Prof. Nawwar Al-Attar
Carotid endarterectomy is the standard treatment for atherosclerotic stenosis of the internal carotid artery. Carotid angioplasty is gaining increasing popularity as a less invasive technique in symptomatic patients with severe (>70%) carotid artery stenosis especially in those with significant co-morbidities.
Carotid endarterectomy has established benefits when compared to medical treatment in the management of symptomatic and asymptomatic internal carotid artery stenosis.
Surgery provides a significant reduction of the long term risk of stroke or death in symptomatic patients with =70% stenosis of the internal carotid artery when compared to medical treatment. In NASCET (North American Symptomatic Carotid Endarterectomy Trial), symptomatic patients with severe carotid stenosis were randomised to medical treatment or carotid endarterectomy (1). In the surgical group,
In symptomatic patients with moderate (58%–69%) stenosis, surgery has also demonstrated a superior risk reduction when compared to medical treatment (6).
Surgery provided superior results when compared to medical treatment in the Asymptomatic Carotid Atherosclerosis Study which included 1662 patients with asymptomatic carotid artery stenosis in patients with carotid artery stenosis >60%.
The long term benefits of carotid endarterectomy for both symptomatic and asymptomatic patients need to be weighed against the immediate risk of complications of the procedure, thus benefit is tangible only in the presence of a low perioperative complication rate. The surgical procedure should be performed by an experienced surgeon with good patient selection and as such continues to be the gold standard.
Carotid angioplasty has evolved with procedural technologic advancements supplemented by the introduction of intravascular stents and new antiplatelet drugs. The SAPPHIRE trial (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy) had concluded that carotid-artery stenting was not inferior to endarterectomy with a lower risk of myocardial infarction within 30 days after carotid stenting.
Subsequent studies such as SPACE (Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy) gave contradictory results.
In the EVA-3S study (Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis)
A meta-analysis of 5 randomised clinical trials revealed a periprocedural complication rate (stroke and death within 30 days) of 8.1% in the carotid stenting group and 6.3% in the endarterectomy group (12).
The use of embolic protection devices has been shown to reduce thromboembolic complications and increase the safety of carotid-artery stenting. However, this remains a continuing debate (13).
Patients should be informed that there are insufficient data for long-term comparison between carotid angioplasty and surgery. Stenting does not seem to be safer than surgery despite a small difference between the two treatments in the order of 4 events in 600 patients per group. The US Food and Drug Administration advocates stenting only in symptomatic patients with stenosis of the internal carotid artery >70% who are at high risk for complications after surgery.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
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Prof. N. Al-Attar Paris, France Web editor of the Working Group on Cardiovascular Surgery
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