Vol 39 # 2 June 2007 - Kma.org.kw

June 2007KUWAIT MEDICAL JOURNALEditorialThe Place of Angioplasty and Stenting in the Treatment ofCarotid Artery StenosisProfessor Sir Peter RF BellDepartment of Surgery, University Hospitals of Leicester NHS Trust, Leicester LE2 2DP, UKKuwait Medical Journal 2007, 39 (2): 95-97Varying degrees of stenosis of the internalcarotid artery is a common problem in patients whohave peripheral vascular disease. The corre c ttreatment of this condition has been a matter ofsome debate for years and surgical endarterectomyor grafting, popularized in the 1950s by DeBakeyand Eastcott, remained a controversial operationuntil two large randomized trials proved inpatients who had severe (>70%) symptomaticcarotid stenosis that surgery was very beneficial [1,2] .The results of these large randomized trials weretaken as a signal to do many more caro t i de n d a r t e rectomies, both in patients who weresymptomatic and asymptomatic, even though thetrials related to symptomatic and not asymptomaticpatients.With this increase in activity it was perhapsinevitable that someone would have the idea that ifthe artery was narrowed then it should be treatedby angioplasty and stenting as were many otherarteries in other parts of the body. Since Dotter [3]first described arterial dilatation as a possible wayof treating such lesions interventional radiologistsand more recently cardiologists have consistentlytried to expand the areas in which dilatation can beapplied. The invention of stents took this processeven further because a tool is now available whichwill keep the artery open and prevent collapse to itsprevious state.In the early days of angioplasty the effect ofdilatation and stenting in terms of release of emboliwere not fully appreciated and therefore a numberof interventional radiologists started to insert stentsinto the carotid arteries and published whatappeared to be excellent results [4] . At the outset oneof them realised that emboli may go into the brainand tried to construct a primitive protection devicewhich would avoid this happening, againpublishing excellent re s u l t s [ 5 ] . Because of thenovelty and potential profit from inserting stentscompanies became involved in pushing the processforward and a variety of stents and protectiondevices were invented. A large number of papersemerged from many centres claiming that stentingwas as good as or better than endarterectomy andavoided the serious side effects of a scar andtemporary cranial nerve palsy. None of thesepublications were level 1 evidence, usually theywere single center experiences and as such of littlescientific value. Comparing endarterectomy andstenting was always going to be difficult andremained so, mainly because authors who favouredstenting wished if possible to avoid dealing withthose cases which may cause complications andentering exactly the same patients into the twoarms of such trials is always difficult.The first randomized trial to address thisp roblem was done in Leicester. This trial wasstopped by the monitoring committee because ofthe excessive complications of angioplasty. Thistrial was done on the basis of intention to treatwithout exclusions and remains the only trial ofthat nature where the cases compared wereidentical [6] . Because this trial contained such smallnumbers it was not sufficient to influence patternsof treatment. Other randomized trials then camealong comparing the two treatments, the first beingthe CAVATAS trial [7] . This trial was flawed becausethe protocol changed half way through and thelevel of complications at 10% for endarterectomyand stenting was clearly unacceptable. The nexttrial, the SAPPHIRE trial [ 8 ] , was anotherr andomized trial which suggested th a tendarterectomy and stenting had similar resultsbut stenting had less complications of a myocardialnature. This trial is deeply flawed and has nowlargely been discounted. It was however the trialused by the FDAin America to allow stenting to becarried out in high risk patients. Because of theinvolvement of industry and many other problemsAddress correspondence to:Professor Sir Peter RF Bell, Emeritus Professor of Surgery, University Hospitals of Leicester NHS Trust, 22 Powys Avenue, Oadby, Leicester LE22DP, UK. E-mail: peterrfbell@ntlworld.com