Early results of carotid endarterectomy versus carotid stenting: Outcomes from a Mediterranean country

Vascular ◽  
2019 ◽  
Vol 27 (5) ◽  
pp. 468-474
Author(s):  
Ricardo Castro-Ferreira ◽  
Alberto Freitas ◽  
Sérgio M Sampaio ◽  
Paulo G Dias ◽  
Armando Mansilha ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Hospital Mortality ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Public Hospitals ◽  
Hospital Length Of Stay ◽  
Mediterranean Country ◽  
Main Diagnosis ◽  
Asymptomatic Patients

Introduction and objectives Which is the best carotid stenosis treatment remains a controversial issue. To present day, no study has compared the results of carotid artery stenting versus carotid endarterectomy in Portugal. We aim to provide real life numbers regarding the outcomes of both procedures in Portuguese public hospitals. Methods Every patient registered between 2005 and 2015 with the main diagnosis of carotid stenosis and submitted to carotid endarterectomy or carotid artery stenting was included. The information was obtained through the Central National Healthcare Administrative database, a mandatory registry for hospital refunding. Primary outcomes were hospital mortality and stroke. Patient demographics, comorbidities and hospital length of stay were also evaluated. Results The study included 6094 patients: 1399 were symptomatic (mention of prior stroke) and 4695 asymptomatic. Carotid artery stenting was performed on 22% of the symptomatic and 18% of the asymptomatic patients. In the symptomatic patients, the in-hospital mortality was significantly higher in those submitted to stenting (3.6% vs. 1.6% in carotid endarterectomy, p = 0.025). No significant differences in outcomes were observed in the asymptomatic group (mortality 0.9% vs. 0.8%, p = 0.852; stroke rate of 2.6% vs. 2.3%, p = 0.652 – carotid artery stenting vs. carotid endarterectomy). In both groups, there was an important increase in the proportion of stenting between 2005 and 2012, followed by a gradual decline until 2015. Conclusion Despite its increasing frequency, a higher early mortality was documented for CAS in symptomatic patients. No worse outcome was observed in asymptomatic patients.

Endovascular Advances for Extracranial Carotid Stenosis

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S92-S101 ◽  
Author(s):  
Jorge L. Eller ◽  
Travis M. Dumont ◽  
Grant C. Sorkin ◽  
Maxim Mokin ◽  
Elad I. Levy ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenosis ◽  
Carotid Artery Stenting ◽  
Carotid Stenting ◽  
Historical Background ◽  
Treatment Modalities ◽  
Endovascular Management ◽  
The Past

Abstract Carotid artery stenting has become a viable alternative to carotid endarterectomy in the management of carotid stenosis. Over the past 20 years, many trials have attempted to compare both treatment modalities and establish the indications for each one, depending on clinical and anatomic features presented by patients. Concurrently, carotid stenting techniques and devices have evolved and made endovascular management of carotid stenosis safe and effective. Among the most important innovations are devices for distal and proximal embolic protection and new stent designs. This paper reviews these advances in the endovascular management of carotid artery stenosis within the context of the historical background.

scholarly journals Physician Approaches to Imaging and Revascularization for Acutely Symptomatic Carotid Stenosis: Insights from the Hot Carotid Qualitative Study

2022 ◽  
Vol 2 (1) ◽  
Author(s):  
Aravind Ganesh ◽  
Benjamin Beland ◽  
Gordon A.E. Jewett ◽  
David J.T. Campbell ◽  
Malavika Varma ◽  
...  
Keyword(s):  
Decision Making ◽  
Carotid Artery ◽  
Qualitative Study ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Practice Patterns ◽  
Imaging Modality ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

Background Evidence informing the choice between carotid endarterectomy and carotid artery stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated and does not factor in contemporary therapies or techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis. Methods We used a qualitative descriptive methodology to examine decision‐making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for hot carotids. We conducted semistructured interviews with purposive sampling of 22 stroke physicians from 16 centers in 6 world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons. Results Qualitative analysis revealed several themes regarding clinical decision‐making for hot carotids. Whereas CT angiography was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. Carotid endarterectomy was generally favored over carotid artery stenting, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CT angiography imaging and carotid endarterectomy over carotid artery stenting but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk‐stratification with imaging features other than just degree of stenosis.

Selection of Treatment for Patients with Carotid Artery Disease: Medication, Carotid Endarterectomy, or Carotid Artery Stenting

Vascular ◽  
2005 ◽  
Vol 13 (2) ◽  
pp. 92-97 ◽  
Author(s):  
Marc Bosiers ◽  
Patrick Peeters ◽  
Koen Deloose ◽  
Jürgen Verbist ◽  
L. Richard Sprouse
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Medical Therapy ◽  
Carotid Artery Stenting ◽  
Carotid Artery Disease ◽  
Limiting Factors ◽  
Treatment Modalities ◽  
Asymptomatic Patients ◽  
Artery Disease ◽  
Selection Of

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.

Carotid Artery Stenting May Be Losing the Battle against Carotid Endarterectomy for the Management of Symptomatic Carotid Artery Stenosis, But the Jury Is Still Out

Vascular ◽  
2009 ◽  
Vol 17 (4) ◽  
pp. 183-189 ◽  
Author(s):  
Kosmas I. Paraskevas ◽  
Dimitri P. Mikhailidis ◽  
Frank J. Veith
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Carotid Artery Stenosis ◽  
Carotid Artery Stenting ◽  
Artery Stenosis ◽  
Long Term Results ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis

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.

Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy: SPACE2 – a Three-Arm Randomised-Controlled Clinical Trial

2009 ◽  
Vol 4 (4) ◽  
pp. 294-299 ◽  
Author(s):  
T. Reiff ◽  
R. Stingele ◽  
H. H. Eckstein ◽  
G. Fraedrich ◽  
O. Jansen ◽  
...  
Keyword(s):  
Primary Prevention ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Stenting ◽  
Carotid Artery Disease ◽  
Controlled Clinical Trial ◽  
Vascular Events ◽  
Asymptomatic Carotid ◽  
Symptomatic Carotid ◽  
Asymptomatic Patients

Moderate to severe (≥70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4–7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; http://www.space-2.de ) with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017.

scholarly journals Recent Update on Carotid Endarterectomy versus Carotid Artery Stenting

2016 ◽  
Vol 43 (1-2) ◽  
pp. 68-75 ◽  
Author(s):  
Raywat Noiphithak ◽  
Anusak Liengudom
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Stenting ◽  
Current Data ◽  
Current Evidence ◽  
Stroke Treatment ◽  
Carotid Revascularization ◽  
Asymptomatic Patients ◽  
Best Medical Treatment ◽  
Meta Analyses

Carotid artery stenosis (CS) is a major cause of ischemic stroke. Treatment of CS consists of best medical treatment and carotid revascularization (CR), including carotid endarterectomy (CEA) and carotid artery stenting (CAS). Both CR techniques have their own procedural risks. Therefore, selection of the appropriate treatment for patients with CS is relatively complicated. Many studies and guidelines have reported the efficacy of each treatment for both symptomatic and asymptomatic patients. However, the results are still controversial, especially concerning the efficacy and safety of CEA and CAS. In this paper, we review and discuss the current evidence and compare results from studies of CEA and CAS, including major randomized trials, meta-analyses and ongoing trials. Moreover, based on the current data, we propose a new comprehensive decision-making for the management of CS.

scholarly journals Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Seong Hwa Jang ◽  
Doo Hyuk Kwon ◽  
Moon-Ku Han ◽  
Hyungjong Park ◽  
Sung-Il Sohn ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Stenosis ◽  
Carotid Artery Stenting ◽  
Standard Dose ◽  
Trend Test ◽  
High Dose ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Asymptomatic Patients ◽  
Significant Difference

Abstract Background Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. Methods Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. Results The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). Conclusions Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting

2018 ◽  
Vol 25 (4) ◽  
pp. 514-521 ◽  
Author(s):  
Hanaa Dakour-Aridi ◽  
Besma Nejim ◽  
Satinderjit Locham ◽  
Husain Alshaikh ◽  
Tammam Obeid ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Incremental Cost ◽  
Carotid Endarterectomy ◽  
Carotid Artery Stenting ◽  
Logistic Models ◽  
Complication Rates ◽  
Healthcare Database ◽  
Asymptomatic Patients ◽  
Significant Difference ◽  
Hospitalization Costs

Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.

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