Fall 2005

Carotid Stenting Offers Alternative to Endarterectomy

Carotid endarterectomy is the second most common vascular surgical procedure, after coronary artery bypass surgery. Carotid endarterectomy has been the gold standard for the treatment of carotid atherosclerosis for stroke prevention ever since studies demonstrated its effectiveness compared to "best medical therapy" in the early 1990s. That may change, however, as the Food and Drug Administration (FDA) has approved carotid stenting as an alternative therapy in certain "high-risk patients" for stroke prevention. The use of carotid stents is on the rise in the United States.

Stents have several potential advantages over traditional surgical endarterectomies, according to UCSF interventional neuroradiologist Randall Higashida, M.D. "The advantages are that stents are considered to be less invasive, we can do them under local anesthesia, there is less morbidity in terms of damage to the surrounding nerves and there is far less problem with local wound healing," he says. Patient discomfort during the operation is similar to that for a cerebral angiogram, he adds.

Since the late 1990s, UCSF has been a leader in national clinical trials of carotid stents. As a result of those trials, Higashida has obtained experience in using stents on high-risk patients, including those who develop recurrent stenosis following a surgical endarterectomy, those who have comorbid conditions such as significant heart or lung disease and those who have lesions, such as high cervical lesions, that are difficult to access via traditional endarterectomy.

There is a clear need for effective therapies for carotid stenosis. The condition accounts for 15 percent to 20 percent of the 700,000 new strokes that occur each year in the United States. Unlike other cerebrovascular arteries, the carotid artery offers surgeons easy access for opening up the artery and cleaning out plaque. The procedure itself, however, carries some risk of inducing strokes.

Postendarterectomy morbidity and mortality were high enough in the 1980s that the National Institutes of Health (NIH) was called on to evaluate the procedure's risks versus benefits in carefully controlled clinical trials. The NIH study determined that the benefits of doing the procedure, if performed within certain guidelines, outweighed the risks.

The approval of carotid stents in certain groups of patients provides a third option for patients at risk for stroke. The only device approved so far by the FDA has a miniature filter basket deployed downstream. This basket catches any plaque, particles or clots that might be dislodged during the stenting procedure, thus lowering the risk of stroke subsequent to implantation of the stent.

To contact Dr. Higashida, call (415) 353-1863.

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