Carotid-artery therapy is one of the principal procedures done by vascular surgeons. Its use has been growing significantly, in terms of carotid endarterectomy, over the past several years. Approximately 200,000 carotid endarterectomies are done per year in the United States; many of these are done by vascular surgeons, but many of them, historically, have been done by general surgeons. This procedural volume initially represented a significant change and was brought about by a landmark 1991 randomized trial 1 that finally, in the dispute-prone health care environment of the time, demonstrated the benefit of revascularization. By clearly establishing its value, that trial changed the practice patterns of all of us in clinical medicine.

A dramatic increase in the number of carotid revascularization procedures began to be noticeable at that time. In the early years of angioplasty, carotid angioplasty was performed. There were many pioneers of the procedure in the United States, and in my early experience, I had the opportunity to do angioplasty alone, as well.

STENTING TURF

Carotid angioplasty was followed by the development of the method used for the placement of stents. As interventional radiologists, many of us direct most of our careers toward trying to alter the status quo by improving the quality of care through the use of less invasive, image-guided therapies. For a number of different reasons, however, the entry of interventional radiologists into carotid-artery therapy was slower than it has been for other areas of vascular intervention. Some teams of physicians began exploring the use of carotid stents as the needed technology became available, but interventional radiologists did not follow them in great numbers. Historically, we had asked why interventional therapy would not be more suitable than surgery in other areas, but we were somewhat reluctant to do so where carotid stenting was concerned. This could have been because many of us had experience with good vascular surgeons and good outcomes; perhaps we felt that there might not be an adequate opportunity for improvement that would warrant our involvement. Nonetheless, it is hard not to recognize the fact that our interventional cardiology colleagues have been very energetic in exploring this area, producing good results, and, in many ways, driving us to respond. We have done so by extending our skills into the area of carotid revascularization.

This competition has been going on for some years, but we are nearing a pivotal point in the evolution of both stenting technology and the patient-care paradigm for carotid stenosis. As Medicare decisions on coverage for carotid stenting approach, it turns out that the future is much closer than we thought. As reimbursement becomes available outside trials, some contention over turf is probable.

CONCLUSION

There is a perception, among many members of the health care community, that radiologists really have no great interest in carotid stenting. In a survey conducted by the Society of Interventional Radiology, however, members indicated that 25% of them have some experience with carotid artery stenting (with or without embolic protection). Our colleagues in other disciplines might find this surprising, but it is obvious that we are excited about carotid stenting. In ranking topics that are important for the society to address through education and related activities, the responding members indicated that stenting, as a priority, was second in importance only to peripheral vascular disease.

Barry T. Katzen, MD, is founder and medical director, Baptist Cardiac and Vascular Institute, Miami. This article has been adapted from Technical Considerations in Carotid Stenting, which he presented at the 29th annual meeting of the Society of Interventional Radiology on March 25, 2004, in Phoenix.

References:

  1. North American Symptomatic Carotid Endarterectomy Trial collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med. 1991;325:445-453.