Volume 05 Issue 04-2025
17
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
A
BSTRACT
The article discusses the advantages of endovascular treatment of carotid artery atherosclerosis as an
effective alternative to traditional carotid endarterectomy. Based on the results of the international ACST-
2 study, comparable efficacy of carotid stenting and endarterectomy in preventing ischemic stroke and
reducing mortality is demonstrated. Data on the clinical advantages of the endovascular approach,
including a reduced risk of myocardial infarction, cranial nerve damage and a shorter rehabilitation period
are presented. Particular attention is paid to the effectiveness of endovascular methods in complex
anatomical variants of damage, in patients at high surgical risk and in multifocal atherosclerosis. Statistical
data on the superiority of endovascular thrombectomy over drug therapy in acute ischemic stroke are
provided, demonstrating a significant increase in the functional independence of patients and a decrease
in mortality. Technological aspects of modern endovascular techniques providing effective
revascularization with minimal trauma to the vascular wall are discussed. The materials of the article are
of interest to vascular surgeons, endovascular specialists, neurologists and cardiologists dealing with
problems of cerebrovascular pathology.
K
EYWORDS
Carotid atherosclerosis, carotid artery stenting, carotid endarterectomy, endovascular surgery, ischemic
stroke.
Journal
Website:
http://sciencebring.co
m/index.php/ijasr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Research Article
Advantages of Endovascular Surgery in Carotid
Atherosclerosis
Submission Date:
February 14,
2025,
Accepted Date:
March 12, 2025,
Published Date:
April 11, 2025
Crossref doi:
https://doi.org/10.37547/ijasr-05-04-03
Mukhammadieva Gulshakhnoza
Master of general surgery, Uzbekistan
Volume 05 Issue 04-2025
18
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
I
NTRODUCTION
Cardiovascular diseases remain the leading cause of mortality worldwide. Among the numerous risk
factors contributing to these pathologies, the issue of multifocal atherosclerosis has become increasingly
relevant. Modern medical practice demonstrates that a significant proportion of fatal outcomes in
cardiology patients are associated with atherosclerotic lesions of the carotid arteries [1].
According to recent studies, stenosing atherosclerosis of the carotid arteries accounts for 9
–
40% of all
ischemic strokes. Despite substantial progress in the pharmacological prevention of cerebrovascular
complications, including the latest antiplatelet and lipid-lowering drugs, their effectiveness in high-risk
patients remains insufficient. Of particular concern is the high probability of recurrent stroke, reaching 2
–
5% per year in asymptomatic carotid atherosclerosis and up to 12% in patients with a history of acute
cerebrovascular accident. These findings justify the active implementation of surgical treatment methods,
especially endovascular technologies, which offer an effective approach to correcting stenotic carotid
artery lesions [2].
M
ETHOD
In modern vascular surgery, two primary methods are actively used to correct atherosclerotic carotid
artery stenosis: traditional carotid endarterectomy (CEA) and endovascular intervention in the form of
carotid angioplasty with stenting (CAS). Classic CEA ensures the radical removal of atherosclerotic plaque
and demonstrates a lower rate of perioperative cerebral complications within the 30-day observation
period. However, this technique is associated with an increased risk of cardiac complications and
peripheral nerve injury [3].
The endovascular approach using CAS is minimally invasive and is associated with a significantly lower
incidence of myocardial infarction and access-related complications. However, current data indicate
slightly higher rates of neurological complications and mortality compared to open surgery [4].
The optimal method for carotid artery revascularization should combine the clinical advantages of both
approaches
—
ensuring effective removal of the atherosclerotic substrate with reliable cerebral protection
while minimizing surgical trauma for the patient.
In the context of discussing the benefits of endovascular surgery for carotid atherosclerosis, special
attention should be given to the ACST-2 (Second Asymptomatic Carotid Surgery Trial). This is the largest
multicenter international randomized study to date comparing carotid stenting (CAS) and carotid
endarterectomy (CEA) in patients with asymptomatic carotid artery stenosis [5].
Volume 05 Issue 04-2025
19
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
The study included 3,625 asymptomatic patients with significant carotid artery stenosis from 130 hospitals
across 33 countries. Patients deemed suitable for both stenting (CAS) and endarterectomy (CEA) were
randomized into two groups: 1,811 patients underwent CAS, and 1,814 underwent CEA. The average
follow-up period was five years.
The ACST-2 results demonstrated that both procedures had similar risks and favorable outcomes. The
procedural risk of disabling stroke or death was approximately 1% for each method, aligning with data
from large representative registries. Notably, after successful completion of either procedure (CAS or CEA),
the annual risk of disabling or fatal stroke was only about 0.5% for both interventions.
An analysis of non-fatal periprocedural events revealed that the risk of non-disabling procedural stroke
was slightly higher with stenting than with endarterectomy. However, this was offset by a higher risk of
myocardial infarction and cranial nerve injury in the endarterectomy group.
During long-term follow-up, no significant differences were found between the groups in terms of overall
mortality (330 cases in the CAS group vs. 313 in the CEA group), stroke-related mortality (23 vs. 25 cases,
respectively), or the incidence of non-procedural strokes (91 vs. 79 cases; hazard ratio 1.16, 95% CI 0.86
–
1.57).
The study authors conclude that the choice between CAS and CEA can be based on the individual
characteristics of the patient, physician preference, and available resources, as the long-term protective
effects of both procedures appear to be similar. A key advantage of endovascular intervention is the lower
risk of cranial nerve injury and myocardial infarction, which are more common in endarterectomy.
Additionally, endovascular treatment may be preferable for patients with high surgical risk, anatomically
challenging lesions, or certain comorbid conditions. This minimally invasive approach provides
comparable stroke protection, a shorter recovery period, and potential quality-of-life benefits, making it
an attractive alternative to traditional surgery for many patients with asymptomatic carotid artery
stenosis.
The ACST-2 study has significantly expanded the evidence base compared to previous research, more than
doubling the number of asymptomatic patients included in clinical trials comparing CAS and CEA. The
results indicate that both procedures offer comparable stroke protection, at least in the first few years
following intervention.
Confirming the equivalent efficacy of endovascular and open surgical procedures is particularly important,
as minimally invasive interventions may have a decisive advantage in certain clinical situations.
Endovascular surgery is especially valuable for patients with multifocal atherosclerosis, who are often
Volume 05 Issue 04-2025
20
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
denied open surgery due to the high risk of intra- and postoperative complications. As clinical practice
shows, endovascular interventions are often the only life-saving treatment option for such patients [6].
The study authors conclude that the choice between CAS and CEA can be based on the individual
characteristics of the patient, physician preference, and available resources, as the long-term protective
effects of both procedures appear to be similar. A key advantage of endovascular intervention is the lower
risk of cranial nerve injury and myocardial infarction, which are more common in endarterectomy.
Additionally, endovascular treatment may be preferable for patients with high surgical risk, anatomically
challenging lesions, or certain comorbid conditions. This minimally invasive approach provides
comparable stroke protection, a shorter recovery period, and potential quality-of-life benefits, making it
an attractive alternative to traditional surgery for many patients with asymptomatic carotid artery
stenosis.
The ACST-2 study has significantly expanded the evidence base compared to previous research, more than
doubling the number of asymptomatic patients included in clinical trials comparing CAS and CEA. The
results indicate that both procedures offer comparable stroke protection, at least in the first few years
following intervention.
Confirming the equivalent efficacy of endovascular and open surgical procedures is particularly important,
as minimally invasive interventions may have a decisive advantage in certain clinical situations.
Endovascular surgery is especially valuable for patients with multifocal atherosclerosis, who are often
denied open surgery due to the high risk of intra- and postoperative complications. As clinical practice
shows, endovascular interventions are often the only life-saving treatment option for such patients [6].
Statistical data confirm the superiority of endovascular thrombectomy over pharmacological therapy:
functional independence at three months after the procedure is achieved in 44
–
45% of patients following
endovascular treatment, compared to 17
–
18.9% in the medical therapy group (OR 2.67; 95% CI: 1.60
–
4.48; p<0.001). Additionally, mortality is reduced from 20
–
26% to 14
–
16.8% (p=0.05), while the rate of
hemorrhagic complications does not differ significantly (7% vs. 4%, p=0.75) [11].
Particularly impressive results have been observed with endovascular treatment of large vessel occlusions
(internal carotid artery, M1 segment of the middle cerebral artery) within the first 24 hours: functional
independence is achieved in 20% of cases, compared to 7% in the conservative therapy group (OR 2.97;
95% CI: 1.60
–
5.51).
Advancements in endovascular instrumentation have expanded the technical capabilities of the method,
enabling revascularization of distal cerebral artery segments (M2
–
M4, A1
–
A2, P1
–
P3, and cerebellar
arteries). The effectiveness of recanalization according to the TICI 2b
–
3 scale has reached impressive
Volume 05 Issue 04-2025
21
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
levels: 86% in all ischemic stroke patients and 76
–
88% in major clinical trials (DEFUSE 3, DAWN, SWIFT-
PRIME) [12].
Alongside high recanalization efficacy, another key advantage of modern endovascular technologies is
their safety and minimal invasiveness. Contemporary thrombectomy techniques allow for the removal of
thrombotic material and the restoration of vessel patency with minimal damage to the vascular wall. This
is particularly important in atherosclerotic vessels, where there is a high risk of plaque fragmentation and
distal embolization. The use of specialized stent retrievers and aspiration systems ensures precise
thrombus removal with minimal impact on surrounding structures [13].
C
ONCLUSIONS
A review of current data on the advantages of endovascular surgery for carotid artery atherosclerosis leads
to several important conclusions. Endovascular treatment of stenotic carotid atherosclerosis, particularly
carotid artery stenting (CAS), serves as an effective alternative to traditional open carotid endarterectomy
(CEA). This is supported by the findings of the large-scale ACST-2 study, which demonstrated comparable
long-term outcomes between the two techniques in terms of stroke prevention and mortality in patients
with asymptomatic carotid stenosis.
The endovascular approach offers significant advantages, particularly for patients with high surgical risk,
multifocal atherosclerosis, or complex vascular anatomy. The minimally invasive nature of the procedure,
the elimination of the need for general anesthesia, and the reduced risk of cranial nerve injury and
myocardial infarction make endovascular treatment especially valuable for select patient groups.
Additionally, the shorter hospitalization and rehabilitation period associated with CAS significantly
improves patients' quality of life.
Endovascular technologies are especially valuable in emergency situations. Endovascular thrombectomy
(EVT) has demonstrated high efficacy in the treatment of acute ischemic stroke, significantly
outperforming isolated pharmacological therapy. Statistical data provide compelling evidence of the
benefits of endovascular intervention in terms of functional independence and reduced mortality.
Moreover, the extension of the therapeutic window to 24 hours has been a groundbreaking advancement,
particularly for patients who experience delays in seeking medical care.
Further advancements in endovascular technologies and materials, as well as the development of cerebral
protection systems, will further improve treatment outcomes for patients with carotid atherosclerosis.
R
EFERENCES
Volume 05 Issue 04-2025
22
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
1.
Jafarov S.M., Mullabaeva G.U., Sunnatov R.D. Endovascular interventions in combined atherosclerosis
of coronary and carotid arteries // Journal of Central Asian Health Research.
–
2021.
–
№1. –
P. 104-
110.
2.
Tvorogova T.V., Bulgakova E.A., Shukurov F.I. Endovascular treatment of carotid artery atherosclerosis:
challenges and perspectives // Rational Pharmacotherapy in Cardiology.
–
2017.
–
Vol. 13, №1. –
P. 80-
87.
3.
Dakour Aridi H., Locham S., Nejim B., Malas M.B. Comparison of 30-day readmission rates and risk
factors between carotid artery stenting and endarterectomy // Journal of Vascular Surgery.
–
2017.
–
Vol. 66, №5. –
P. 1432-1444.
4.
Safian R.D. Asymptomatic carotid artery stenosis: revascularization // Progress in Cardiovascular
Diseases.
–
2017.
–
Vol. 59, №6. –
P. 591-600.
5.
Halliday A., Bulbulia R., Bonati L.H. [et al.] Second Asymptomatic Carotid Surgery Trial (ACST-2): a
randomized comparison of carotid artery stenting versus carotid endarterectomy // The Lancet.
–
2021.
–
Vol. 398, №10305. –
P. 1065-1073.
6.
Belyi A.I., Suslov E.S., Efimov V.V., Fedorchenko A.N. Endovascular surgery for the correction of stenotic
lesions of the internal carotid artery under complex anatomical conditions // Innovative Medicine of
Kuban.
–
2022.
–
№1(25). –
P. 27-33.
7.
Brown C.R., Brown N.D., Brown M.R. Surgical considerations and strategies for anatomically variant and
diseased carotid arteries // IntechOpen.
–
2024.
–
doi: 10.5772/intechopen.114969.
8.
Grigoruk S.P. The role of endovascular surgeries in the comprehensive surgical treatment of combined
atherosclerotic lesions of cerebral and coronary arteries // Ukrainian Interventional Neuroradiology
and Surgery.
–
2014.
–
№1(7). –
P. 53-60.
9.
Stilo F., Montelione N., Calandrelli R. [et al.] The management of carotid restenosis: a comprehensive
review // Annals of Translational Medicine.
–
2020.
–
Vol. 8, №19. –
P. 1272-1284.
10.
Alidzhanova Kh.G. Modern aspects of endovascular thrombectomy for acute ischemic stroke. Selection
criteria for endovascular thrombectomy. Prediction of treatment outcomes / Kh.G. Alidzhanova, K.A.
Popugaev, G.R. Ramazanov [et al.] // N.V. Sklifosovsky Journal of Emergency Medical Care.
–
2024.
–
Vol. 13, No. 3.
–
P. 451-464.
11.
Albers G.W. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging / G.W.
Albers, M.P. Marks, S. Kemp [et al.] // New England Journal of Medicine.
–
2018.
–
Vol. 378, No. 8.
–
P.
708-718.
12.
Karamchandani R.R. Mortality after large artery occlusion acute ischemic stroke / R.R. Karamchandani,
J.B. Rhoten, D. Strong [et al.] // Scientific Reports.
–
2021.
–
Vol. 11, No. 1.
–
P. 10033-10041.
13.
Logvinenko R.L. Comparative assessment of the outcomes of combined thrombectomy and systemic
thrombolytic therapy in patients with acute ischemic stroke: Dissertation for the degree of Candidate
Volume 05 Issue 04-2025
23
International Journal of Advance Scientific Research
(ISSN
–
2750-1396)
VOLUME
05
ISSUE
04
Pages:
17-23
OCLC
–
1368736135
of Medical Sciences: 14.01.13 / Logvinenko Roman Leonidovich; [Defense location: First Moscow State
Medical University named after I.M. Sechenov].
–
Moscow, 2021.
–
140 p.
