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CLINICAL RESEARCH: PERIPHERAL VASCULAR DISEASE: VIEWPOINT

A cardiologist in the carotids

^* Endovascular Care, Swedish Cardiovascular Research, Seattle, Washington, USA

Manuscript received October 30, 2003; accepted November 6, 2003.

^* Reprint requests and correspondence: Dr. William A. Gray, Director, Endovascular Care, Swedish Cardiovascular Research, Suite 1020, 1221 Arnold, Seattle, Washington 98104, USA.
william.gray{at}swedish.org

Carotid endarterectomy for stroke prevention has been the standard of care for 50 years in patients with extra-cranial carotid bifurcation disease. Over the past decade, carotid stenting has emerged as a viable alternative to surgery. Combined with filter embolic protection devices, both a randomized control trial (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy registry [SAPPHIRE]) as well as registry data (ACCULINK for Revascularization of Carotids in High Risk Patients registry [ARCHeR] and Registry Study to evaluate the Neuroshield Bare-Wire Cerebral Protection System and X-Act Stent in patients at high risk for Carotid Endarterectomy [SECuRITY]) have compared favorably to endarterectomy in patients at high risk for operative revascularization. Conditions associated with high operative risk included patients with significant cardiac, pulmonary, and renal disease; previous neck operation; previous radiation; and anatomically difficult surgical access. On the basis of these results, a carotid stent system approved by the Food and Drug Administration (FDA) is anticipated in 2004. Although this will be a welcome addition to endarterectomy in the armamentarium of therapeutic options for patients with carotid disease, several challenges lie ahead. Coverage and reimbursement for the carotid stenting has been severely restricted to include only those procedures performed as part of an FDA investigational device exemption trial protocol, and a national noncoverage decision will have to be reckoned with before broader coverage can be put into place (assuming FDA approval). In addition, the level of national expertise in carotid endovascular intervention is limited, and training will need to be tailored to the three specialties likely to perform the procedure: cardiology, radiology, and vascular surgery. Each of these specialties will have specific, and different, requirements for their training, further complicating the task of education.

Abbreviations and Acronyms   ARCHeR = ACCULINK for Revascularization of Carotids in High Risk Patients registry   FDA = Food and Drug Administration   IDE = Investigational Device Exemption   SAPPHIRE = Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy registry   SECuRITY = Registry Study to evaluate the Neuroshield Bare-Wire Cerebral Protection System and X-Act Stent in patients at high risk for Carotid Endarterectomy

This article has been cited by other articles:

				W. A. Gray Reply J. Am. Coll. Cardiol., January 18, 2005; 45(2): 327 - 327. [Full Text] [PDF]

				G. H. Wheatley III Cardiologist in the carotids J. Am. Coll. Cardiol., January 18, 2005; 45(2): 326 - 327. [Full Text] [PDF]