Future Projections for Coronary Angioplasty Stenting – The Next Five Years

Data from several on-going and future clinical trials will hopefully clarify the role of CAS in the management of patients who are not high risk for CEA. The non-high-risk patient population holds the key, perhaps, to the future of CAS since the largest ‘market’ for carotid revascularisation resides with this group, especially those who are asymptomatic. Approximately 70% of CEA operations performed in the US today are conducted on patients without symptoms.

One important piece missing in many of the trials and registries conducted over the past several years is the study of modern-day pharmacological treatment, especially the use of statins that may well make a significant difference. These will undoubtedly form part of all future trials, and are likely to be compared with surgical and/or interventional approaches in the management of asymptomatic patients. Much of this will be completed and their results disseminated within the next five years.

It is likely that asymptomatic patients with carotid stenosis may be treated increasingly without intervention in the future. This is in fact already happening in some European countries and worldwide.

It could also be predicted that, within the next five years, the issue of cerebral microembolisation – with use of distal filter protection – is going to be elucidated once and for all, allowing treating physicians to make better informed decisions on appropriateness and safety of CAS intervention for patients over the age of 80 and others who might have diminished reserve.

The relative merits of proximal occlusion devices will be studied on one or more clinical trials. It would appear that such devices may offer benefits in several situations where distal filters cannot or should not be used.

The nature of the plaque itself, as characterised by ultrasound, is something of great theoretical and practical importance. The impact on the CAS procedure itself and its outcome may be significant. It may even have influence on equipment choice in the future, i.e. the choice of open versus closed cell stent designs.

The nature of the plaque itself, as characterised by ultrasound, is something of great theoretical and practical importance. The impact on the CAS procedure itself and its outcome may be significant. It may even have influence on equipment choice in the future, i.e. the choice of open versus closed cell stent designs.

The concept that CAS should be offered almost exclusively to patients who are at high risk for CEA should be revisited. The result of such policy is that most patients undergoing stent intervention have one or more high-risk factors and unfavourable features. This carries significant potential for lessthan- optimal outcomes. Some leading investigators are beginning to look at this paradigm in a different manner. In future, patients who are at low risk for CAS, as opposed to high risk for CEA should probably be sought. It may well be the best way to optimise interventional outcomes.

Lastly, what if any will be the future for CEA? While it is essentially impossible to predict with any degree of accuracy at this time, it would be safe to state that CEA will undoubtedly ‘survive’ in the foreseeable future, and its role – while somewhat diminished – will continue to be a most important one.