Endovascular intervention compared with carotid endarterectomy

Abstract

Abstract Background Endovascular intervention has only recently been used for the treatment of carotid disease. The 30-day outcome of 226 endovascular carotid interventions for atherosclerosis performed since August 1993 is presented. Methods All patients were symptomatic apart from four (2 per cent) who underwent intervention before coronary artery bypass. The last presenting symptom was transient ischaemic attack (TIA) (40 per cent), amaurosis fugax (31 per cent), retinal artery occlusion (3 per cent) and stroke (24 per cent). A moderate stenosis (50–69 per cent; North American Symptomatic Carotid Endarterectomy Trial technique) was present in 24 patients (11 per cent), a severe stenosis (70–95 per cent) in 144 (64 per cent), and a preocclusive stenosis (more than 95 per cent) in 58 (26 per cent). The contralateral internal carotid artery was significantly diseased (greater than 70 per cent) or occluded in 65 patients (29 per cent). All patients were pretreated with aspirin; 5000 units heparin and 1·2 mg atropine were given during the procedure. Initially, stents were reserved for treating residual stenosis after angioplasty (16 of 108 procedures). Later, a change was made to primary stenting (116 procedures). A femoral approach was used for all patients. Results At 30 days there were four deaths (2 per cent) and eight disabling strokes (4 per cent) (death and disabling stroke rate 5 per cent; death and all-strokes rate 8 per cent). For angioplasty and selective stenting the death and disabling stroke rate and the death and all-strokes rate were 6 and 9 per cent respectively, compared with 5 and 8 per cent for primary stenting (P not significant). However, there was a significant difference between the incidence of all adverse events (31 versus 11 per cent) as a result of fewer TIAs associated with primary stenting. During the same interval, 300 carotid endarterectomies (similar indications and severity of disease) were performed. There were six deaths (2 per cent) and eight disabling strokes (3 per cent) (death and disabling stroke rate 5 per cent; death and all-strokes rate 6 per cent). The complications of both endovascular intervention and conventional endarterectomy seem to be improving with time. Conclusion These data confirm the feasibility of endovascular carotid intervention and highlight the need for a large randomized trial comparing it with conventional surgery. The benefit of stents and cerebral protection systems also requires further investigation.