Which specialty—neurosurgery or vascular surgery—performs internal carotid artery (ICA) stenting?

ICA Stenting: A Multispecialty Procedure

Internal carotid artery (ICA) stenting is performed by multiple specialties including interventional cardiology, vascular surgery, interventional radiology, and neurointerventional surgery—no single specialty has exclusive domain over this procedure. 1

Multispecialty Consensus on Training and Credentialing

The evidence clearly establishes that physicians from various clinical backgrounds (surgery, cardiology, radiology, vascular medicine, neurology) can perform carotid stenting safely and effectively when properly trained. 1 The key determinant is not specialty affiliation but rather achievement of specific competency standards. 1

Training Pathways

Two distinct pathways exist for achieving competency in carotid stenting: 1

• Formal training pathway: Within accredited postgraduate residency or fellowship programs in interventional cardiology, interventional radiology, or vascular surgery, concurrent with peripheral angioplasty training 1
• Practice pathway: For physicians who have completed training and seek carotid stenting skills in a clinical practice environment 1

Minimum Competency Requirements

Regardless of specialty background, operators must demonstrate: 1

• 30 diagnostic cervico-cerebral angiograms (half as primary operator) 1
• 25 carotid stent procedures (half as primary operator) 1
• High-level expertise with antiplatelet therapy and procedural anticoagulation 1
• Comprehensive knowledge of cerebrovascular disease pathophysiology, natural history, and stroke syndromes 1

Specialty-Specific Considerations

Starting Points Vary by Background

The guidelines explicitly acknowledge that different specialists begin at different points on the interventional learning curve: 1

• Surgeons may have limited experience with 0.014" guidewire balloon and stent systems or embolic protection devices, but possess thorough understanding of extracranial carotid artery disease diagnosis and management 1
• Interventional cardiologists may have advanced interventional skills but require additional training in neurovascular anatomy and stroke syndromes 1
• All specialties must achieve identical cognitive, clinical, and procedural skills upon completion of training 1

Clinical Trial Experience

Major randomized trials comparing carotid stenting to endarterectomy have included operators from multiple specialties: 2

• CREST trial (2502 patients) included 117 centers with operators from various backgrounds, all meeting rigorous credentialing standards 2
• ICSS trial required interventionists to have performed at least 50 stenting procedures and minimum of 10 carotid stents for classification as "experienced" 2

Contemporary Practice Patterns

Recent case reports demonstrate the evolving landscape: 3, 4

• Neurovascular interventionalists are increasingly managing complex intracranial ICA pathology, including post-CEA dissections requiring extensive intracranial stenting 3
• Transcarotid artery revascularization (TCAR) techniques are being applied by vascular surgeons and interventionalists for both cervical and intracranial ICA stenosis 4

Critical Caveat

The diversity of physician backgrounds in carotid stenting is advantageous and should be encouraged, but only when rigorous training, oversight, and quality assurance programs are in place. 1 Small procedural errors can have catastrophic consequences, making standardized competency requirements essential regardless of specialty. 1

Institutional Credentialing

Physicians seeking to perform carotid stenting must: 1

• Be fully credentialed to perform peripheral interventions at their institution 1
• Be actively performing endovascular procedures prior to undertaking focused carotid training 1
• Demonstrate adequate catheter-based skills with equipment and devices utilized during carotid angioplasty and stenting 1