Treatment Of Symptomatic Carotid Stenosis Research Articles

He Who Pays the Piper…

He Who Pays the Piper…

Poor outcomes after endovascular treatment of symptomatic carotid stenosis: time for a moratorium

Poor outcomes after endovascular treatment of symptomatic carotid stenosis: time for a moratorium

Carotid Artery Stenting May Be Losing the Battle against Carotid Endarterectomy for the Management of Symptomatic Carotid Artery Stenosis, But the Jury Is Still Out

Carotid artery stenting (CAS) has emerged as a potential alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. The purpose of this article is to provide an evaluation and critical overview of the trials comparing the early and later results of CAS with CEA for symptomatic carotid stenosis. The CochraneControlled Trials Register, PubMed/Medline, and EMBASE databases were searched up to February 1, 2009, to identify trials comparing the long-term outcomes of CAS with CEA. The MeSH terms used were "carotid artery stenting," "carotid endarterectomy," "symptomatic carotid artery stenosis," "treatment," "clinical trial," "randomized," and "long-term results," in various combinations. One single-center and three multicenter randomized studies reporting their long-term results from the comparison of CAS with CEA for symptomatic carotid stenosis were identified. All four studies independently reached the conclusion that CAS may not provide results equivalent to those of CEA for the management of symptomatic carotid stenosis. A higher incidence of recurrent stenosis and peri- and postprocedural events accounted for the inferior results reported for CAS compared with CEA. Current data from randomized studies indicate that CAS provides inferior long-term results compared with CEA for the management of symptomatic carotid artery stenosis. However, it can be argued that all of these trials were performed when both CAS equipment and CAS operators had not evolved to their current status. Given that current equipment and mature experience are required for CAS before comparing it with the current "gold standard" procedure (CEA), the results of soon-to-be reported trials (Carotid Revascularization Endarterectomy vs Stenting Trial [CREST], International Carotid Stenting Study [ICSS], or others) may alter the current impression that CAS is inferior to CEA for the treatment of symptomatic carotid stenosis.

Kognitive Leistungsfähigkeit nach Operation und stentgeschützter Angioplastie einer Karotisstenose

This prospective, controlled, randomised study evaluates differences concerning cognitive functions between carotid endarterectomy (CEA) and stent-protected angioplasty (CAS) as a treatment for symptomatic carotid stenosis. Both techniques include risks whose effect on neuropsychological abilities remains yet unknown. Twenty-seven patients suffering from high-grade symptomatic carotid stenosis underwent neuropsychological testing before, 1 month, and 6 months after treatment. After the first testing patients were randomly assigned for CEA (n=10) or CAS (n=17) as treatment. The patients' cognitive functions were compared to those of 13 healthy controls. Whether patients underwent CEA or CAS made no difference in the neuropsychological outcome 4 weeks and 6 months after treatment. Patients always performed worse than the healthy controls. Both techniques seem to have no different effect on cognitive functions.

Symptomatic carotid artery stenosis: the dilemma for a reasonable selection of carotid stenting or endarterectomy

An excellent meta-analysis from Gurm et al. 1 updates the data concerning the treatment of symptomatic carotid stenosis by a surgical or endovascular approach. The last two randomized trials, SPACE2 and EVA3S,3 did not, in fact, confirmed the equivalence of the two methods and there followed a general unfavourable feeling towards carotid stenting. The article by Gurm et al. , 1 which eliminates some old randomized studies such as CAVATAS4 and the stopped Leicester trial,5 appears statistically sound. We can learn that there is no significant difference between carotid stenting (CAS) and endarterectomy (CAE). Today, the data are heterogeneous and difficult to analyse; the authors have shown that we can approach the truth and keep the two options without bringing them into conflict. Patients with symptomatic tight carotid stenosis have to be treated because the risk of a cerebrovascular accident is ∼20% at 1 year. In the 1980s, surgical treatment was compared with medical treatment by lengthy randomized trials such as NACST6 and ECST,7 and has been recognized as the reference treatment. The contribution of antiplatelet agents and statins today offers much better patient care for atherosclerotic disease and raises questions about the validity of these outdated studies. CAS is still in evolution, with a … Corresponding author. Tel: +33 49180 69 05, fax: +33 49180 69 26. Email: pbergeron{at}hopital-saint-joseph.fr; endovasc{at}hopital-saint-joseph.fr

Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis

Previous studies compared carotid endarterectomy (CEA) and carotid artery stent placement (CAS) for treatment of symptomatic carotid artery stenosis. Whereas most previous studies showed both treatment modalities to be associated with a comparable risk of periprocedural cerebrovascular complications, these previous studies have shown significantly more microemboli and significantly more lesions in diffusion-weighted MR imaging after CAS compared to CEA. The clinical relevance of these differences remains unknown. We therefore compared the neuropsychological consequences of CAS and CEA and additionally measured the S100beta protein, a marker of cerebral damage. A total of 48 patients with symptomatic carotid artery stenosis greater than 70 % (according to ECST criteria) were enrolled and 45 patients participated in the follow-up. The patients were randomly assigned for CEA (24 patients) or CAS (21 patients). S100beta protein values were evaluated 2 hours before the procedure, as well as one and two hours thereafter. Patients were assessed before treatment, and again 6 and 30 days after treatment using a comprehensive neuropsychological test battery. Patients of the CAS and the CEA groups did not significantly differ in terms of age, gender, education, degree of carotid artery stenosis, cerebrovascular symptoms and vascular risk factors. Following previously used criteria, a cognitive change in patients was assumed to have occurred when there was a decline of more than one standard deviation in two or more tests assessing various cognitive domains. Six days and 30 days after the treatment both groups showed a comparable number of patients with cognitive changes compared to baseline. There were no significant differences in S100beta protein values. These results provide some reassurance that CAS is not associated with greater cognitive deterioration than CEA is.

Risk Factors for Early Recurrent Cerebral Ischemia Before Treatment of Symptomatic Carotid Stenosis

In patients with a recently symptomatic carotid stenosis, surgical or interventional treatment is often delayed for weeks to months. Because therapy should be instituted as early as possible in patients at highest risk for recurrent ischemia, the aim of this study was to identify these individuals using clinical data and serial diffusion-weighted imaging (DWI). One hundred thirty-one patients (98 male; mean age 68+/-9 years) who had been referred to our department within 14 days (median; interquartile range, 4 to 36 days) after experiencing an ischemic event caused by a carotid stenosis were followed-up until carotid angioplasty and stenting. Risk factors predicting recurrent transient ischemic attack, stroke, or new DWI lesions were examined. During a median follow-up period of 7 days (interquartile range, 5 to 13 days) no patient experienced a stroke, 4 patients (3.1%) developed a hemispherical transient ischemic attack, and in 15 patients (12%) new asymptomatic DWI lesions were present in the territory of the treated artery. Multivariable regression analysis revealed that motor symptoms (odds ratio, 5.6; 95% CI, 1.2 to 26.3; P<0.05) or the presence of a contralateral carotid occlusion (odds ratio, 4.6; 95% CI, 1.0 to 20.4; P<0.05) were significant independent predictors of further cerebral ischemic events before carotid angioplasty and stenting. In patients with a recently symptomatic carotid stenosis, the risk of early recurrent ischemia is highest in those with motor symptoms and in those with a contralateral carotid occlusion. In these high-risk patients urgent preventive treatment might be warranted.

Neuropsychological consequences of endarterectomy and endovascular angioplasty with stent placement for treatment of symptomatic carotid stenosis: a prospective randomised study

Background and purpose: Previous studies compared carotid endarterectomy (CEA) and carotid artery stent placement (CAS) for treatment of symptomatic carotid artery stenosis. Whereas both treatment modalities are associated with a comparable risk of periprocedural cerebrovascular complications, CAS seems to lead to significantly more microemboli and more lesions in diffusion-weighted MR imaging. The clinical relevance of these differences remains unknown. We therefore compared the neuropsychological consequences of CAS and CEA and additionally measured the S100ß protein, a marker of cerebral damage.

Risk factors for early recurrent cerebral ischaemia prior to treatment of symptomatic carotid stenosis

Risk factors for early recurrent cerebral ischaemia prior to treatment of symptomatic carotid stenosis

Early carotid endarterectomy after acute stroke.

Carotid endarterectomy (CEA) after acute stroke is generally delayed 6 to 8 weeks because of fear of stroke progression. This delay can result in an interval stroke rate of 9% to 15%. We analyzed our results with CEA performed within 1 to 4 weeks of stroke. Records for all patients undergoing CEA after stroke between 1980 and 2001 were analyzed. Perioperative evaluation included carotid duplex scanning or angiography, and head computed tomography or magnetic resonance imaging. All patients with nonworsening neurologic status, additional brain territory at risk for recurrent stroke, and severe ipsilateral carotid stenosis underwent CEA. Patients were grouped according to time of CEA after stroke: group 1, first week; group 2, second week; group 3, third week; group 4, fourth week. Statistical analysis was performed with the chi(2) test, logistic regression, and analysis of variance. Two hundred twenty-eight patients underwent CEA within 1 to 4 weeks of stroke. Perioperative permanent neurologic deficits occurred in 2.8% of patients in group 1 (72 procedures), 3.4% of patients in group 2 (59 procedures), 3.4% of patients in group 3 (29 procedures), and 2.6% of patients in group 4 (78 procedures). There was no relationship between location or size of preoperative infarct and time of surgery. Only preoperative infarct size correlated with probability of neurologic deficit after CEA (P <.05). Incidence of postoperative stroke exacerbation is similar at all intervals. The results are within acceptable limits for treatment of symptomatic carotid stenosis. CEA may be performed within 1 month of stroke with similar results at all intervals during this period.

Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital

The goal of this study was to determine whether carotid angioplasty and stenting (CAS) is equivalent to carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis >70% by a randomized, controlled trial in a community hospital. Carotid angioplasty and stenting has been suggested to be as effective as CEA for treatment of symptomatic carotid artery stenosis. A total of 104 patients presenting with cerebrovascular ischemia ipsilateral to carotid stenosis were selected randomly for CEA or carotid stenting and followed for two years. Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique as determined by sequential ultrasound. One death occurred in the CEA group (1/51); one transient ischemic attack occurred in the CAS group (1/53); no individual sustained a stroke. The perception of procedurally related pain/discomfort was similar. Hospital stay was similar, although the CAS group tended to be discharged earlier (mean = 1.8 days vs. 2.7 days). Complications associated with CAS prolonged hospitalization when compared with those sustaining a CEA-related complication (mean = 5.6 days vs. 3.8 days). Return to full activity was achieved within one week by 80% of the CAS group and 67% of the patients receiving CEA. Hospital charges were slightly higher for CAS. Carotid stenting is equivalent to CEA in reducing carotid stenosis without increased risk for major complications of death/stroke. Because of shortened hospitalization and convalescence, CAS challenges CEA as the preferred treatment of symptomatic carotid stenosis if a reduction in costs can be achieved.

Carotid angioplasty-stent: Clinical experience and role for clinical trials

Carotid angioplasty-stenting (CAS) is a relatively new endovascular procedure that has been used increasingly in recent years. Its popularity is due to, at least in part, the perceived advantages of a less invasive treatment for extracranial carotid occlusive disease. However, valid data that contrast the efficacy of CAS and carotid endarterectomy (CEA), the gold standard for the treatment of symptomatic carotid stenosis, are not available. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will contrast the relative efficacy of CAS with CEA in the prevention of stroke, myocardial infarction, or death during a 30-day periprocedural period or an ipsilateral stroke thereafter during a follow-up period extending up to 4 years. Stroke events will be verified by an adjudication committee masked to the assigned treatment. Secondary outcomes will (1) describe differential efficacy of CAS and CEA in men and women, (2) contrast periprocedural (30-day) morbidity and postprocedural (after 30-days) morbidity and mortality rates, (3) estimate and contrast the restenosis rates of the two procedures, (4) evaluate the differences in measures of health-related quality of life and cost effectiveness, and (5) identify subgroups of participants at differential risk for CAS and CEA. The primary eligibility criterion is a >50% stenosis of the carotid artery in patients with ipsilateral amaurosis fugax (transient monocular blindness), transient ischemic attack, or nondisabling stroke. Men and women will be eligible for the trial, but patients with medical conditions likely to limit their participation during the follow-up or to interfere with outcome evaluation will be excluded. After a credentialing and training phase, 2500 patients will be randomized to the treatments. Statistical analysis of the primary outcome will use standard survival methods.

703 Early Results Comparing Stenting with Endarterectomy for Treatment of Symptomatic Carotid Stenosis: A Randomized Community Hospital-based Trial

703 Early Results Comparing Stenting with Endarterectomy for Treatment of Symptomatic Carotid Stenosis: A Randomized Community Hospital-based Trial

Status report on the carotid revascularization endarterectomy versus stent trial

Carotid angioplasty and stenting (CAS) is a relatively new procedure that has been used increasingly in recent years. Its growth is caused, at least in part, by the perceived advantages of a less invasive treatment for extracranial carotid occlusive disease. However, data comparing the efficacy of CAS with carotid endarterectomy (CEA), which is the gold standard for treatment of symptomatic carotid stenosis, are not available. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will compare the relative efficacy of CAS with CEA in preventing stroke, myocardial infarction, and death during a 30-day periprocedural period. The efficacy of the 2 procedures in preventing ipsilateral stroke over a follow-up period of up to 4 years will also be assessed. Cerebrovascular events will be verified by an Adjudication Committee masked to the assigned treatment. Secondary outcomes assessment will include the following: (1) differential efficacy of CAS and CEA in men and women, (2) comparison of periprocedural (30-day) morbidity with late postprocedural (after 30-days) morbidity and mortality that is associated with the procedures, (3) estimation and comparison of the restenosis rates associated with the 2 procedures, (4) evaluation of differences in measures of health-related quality of life and cost effectiveness, and (5) identification of subgroups of participants at differential risk for CAS and CEA. The primary eligibility criteria are a significant (greater than 50% as shown by cerebral angiography) stenosis of the carotid artery in a patient with amaurosis fugax (transient monocular blindness), transient ischemic attack, or ipsilateral nondisabling stroke. Men and women will be eligible for the trial, but patients with medical conditions that are likely to limit their participation during the follow-up or to interfere with outcome evaluation will be excluded. After a credentialing and training phase, 2,500 patients will be randomized to the treatment groups. Statistical analysis of the primary outcome will use standard survival methodology.

10.1016/j.ysur.2015.10.005

10.1016/j.ysur.2015.10.005

Stroke Risk Low in Asymptomatic Carotid Disease

While there is strong evidence to justify carotid endarterectomy in patients with transient ischemic attacks and severe ipsilateral carotid artery stenosis, the proper approach to screening for and treating asymptomatic carotid disease remains controversial. The European Carotid Surgery Trialists Collaborative Group previously studied more than 2300 patients randomized to medical or surgical treatment for symptomatic carotid stenosis. They found a surgical benefit for patients with severe (70%-99%) obstructive …

Surgical treatment of symptomatic carotid stenosis and asymptomatic ipsilateral intracranial aneurysm. Case report.

✓ The occurrence of symptomatic carotid stenosis and asymptomatic ipsilateral intracranial aneurysm is reported. The successful management by planned staged surgical treatment of both lesions is discussed.