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Does carotid stenting measure up to endarterectomy? A vascular surgeon's experience
Mark K Eskandari1, G Matthew Longo, Joseph D Vijungco
1Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill. 60611, USA. meskanda@nmh.org
Insights
Carotid angioplasty and stenting shows promising outcomes for high-risk patients, with no major strokes or deaths in a recent study. Further trials are needed to confirm its long-term efficacy compared to carotid endarterectomy.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurology
Background:
- Carotid endarterectomy is a standard treatment for carotid stenosis.
- High-risk patients often face increased complications with traditional surgery.
Purpose of the Study:
- To evaluate the safety and efficacy of carotid angioplasty and stenting (CAS) in high-risk patients.
- To compare CAS outcomes with historical data from carotid endarterectomy.
Main Methods:
- A single-center case-control study involving 53 patients undergoing elective CAS for cervical carotid stenosis.
- Patients had indications such as prior neck surgery, recurrent stenosis, or severe comorbidities.
- Follow-up included duplex scanning and clinical assessment for complications and outcomes.
Main Results:
- No deaths or major/minor strokes occurred within 30 days post-procedure.
- One case of transient amaurosis fugax and four access-related complications were reported.
- Intraoperative seizures and asystolic arrest occurred but were successfully treated; 5.0% experienced re-stenosis.
Conclusions:
- Vascular surgeons with advanced skills can safely perform CAS, achieving perioperative results comparable to carotid endarterectomy.
- The study suggests CAS is a viable option for high-risk patients.
- Randomized national trials are necessary to establish the definitive efficacy and durability of CAS versus endarterectomy.
Hypothesis:
Carotid angioplasty and stenting seems to have equal or better outcomes in high-risk patients than carotid endarterectomy.
Design:
Single-center case-control study.
Setting:
University hospital tertiary referral center.
Patients:
Individuals (n = 53) undergoing elective carotid angioplasty and stenting for cervical carotid stenosis (n = 57) between April 2001 and October 2003. All patients were referred to and treated by the primary author (M.K.E.).
Results:
Mean +/- SD age was 68.8 +/- 1.2 years (64% men [34] and 36% women [19]), and overall mean +/- SD rate of stenosis was 79% +/- 10%. Preprocedural neurologic symptoms were present in 42% of the group. Indications for treatment included prior neck surgery with irradiation (4), recurrent stenosis (19), and severe comorbidities (34). Duplex scanning 24 hours after stenting showed immediate mean percentage reductions in peaksystolic velocity and end diastolic velocity of 74% and 76%, respectively. After a 30-day follow-up period, there were no deaths and no major or minor strokes. One patient (1.7%) developed transient amaurosis fugax 12 hours after the procedure. Four patients (7.0%) experienced access-related complications. Intraoperative complications included 1 seizure (1.7%) and 1 asystolic arrest (1.7%), both treated successfully. During follow-up, 3 cases of re-stenosis (5.0%) occurred. One asymptomatic occlusion (1.7%) was detected at the 6-month follow-up visit. There have been no late carotid-related complications or deaths.
Conclusions:
Vascular surgeons possessing advanced catheter-based skills can safely perform carotid angioplasty and stenting and can achieve perioperative results comparable with carotid endarterectomy. Determination of the true efficacy and durability of carotid angioplasty and stenting as compared with endarterectomy awaits ongoing randomized national trials.
