Are symptomatic patients currently appropriate candidates for carotid artery stenting? Yes
Efthimios D Avgerinos1, Elias N Brountzos, Ilias Dalainas
1Department of Vascular Surgery, Attikon University Hospital, Athens, Greece. efavgerinos@gmail.com
Insights
Carotid artery stenting (CAS) may be a viable alternative to carotid endarterectomy (CEA) for symptomatic patients. Current trials condemning CAS have methodological flaws, suggesting a need for further evaluation in specialized centers.
Area of Science:
- Vascular surgery
- Interventional cardiology
- Clinical trials methodology
Background:
- Randomized trials comparing carotid artery stenting (CAS) to carotid endarterectomy (CEA) in symptomatic patients generally show inferior outcomes for CAS.
- However, these trials are criticized for significant methodological flaws, including small sample sizes, outdated equipment, and inadequate use of cerebral protection devices.
Purpose of the Study:
- To critically evaluate the existing randomized controlled trials (RCTs) comparing CAS and CEA.
- To discuss the limitations of current evidence and the potential role of CAS in managing symptomatic carotid artery disease.
Main Methods:
- Review and critique of published randomized controlled trials (RCTs) on CAS versus CEA.
- Analysis of methodological limitations and their impact on study outcomes.
- Discussion of the learning curve and center volume effects in CAS procedures.
Main Results:
- Published RCTs often suffer from underpowering, outdated technology, and insufficient use of protective measures, questioning their validity in condemning CAS.
- Experienced vascular surgeons performing CAS in high-volume, specialized centers report optimistic outcomes.
- Restenosis rates require careful evaluation based on clinical need, and repeat endovascular procedures for restenosis are safe with low complication rates (<1%).
Conclusions:
- Vascular surgeons should not prematurely dismiss CAS as an alternative to CEA due to flaws in current comparative trials.
- Advancements in technology and the establishment of high-volume, specialized centers are crucial for the successful implementation of CAS.
- Continued engagement with CAS is recommended for vascular surgeons to remain current with evolving endovascular techniques.
Abstract:
Most of the currently published randomized trials (RCTs) for carotid artery stenting (CAS) versus carotid endarterectomy (CEA) on symptomatic patients have concluded that CAS is associated with outcomes that are inferior to those of CEA. However, before final decision making on the future of CAS, there are some major issues of concern. Randomized controlled trials condemning CAS suffer from major study flaws, rendering comparison with CEA ineffective. These trials are challenged by methodological gaps, underpowered results, old-fashioned equipment and underuse of cerebral protection devices or even of stents. On the other hand, physicians' experience in CAS has not been that much appreciated, whereas CEA has been widely performed during the last 30 years by experienced and fully trained vascular surgeons. CAS is a recently emerged treatment that cannot yet be standardized. No matter the final verdict on CAS, the procedure will never be for low volume practitioners. It is required that CAS be performed exclusively in high volume centers with specific dedicated experience and adequate training. Yet, optimistic results on CAS have been constantly reported from single, highly specialized CAS centers around the world. Regarding restenosis rates, they should be evaluated on the true need for re-intervention, since its clinical significance is still debated; but even when decision is undertaken to operate a restenosis, a repeat endovascular procedure is safe with reported complication rates < 1%. Concluding, vascular surgeons should be thoughtful about rejecting it as an alternative to CEA, because with advancing technology, vascular surgeons electing to stay away, and not perform CAS, will stay out of the "race."
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