Randomized Controlled Trials Comparing Endarterectomy and Endovascular Treatment for Carotid Artery Stenosis

Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.

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Benefit of carotid endarterectomy for symptomatic and asymptomatic severe carotid artery stenosis: a Markov model based on data from randomized controlled trials

Journal of Neurosurgery ◽

10.3171/2009.4.jns08568 ◽

2009 ◽

Vol 111 (5) ◽

pp. 970-977 ◽

Cited By ~ 14

Author(s):

Tomohito Nagaki ◽

Koji Sato ◽

Takaaki Yoshida ◽

Yuhei Yoshimoto

Keyword(s):

Carotid Artery ◽

Markov Model ◽

Randomized Controlled Trials ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenosis ◽

Controlled Trials ◽

Asymptomatic Carotid ◽

Randomized Controlled ◽

Comorbidity Index

Object Several major randomized controlled trials of carotid endarterectomy (CEA) in patients with both symptomatic and asymptomatic carotid artery stenosis have addressed the net effects of CEA on the risk of stroke. However, because the risk of stroke among patients with asymptomatic carotid stenosis is relatively low, whether to treat their stenosis with CEA remains an important public health issue. Methods The authors constructed a Markov model to evaluate the effectiveness of CEA. In modeling 4 health states, the probability of transition to another state was estimated using data from major randomized controlled trials. Adopting 3 comorbidity index values for baseline analyses, the authors expressed outcomes in terms of the expected number of quality-adjusted life years (QALYs) for a hypothetical cohort undergoing CEA and another without treatment. Results In the authors' baseline analysis, CEA for asymptomatic stenosis yielded a very small benefit (0.07 QALY) for 70-year-old, normal-risk CEA candidates. Benefits decreased further, often becoming negative, as patient age, surgical risk, or comorbidity index increased. In patients with symptomatic stenosis, CEA was always more effective than conservative management, even considering variables such as comorbidities limiting life expectancy, advanced age, and increased perioperative risk. Conclusions Carotid endarterectomy for severe carotid stenosis consistently and significantly benefits patients with recent symptoms. However, surgery for asymptomatic stenosis appears justified only in carefully selected conditions: low treatment risks in relatively young individuals without any comorbidities.

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