Carotid Artery Stenting Viable Alternative to Surgery

Pam Harrison

March 27, 2013

VIENNA, Austria — Carotid artery stenting is a viable alternative to endarterectomy for symptomatic stenosis or asymptomatic severe stenosis, provided patients are carefully selected and are managed at experienced centers.

These are the findings of a long-term study presented here at the European Congress of Radiology 2013.

Both procedures are considered safe and efficient, and have "almost the same rate of complications," said Alessandro Cannavale, MD, from Sapienza University in Rome, Italy.

He explained that "carotid artery stenting is gaining ground over surgery because it is less invasive. However, surgery is not always possible if the field is not clean or if a patient has had a previous intervention on the neck. For these patients, carotid artery stenting is a viable approach."

Dr. Cannavale's team retrospectively reviewed 636 patients who had undergone carotid artery stenting with a minimum follow-up of 6 months.

"We included patients with stenosis greater than 50% who were symptomatic," he noted. "We also treated asymptomatic patients with stenosis greater than 80%, as well as those with stenosis greater than 50% whose plaque was irregular and ulcerated and who were at high risk for thromboembolic events."

A cerebral protection device was used in about 95% of patients to reduce the likelihood of triggering a thromboembolic event with thrombotic debris during or immediately after the intervention. In the remaining 5% of patients, anatomical complexity meant that a protective device could not be used.

Patients received standard protocol medication before and after the intervention.

Carotid artery stenting can be considered a valid method for the treatment of the carotid pathology.

"Technical success was achieved in all cases," Dr. Cannavale reported. The rate of 30-day mortality was under 2.0%, and the rate of in-stent restenosis was only 1.3%.

In all cases, restenoses were corrected with either angioplasty or restenting. The primary patency rate was close to 99%; secondary patency rates were 100%. After a mean follow-up of 76.4 months, 70% of patients were still alive.

"The more experienced the operator, the lower the risk of neurologic complications," Dr. Cannavale said. That risk was 3% to 4% at experienced centers (performing at least 100 procedures), which is lower than that generally reported at centers where the volume of procedures is lower. This suggests that experience is an important determinant of success in carotid artery stenting, Dr. Cannavale observed.

Neurologic complications were also more likely to occur in the presence than in the absence of symptoms (4.5% vs 1.9%; = .001), in patients older than 89 years than in those younger than 80 years (6.4% vs 2.7%; < .05), and in those with complex plaque morphology than in those with stable plaques (6.1% vs 1%; < .001).

"Our study confirmed that carotid artery stenting can be considered a valid method for the treatment of the carotid pathology," Dr. Cannavale said. However, he added that the accurate evaluation of suitable candidates for the procedure is mandatory.

Elke Gizewski, MD, from the Medical University in Innsbruck, Austria, who was asked by Medscape Medical News to comment on this study, noted that carotid artery stenosis is a very common pathology, but that there is controversy surrounding its management around the world.

Although the use of carotid endarterectomy for symptomatic patients is well established, carotid artery stenting has become a widely accepted alternative — even though randomized studies to date have not demonstrated clear superiority of stenting over surgical treatment, she explained.

However, "stenting does not seem to be gaining ground in all centers around the world," she noted.

Therefore, this review is "of great importance for argumentation of minimally invasive therapy in this patient group," Dr. Gizewski said. "The results concerning high- and low-volume centers with respect to complication rates provide evidence for some findings from multicenter studies."

Dr. Cannavale and Dr. Gizewski have disclosed no relevant financial relationships.

European Congress of Radiology (ECR) 2013: Abstract B-300. Presented March 8, 2013.