatomical criteria. Randomised controlled trials and pooled analyses have demonstrated that CAS is more hazardous than CEA. The CGSC therefore recommends that CAS should not be performed in the majority of patients requiring carotid revascularisation. There is currently no evidence to support CAS as a treatment for asymptomatic carotid stenosis. The use of distal protection devices during CAS remains controversial with increased risk of clinically silent stroke. The knowledge requirements for the safe performance of CAS include an understanding of the evidence base from randomised controlled trials, carotid and aortic arch anatomy and pathology, and recognition and management of periprocedural complications. It is critical that all patients being considered for a carotid intervention have adequate pre-procedural neuroimaging and peri-procedural, independent, neurological assessment. Maintenance of proficiency in CAS requires active involvement in surgical/endovascular audit and continuing medical education programmes. These standards should apply in the public and private health-care settings.

These guidelines represent the consensus of an intercollegiate committee in order to direct appropriate patient selection to perform CAS. Advances in endovascular technologies and the results of randomised controlled trials will guide future revisions of this document.

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