Management practices in carotid stenting.

Carotid endarterectomy can be regarded as the standard of care for low-risk patients with severe carotid stenosis; however, this technique is less appropriate for certain patient groups. For high-risk patients, carotid stenting currently represents a suitable alternative to endarterectomy. The major cause of morbidity and mortality linked to carotid intervention is release of plaque material, which leads to microembolic obstruction of distal intracranial branch vessels and arterioles. Emboli retrieval devices are in development to help prevent distal occlusion, and effective antiplatelet therapy has a role in mitigating the clinical consequences of microembolization. Initial experience has shown that antiplatelet therapy with the adenosine diphosphate receptor antagonist clopidogrel plus aspirin (+/- abciximab) is associated with a very low risk of procedural stroke or stent thrombosis and does not appear to increase the risk of intracranial haemorrhage. The availability of potent antiplatelet regimens, emboli prevention devices and nitinol stents will greatly expand the spectrum of carotid disease that can be safely treated with endovascular therapy.