Carotid artery stenting

Policy context

Treatment options for carotid artery stenosis include medical therapy, surgery to remove the atherosclerotic plaques (carotid endarterectomy or CEA), and the percutaneous placement of stents (CAS) in the affected area. In general, persons undergoing CEA or CAS will also be receiving medical therapy. During CAS, the clinician threads a catheter through an artery up from the groin and up to the carotid artery. The catheter has an attached balloon which expands the artery and inserts a stent to hold the artery open. Multiple stents may be placed depending on lesion length. Because there is a risk of disrupting the plaque along the artery walls during this type of procedure, CAS is usually performed along with a filter, or distal embolic protection device (EPD) which is used to capture any debris that becomes dislodged, reducing the risk of embolization.

Status: Decision completed

Primary criteria ranking

  • Safety = High
  • Efficacy = High
  • Cost = Medium
Documents

Assessment timeline

  • Draft key questions published: November 26, 2012
  • Public comment period: November 26 to December 11, 2012
  • Draft report published: June 28, 2013
  • Public comment period: June 28 to July 30, 2013
  • Final report published: August 15, 2013
  • HTCC public meeting: September 20, 2013

Background

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in both men and women in the United States. One or more types of CVD effect more than 1 in 3 adults, mostly over 60 years of age or older. When considered separately from other CVDs, stroke is the fourth leading cause of death (behind heart disease, cancer, and chronic lower respiratory disease). The carotid arteries provide the main blood supply to the brain and narrowing of these arteries (stenosis) due to atherosclerosis accounts for nearly 20% to 25% of these strokes. The most common site of plaque formation and stenosis in the carotid artery is near the bifurcation of the common carotid artery into the internal and external carotid arteries. The risk of stroke depends upon the severity of the carotid stenosis. Persons with carotid artery atherosclerosis will generally have concomitant medical problems such as diabetes, high cholesterol or hypertension and various risk factors such as smoking and obesity. The standard of care is to address these problems and risk factors independent of the carotid artery disease.