Surgery — carotid endarterectomy — has been the gold standard for stroke prevention in carotid stenosis. There has been recent interest in stenting as a less invasive approach, especially after some studies indicated that stenting might be equivalent for patients at increased risk for surgery. CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial) and other recent studies compared the two procedures for a wider range of patients, including those with average surgical risk, with or without symptoms.
Although some headlines noted that CREST found the approaches roughly equivalent, a more careful reading indicates that if stroke prevention is the primary treatment goal, then surgery is still preferred for most patients.
A similar European study of 1,700 patients, called the International Carotid Stenting Study (ICSS), recently reported safety data and also found the incidence of stroke was significantly worse for stenting. Brain imaging (MRI) in the ICSS found evidence of silent brain injuries in three times as many patients receiving stents compared with endarterectomy.
Thus, the results of CREST and ICSS differ in some minor respects, but are broadly similar regarding stroke risk. I don't think these results should dictate a major change in the current paradigm.
The endpoint. CREST evaluated the two approaches for a composite endpoint of death, stroke or heart attack. The two procedures were more or less equivalent if you're looking at the combination; but when looking strictly at death and stroke, surgery was better. A recent editorial in the "New England Journal of Medicine" made that point and also noted that many people in the field, including patients in the trial, believe that stroke is much more disabling than the generally minor heart attacks that occur during surgery.
The recent studies didn't settle the debate; everyone is still waiting for the subgroup analyses in follow-up papers. But the good news from CREST is that the results for both procedures were better than seen in prior trials. The choice depends on the specific risk factors of the patient and the experience of the physician.
For most patients who are likely to benefit from carotid treatment, I still believe surgery is the best choice for prevention of stroke.
The point is, however, that there isn't going to be one answer for all patients. We have two good options. We will have to:
To contact Michael S. Conte, M.D. call (415) 353–4366.
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