Which patients benefit from carotid stenting? What recent trials show
ABSTRACTSo far, angioplasty with stenting of the carotid arteries does not seem to offer any clear advantage over traditional carotid endarterectomy for patients with symptomatic or asymptomatic stenosis. This paper reviews recent and ongoing studies of carotid revascularization, with conclusions on how these treatments should be used, based on what we know now.
KEY POINTS
- In patients with asymptomatic carotid stenosis greater than 60% or symptomatic carotid stenosis greater than 50%, carotid endarterectomy has been proven to be superior to medical therapy alone.
- In clinical trials, carotid stenting did not appear to have a clear advantage over endarterectomy in patients at average surgical risk.
- Stenting may be most advantageous when used in patients with symptomatic carotid stenosis who would be at high risk of perioperative complications if they were to undergo carotid endarterectomy.
WHAT CAN WE SAY AT THIS POINT?
Given the multiple recent and ongoing trials of stenting vs endarterectomy in carotid stenosis, debate continues as to what the role of stenting will be in the future. What can we say at this point?
In patients with asymptomatic carotid stenosis of greater than 60% or symptomatic carotid stenosis of greater than 50%, carotid endarterectomy has been proven to be superior to medical therapy alone.
The efficacy and safety of carotid stenting compared with carotid endarterectomy is still uncertain. In the trials reviewed above, carotid stenting did not appear to have a clear advantage over endarterectomy in patients at average surgical risk. Stenting may be most advantageous when used in patients with symptomatic carotid stenosis who would be at high operative risk, as indicated by the SAPPHIRE trial.
In patients with severe but asymptomatic carotid stenosis who are at high operative risk, the addition of carotid angioplasty and stenting to maximum medical therapy remains controversial. The periprocedural complication rate in these patients may actually exceed the rate of stroke in asymptomatic patients with greater than 60% stenosis who do not undergo stenting or surgery. In addition, subgroup analyses of patients with 70% to 99% symptomatic stenosis in various trials show that surgical benefit is greater in men than in women, and it remains to be seen whether there is any benefit in women with moderate stenoses, asymptomatic lesions, or both.17
Further experience and study are needed, and the results of the Carotid Stenting vs Surgery of Severe Carotid Artery Disease and Stroke Prevention in Asymptomatic Patients (ACT I) study (comparing stenting and surgery in asymptomatic carotid stenosis), and the ongoing CREST trial (comparing stenting and surgery in symptomatic and asymptomatic carotid stenosis) are eagerly awaited. Until then, clinicians should continue to weigh individual patient risks and benefits when referring patients for surgical treatment of carotid athero-sclerotic disease. Regardless of whether surgery is undertaken, maximal medical therapy with the use of antiplatelet agents, blood pressure control, and statin therapy remains the mainstay of treatment.
