A New Management Strategy For Extra-Cranial Carotid Artery Bifurcation Disease: Carotid Artery Stenting

Mitchell J. Silver, D.O. Department of Cardiology and Vascular Medicine, Mid-Ohio Cardiology Consultants, Midwest Cardiology Research Foundation, Columbus, Ohio

 

Introduction

Endovascular treatment of occlusive atherosclerotic disease has been well established for coronary, aortoiliac, femoral-popliteal, and renal revascularization. Endovascular therapy offers the potential for being safer, less traumatic, more cost effective, and useable in patients at high surgical risk.

In regards to atherosclerotic stenosis of the extracranial carotid artery, carotid endarterectomy has become the preferred method for treatment of symptomatic2,3,4 and asymptomatic5,6 patients with high-grade carotid stenosis. However, during the last several years, the performance of carotid angioplasty and stenting has been recommended by some clinicians as an alternative to carotid endarterectomy for patients who have extracranial carotid atherosclerotic disease. Since the initial description of carotid angioplasty in 1980, an increasing number of reports of this procedure, with and without stent placement, have appeared in the medical literature. There have been several unresolved issues which have prevented its rapid development including distal embolization, stent selection, and pre-procedural and post-procedural neurologic assessment. Although there is limited data regarding many of the newer interventions with carotid artery angioplasty and stenting, this review will provide a background in which to understand how the field of carotid angioplasty and stenting is evolving.

The Procedures: Endovascular Versus Surgical

Before reviewing the published outcome data for carotid artery angioplasty and stenting, it is worth considering the inherit benefits and potential additional advantages that angioplasty techniques may possess in comparison to surgery. Carotid angioplasty is usually performed under local anesthesia (compared with general anesthesia used in the majority of cases of carotid endarterectomy) and therefore severe concomitant cardiac or pulmonary morbidity, which is common, is not an absolute contraindication of treatment, as it may be for the patient who would require a general anesthetic for a conventional carotid endarterectomy. With carotid angioplasty and stenting, clinical patient monitoring can be performed whereby any neurological events or deficits can be detected quickly, allowing for rapid appropriate intervention. Operative complications such as cranial nerve injuries and neuropraxia are avoided, and areas inaccessible to surgery, such as stenotic plaques above the cervical portion of the carotid artery, are approachable. Available data on the incidence of cranial nerve palsies following carotid endarterectomy suggests restenosis after carotid endarterectomy are quite suitable for carotid artery angioplasty and stenting compared with the re-do endarterectomy, which is a potentially difficult procedure. Finally, although there are large prospective randomized trials in North America i.e. the North American Symptomatic Carotid Endarterectomy Trial (NASCET) 2, and the Asymptomatic Carotid Artery Stenosis (ACAS) study 6 which demonstrated: 1) better results with endarterectomy than with standard medical therapy (antiplatelet), and 2) that the major complication rates in these trials were low, the patients studied were not typical of the overall endarterectomy population and these results cannot be compared with those in the community setting, where clinical events (i.e. major stroke or death) occur in 5%-20% of cases.10-12

Current Status of Carotid Artery Angioplasty and Stenting

Although there has been rapid growth in the number of centers performing carotid artery angioplasty and stenting, this review will focus on the results from high volume centers with regards to technical success, complication rates, and restenosis. Finally, the rapidly evolving concept of cerebral protection will be discussed in regards to both pharmacologic and mechanical interventions.

A recent review by Wholey and colleagues13 provides data regarding carotid artery stenting from major interventional centers in Europe, South America, and North America. This report utilized surveys which were answered by physicians actually involved in the carotid stent procedure, and also information from peer reviewed journals. The survey asked various questions regarding the patients enrolled, procedural techniques, and the results of carotid stenting, including complications and restenosis. Interestingly, 41% of the total number of procedures reported in this study by Wholey and colleagues, were performed at so-called high volume carotid stent centers in both Europe and North America.13 This series reported on a total of 2,044 carotid artery stent placement procedures as of June 1997. The overall technical success from this large series was 98.6%, with 2,019 patients receiving carotid stents; technical success was defined as less than 30% residual stenosis covering a region no longer than the original lesion without any decreased or abnormal intracranial arterial anatomy. A total of 33.6% of patients were asymptomatic in the series. It was interesting to note, that certain institutions would primarily use one type of carotid stent rather than choosing a variety from the options available. This is likely a result of each individual operators comfort level that is acquired when using a particular device repetitively. Stent deformation was evaluated by anterior, posterior and lateral x-rays or by rotational fluoroscopy and subsequently classified as 30% or more narrowing or compression of the stent. Interestingly, there were sixteen stent deformations occurring exclusively with the Palmaz stent (Cordis; Johnson and Johnson Interventional Systems; Warren, NJ). At a follow-up period of six months, the Palmaz stent had a rate of deformation of 1.4%. Events that occurred during carotid stent placement or within a 30 day period following placement were recorded. In regards to minor strokes, this was classified as a new neurologic event that resulted in slight impairment of neurologic function that either completely resolved within seven days or caused an increase in the NIH stroke scale of less than four .14, 15 Minor stroke rates varied from 0%-7% with a total of 63 minor strokes or an event rate of 3.08%. Lower volume centers had a minor stroke rate of 2.5% (centers with less than 100 stent procedures) compared to high volume centers where there was a 3.4% event rate. A major stroke was defined as a new neurological deficit that persisted after seven days and increased the NIH stroke scale by four or more.14, 15 In this series of 2,081 carotid stent placements, there was a total of 27 major strokes, for an event rate of 1.32%. The overall range of major strokes varied between 0%-3.85%. Both procedural death and death secondary to myocardial infarction within a 30 day period were reported. There was a total of 28 deaths, resulting in a mortality rate 1.37%. The overall complication rate demonstrated a combined minor and major stroke and death rate of 5.77% for all those completing the survey. In terms of follow-up regarding restenosis, ultrasound studies were performed at least at 1 and 6 month post-stent placement at all the high volume centers.15-19 Using a residual stenosis of greater than 50%, this survey reported an overall restenosis rate of approximately 4.8%.

The experience of individual high volume carotid stenting centers will now be reviewed. In the first large series of carotid stenting, Yadav and colleagues15 reported a major ipsilateral stroke and mortality rate of 1.6% in their series of 126 carotid revascularizations in 107 patients, where stents were deployed after angioplasty. Over 70% of patients in their study group were classified as high risk (by NASCET standards or protocol) and would have been excluded from participating in either the NASCET or ACAS trial. Of the carotid procedures in this series, 74 were performed in symptomatic cases and there was no statistical difference in the complication rates between asymptomatic and symptomatic patients, although absolute differences were observed (4% and 11%, P = 0.17 respectively). Six month clinical follow-up was available on all patients. Eighty-one patients (76%) had either follow-up angiography (71 patients) or ultrasound (10 patients). The minimum lumen diameter at six months was ± 1.3 mm, for a late loss of 25% (0.9 mm). The mean angiographic stenosis by QCA at six months was 18 ± 16% with a range of minus 21% to 57%. All patients with a negative stenosis at follow-up had a negative stenosis at the conclusion of the procedure. In total, 4.9% of patients had restenosis; all were asymptomatic. Finally, two patients (3.2%) died at five months after the procedure of pneumonia and aortic stenosis.

In an extension of their above reported initial experience, the University of Alabama at Birmingham group reported their results in 146 patients.18 Technical success was achieved in 99% of 146 procedures; 210 stents were placed in 152 vessels, with only one instance of stent thrombosis. A total of seven patients suffered minor stroke, but only two were left with minor weakness. The rate of major in-hospital complications was unexpectedly low, with only one death and two major strokes. At six month follow-up, 69 of 74 patients were evaluated by angiography or ultrasound, which detected 8 cases of stent deformation and a restenosis rate of less than 5%. Later on in this series, these investigators abandoned the use of the Palmaz stent due to the issue of stent deformation. In the last 50 patients, these investigators utilized a self-expanding Wallstent (Schneider Inc; Minneapolis, MN) which cannot be compressed, and provides a smoother transition between the diseased internal carotid and common carotid that is also frequently diseased. With regard to in-hospital complications, only one death occurred among those electively stented patients, which involved an off-protocol patient. The cause of death was retroperitoneal hemorrhage. No deaths occurred in this series from on-protocol femoral percutaneous stenting.

Theron and colleagues17 utilized carotid artery stent placement selectively in 69 of 259 patients following angioplasty when radiological images suggested the presence of dissection or incomplete arterial dilation. Carotid artery angioplasty was performed for carotid artery stenosis in a total of 259 patients in this series. Cerebral protection utilizing a triple co-axial catheter was used in 136 cases of atherosclerotic stenosis in the internal carotid artery, or in the carotid bifurcation. Cerebral protection was not used in 123 cases. In regards to outcome in this series of 259 patients, no procedural related complications occurred in the 71 cases of non-atherosclerotic stenosis or in 14 cases of proximal carotid artery and siphon atherosclerotic disease. Among 38 patients who underwent angioplasty without cerebral protection, dissection occurred in two (5%) and embolic complications occurred in 3 (8%) during the procedure. Among 136 patients in this series in whom cerebral protection was implemented, no embolic complications occurred during the angioplasty, and two (1%) occurred during and after stent placement without protection. No residual dissections were found after stents were deployed, and the restenosis rate decreased from 16% to 4% utilizing carotid artery stents. It appears in this series that the triple co-axial catheter system used for emboli protection was efficacious, and stent placement limited the risk of immediate dissection and delayed restenosis.

In a series reported by Wholey and colleagues ,19 a total of 108 consecutive patients with greater than or equal to 70% carotid stenosis were treated with percutaneous stent implantation under a protocol that featured independent neurological review. A total of 56% of these patients were symptomatic. In this series the investigators utilized Palmaz stents without cerebral protection following a preliminary balloon dilation, and in two patients with long areas of disease, the self-expanding Wall stent was employed. The investigators reported a 95% technical success rate with 108 of 114 carotid stents successfully deployed. There were two major (1.8%) and two minor (1.8%) strokes in this series, all in symptomatic patients, one of whom expired. One other patient died of a cardiac event on post-operative day 20. The combined stroke or death rate was 5.3% based on 114 arteries at risk (5.6% in 108 patients). In regards to restenosis, there was one patient with stent compression that was successfully redilated. Finally, these investigators reported no neurological sequela, cranial nerve palsy, or cases of stent or vessel thrombosis during follow-up.

Results from the recently completed CAVATAS trial (Carotid and Vertebral Artery Transluminal Angioplasty Study) have been recently released (Martin Brown - personal communication). A total of 504 patients with symptomatic (> 70% stenosis) carotid and vertebral artery disease were randomized to either surgery (253 pts) or angioplasty (251 pts; 25% stents). The patients received identical medical treatment in both arms and were followed for a total of 3 years. A total of 6.4% of patients in the angioplasty arm versus 5.9% of patients in the surgical arm (P = NS) had a disabling stroke or death at 30 days. The total stroke rate (major and minor) was 10% in the angioplasty arm and 9.9% in the surgical arm (P = NS). Local complications were greater in the surgical arm: cranial nerve palsy (8.7% versus 0%; p< 0.05) and hematoma requiring surgery or prolonged hospitalization (6.7% versus 1.2%; p< 0.05). In summary, angioplasty and carotid endarterectomy were identical in regards to stroke and death, but local complications were greater for carotid endarterectomy.

Finally, the Cleveland Clinic carotid stenting program (Yadav and colleagues) reports an overall technical success rate of 99% in a total of 94 patients. This series is unique in that all patients are reviewed by a vascular surgeon and only patients at increased surgical risk are considered for carotid stenting. The overall neurological complication rate is 3.5%, with a total combined stroke and death rate of approximately 4.6%. Follow-up ultrasound data in this series is pending at this time.

Cerebral Protection During Carotid Artery Angioplasty and Stenting

When transcranial Doppler monitoring of the middle cerebral artery during carotid artery stenting is performed, there is consistent evidence that sub-clinical embolization is occurring in all patients. Jordan and colleagues20 recently reviewed 105 patients who underwent transcranial Doppler monitoring during carotid endarterectomy (N = 75) and carotid angioplasty and stenting (N = 40). In percutaneous transluminal angioplasty procedures, there was a mean of 7.4 emboli per stenosis with four neurological events. In carotid endarterectomy procedures, there was a mean of 8.8 emboli per stenosis with one neurological event. Non-ulcerative plaques produced a significantly greater number of micro-emboli than ulcerative plaques. The mean number of micro-emboli was 56.8 with patients with neurologic complications and 31.2 in those without (P < 0.02). Indeed, embolization appears to be the cause of most acute complications associated with carotid stenting since vessel closure is extremely rare.

Cerebral protection during carotid artery intervention can be categorized into either pharmacological or mechanical methods. Much of the interest in pharmacological cerebral protection during carotid artery intervention comes from the experience during coronary artery angioplasty and stenting using both oral antiplatelet agents and intravenous glycoprotein IIBIIIA inhibitors. In contrast, the mechanical cerebral protection techniques essentially provide a mechanism to retain particles and debris which are generated during the procedure in an effort to reduce the frequency of neurologic complications. In a broad sense, several pharmacologic and mechanical techniques have been and are actively being pursued, to the extent that once these protection devices are marketed, cerebral protection will likely extend to all cerebral angioplasty procedures, allowing for a wider range of indications available for carotid artery intervention. In addition, if these cerebral protection techniques are integrated into the randomized controlled studies of carotid artery intervention versus surgery, this will provide more insight into whether these devices and pharmacologic therapies will actually produce lower complication rates with carotid artery intervention compared with conventional carotid endarterectomy.

Pharmacological Cerebral Protection

Much of the pharmacological embolization protection experience has been taken from the interventional cardiology arena using the platelet glycoprotein IIBIIIA inhibitor abciximab (Centocor; Malvern, PA). Given the pathophysiology following angioplasty whereby there is dilation of an atherosclerotic plaque with subsequent intimal injury and platelet activation occurring, platelet aggregates are likely to be a significant component of the emboli occurring during carotid artery stenting. The role of abciximab during percutaneous coronary revascularization has been assessed in three large scale placebo controlled, randomized trials, enrolling in total more than 7,000 patients. The first of these trials, EPIC, focused on patients considered to be at high risk for thrombotic complications.21 EPILOG22 extended the findings of EPIC21 to the broad spectrum of patients undergoing coronary balloon angioplasty or atherectomy. EPISTENT investigated the complimentary role of abciximab therapy with the recent dominant revascularization technique in interventional cardiology-elective coronary stenting. 23 End-point myocardial infarctions likely secondary to micro-vascular platelet embolization and aggregation were defined by electrocardiographic and enzymatic criteria. The EPIC, EPILOG, and EPISTENT randomized placebo controlled trials provide a compelling body of evidence among over 7,000 patients of the unequivocal and profound efficacy of abciximab in reducing the ischemic complications of death, myocardial infarction, or urgent repeat revascularization associated with percutaneous coronary interventional procedures. 21-23

It is a logical assumption therefore that if microvascular platelet aggregation can be diminished in the coronary circulation utilizing glycoprotein IIBIIIA inhibitors, cerebral microvascular perfusion would likely benefit from glycoprotein IIBIIIA inhibition during and following carotid angioplasty and stenting. In fact, the experience from the coronary intervention arena has been applied to selected patients by Chastain and colleagues in 22 carotid stent procedures involving visible thrombus, total occlusion, or acute stroke.24 In this series of high risk lesions, two (7%) central nervous system bleeding complications occurred, one a hemorrhagic transformation of a previously ischemic stroke and the other a subarachnoid hemorrhage from a ruptured aneurysm. Periprocedural glycoprotein IIBIIIA receptor inhibition may in fact be safer and more effective when used in a routine, prophylactic manner and this approach is currently being evaluated at the Cleveland Clinic Foundation. This unpublished experience of 95 patients using abciximab for elective carotid artery angioplasty and stenting has not resulted in periprocedural strokes or hemorrhage. One patient had a small hemorrhage into a previously infarcted area four days post-procedure and made a remarkable recovery.

Mechanical Cerebral Protection

Since the content of atheroemboli during carotid artery angioplasty and stenting is not solely made up of platelets, red blood cells, and thrombin aggregates, efforts towards employing a mechanical means to reduce the incidence of stroke following embolization during carotid artery stenting has been the focus of much recent research. In a series by Henry and colleagues, 27 carotid artery stent procedures were performed using a proto-type cerebral protection catheter comparing the results to 104 additional cases treated without the emboli protection device.25 This cerebral protection catheter is a low profile, balloon tipped device designed to block cerebral emboli when positioned in the internal carotid artery distal to the target lesion. Conceptually, the protection balloon occludes the run-off circulation to the brain, trapping any particles dislodged following balloon angioplasty or stent delivery so that they can subsequently be extracted via aspiration into the guiding catheter. In this series, Henry and colleagues25 reported two major strokes with the cerebral protection balloon catheter and one minor stroke, and three transient ischemic attacks without its use.

An important consideration utilizing balloon occlusion emboli protection devices is the tolerance of the occlusion which has long been recognized by vascular surgeons as an important issue and the sole reason for the development of intra-operative shunting. Certainly situations such as the presence of a severe contralateral carotid lesion, or the presence of a total occlusion in the presence of a diseased circle of Willis with poor collateral circulation makes the use of these balloon occlusion emboli protection devices potentially complicated. Due to these theoretical concerns, an alternative mechanical embolization device which allows continued perfusion while capturing emboli is being developed . The theoretical concerns with these mechanical filter devices include the minimum size of the particle that needs to be stopped which will dictate the maximum pore size of the filter. These filter type devices have been used successfully to treat carotid as well as coronary, saphenous vein graft, and renal artery lesions and should be available in the near future as part of randomized clinical trials.

Future Clinical Trials

Based on the promising results with carotid artery angioplasty and stenting, a randomized trial comparing percutaneous stenting with carotid endarterectomy is certainly indicated. Since the results of carotid endarterectomy are quite acceptable in low surgical risk patients, the greatest need for alternative revascularization procedures has been in the high surgical risk patients. There will be a prospective, randomized multi-center trial of carotid endarterectomy versus carotid artery stenting in high surgical risk patients called The SAPPHIRE trial (Study of Angioplasty with Protection in Patients at High Risk for Endarterectomy). A total of 720 patients at 24 sites will be enrolled, and there will be parallel stent and surgical registries for non-randomizable patients. Both de-novo and restenotic lesions will be treated in symptomatic (>75% stenosis) or asymptomatic (> 80% stenosis) patients. Patients must have conditions that increase their surgical risk such as unstable angina, severe congestive heart failure, previous cervical radiation therapy or radical neck dissection, very distal or proximal lesions, need for open heart surgery, previous endarterectomy or contralateral occlusions. The primary end-point is a 30 day composite of any stroke, death, or MI. The secondary end-point is the one year ipsilateral stroke and death rate. This trial will employ the SMART nitinol stent (Johnson & Johnson, Cordis, Warren, NJ) and the Angioguard (Johnson & Johnson, Cordis, Warren, NJ) emboli protection device.

The CREST trial (Carotid Revascularization Endarterectomy Versus Stent Trial) will randomize patients to stenting or surgery who are at low surgical risk. The primary outcome events will include: (1) any stroke, myocardial infarction or death during the 30 day peri-operative or peri-procedural period, or (2) ipsilateral stroke after 30 days. The sample size will be approximately 2500 patients because event rates are expected to be low in both treatment arms. This trial will utilize the Acculink nitinol stent (Guidant, Ternacula, CA).

Conclusions

The available published data on carotid angioplasty and stenting has demonstrated a peri-operative stroke and death rate of 5.3%-8.2%15-19, which is comparable to those following carotid endarterectomy. Although the results of carotid artery angioplasty and stenting are surprisingly good, particularly in the high risk patients that have been reported in these series, the issue of embolization remains an unsolved problem. In addition, carotid angioplasty and stenting is currently being performed with so-called "off the shelf" devices not specifically designed for the extra-cranial circulation.26 It is becoming increasingly apparent that cerebral protection will be the technique of the future, and other technology such as guide catheters and stents specifically designed for the carotid circulation will be made available from industry. Given the limitation of the available technology to date, only certain patient groups should be considered for carotid artery angioplasty and stenting including those with contralateral occlusions, post-endarterectomy restenosis, severe synchronous carotid and coronary artery disease, pre-existing cranial nerve palsy, very distal and proximal lesions, and finally unusual cervical anatomy or scarring. For the remaining low risk patients, carotid endarterectomy should remain the standard of care.

References

  1. Hurst RW: Carotid angioplasty, Radiology 201:613-616, 1996.
  2. North American Symptomatic Carotid Endarterectomy Trial Collaborators, Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis, N Engl J Med. 1991;325:445-453.
  3. European Carotid Surgery Trialists' Collaborative Group. MCR European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991;337:1235-1243.
  4. Mayberg MR, Wilson SE, Yatsu F and the VA Symptomatic Carotid Stenosis Group. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991; 266:3289-3294.
  5. Hobson RW, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB, Wright CB, and the Veterans Affairs Cooperative Study Group. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N. Engl J Med 1993;328:221-227.
  6. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study: Endarterectomy for asymptomatic carotid stenosis. JAMA 1995;273:1421-1428.
  7. Lusby RJ, Wylie EJ, Complications of carotid endarterectomy. Surg Clin North Am. 1983;63:1293-1301.
  8. Zierler RE, Brandyk DF, Thiele BL, Strandness ED. Carotid artery stenosis following endarterectomy. Arch Surg, 1982;117:1408-1415.
  9. Edwards WH Jr, Edward WH Sr, Mulherin JL Jr, Martin RS. Recurrent carotid artery stenosis. Ann Surg, 1989;209662-669.
  10. McCrory DC. Goldstein LB. Samsa GP, et al. Predicting complications of carotid endarterectomy. Stroke. 1993;24:1285-91
  11. Rothwell PM Slattery J. Warlow CP. A systematic comparison of the risks of stroke and death due to carotid endarterectomy for symptomatic and asymptomatic stenosis. Stroke. 1996;27:266-9.
  12. Wennberg DE, Lucas FL, Birkmeyer JD, et al. Variation in carotid endarterectomy mortality in the medicare population. Trial hospitals, volume and patient characteristics. JAMA 1998;279:1278-1281.
  13. Wholey MH, Current Global Status of Carotid Artery Stent Placement. Cathet cardiovasc Diagn 1998;44:1-6.
  14. Yadav JS, Roubin GS, King P, Iyer S, Vitek J: Angioplasty and stenting for restenosis after carotid endarterectomy. Stroke 27:2075-2079, 1996.
  15. Yadav JS, Roubin GS, Iyer S, Vitek J, King P, Jordan WD, Fisher Ws: Elective Stenting of the extracranial carotid arteries. Circulation 95:376-381, 1997.
  16. Dietrich EB, Ndiaye M, Reid DB: Stenting in the carotid artery: Initial experience in 110 patients. J Endovasc Surg 3;42-46, 1996.
  17. Theron JG, Payell GG, Coskun O, Huet HF, Guimaraens L: Carotid artery stenosis: Treatment with protected balloon angioplasty and stent placement. Radiology 201;627-636, 1996.
  18. Roubin GS, Yadav S, Iyer SS, Vitek J: Carotid stent supported angioplasty: A neurovascular Intervention to Prevent Stroke. AMJ Cardiol 1996;78 (8-12)
  19. Wholey MH, Wholey MH, Jarmolowski CR, Eles G, Levy D, Buecthel J, Endovascular stents for carotid artery occlusive disease. J Endovasc Surg 1997, 4(4):326-38.
  20. Jordan WD, Voellinge RDC, Doblar DD, et al. Microemboli detected by transcranial Doppler monitoring in patient during carotid angioplasty versus carotid endarterectomy. Cardiovasc Surg 1997;7:33-9.
  21. EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330:956-961.
  22. The EPILOG Investigators. Platelet glycoprotein Iib/IIIa blockade with abciximab with low-dose heparin during percutaneous coronary revascularization, N Engl J Med 1997;336:1689-1696.
  23. The EPISTENT Investigators. Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein Iib/IIIa blockade.Lancet 1998;352:87-92.
  24. Chastain HDII, Wong P, Mathur A, et al. Does abciximab reduce complications of cerebral vascular stenting in high risk lesions? Circulation (Suppl I) 1997;96:I-283.
  25. Henry M, Amor M, Henry I, et al. Endovascular treatment of atherosclerotic stenosis of the internal carotid JVIR 1998 (Suppl);9:162.
  26. Mendelsohn FO, Mahaffey KW, Yadav JS. Management of atherosclerotic carotid disease: Medical, surgical and Interventional Aspects, in Textbook of Cardiovascular Medicine, ed by Topol EJ, Lippincott Williams & Wilkins Healthcare, 1999 vol 2, #1.
Jacksonville Medicine / December, 2000

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