Carotid Artery Endarterectomy vs. Stenting - WVU School of Medicine

Evaluation options◦ Duplex Doppler ultrasonography◦ Carotid Doppler ultrasonography◦ Magnetic resonance angiography (MRA)◦ Carotid angiography (gold standard)• Not done as often because this is an invasiveprocedure associated with risk ofischemic/hemorrhagic event◦ Sensitivity/specificity of noninvasive teststo predict stenosis >70% is 83-86%/89-94%

To Screen or Not to ScreenCurrent recommendations◦ USPSTF: recommends against screeningfor asymptomatic carotid artery stenosisin the general populations◦ American Heart Association/AmericanStroke association: screening is unlikelycost effective.◦ The American Society of Neuroimaging:Screening for general population is notrecommended but may be considered forpatients older than 65years with riskfactors of vascular disease.

WHO TO TREAT◦ Treatment recommended for:• Asymptomatic pts with >60% stenosis• Symptomatic pts with >50% stenosis

Carotid Artery Endarterectomy◦ Performed through neckincision, usually alongsternocleidomastoidmuscle◦ Proximal and distalcontrol of artery isobtained◦ While patient isheparinized, internal andexternal carotid arteriesare clamped◦ Longitudinal arteriotomyis performed, carotidplaque is removed, andvessel is closed over apatch

Carotid Artery Stenting◦ Catheter withumbrella tip isinserted through thefemoral artery◦ Balloon is inflated todilate artery◦ Stent is placed inartery to maintainpatency◦ Filters are used tocapture embolicparticles

Direct comparison of CEA vs. Stenting◦ Several studies exist comparing theefficacy/safety of CEA to stenting.◦ Studies are designed to look atpost-procedure outcome. (i.e.stroke, embolism, hyperperfusioninjury, etc.)

Direct comparison of CEA vs. Stenting◦ WALLSTENT trial◦ N: 219 patients◦ Carotid arteries were60-90% occluded◦ Patients randomlyassigned to treatmentgroup◦ 1-yr follow-up:significantly higher rateof post-procedure strokewith angioplasty andstenting groupcompared to CEA group(12.2 vs 3.6%)◦ SAPPHIRE STUDY◦ N: 334 patients◦ Symptomatic carotidstenosis of ≥50% orasymptomatic stenosisof ≥80%◦ Looking for end point ofmajor cardiovasculardisease within 1 year.◦ Result: majorcardiovascular diseasewas more common inCEA patients. Howeverrevascularization wasless necessary in CEApatients.

CEA vs stenting in elderly patients◦ Retrospective study of pts ≥75 years old◦ N: 53 pts◦ Primary outcome: MI, stroke within onemonth of treatment◦ Incidence of stroke within 30 days oftreatment was higher in stenting than inCEA group (11.3% to 1.8%, P

Meta-analysis of CEA vs. Carotid arterystenting◦ Number of trials: eight◦ Total N: 2942◦ Outcome: stroke/death/MI at 30 daysand 1 year post procedure◦ Result: The rates of stroke did notdiffer significantly between CEA andCAS. However, the relative risk of MIwas significantly higher in CEApatients. Re-stonsis after 1 yearoccurred more often in CAS patients

CaRESS: 4 year outcomes◦ N: 397 patients◦ Study looked at outcomes 4 years postprocedure◦ Endpoints evaluated:• Primary: mortality, stroke and MI• Secondary: re-stenosis, repeat angiographyand carotid revascularizatoin◦ Results:• Primary endpoints: No significant differencebetween CEA and CAS• Secondary endpoints: CAS resulted more oftenin need for repeat procedure due to restenosis

CONCLUSION◦ Patients with significant comorbiditieswho are poor surgical candidates aremore likely to benefit from angioplastyand stenting than CEA◦ In considering elderly patients there is anacute (

References◦ Liu, Zhenjie, et al: Carotid Artery Stenting Versus CarotidEndarterectomy: Systematic Review and meta-analysis; World Journal ofSuergery; vol. 33: pp. 586-596 (2009)◦ Zarins, C.K., et al; Carotid Revascularization Usuing Endareterectomy orStenting systems; Journal of Endovascular Therapy; Vol. 16: pp. 397-409(2009)◦ Brahmanandam, Soma, et al; Clinical results of Carotid Artery StentingCompared with Carotid Artery Endarterectomy; Journal of VascularSurgery, Vol. 47: pp. 343-349 (2008)◦ Eskandari, M.K., et al; Does Carotid Stenting Measure Up toEndarterectomy? A Vascular Surgeon’s Experience; Archives of Surgery,Vol.139, pp. 734-738 (2004).◦ Greelish, J.P., et al; Nonsurgical carotid revascularization; UpToDate,www.uptodate.com.◦ Greelish, J.P., et al; Carotid endarterectomy: Preoperative evaluation,surgical technique, and complications; UpToDate, www.uptodate.com.◦ Kastrup, A., et al; Comparison of angioplasty and stenting with cerebralprotection versus endarterectomy for treatment of internal carotid arterystenosis in elderly patients; Journal of Vascular Surgery, Nov. 2004.

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