Carotid Endarterectomy versus Endovascular Stent Placement as Therapy for Symptomatic Carotid Artery Disease

Carotid Endarterectomy versus Endovascular Stent Placement as Therapy for Symptomatic Carotid Artery Disease

YS Kim
Interventional Cardiology Volume 4 Issue 1
Published: November 2009
download article View ebook

| More
dots

Stroke-related morbidity and mortality remain unacceptably high. Recent estimates suggest that it accounts for approximately one out of every 17 deaths in the US, with one death from the direct consequences of stroke every three to four minutes. Of the almost 800,000 strokes that occur annually, 87% are ischaemic, the remainder occurring predominantly as a consequence of intracerebral haemorrhage. The accessibility of the extracranial internal carotid artery to revascularisation, together with the strong correlation between the severity of carotid artery stenosis and the further risk of stroke in patients who have already experienced a transient ischaemic attack (TIA) or stroke (up to 35% at five years in one series), has driven the field of carotid endarterectomy (CEA) and carotid artery stenting (CAS). In this article we will discuss the merits and risks of both of these revascularisation methods for patients with symptomatic extracranial carotid artery disease.

Stroke-related morbidity and mortality remain unacceptably high. Recent estimates suggest that it accounts for approximately one out of every 17 deaths in the US, and that a person dies from the direct consequences of stroke every three to four minutes.1 Of the almost 800,000 strokes that occur annually, 87% are ischaemic, the remainder occurring predominantly as a consequence of intracerebral haemorrhage.2 While 15% of patients who experience a stroke have suffered a preceding transient ischaemic attack (TIA), thereby potentially giving an opportunity for medical intervention, only about 50% are likely to report the episode to their physician.3 The 90-day risk of stroke after a TIA is as high as 17.3% and the 10-year cumulative risk of stroke, myocardial infarction (MI) or vascular death is over 42%.4 Confronted with these statistics, the personal and financial burden to the nation associated with stroke is overwhelming, often representing the single greatest medical fear among the public.

Although almost half of all strokes result from cerebral ischaemia within the vascular territory supplied by the internal carotid artery, brain parenchymal infarction results from carotid artery atheroembolic disease in only about 15% or less of all stroke patients.5,6 Ois et al. recently reported the factors associated with a high risk of stroke recurrence in almost 700 patients who had an initial minor stroke or TIA.7 The presence of weakness and a prior history of TIA together with severe extracranial arterial disease were strongly associated with the highest risk of recurrence. The accessibility of the extracranial carotid artery to revascularisation, together with the strong correlation between the severity of carotid artery stenosis and the further risk of stroke in patients who have already experienced a TIA or stroke (up to 35% at five years in one series),8 has driven the adoption of carotid artery endarterectomy (CEA) and stenting (CAS). Given the fact that the vast majority of cerebrovascular accidents do not result from atheroembolic carotid artery disease, a comprehensive clinical evaluation, consisting of a thorough history (including a third-party account where possible) and physical examination of the patient, is warranted in all cases where either CEA or CAS is being considered. The true differentiation of the ‘symptomatic’ patient with a carotid artery lesion from the asymptomatic patient is of paramount importance when dictating further clinical management options. For the purposes of carotid artery revascularisation, patients are termed ‘symptomatic’ if they have experienced a TIA (defined as a focal neurological deficit as a consequence of ischaemia persistent for under 24 hours)9 or a non-disabling stroke within the carotid artery vascular territory. Patients who have suffered a major disabling or completed stroke were not enrolled in the pivotal North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST).10,11 Norris and Hachinski, in a study of over 800 patients initially diagnosed with stroke, reported a misdiagnosis rate of 13%.12 Specific patient groups (i.e. women and African-Americans) need particular consideration as they may be more likely to present with atypical features of a TIA or stroke.13,14

Keywords:
Symptomatic carotid disease, carotid endarterectomy (CEA), carotid artery stenting (CAS)

References:
  1. National Center for Health Statistics, Vital Statistics of the United States, 2008.
  2. Incidence and Prevalence: 2006 Chart Book on Cardiovascular and Lung Diseases, Bethesda: National Heart, Lung, and Blood Institute, 2006.
  3. Johnston SC, Fayad PB, Gorelick PB, et al., Prevalence and knowledge of transient ischemic attack among US adults, Neurology, 2003;60(9):1429–34.
  4. Clark TG, Murphy MF, Rothwell PM, Long term risks of stroke, myocardial infarction, and vascular death in “low risk” patients with a non-recent transient ischaemic attack, J Neurol Neurosurg Psychiatry, 2003;74(5):577–80.
  5. Bogousslavsky J, Van Melle G, Regli F, The Lausanne Stroke Registry, Stroke, 1988;19(9):1083–92.
  6. Fairhead JF, Mehta Z, Rothwell PM, Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke, Neurology, 2005;65(3):371–5.
  7. Ois A, Gomis M, Rodriguez-Campello A, et al., Factors associated with a high risk of recurrence in patients with transient ischemic attack or minor stroke, Stroke, 2008;39(6):1717–21.
  8. Dennis MS, Bamford JM, Sandercock PA, Warlow CP, A comparison of risk factors and prognosis for transientischemic attacks and minor ischemic strokes, Stroke, 1989;20(11):1494–9.
  9. Ziegler DK, Hassanein RS. Prognosis in patients with transient ischemic attacks, Stroke, 1973;4(4):666–73.
  10. Ferguson GG, Eliasziw M, Barr HW, et al.,The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients, Stroke, 1999;30(9):1751–8.
  11. Randomised trial of endarterectomy for recently symptomatic carotid stenosis), Lancet, 1998;351(9113): 1379–87.
  12. Norris JW, Hachinski VC, Misdiagnosis of stroke, Lancet, 982;1(8267):328–31.
  13. Stuart-Shor EM, Wellenius GA, DelloIacono DM, et al., Gender differences in presenting and prodromal stroke symptoms, Stroke, 2009;40(4):1121–6.
  14. Rathore SS, Hinn AR, Cooper LS, et al., Characterization of incident stroke signs and symptoms, Stroke, 2002;33(11):2718–21.
  15. Goldstein LB, Simel DL, Is this patient having a stroke?, JAMA, 2005;293(19):2391–2402.
  16. Reeves M, Bhatt A, Jajou P, et al., Sex differences in the use of intravenous rt-PA thrombolysis treatment for acute ischemic stroke, Stroke, 2009;40(5):1743–9.
  17. Bamford J, Sandercock P, Dennis M, et al., Classification and natural history of clinically identifiable subtypes of cerebralinfarction, Lancet, 1991;337(8756):1521–6.
  18. Lindley RI, Warlow CP, Wardlaw JM, et al., Interobserver reliability of a clinical classification of acute cerebral infarction, Stroke, 1993;24(12):1801–4.
  19. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis, N Engl J Med, 1991;325(7):445–53.
  20. Barnett HJ, Taylor DW, Eliasziw M, et al., Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis, N Engl J Med, 1998;339(20):1415–25.
  21. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0- 9%) carotid stenosis. European Carotid Surgery Trialists’ ollaborative Group, Lancet, 1991;337(8752):1235–43.
  22. Plum F, Extracranial-intracranial arterial bypass and cerebral vascular disease, N Engl J Med, 1985;313(19):1221–3.li> Easton JD, Sherman DG, Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations, Stroke, 1977;8(5):565–8.
  23. Rothwell PM, Gibson RJ, Slattery J, et al., Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European Carotid Surgery Trialists’ Collaborative Group, Stroke, 1994;25(12):2435–9.
  24. Mayberg MR, Wilson SE, Yatsu F, et al., Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group, JAMA, 1991;266(23): 3289–94.
  25. Sacco RL, Adams R, Albers G, et al., Guidelines for prevention of stroke in patients with ischemic stroke ortransient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline, Stroke, 2006;37(2):577–617.
  26. Wennberg DE, Lucas FL, Birkmeyer JD, et al., Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics, JAMA, 1998;279(16):1278–81.
  27. North American Symptomatic Carotid Endarterectomy Trial.Methods, patient characteristics, and progress, Stroke, 1991;22(6):711–20.
  28. Taylor DW, Barnett HJ, Haynes RB, et al., Low-dose and highdose acetylsalicylic acid for patients undergoing carotidendarterectomy: a randomised controlled trial. ASA and Carotid Endarterectomy (ACE) Trial Collaborators, Lancet,1999;353(9171):2179–84.
  29. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee, Lancet, 1996;348(9038):1329–39.
  30. Halkes PH, van Gijn J, Kappelle LJ, et al., Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemiaof arterial origin (ESPRIT): randomised controlled trial, Lancet, 2006;367(9523):1665–73.
  31. Sacco RL, Diener HC, Yusuf S, et al., Aspirin and extendedrelease dipyridamole versus clopidogrel for recurrent stroke, N Engl J Med, 2008;359(12):1238–51.
  32. Vaughan CJ, Delanty N, Neuroprotective properties of statins in cerebral ischemia and stroke, Stroke, 1999;30(9):1969–73.
  33. Yusuf S, Sleight P, Pogue J, et al., Effects of an angiotensinconverting- enzyme inhibitor, ramipril, on cardiovascularevents in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators, N Engl J Med, 2000;342(3):145–53.
  34. Collins R, Peto R, MacMahon S, et al., Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context, Lancet, 1990;335(8693):827–38.
  35. Rothwell PM, Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis, Cerebrovasc Dis, 2007;24(Suppl. 1):116–25.
  36. Bond R, Rerkasem K, Rothwell PM, Systematic review of therisks of carotid endarterectomy in relation to the clinical indication for and timing of surgery, Stroke, 2003;34(9):2290–2301.
  37. Bockenheimer SA, Mathias K, Percutaneous transluminal angioplasty in arteriosclerotic internal carotid artery stenosis, AJNR, 1983;4(3):791–2.
  38. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial, Lancet, 2001;357(9270):1729–37.
  39. publications committee of the WALLSTENT MJA, Results of a multicenter prospective randomized trial of carotid artery stenting versus carotid endarterectomy (abstr), Stroke, 2001;32:325.li> Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results, J Vasc Surg, 2005;42(2):213–19.
  40. Yadav JS, Wholey MH, Kuntz RE, et al., Protected carotidartery stenting versus endarterectomy in high-risk patients, N Engl J Med, 2004;351(15):1493–1501.
  41. LoGerfo FW, Carotid stents: unleashed, unproven, Circulation, 2007;116(14):1596–1601, discussion 1601.
  42. Gurm HS, Yadav JS, Fayad P, et al., Long-term results of carotid stenting versus endarterectomy in high-risk patients, N EnglJ Med, 2008;358(15):1572–9.
  43. Ringleb PA, Allenberg J, Bruckmann H, et al., 30 day resultsfrom the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial, Lancet, 2006;368(9543): 1239–47.
  44. Mas JL, Chatellier G, Beyssen B, et al., Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis, N Engl J Med, 2006;355(16):1660–71.
  45. Samuelson RM, Yamamoto J, Levy EI, et al., The argument to support broader application of extracranial carotid artery stent technology, Circulation, 2007;116(14):1602–10, discussion 1610.
  46. Maree AO, Rosenfield KA, Endarterectomy versus stenting for carotid stenosis, N Engl J Med, 2007;356(3):306, author reply 306–7.
  47. Theiss W, Hermanek P, Mathias K, et al., Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the Pro-CAS data, Stroke, 2008;39(8): 2325–30.
  48. Gurm HS, Nallamothu BK, Yadav J, Safety of carotid artery stenting for symptomatic carotid artery disease: a metaanalysis, Eur Heart J, 2008;29(1):113–19.
  49. Brooks WH, McClure RR, Jones MR, et al., Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital, J Am Coll Cardiol, 2001;38(6):1589–95.
  50. Criado FJ, Gashti M, Are there patients truly at high-risk for carotid endarterectomy or carotid stenting? Can they be identified?, Sem Vasc Surg, 2008;21(3):139–42.li> Kang JL, Chung TK, Lancaster RT, et al., Outcomes after carotid endarterectomy: is there a high-risk population? A National Surgical Quality Improvement Program report, J Vasc Surg, 2009;49(2):331–8, 339, e331, discussion 338–9.
  51. II HR, Update on the Carotid Revascularization Endarterectomy vs Stent Trial (CREST) protocol, J Am Coll Surg, 2002(194 Suppl.):S9–S14.
  52. Featherstone RL, Brown MM, Coward LJ, International carotid stenting study: protocol for a randomised clinical trial comparing carotid stenting with endarterectomy insymptomatic carotid artery stenosis, Cerebrovasc Dis, 2004;18(1):69–74.
  53. Brown MM EJ, Bonati LH, et al., Early outcomes of patients randomised between carotid stenting and endarterectomyfor symptomatic carotid stenosis, European Stroke Conference 2009, Stockholm, Sweden, 27 May 2009; abstract 3.

Copyright® 2004 - 2010 Business Briefings, Ltd. All rights reserved.
Touch Cardiology is for informational purposes and should not be considered medical advice, diagnosis or treatement recommendations.