Carotid Artery Interventions Break Three Ways
As a result, patients with other forms of carotid disease often do not have insurance coverage for CAS.
"The issue for us is primarily reimbursement. If we can do [a procedure] and be reimbursed, we often stent the patient," said Dr. Carlos H. Timaran, a vascular surgeon and chief of endovascular surgery at the University of Texas Southwestern Medical Center in Dallas.
"For my private practice patients, we assess their risk based on their
[anatomical] and medical criteria. If they are high risk, we usually stent. We have a bias toward stenting because it is faster and easier. Some people say they can do endarterectomy in an hour, but I don’t believe that. I do CEA with residents and fellows, and it takes 2 hours. But with stenting, I can do it in 40 minutes, even with a fellow. If I have three patients with carotid disease to treat [and] if I do CEA on all three, it will take all day. If I do CAS, it will take the morning, or less," he said in an interview.
In addition, "CEA is a nice procedure, but you need anesthesia. CAS is easier, I can do it myself, and I don’t need anesthesia. I am in more control of the case," Dr. Timaran said.
For patients who are eligible for both CAS and CEA, "it also comes down to anatomy," he grants. But if the patient has anatomy favorable to either method, "I offer patients both, and they will probably go for a stent," because patients usually prefer the quicker recovery that stenting offers, compared with CEA.
An interesting footnote to the issue of how to best manage patients who are eligible for CAS under CMS rules is that the CREST results offer no direct guidance on the relative safety and efficacy of CAS and CEA in patients with Medicare coverage. That’s because "the CREST cohort was a conventional-risk cohort; most criteria that would make someone a high surgical risk would have been excluded from CREST," Dr. Thomas G. Brott, professor of neurology at the Mayo Clinic in Jacksonville, Fla., and lead investigator for CREST. "The high-surgical-risk patients who are currently covered by Medicare would not have even been enrolled in CREST," Dr. Brott said in an interview.
Where Does Medical Therapy Fit In?
Although Dr. Timaran sees the potential value of medical therapy only for asymptomatic patients, he also urges caution.
"I don’t think [the efficacy of medical treatment] has been proven, and until it’s proven I don’t think physicians should deny revascularization treatment to these patients," he said. "The standard of care for a patient with severe carotid stenosis is revascularization, even if the patient is asymptomatic, unless there is some other consideration." But, he admitted, "there is little downside to medical treatment in asymptomatic patients, even if they have severe stenosis." That’s because their stroke risk is low regardless of which option a patient chooses.
"I tell asymptomatic patients that ‘based on the data, your risk of stroke is 2% per year, and that risk may be even lower with best medical therapy.’ With a carotid intervention, we can lower their risk to 1% per year." In other words, the patient’s stroke risk is low regardless of which option is chosen. Plus, medical therapy only is the best choice for patients with special risk factors, such as radiation-induced stenosis, Dr. Timaran added.
Other experts see medical treatment alone as an excellent option for many carotid-stenosis patients.
"The majority of patients I see don’t get an intervention; we use medical treatment only," said Dr. Jon S. Matsumura in an interview. "I think that’s true for most vascular surgery practices, and in cardiology and neurology practices. A lot of these patients just need reassurance," said Dr. Matsumura, professor and chairman of vascular surgery at the University of Wisconsin in Madison.
"Most asymptomatic patients [with carotid stenosis] should be treated by best medical therapy, with very few – fewer than 5% – treated by CAS or CEA," said Dr. Frank J. Veith at the International Symposium on Endovascular Therapy (ISET 12) in January. He acknowledged that well-controlled trials done during the 1990s showed that CEA led to superior outcomes compared with medical therapy, but since the early 2000s, "best medical therapy to prevent strokes leapt forward," he said, especially with improved statin therapy. He cited findings from a 2010 prospective study that showed asymptomatic Canadian patients managed starting in 2003 with best medical therapy had an annual stroke rate of 0.7% (Arch. Neurol. 2010;67:180-6).
