Systematic Review of Length of Stay After Carotid Endarterectomy and Carotid Artery Stenting

Critique of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): Flaws in CREST and its Interpretation

Elderly patients are at higher risk of procedural complications. Surgical revascularization has been performed successfully in selected octogenarians.1,2 Nevertheless, it is widely believed that percutaneous approaches are safer in the elderly. Indeed, percutaneous coronary intervention is now successfully being performed even in selected nonagenarians.3 Thus, it is tempting to presume that carotid revascularization in the elderly might be safer if done via endovascular means (Figure).4 Figure. Angiography before (A) and after (B) a right carotid artery stent in an 81-year-old man with amaurosis fugax. Article see p 2343 The data to date, however, have been conflicting, with several reports demonstrating very high rates of stroke or death with carotid stenting in octogenarians. Furthermore, although carotid stenting with embolic protection has been shown to be noninferior to carotid endarterectomy in patients at high surgical risk, whether carotid stenting is equivalent to carotid endarterectomy remains an open question in patients at low surgical risk.5–7 Additionally, especially for asymptomatic patients, the question arises whether a patient will live long enough to derive potential benefit from any procedure. This question becomes more pressing as the elderly population expands and the definition of elderly creeps upward, and also as clinical trials continue to underenroll the elderly. The cut point where appropriate clinical caution turns instead into preconceived notions and age-related bias is difficult to define. In this issue of Circulation , Chiam et al report on 142 consecutive patients aged 80 years or older who underwent carotid stenting.8 This series of patients has previously been reported, with the current article adding observations related to intermediate-term …

Scientific evidence demonstrating the safety of carotid angioplasty and stenting: Do we have enough to draw conclusions yet?

Carotid artery stenting—evolution of a technique to rival carotid endarterectomy

Risk-adjusted 30-day outcomes of carotid stenting and endarterectomy: Results from the SVS Vascular Registry

Reporting Standards for Carotid Artery Angioplasty and Stent Placement

Carotid artery disease is a major cause of ischemic stroke, the risk of which is directly related to the severity of stenosis and presence of symptoms.1,2 Stroke is the third leading cause of death in the United States, with approximately three quarters of a million strokes per year. Stroke is the leading cause of functional impairment, with more than 20% of survivors requiring institutional care and up to one third having a permanent disability.3 More worrisome, however, is the fact that as the population ages, the number of patients having strokes appears to be increasing.4 The pathophysiology of stroke may be broadly classified as hemorrhagic, embolic, or ischemic. The majority of strokes are caused by embolic events due to atheroemboli from the carotid artery, the ascending aorta, and arch vessels or cardiac thromboembolism from the left atrium or ventricle. It is estimated that carotid artery stenosis is responsible for 15% to 20% of all strokes.5 As percutaneous treatment options expand, there is uncertainty about appropriate therapy for carotid disease. This document will focus on 3 current controversies: (1) carotid artery revascularization in asymptomatic patients, (2) carotid artery stenting (CAS) in patients who are considered to be at increased surgical risk for carotid endarterectomy (CEA), and (3) the current role for CAS in patients at average surgical risk. ### Prevalence and Natural History The prevalence of asymptomatic extracranial carotid stenosis (≥50%) in persons >65 years of age is estimated to be between 5% and 10%, whereas ≤1% of patients are estimated to have a severe narrowing (>80%).6 In asymptomatic patients with ≥50% carotid artery stenoses, the annual risk of stroke is between 1% and 4.3%.2,7 Long-term (10- to 15-year) cohort studies in asymptomatic patients with moderate to severe carotid stenosis demonstrate an ipsilateral stroke rate between 0.9% and 1.1% per …

Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy

Carotid artery stenting versus endarterectomy for carotid stenosis – Authors' reply

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry

A 64-year-old man with a past medical history of diabetes mellitus, hyperlipidemia, and hypertension presented with acute-onset left hemiparesis, hemisensory loss, and dysarthria. He was diagnosed with a right middle cerebral artery stroke and treated with systemic thrombolysis. His poststroke workup included a carotid duplex ultrasound and computed tomographic angiogram of the carotid arteries (Figure 1), which confirmed a severe (70%–99%) stenosis in the right internal carotid artery (ICA) secondary to a 20-mm-long atherosclerotic plaque extending from the carotid bifurcation to the level of C2-C3 disc space. The left ICA showed moderate (50%–69%) stenosis. Should this patient be recommended for carotid artery revascularization, and, if so, by which method? Figure 1. Computed tomographic angiogram of the 64-year-old patient presented in this case, showing severe right internal carotid artery stenosis (arrow) in coronal ( A ) and sagittal ( B ) views. Stroke, defined as acute development of a focal neurological deficit attributable to the disruption of blood flow to the brain, is caused by 1 of 2 main causes: ischemia or hemorrhage. The majority (>80%) of strokes are of ischemic etiology, of which ≈15% to 20% are attributable to atherosclerosis of the extracranial carotid arteries. The risk of death and recurrent stroke increases following an ischemic stroke. Transient ischemic attacks, or strokelike symptoms that last <24 hours, are also associated with an increased risk of early recurrent stroke, particularly in patients with carotid artery atherosclerosis. The bifurcation point of the common carotid artery, or carotid bulb, is predisposed to the development of atherosclerosis owing to low wall shear stress and resulting flow stagnation. Narrowing or stenosis of the carotid bulb and ICA because of atherosclerosis can lead to ischemic stroke secondary to plaque embolization or hypoperfusion. The prevalence of ICA stenosis is estimated to be 2% to 3% in the general population, with increased prevalence noted …

As new technology becomes available, the stent technique for the extracranial carotid artery continues to evolve into a safer, more effective therapy for stroke prevention. With the availability of embolic protection, improved stent designs, and added endovascular physician experience, outcomes for carotid artery stenting (CAS) now consistently parallel those for carotid endarterectomy (CEA). Although carotid endarterectomy was established as the gold standard for carotid revascularization, the available scientific evidence must continue to be interpreted in the context of further advancements in nearly all related areas of medicine. One multicenter randomized trial and several nonrandomized registries have successfully established the CAS indications for patients with high surgical risk and have provided evidence to support the use of CAS techniques in patients with low surgical risk. Clinicians must continue to improve their understanding of patient-specific factors and conduct research that will refine indications while optimizing current medical therapy and that will integrate CAS and carotid endarterectomy as complementary treatments. Response by LoGerfo p 1610 The outcomes for CAS have been improving over the past 10 years and now appear nearly equivalent to those for CEA. In fact, many historical similarities are seen in the development of these 2 techniques. Although CEA was established as the gold standard for extracranial carotid revascularization, the available scientific evidence must continue to be interpreted in the context of further advancements in nearly all related areas of medicine. The current research comparing CAS and CEA has not shown a clinically robust and statistically significant difference between the 2 treatments. When differences do exist, clinicians must continue to refine patient-specific indications and to conduct further research to understand these complex risk-benefit analyses in the context of advanced medical treatments and complementary revascularization techniques. The following review details the argument to support implementation of CAS technology for athero-occlusive carotid …

Approximately 10-15% of all ischaemic strokes are caused by atherosclerotic stenosis of the carotid artery. Conventionally, carotid stenosis was treated by surgical removal of the atherosclerotic plaque (carotid endarterectomy). Since the introduction of carotid artery stenting as a less invasive treatment alternative almost 20 years ago, the choice of the optimal treatment for the individual patient with carotid stenosis has remained controversial. This PhD thesis consisted of three individual projects and aimed to enable personalised treatment decisions for individual patients with carotid disease and explore parameters specifically linked to the mechanisms of stroke occurring as a complication of both revascularisation procedures. The first project consisted of a systematic review and meta-analysis with the aim to compare short-term risks and long-term effects on stroke prevention between carotid stenting and endarterectomy in patients with symptomatic or asymptomatic carotid stenosis. To this end, we performed a systematic Cochrane Review of all published randomised trials comparing carotid stenting versus endarterectomy to obtain precise overall estimates of procedural risks and long-term stroke recurrence rates. We found that in patients with symptomatic carotid stenosis, stenting and endarterectomy are equally effective in preventing recurrent stroke in the long-term, while stenting is associated with a higher risk of procedure related stroke or death. In patients with asymptomatic carotid stenosis, there may be a small increase in the risk of procedure related stroke or death associated with stenting. However, more data from randomised trials are needed. Concerning the durability of carotid stenting in the long-term, only limited data are currently available for asymptomatic patients and the existing evidence does not yet allow any firm conclusions. The second project comprised the systematic assessment of the anatomy of all supra-aortic arteries and pre-defined stenosis characteristics in order to investigate the association between vascular anatomy and the occurrence of procedure-related cerebral ischaemia after carotid artery stenting or carotid endarterectomy in patients with symptomatic carotid stenosis. We identified complex vascular anatomy as an important predictor for cerebral ischaemia during stenting, but not during endarterectomy. The third and fourth projects consisted of an individual patient data meta-analysis of four randomised clinical trials comparing carotid artery stenting versus endarterectomy for treatment of symptomatic carotid stenosis. This work resulted in two separate manuscripts. Within the first, we investigated whether the temporal distribution of stroke or death occurring within 30 days of treatment differed between the two procedures. In the second, we investigated if the procedural risks associated with carotid stenting and carotid endarterectomy within the examined trials had decreased over time. Our analysis revealed that the excess occurrence of stroke or death associated with stenting is limited to the day of treatment. In our analysis of temporal trends in procedure related risks, we were able to show that carotid revascularisation procedures became safer over time within the examined trials. This decline in risk was particularly apparent for endarterectomy.

Dr Roubin cites exciting observational data supporting carotid artery stenting as treatment for focal carotid artery disease. Unfortunately, observational studies cannot substitute for randomized trials.1 The design is not experimental. The treatment for each patient is chosen by the interventionalist, and so selection bias cannot be avoided. Assessment of outcomes is vulnerable to investigator ascertainment bias and in some cases conflict of interest. Full reporting cannot be ensured, nor can publication bias be avoided. Comparison to historical controls is not valid because the competing medical and surgical treatments have advanced. For surgical therapy, randomized trials have shown that absolute risk reduction may be high as 5% per year for symptomatic patients with stenosis ≥70%,2,3⇓ approximately 1% per year for symptomatic patients with stenosis ≥50% to 69%,3 and up to 1% per year in asymptomatic patients with stenosis ≥60%, when surgical results are optimal.4 Benefits …

Risk factors and impact of postoperative hypotension after carotid artery stenting in the Vascular Quality Initiative