Tag Archives: Carotid Stenosis

Medical Management and Revascularization for Asymptomatic Carotid Stenosis

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“The treatment of high-grade carotid-artery stenosis varies considerably internationally. Some countries limit revascularization primarily to patients with symptoms, whereas others more commonly recommend that asymptomatic patients undergo revascularization. In the United States, 75 to 80% of patients who undergo carotid-artery stenting or endarterectomy are asymptomatic. Randomized trials from the 1990s and early 2000s showed that carotid
endarterectomy led to a lower risk of stroke among asymptomatic patients with high-grade
stenosis than medical therapy. Improvements in carotid endarterectomy, carotid-artery
stenting, and medical therapy and the results of two recent small trials have challenged
our understanding of appropriate treatments. Here, we present results from the Carotid
Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trials
(CREST-2), which tested whether carotid artery stenting or carotid endarterectomy plus
intensive medical management would be superior to intensive medical management alone
for preventing stroke in patients with high-grade carotid stenosis without recent stroke
symptoms.”

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Carotid endarterectomy for symptomatic carotid stenosis

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“Stroke is the third leading cause of death and the most common cause of long‐term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017.” (Rerkasem)

Rerkasem
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Treatment methodologies of carotid stenosis

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Bae C, et al. Comparative Review of the Treatment Methodologies of Carotid Stenosis. Int J Angiol. 2015 Sep;24(3):215-22. .

Free full-text.

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

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The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

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One discussion this week involved the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).

Reference: Brott TG, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010 Jul 1;363(1):11-23. doi:10.1056/NEJMoa0912321.

Summary:  CREST is an RCT with blinded end-point adjudication whose aim was “to compare the outcomes of carotid-artery stenting with those of carotid endarterectomy among patients with symptomatic or asymptomatic extracranial carotid stenosis” (p.12).

Between December 2000 through July 2008, 2522 patients were enrolled in 108 centers in the US and 9 in Canada. Of those, 1271 patients were randomly assigned to undergo carotid-artery stenting.

Primary findings include (p.18):

  • Carotid revascularization performed by highly qualified surgeons and interventionists is effective and safe.
  • Stroke was more likely after carotid-artery stenting.
  • Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
  • Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy.
  • Older patients had few events after carotid endarterectomy.
  • Low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and reflect advances in medical therapy.