Practical Carotid Artery Stenting. Sumaira Macdonald, Gerry Stansby (Editors). Springer 2009, 208 pages, 76 illustrations, $119.00.
The safety of carotid artery stenting (CAS) remains inferior to carotid endarterectomy (CEA) for treatment of symptomatic extracranial carotid artery stenosis in the immediate postoperative period. However, beyond the postoperative period, data continues to support a role for CAS in selected patients. A recently published large systematic review of 206 individual studies (54,713 total patients) undergoing CAS found the cumulative 30-day risk of stroke or death to be 7.6% in symptomatic and 3.3% in asymptomatic patients (Touze E, et al. Systematic review of the perioperative risks of stroke or death after carotid angioplasty and stenting. Stroke 2009; 40:e683-e693). Appropriate patient selection and experienced operating physicians’ hands remain vital for an excellent outcome.
As experts, Macdonald and Stansby intended to create a comprehensive practical guide for all interested in CAS from various background including radiologists, neurologists, vascular surgeons, cardiologists, and those physicians who are involved in periprocedural care of patients undergoing carotid artery treatment. Thus, 30 authors from across these disciplines were asked to contribute to this single-volume 208-page textbook comprised of 17 chapters. Each chapter is well structured with a list of “Key Points” in bullet form at the end summarizing the content. Finally, each chapter has an appropriate number of key references attached. The first three chapters discuss “Carotid Stenting: The Evidence Base”, “Patient Selection for Carotid Stenting”, and evidence for treating asymptomatic patients with carotid artery disease. These chapters are well written and informative with some excellent tables on natural risk associated with carotid artery disease, risk factors, patient selection, and outcome of various stent trials in symptomatic and asymptomatic patients. A thoughtful structured chapter written by the editors follows on training standards, skill requirements, accreditation, and proctorship in CAS. I enjoyed reading this section because a lively discussion has flared mainly for monetary reasons, sadly and shamefully, about who should be doing CAS since its inception. A chapter on carotid imaging (MRA, CTA, DSA) follows. Although some new imaging tools such as 3D roadmapping are introduced, for a weathered diagnostic and interventional neuroradiologist, this may be a less exciting part of the book.
The 6th chapter introduces the reader to variations of aortic arch configuration, the vasculature of the neck, and the cerebrovascular anatomy. Personally, I would have placed this part more to the beginning of the book. Unfortunately, this chapter is poorly written, several figures are of substandard quality and mislabeled. There is a substantial amount of information on the posterior circulation that is redundant for CAS. A chapter follows on patient selection based on vascular anatomy of the aortic arch and the common carotid artery. The authors introduce us to several methods used to evaluate tortuosity of the vascular system that is critical for accessibility for a safe and successful CAS. As discussed by the authors these guidelines may be helpful for inexperienced practitioners to reduce the periprocedural morbidity.
Chapter 8 covers the value of Ultrasound for detection of vulnerable carotid plaque, discusses scaffolding aspects of various stent designs and performance of currently available cerebral distal protection devices and its impact on CAS outcome. The authors discuss some recent information on stabilizing effects of statins on vulnerable plaque and its role in reducing perioperative embolic complications associated with CAS. While the information provided in this poorly organized and edited chapter may be valuable for some readers, its practical implication for daily practice is questionable. It might have been useful to have provided some images and references to recent work on vulnerable plaque using MRI, CT and molecular imaging. On the other hand, chapter 9 on “Pharmacological Support” in CAS is very well-written, updated and informative. It includes the role of anticoagulants/antiplatelet agents, their limitations and discusses in the second part the “Periprocedural Pharmacotherapy”. This chapter as well as the following chapter 10 would be better situated in the first part of the book. The latter chapter on “Equipment, Basic and Advanced: An Overview” has some nice tables summarizing most commonly used and well-known materials in CAS. For the less experienced interventionist some illustrations and figures would have been welcome.
The next two chapters “Difficult Access: Tips and Tricks” and “Procedural Tips and Tricks” should have been combined to one in order avoid redundancy. Some basic catheter handling, commonly known to most active (neuro) interventionalist, and a few useful tricks are described with significant and justified emphasizes on the aortic arch anatomy. As with all technical disciplines and with recent introduction of newer technologies and materials, some methods listed are outdated. Both chapters fail to elaborate on the anterior and, to a certain degree, on the posterior cerebral circulations, which is important in CAS (collateral circulation, tandem lesions, etc.).
Chapter 13 “Embolic Containment Devices and How to Avoid Disaster” is comprehensive on all currently used cerebral protection devices and provides some useful information on how to avoid potential thromboembolic complications. This chapter could partly be absorbed in to chapter 8 and the previous two chapters. The following chapter by the lead editor discusses “Relevance of Periprocedural Hemodynamics including hypoperfusion and hyperperfusion syndrome and risks for procedural related neurological insult. Chapter 15 “Dealing with Complications: Neurorescue” is a theoretical discourse on the use of intraarterial thrombolytics and clot busters for thromboembolic complications. The chapter is missing figure legends and the thrombectomy devices are listed without any prove of their usefulness for embolic stroke in CAS. A single case is presented with a successful revascularization of a CAS related thromboembolic occlusion of the left middle cerebral artery (MCA) and labeled as “complete recanalization” while the angiogram shows multiple MCA branch still occluded with poor distal perfusion.
Chapter 16 provides helpful information on “Surveillance: Diagnosis and Management of In-Stent Restenosis” using multiple tables and illustrations. Different types of in-stent stenosis (focal, diffuse, diffuse proliferative) are discussed. It would have been useful to have added some illustrative cases. The final chapter “Optimizing Outcomes” reads very well and summarizes previous chapters emphasizing the need for a careful patient selection for a successful outcome and includes discussions on anatomical risk factors, plaque analysis, use of distal protection devices, periprocedural anticoagulation, antiplatelet management, and hemodynamics. Although the index is comprehensive, it is inconsistent as some of the referenced authors and some of the devices are listed while several others are missing.
Most of the data provided in the book can be found in other books on CAS and publications. However, the editors manage to bring all the relevant information on CAS into one volume. Inadvertently, as with other multi-authored books, there are chapters that have some degree of overlapping but not distracting material. A proper organization into broader categories such as anatomy, imaging, devices, drugs, procedure and pitfalls as well as summary of clinical trials, would have improved reading.
In summary, I enjoyed reading this book would highly recommended for anyone who deals with CAS patients, including primary care providers, emergency medicine physicians, internists, (neuro)radiologist, vascular surgeons, interventional cardiologists, and intensivists. As repeatedly stated by the editors, a theoretical guide will never replace the hands-on training under the tutelage of a master in CAS.
