European Heart Journal Advance Access originally published online on July 10, 2007
European Heart Journal 2007 28(16):2045; doi:10.1093/eurheartj/ehm252
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Concerns on carotid stenting in octogenarians: reply
Med. Klinik 8
Kardiologie/Angiologie/Internistische Intensivmedizin Klinikum, Nürnberg Süd
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Herzzentrum
Kardiologie Klinikum Ludwigshafen
Ludwigshafen
Germany
Herzzentrum
Kardiologie Klinikum Ludwigshafen
Ludwigshafen
Germany
Herzzentrum
Kardiologie Klinikum Ludwigshafen
Ludwigshafen
Germany
Kardiologie Klinikum München-Neu-Perlach
München
Germany
Tel: +49 911 398 2989 Fax: +49 911 398 2988 E-mail address: erzahn{at}aol.com
Barracchini and Ballotta1 point out some important issues concerning our registry data on carotid artery stenting (CAS) as well as on CAS in general.
They mention that a distinction neither between ischemic and haemorrhagic stroke nor between different types of ischemic strokes was made. We also regret not to have collected this information. However, concerning stroke as a complication of CAS or endarterectomy (CEA), the large, randomized studies on this issue also summarized all strokes into the primary endpoint of death or stroke.2–4 This makes sense because either CAS or CEA could be complicated by an excess of haemorrhagic strokes, for example, by the use of heparin in CAS.
In concordance with Barracchini and Ballotta,1 we are not sure that all symptoms in the symptomatic patients were as a result of carotid disease; however, this was the judgement of the treating physicians, which we have to accept in such a registry.
We also agree that timing of CAS or CEA in symptomatic patients with carotid stenoses is of crucial importance, which is emphasized in recent guidelines.5 In 84.5% (91.6% in octogenarians and 83.2% in non-octogenarians) of our symptomatic patients, symptoms occurred within 180 days before CAS.
The decision to treat a patient with CAS was left to treating physician. Although we share the caution of Barracchini and Ballotta1 to treat octogenarians for carotid stenoses at all, especially the asymptomatic ones, this is true for CAS as well as CEA. As pointed out in our discussion1: "The results of the Asymptomatic Carotid Surgery Trial (ACST)(6) showed, that CEA was superior to medical treatment only in patients with high-grade but asymptomatic carotid stenoses. However, in patients older than 74 years, there was no advantage of CEA, mainly due to a high mortality rate in the following years in both groups. Thus the selection of more symptomatic patients in our registry may already reflect the restriction of the treating physicians to high risk candidates of stroke in the very old". Our data also reflect only the use of CAS in our registry, not the practice or conviction of the authors.
We do not believe that a residual stenosis after CAS of about 10% is a treatment failure, for we do not have data to show us that such minor residual stenoses are associated with a worse outcome after CAS. The proportion of aborted procedures in this intention-to-treat CAS registry is an important quality measurement of this registry.
References
- Zahn R, Ischinger T, Hochadel M, Zeymer U, Schmalz W, Treese N, Hauptmann KE, Seggewiss H, Janicke I, Haase H, Mudra H, Senges J. Carotid artery stenting in octogenarians: results from the ALKK carotid artery stent (CAS) registry. Eur Heart J (2007) 28:370–375.
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