Dr. Safi:
Carotid endarterectomy is a time-tested, effective, durable and safe procedure that has been used in clinical practice since its introduction, in Houston, by Dr. DeBakey in 1953. Current case volumes are in the range of 140,000 per year in the USA. Combined perioperative death and stroke risk is 2-5% in the community, and is substantially better – around 1% in high-volume centers. Endarterectomy has been subjected to rigorous testing in large randomized trials, and has been shown reliably to be superior to medical management, with a number needed to treat of 6 for symptomatic patients in the NASCET trial. Results of carotid stent trials have been mixed, with some showing benefit and some showing harm. Until a treatment superior to endarterectomy is not only developed but proven, the surgical approach should be the standard of care.
Dr. McPherson:
Significant progress has been made in the design and deployment of carotid arterial stents since the first-generation devices were introduced a decade ago, most importantly in the area of distal protection device development. Although early trial results were mixed, a recent large randomized trial (SAPPHIRE) using contemporary technology has shown noninferior or even favorable results of stenting compared to endarterectomy for symptomatic patients. Currently, the CREST trial is evaluating stents in patients with and without symptoms, and should produce additional level one evidence soon. Carotid stenting is particularly attractive in cases where patients have hostile necks or other difficult anatomy. Catheter-based technologies are constantly improving and are here to stay.
Sapphire is a poster child for clever manipulation of patient sourcing and selecting/ignoring primary outcomes for the convenience of positive results. EVA-3S was prospectively randomized and showed superiority of endarterecdtomy over CAS (and the knee-jerk criticism that its results were the consequence of a greater procedural expoertise in the surgical group than in the stent group have been debunked through retrospective outcome analysis) Until CREST is concluded the best proven outcomes remain on the side of carotid endarterectomy.
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The SPACE trial results are amongst the most robust of all the comparative RCTs and show no clinically relevant difference in outcomes between CAS & CEA.
At least part of the problem is that most surgeons who offer CEA cannot provide CAS – and vice versa; hence the antagonism and spurious need for one technique to prove superiority over the other – for all presentations. Patient selection for the most appropriate method gives best results and will probably be the future.
1/ treatment of carotid atheroma in symptomatic patients is clearly beneficial only if the morbimortality rate of the procedure is low, below 3% as medical treatment had improved very substantially with the combination of 80 mg atorvastatin and antiplatelet agents.
2/ treatment of asymptomatic patients is in my mind very controversial. Only centers with very low MMR could discuss such cases and operate on these patients. I am not aware of RCT of asymptomatic patients where CAS performed a MMR
The requirements to acheive reduction of carotid plaque are very similar to the approach we use to reduce coronary plaque. One difference is that hypertension may play a more important role with carotid plaque and needs to be reduced confidently to the normal range before carotid plaque is controlled.