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CardioVascular and Interventional Radiology
Published in: CardioVascular and Interventional Radiology 2/2012

01-04-2012 | Review

A Surgeon’s View on Endarterectomy and Stenting in 2011: Lest We Forget, It’s All About Preventing Stroke

Author: A. Ross Naylor

Published in: CardioVascular and Interventional Radiology | Issue 2/2012

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Abstract

It has been nearly 60 years since Felix Eastcott published his seminal paper on carotid reconstruction, which paved the way for carotid endarterectomy (CEA) and then carotid artery stenting (CAS) to assume prominent roles in the prevention of stroke. Yet the ensuing 60 years has witnessed repeated cycles of challenges to practice, professional mistrust, conflicts of interest, dogmatic retention of traditional management strategies, inappropriate corporate interventions, and a general failure to adapt to new evidence. Even the performance of large-scale randomised trials has been associated with rancour and a lack of consensus. This article reviews the history of invasive interventions in the treatment of carotid disease and makes a plea to both the surgical and interventional communities that the fundamental priority must always be the prevention of stroke. It concludes with an appeal for colleagues to collaborate to determine how best to treat patients during the hyperacute period after the onset of symptoms and to identify a smaller cohort of asymptomatic patients who are truly at high risk for stroke in whom to target CAS or CEA.
Literature
1.
Fisher M (1951) Occlusion of the internal carotid artery. Arch Neurol Psych 65:346–377
2.
Eastcott HH, Pickering GW, Robb CG (1954) Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 267:994–996PubMedCrossRef
3.
4.
Barnett HJM, Polum F, Walton JN (1984) Carotid endarterectomy: an expression of concern. Stroke 15:941–943PubMedCrossRef
5.
Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook RH (1988) The appropriateness of carotid endarterectomy. N Engl J Med 318:721–727PubMedCrossRef
6.
European Carotid Surgery Trialists’ Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387CrossRef
7.
North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 325:445–453CrossRef
8.
Hsia DC, Krushat WM, Moscoe LM (1992) Epidemiology of carotid endarterectomies amongst Medicare beneficiaries. J Vasc Surg 16:201–208PubMedCrossRef
9.
Chambers BR, Norris JW (1984) The case against surgery for asymptomatic carotid stenosis. Stroke 15:947–964CrossRef
10.
Barnett HJM, Haines SJ (1993) Carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med 328:276–279PubMedCrossRef
11.
Thompson JE, Patman RD, Talkington CM (1978) Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls. Ann Surg 188:308–316PubMedCrossRef
12.
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421–1428CrossRef
13.
Hsia DC, Moscoe LM, Krushat WM (1998) Epidemiology of carotid endarterectomy among Medicare beneficiaries: 1985–1996 update. Stroke 29:346–350PubMedCrossRef
14.
Barnett HJM, Eliasziw M, Meldrum HE, Taylor DW (1996) Do the facts and figures warrant a tenfold increase in the performance of carotid endarterectomy on asymptomatic patients’. Neurology 46:603–608PubMed
15.
Perry JR, Szalai JP, Norris JW (1997) Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis: the Canadian Stroke Consortium. Arch Neurol 54:25–28PubMedCrossRef
16.
Brown MM (1992) Balloon angioplasty for cerebrovascular disease. Neurol Res 14(Suppl):159–163PubMed
17.
Gray WA (2007) The rise of the registry: of signal importance in carotid artery stenting. Endovascular Today 6:47–51
18.
Economoupoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanandis C (2011) Carotid artery stenting versus carotid endarterectomy: comprehensive meta-analysis of short and long-term outcomes. Stroke 42:687–692CrossRef
19.
Naylor AR, Bolia A, Abbott RJ, Pye IF, Smith J, Lennard N et al (1988) Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg 28(2):326–334CrossRef
20.
Alberts MJ, WALLSTENT Publications Committee (2001) Results of a multicenter prospective randomized trial of carotid artery stenting versus carotid endarterectomy [abstract]. Stroke 32:325CrossRef
21.
Ederle J, Dobson J, Featherstone RL, Gaines PA, Beard JD, Venables GS, on behalf of the CAVATAS Investigators (2009) Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long term follow-up of a randomised trial. Lancet Neurol 8:898–907PubMedCrossRef
22.
Naylor AR (2007) Where next after SPACE and EVA-3S: the good, the bad and the ugly! Eur J Vasc Endovasc Surg 33:44–47PubMedCrossRef
23.
Brooks WM, McClure RR, Jones MR, Coleman TC, Breathitt L (2001) Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 38:1589–1595PubMedCrossRef
24.
Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L (2004) Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomised trial in a community hospital. Neurosurgery 54:318–324PubMedCrossRef
25.
Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen B, Mishkel MR, for the SAPPHIRE Investigators et al (2004) Protected carotid artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:1493–14501PubMedCrossRef
26.
Gray WA, Chaturvedi S, Verta P (2009) Thirty-day outcomes for carotid artery stenting in 6320 patients from two prospective, multicentre, high-surgical-risk registries. Circ Cardiovasc Intervent 2:159–166CrossRef
27.
Roubin GS, Iyer S, Halkin A, Vitek J, Brennan C (2006) Realizing the potential of carotid artery stenting: proposed paradigms for patient selection and procedural technique. Circulation 113:2021–2030PubMedCrossRef
28.
Mas J-L, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin J-P et al (2006) Endarterectomy versus stenting in patients with severe symptomatic stenosis. N Engl J Med 355:1660–1671PubMedCrossRef
29.
SPACE Collaborators (2006) Stent protected angioplasty versus carotid endarterectomy in symptomatic patients: 30 days results from the SPACE trial. Lancet 368:1239–1247CrossRef
30.
ICSS Investigators (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis: interim analysis of a randomised controlled trial. Lancet 375:985–997CrossRef
31.
Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W et al (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11–23PubMedCrossRef
32.
Carotid Stenting Trialists Collaboration (2010) Short term outcome after stenting versus carotid endarterectomy for symptomatic carotid stenosis: preplanned meta-analysis of individual patient data. Lancet 376:1062–1073CrossRef
33.
Roffi M, Sievert H, Gray WA, White CJ, Torsello G, Cao P et al (2010) Carotid artery stenting versus surgery: adequate comparisons? Lancet Neurol 9:339–341PubMedCrossRef
34.
Smout J, MacDonald S, Weir G, Stansby G (2010) Carotid artery stenting: relationship between experience and complication rate. Int J Stroke 5:477–482PubMedCrossRef
35.
Arquizan C, Trinquart L, Touboul P-J, Long A, Feasson S, Terriat B et al (2011) Restenosis is more frequent after carotid stenting than after endarterectomy: the EVA-3S study. Stroke 42:1015–1020PubMedCrossRef
36.
Eckstein HH, Ringleb P, Allenberg J-R, Berger J, Fraedrich G, Hacke W et al (2008) Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol 10:893–902CrossRef
37.
Gurm HS, Yadav JS, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK et al (2008) Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 358:1572–1579PubMedCrossRef
38.
Bonati LH, Jongen LM, Haller S, Flach HZ, Dobson J, Nederkoorn PJ et al (2010) New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: substudy of the ICSS. Lancet Neurol 9:353–362PubMedCrossRef
39.
Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC et al (2011) Guidelines for prevention of stroke in patients with stroke/TIA: a guideline for healthcare professionals from the AHA/ASA. Stroke [Epub 2010 Oct 21]
40.
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al (2011) ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: guideline on management of patients with extracranial carotid and vertebral artery disease. Stroke [Epub 2011 Feb 1]
41.
Bladin C, Chambers B, Crimmins D, Davis S, Donnan G, Frayne J et al (2011) Guidelines for patient selection and performance of carotid-artery-stenting: Inter-Collegiate Committee of the RACP/RACS/RANZCR. Intern Med J 41:344–347CrossRef
42.
43.
44.
Barnett HJM, Pelz DM, Lownie SP (2010) Reflections by contrarians on the post-CREST evaluation of carotid stenting for stroke prevention. Int J Stroke 5:455–456PubMedCrossRef
45.
MacDonald S, Lee R, Williams R, Stansby G, Delphi Carotid Stenting Consensus Panel (2009) Towards safer carotid artery stenting: a scoring system for anatomic suitability. Stroke 40:1698–1703PubMedCrossRef
46.
Amarenco P, Labreuche J, Mazighi M (2010) Lessons from carotid endarterectomy and stenting trials. Lancet 376:1028–1031PubMedCrossRef
47.
48.
Kim LJ, Martinez EA, Faraday N, Dorman T, Fleisher LA, Perler BA et al (2002) Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 106:2366–2371PubMedCrossRef
49.
Blackshear JL, Cutlip DE, Roubin GS, Hill MD, Leimgruber PP, Begg RJ et al (2011) Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation 123:2571–2578PubMedCrossRef
50.
ACST Collaborators (2004) MRC asymptomatic carotid surgery trial: carotid endarterectomy prevents disabling and fatal carotid territory strokes. Lancet 363:1491–1502CrossRef
51.
52.
Naylor AR (2008) Delay may reduce the procedural risk, but at what price to the patient? Eur J Vasc Endovasc Surg 35:383–391PubMedCrossRef
53.
Giles MF, Rothwell PM (2007) Risk of stroke after TIA: systematic review and meta-analysis. Lancet Neurol 6:1063–1072PubMedCrossRef
54.
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJM, for the Carotid Endarterectomy Trialists Collaboration (2004) Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 363:915–924PubMedCrossRef
55.
Salem MK, Sayers RD, Bown MJ, Eveson DJ, Robinson TG, Naylor AR (2011) Rapid access carotid endarterectomy can be performed without a significant increase in the procedural risk. Eur J Vasc Endovasc Surg 41:222–228PubMedCrossRef
56.
McPhee JT, Schanzer A, Messina LM, Eslami MH (2008) Carotid artery stenting has increased rates of post-procedure stroke, death and resource utilization than carotid endarterectomy in the US. J Vasc Surg 48:1442–1450PubMedCrossRef
57.
Naylor AR (2011) Time to rethink management strategies in asymptomatic carotid disease. Nat Rev Cardiol (in press)
58.
Naylor AR, Gaines PA, Rothwell PM (2009) Who benefits most from intervention for asymptomatic carotid stenosis: patients or professional? Eur J Vasc Endovasc Surg 37:625–632PubMedCrossRef
59.
Naylor AR, Gaines PA, Rothwell PM (2009) Who benefits most from intervention for asymptomatic carotid stenosis: Patients or professional? [Erratum]. Eur J Vasc Endovasc Surg 38:657CrossRef
60.
Schneider PA, Naylor AR (2010) Asymptomatic carotid artery stenosis: medical therapy alone versus medical therapy plus CEA/CAS. Eur J Vasc Endovasc Surg 40:274–281PubMedCrossRef
61.
Schneider PA (2010) Response to comments regarding the transatlantic debate: asymptomatic carotid artery stenosis. Eur J Vasc Endovasc Surg 40:679CrossRef
62.
Wholey MH, Barbato JE (2007) Is carotid stenting justified in the asymptomatic patient? Perspectives on indications for CAS. Catheter Cardiovasc Interv 69:1081–1083PubMedCrossRef
63.
Chiche L, Goulfier C (2010) Best practice for asymptomatic carotid disease. In: Jacobs M (ed) Best practice in vascular procedures. Minerva Medica, Turin, pp 21–36
64.
65.
Chaturvedi S (2003) Should the multicenter carotid endarterectomy trials be repeated? Arch Neurol 60:774–775PubMedCrossRef
66.
Spence JD (2010) Is there a role for revascularization in asymptomatic carotid stenosis? No. Brit Med J 341:c4900PubMedCrossRef
67.
Abbott A (2008) Asymptomatic carotid artery stenosis: it’s time to stop operating. Nature Clin Pract Neurol 4:4–5CrossRef
68.
Metadata
Title
A Surgeon’s View on Endarterectomy and Stenting in 2011: Lest We Forget, It’s All About Preventing Stroke
Author
A. Ross Naylor
Publication date
01-04-2012
Publisher
Springer-Verlag
Published in
CardioVascular and Interventional Radiology / Issue 2/2012
Print ISSN: 0174-1551
Electronic ISSN: 1432-086X
DOI
https://doi.org/10.1007/s00270-011-0282-z

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