Symptomatic carotid artery stenosis: a solvable problem. North American Symptomatic carotid Endarterectomy Trial.

Carotid artery stenting (CAS) has emerged as a potential alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. The purpose of this article is to provide an evaluation and critical overview of the trials comparing the early and later results of CAS with CEA for symptomatic carotid stenosis. The Cochrane Controlled Trials Register, PubMed/Medline, and EMBASE databases were searched up to February 1, 2009, to identify trials comparing the long-term outcomes of CAS with CEA. The MeSH terms used were “carotid artery stenting,” “carotid endarterectomy,” “symptomatic carotid artery stenosis,” “treatment,” “clinical trial,” “randomized,” and “long-term results,” in various combinations. One single-center and three multicenter randomized studies reporting their long-term results from the comparison of CAS with CEA for symptomatic carotid stenosis were identified. All four studies independently reached the conclusion that CAS may not provide results equivalent to those of CEA for the management of symptomatic carotid stenosis. A higher incidence of recurrent stenosis and peri- and postprocedural events accounted for the inferior results reported for CAS compared with CEA. Current data from randomized studies indicate that CAS provides inferior long-term results compared with CEA for the management of symptomatic carotid artery stenosis. However, it can be argued that all of these trials were performed when both CAS equipment and CAS operators had not evolved to their current status. Given that current equipment and mature experience are required for CAS before comparing it with the current “gold standard” procedure (CEA), the results of soon-to-be reported trials (Carotid Revascularization Endarterectomy vs Stenting Trial [CREST], International Carotid Stenting Study [ICSS], or others) may alter the current impression that CAS is inferior to CEA for the treatment of symptomatic carotid stenosis.

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Investigating Factors That Delay Carotid Endarterectomy in Patients With Symptomatic Carotid Artery Stenosis

Journal of Vascular Surgery ◽

10.1016/j.jvs.2016.08.005 ◽

2016 ◽

Vol 64 (5) ◽

pp. 1531

Author(s):

Daniel Meyer ◽

Erwin Karreman ◽

David Kopriva

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenosis ◽

Artery Stenosis ◽

Symptomatic Carotid

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Middle cerebral artery pulsatility index and cognitive improvement after carotid endarterectomy for symptomatic stenosis

Journal of Neurosurgery ◽

10.3171/2013.8.jns13931 ◽

2014 ◽

Vol 120 (1) ◽

pp. 126-131 ◽

Cited By ~ 9

Author(s):

Eric J. Heyer ◽

Joanna L. Mergeche ◽

E. Sander Connolly

Keyword(s):

Carotid Artery ◽

Middle Cerebral Artery ◽

Carotid Endarterectomy ◽

Cerebral Artery ◽

Carotid Artery Stenosis ◽

Pulsatility Index ◽

Artery Stenosis ◽

Symptomatic Carotid ◽

Cognitive Improvement ◽

Cerebral Resistance

Object Transcranial Doppler (TCD) is frequently used to evaluate peripheral cerebral resistance and cerebral blood flow (CBF) in the middle cerebral artery prior to and during carotid endarterectomy (CEA). Patients with symptomatic carotid artery stenosis may have reduced peripheral cerebral resistance to compensate for inadequate CBF. The authors aim to determine whether symptomatic patients with reduced peripheral cerebral resistance prior to CEA demonstrate increased CBF and cognitive improvement as early as 1 day after CEA. Methods Fifty-three patients with symptomatic CEA were included in this observational study. All patients underwent neuropsychometric evaluation 24 hours or less preoperatively and 1 day postoperatively. The MCA was evaluated using TCD for CBF mean velocity (MV) and pulsatility index (PI). Pulsatility index ≤ 0.80 was used as a cutoff for reduced peripheral cerebral resistance. Results Significantly more patients with baseline PI ≤ 0.80 exhibited cognitive improvement 1 day after CEA than those with PI > 0.80 (35.0% vs 6.1%, p = 0.007). Patients with cognitive improvement had a significantly greater increase in CBF MV than patients without cognitive improvement (13.4 ± 17.1 cm/sec vs 4.3 ± 9.9 cm/sec, p = 0.03). In multivariate regression model, a baseline PI ≤ 0.80 was significantly associated with increased odds of cognitive improvement (OR 7.32 [1.40–59.49], p = 0.02). Conclusions Symptomatic CEA patients with reduced peripheral cerebral resistance, measured as PI ≤ 0.80, are likely to have increased CBF and improved cognitive performance as early as 1 day after CEA for symptomatic carotid artery stenosis. Revascularization in this cohort may afford benefits beyond prevention of future stroke. Clinical trial registration no: NCT00597883 (ClinicalTrials.gov).

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