Carotid Endarterectomy Versus Stenting: An International Perspective

Abstract

HomeStrokeVol. 37, No. 2Carotid Endarterectomy Versus Stenting: An International Perspective Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBCarotid Endarterectomy Versus Stenting: An International Perspective Werner Hacke Martin M. Brown Jean-Louis Mas Werner HackeWerner Hacke Department of Neurology, Ruprecht-Karls-University Heidelberg, Germany Search for more papers by this author Martin M. BrownMartin M. Brown University College London, ICSS Central Office, The National Hospital for Neurology and Neurosurgery, London, UK Search for more papers by this author Jean-Louis MasJean-Louis Mas Service de Neurologie, Unité Neuro-Vasculaire, Hôpital Sainte-Anne, Paris Cedex, France Search for more papers by this author Originally published5 Jan 2006https://doi.org/10.1161/01.STR.0000199664.59711.21Stroke. 2006;37:344Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 5, 2006: Previous Version 1 To the Editor:With interest we read the comment of Hobson et al entitled “Carotid Artery Stenting and the Recruitment Challenges in a clinical trial.”1Although we completely share the concerns of the authors regarding slow recruitment into the CREST Trial, constantly growing use of carotid stenting in symptomatic patients outside of protocols, and the lack of evidence in this area, we cannot agree with the perception that it is mostly up to CREST to solve the problems.The authors mention shortly that larger clinical trials “are currently underway in North America and Europe.” With reference 10 they cite the CAVATAS trial that finished recruitment long ago. They state that “recruitment into these trials will also be slow and the data may not be available for the next 2 to 3 years.”As the principal investigators of 3 European Trials, we would like to update the organizers of CREST and the readers of Stroke in the field of what’s going on in the randomized symptomatic carotid endarterectomy versus stenting trials outside of North America.The early results of CAVATAS were published 3 years ago and the results of long-term follow-up were presented at this year’s European Stroke Conference and will be submitted for publication soon.The next on-going trial is the International Carotid Stenting Study (ICSS), the follow-up to the CAVATAS trial. This trial includes North American centers in Canada as well as several European countries and Australia, and its study protocol has been recently published.2 Almost 600 patients are already included in this trial.The second trial, which is also not cited in this article, is the French EVA 3S Trial. Its trial design and protocol amendment has also recently been published.3,4 Almost 500 patients are already included in this trial.The third one is the SPACE Trial. The trial protocol of SPACE has also been published.5,6 It is not adequately referenced by mentioning a poster at the ASA Meeting 2 years ago. This trial is probably the most advanced trial, and termination of recruitment is expected in the next couple of months. Therefore, it will not take 3 years until data from this German-Austrian Trial are available.By the way, it should be mentioned that the 3 European Trials have already agreed to perform a joint data analysis after completion and publication of all 3 trials.7 We hope we will also be able to include results from CREST in this meta-analysis.We wish our American colleagues a lot of success in improving the recruitment rates. We need much more data from all the trials before it will be clear which treatment is optimal for symptomatic carotid stenosis.1 Hobson RW II, Brott TG, Roubin GS, Silver FL, Barnett HJM. Carotid Artery Stenting Meeting the Recruitment Challenge of a Clinical Trial. Stroke. 2005; 36: 314–315.Google Scholar2 Featherstone RL, Brown MM, Coward LJ; for the ICSS Investigators. International carotid stenting study: protocol for a randomised clinical trial comparing carotid stenting with endarterectomy in symptomatic carotid artery stenosis. Cerebrovasc Dis. 2004; 18: 69–74.CrossrefMedlineGoogle Scholar3 Mas JL. Endarterectomy vs. Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) Trial. Cerebrovasc Dis. 2004; 18: 62–65.CrossrefMedlineGoogle Scholar4 EVA-3S Investigators. Carotid Angioplasty and Stenting With and Without Cerebral Protection: Clinical Alert From the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) Trial. Stroke. 2004; 35: 18–20.LinkGoogle Scholar5 Ringleb P, Kunze A, Allenberg J, Hennerici M, Jansen O, Maurer P, Zeumer H, Hacke W. Evaluation der stentgeschützten Angioplastie zur Therapie von symptomatischen Stenosen der A. carotis. SPACE und andere randomisierte Studien Nervenarzt. 2003; 74: 482–489.Google Scholar6 Ringleb P, Kunze A, Allenberg J, Hennerici M, Jansen O, Maurer P, Zeumer H, Hacke W. The Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial. Cerebrovasc Dis. 2004; 18: 66–68.CrossrefMedlineGoogle Scholar7 Brown M, Hacke W. Carotid artery stenting: the need for randomised trials. Cerebrovasc Dis. 2004; 18: 57–61.CrossrefMedlineGoogle ScholarstrokeahaStrokeStrokeStroke0039-24991524-4628Lippincott Williams & WilkinsResponse:Hobson Robert W., Brott Thomas G., Roubin Gary S., and Silver Frank L.01022006We wish to thank the authors for their response to our recently published commentary on carotid artery stenting (CAS).1 Our intent was to stimulate clinicians in the United States and Canada to become more involved in the NINDS, NIH-sponsored CREST (Carotid Revascularization Endarterectomy versus Stenting) protocol. Although recruitment to CREST was described as slow, we are pleased to announce that randomization continues to accelerate following publication of the commentary and now exceeds 600 participants at our over 100 clinical sites.We have great admiration for our European colleagues and their accomplishments in the field of CAS and will welcome the early publication of data from the SPACE Trial. Our brief commentary was not designed as a comprehensive review. Nonetheless, we regret the impression or the inadvertent failure to acknowledge all currently active trials.We welcome the opportunity to agree with the authors that expanded use of CAS outside organized randomized clinical trials threatens rigorous study of potential alternatives to carotid endarterectomy. As noted in our commentary, “If we fail to achieve a study of adequate size, we will not produce convincing evidence of the value of carotid stenting in stroke prevention.” We also agree that ultimate joint analyses of the trial results will be desirable. Dr Hobson corresponded previously with Professor Brown recommending such an effort and expressing our willingness to cooperate in these activities.The CREST investigators applaud the performance of clinical trials in North America and Europe to clarify the role of carotid endarterectomy and stenting in the management of extracranial carotid occlusive disease. We have no disagreement with our European colleagues on this crucial point. Previous Back to top Next FiguresReferencesRelatedDetailsCited ByKnappich C, Kuehnl A, Haller B, Salvermoser M, Algra A, Becquemin J, Bonati L, Bulbulia R, Calvet D, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Malas M, Ringleb P, Brown M, Mas J, Brott T, Morris D, Lewis S and Eckstein H (2019) Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis, Stroke, 50:12, (3439-3448), Online publication date: 1-Dec-2019. Wodarg F, Turner E, Dobson J, Ringleb P, Mali W, Fraedrich G, Chatellier G, Bequemin J, Brown M, Algra A, Mas J, Jansen O and Bonati L (2018) Influence of stent design and use of protection devices on outcome of carotid artery stenting: a pooled analysis of individual patient data, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2017-013622, 10:12, (1149-1154), Online publication date: 1-Dec-2018. Balucani C, Arnedo V, Weedon J, Leys D, Mas J, Brown M, Grotta J, Gonzales N, Hacke W, Brott T and Levine S (2018) Transatlantic Differences in Management of Carotid Stenosis: BRIDGing the Gap in StrokE Management (BRIDGE) Project, The Neurohospitalist, 10.1177/1941874417747772, 8:3, (113-123), Online publication date: 1-Jul-2018. Rantner B, Kollerits B, Roubin G, Ringleb P, Jansen O, Howard G, Hendrikse J, Halliday A, Gregson J, Eckstein H, Calvet D, Bulbulia R, Bonati L, Becquemin J, Algra A, Brown M, Mas J, Brott T and Fraedrich G (2017) Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients With Symptomatic Stenosis of the Internal Carotid Artery, Stroke, 48:6, (1580-1587), Online publication date: 1-Jun-2017. AbuRahma A and Mousa A (2016) Current Status of Carotid Stenting Versus Endarterectomy, Advances in Surgery, 10.1016/j.yasu.2016.04.004, 50:1, (235-256), Online publication date: 1-Sep-2016. Rantner B, Goebel G, Bonati L, Ringleb P, Mas J and Fraedrich G (2013) The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms, Journal of Vascular Surgery, 10.1016/j.jvs.2012.08.107, 57:3, (619-626.e2), Online publication date: 1-Mar-2013. Rogers R and Casserly I (2012) Carotid and Cerebrovascular Intervention Textbook of Interventional Cardiology, 10.1016/B978-1-4377-2358-8.00039-5, (513-533), . Margey R and Drachman D (2011) Carotid Artery Disease and Stenting: Insights From Recent Clinical Trials, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-011-0116-y, 13:2, (129-145), Online publication date: 1-Apr-2011. Bonati L and Fraedrich G (2011) Age Modifies the Relative Risk of Stenting versus Endarterectomy for Symptomatic Carotid Stenosis – A Pooled Analysis of EVA-3S, SPACE and ICSS, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2011.01.001, 41:2, (153-158), Online publication date: 1-Feb-2011. (2010) Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data, The Lancet, 10.1016/S0140-6736(10)61009-4, 376:9746, (1062-1073), Online publication date: 1-Sep-2010. (2010) Management of Acute Ischemic Infarction Toole's Cerebrovascular Disorders, 10.1017/CBO9781139644235.028, (356-376) (2010) Atherosclerosis of the Cervicocranial Arteries Toole's Cerebrovascular Disorders, 10.1017/CBO9781139644235.010, (105-117) Liapis C, Bell S, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, Biasi G and Norgren L (2009) ESVS Guidelines. Invasive Treatment for Carotid Stenosis: Indications, Techniques, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2008.11.006, 37:4, (1-19), Online publication date: 1-Apr-2009. (2007) Endarterectomy versus Stenting for Carotid Stenosis, New England Journal of Medicine, 10.1056/NEJMc063228, 356:3, (305-307), Online publication date: 18-Jan-2007. Mahagne M (2007) Infarctus cérébral: prise en charge en urgence et prévention secondaire, La Presse Médicale, 10.1016/j.lpm.2006.11.008, 36:1, (128-133), Online publication date: 1-Jan-2007. Biasi G, Froio A, Deleo G and Lavitrano M (2006) Indication for Carotid Endarterectomy Versus Carotid Stenting for the Prevention of Brain Embolization From Carotid Artery Plaques: In Search of Consensus, Journal of Endovascular Therapy, 10.1583/05-1726.1, 13:5, (578-591), Online publication date: 1-Oct-2006. February 2006Vol 37, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000199664.59711.21PMID: 16397168 Originally publishedJanuary 5, 2006 PDF download Advertisement