Assessing the Suitability of the Carotid Bifurcation for Stenting: Anatomic and Morphologic Considerations

Abstract Objective Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomical characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. Methods Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting are described in detail. These are accompanied with evidence-based outcomes and results. Results Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. Conclusions CAS can be viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile-plaque, swollen ICA sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described—TCAR may offer improved periprocedural success, and CAS may attain better long-term durability.