Carotid Stents and Stroke

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Carotid Stents may raise patient risk for another stroke

Confirming an earlier report in February, 2010, The International Carotid Stenting Study (ICSS) study showed a continued higher event rate of stroke, death, or peri-procedural MI with stenting vs. surgery for symptomatic carotid stenosis.

(ICSS, which compared carotid artery stenting with carotid endarterectomy in patients with symptomatic carotid artery stenosis, showed a higher incidence of stroke and death with stenting than with endarterectomy. As the ICSS investigators mention, these results are consistent with those seen in previous randomized trials comparing stenting with endarterectomy in symptomatic patients (Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA-3S] and Stent-Protected Angioplasty versus Carotid Endarterectomy [SPACE], as well as the CREST trial, published elsewhere on this website)..

The study showed almost twice the risk of stroke and three times the risk of death comparing stents to surgery:

ICSS: 120-day interim safety results
End point Stenting Carotid endarterectomy Hazard ratio (95% CI) p
Disabling stroke or death 4.0 % 3.2 % 1.28 (0.77–2.11) 0.34
Stroke, death, or procedural MI 8.5 % 5.2 % 1.69 (1.16–2.45) 0.006
Any stroke 7.7 % 4.1 % 1.92 (1.27–2.89) 0.002
All-cause death 2.3 % 0.8 % 2.76 (1.16–6.56) 0.017
(From: International Carotid Stenting Study investigators.  Lancet 2010, http://www.thelancet.com)  

In a follow-up sub-study, 231 patients (124 in the stenting group and 107 in the endarterectomy group) had MRI before and after treatment. Here, about three times more patients in the stenting group than in the endarterectomy group had new lesions on post-treatment scans:

End point Stenting Carotid endarterectomy Hazard ratio (95% CI) p
Stroke or TIA 10% 3% 4·06 (1·20–13·63) 0·035
(From: New ischemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis:  a sub-study of ICSS, The Lancet Neurology, Volume 9, Issue 4, April 2010, Pages 353-362)

Conclusion:

Carotid endarterectomy should remain the treatment of choice for patients suitable for surgery.

A number of large trials, including the study published here, have shown the benefits of surgery vs. stents in the treatment of stroke prevention.

It is ironic that a procedure, stenting of the Carotid artery, designed to prevent this complication, may actually be responsible for an increased stroke rate, not only immediately, but long-term. Stents have also been shown more expensive than surgery (called Carotid Endarterectomy) and require expensive long term medications.

Once a stent has been placed, surgery is no longer possible in that area. Younger patients should be aware that they suffer from a chronic disease that will likely progress and recur in the same location. In contrast, surgery in the hands of an experienced vascular surgical team has continued to be the gold standard, and can be repeated if necessary.

Joan F. Tryzelaar, M.D.

 

End point

Stenting

Carotid endarterectomy

Hazard ratio (95% CI)

p

Stroke or TIA

10%

3%

4·06 (1·20–13·63)

0·035

(From: New ischemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a sub-study of ICSS, The Lancet Neurology, Volume 9, Issue 4, April 2010, Pages 353-362)

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