CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

June 4th, 2010

Carotid  Stenosis: Stent, Remove or Don’t Touch?

The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) compared carotid stenting with endarterectomy in patients with symptomatic or asymptomatic carotid stenoses. The risk of the composite primary outcome — stroke, MI, or death — was similar for both treatments over the 2.5 years of follow-up.

What’s the nitty gritty?

Periprocedural stroke was more likely after stenting, and periprocedural MI was more likely after endarterectomy; but stroke had a greater impact on quality of life than MI.

Given that neither CREST nor other recent trials have compared revascularization (by either stenting or endarterectomy) with optimal medical therapy in asymptomatic patients, the finding that rates of ipsilateral and contralateral stroke in these patients were similar (≈1%/yr) after the perioprocedural period could mean that (a) revascularization is durable (i.e., prevented cerebrovascular events) or (b) asymptomatic carotid stenosis is benign if treated medically.

Get off the fence….

If YOU had asymptomatic 90% carotid stenosis, would you opt for medical therapy alone or request revascularization too?  If so, how?

Would you want additional risk stratification (i.e., transcranial Doppler) before making the decision?

Categories: Cardiac Surgery, General, Vascular
Tags:


You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

5 Responses to “Carotid  Stenosis: Stent, Remove or Don’t Touch?”

  1. William L Blanchet, MD says:
    June 7, 2010 at 10:38 pm

    I would first kick myself for being stupid enough to rely on traditional risk factors and not do appropriate atherosclerosis screening before the plaque burden became this problematic!

    That said, if I was asymptomatic and had a widely patent circle of Willis based on CTA or MRA, I would likely elect medical management. If the collateral circulation was compramized, I would elect surgical endarterectomy. I would trade an MI for a CVA anyday.

  2. Dan Hackam, MD PhD says:
    June 8, 2010 at 10:42 am

    And I would want my plaque burden followed every 6 or 12 months to ensure it was regressing on the therapy I was taking, titrating that therapy to ensure regression.

  3. Richard A. Lange, MD, MBA says:
    June 9, 2010 at 7:30 pm

    Surprise, surprise, surprise.

    I’m surprised that neither Bill nor Don were interested in using transcranial Doppler (TCD) to guide their treatment.

    The Asymptomatic Carotid Emboli Study (ACES) published online in Lancet showed that detection of asymptomatic embolisation on TCD identifed patients with asymptomatic carotid stenosis who are at a higher risk of stroke (3.6% annual risk) — and conversely, also those with a low absolute stroke risk (<1% annual risk)

  4. Richard A. Lange, MD, MBA says:
    June 9, 2010 at 7:31 pm

    Oops… a typo

    Dan….not Don….sorry about the typo

  5. William L Blanchet, MD says:
    June 9, 2010 at 10:31 pm

    Increased risk is apparent but is there a demonstrated benefit?

    Intracranial Doppler demonstrates increased risk but does that translate to improvement with surgical intervention?

    Competing Interests: See above