Published by Oxford University Press on behalf of the European Society of Cardiology 2008
Symptomatic carotid artery stenosis: the dilemma for a reasonable selection of carotid stenting or endarterectomy
Department of Thoracic and Cardiovascular Surgery, Hôpital Saint Joseph, 26, bd de Louvain, Marseille 13285, Cedex 08, France
Corresponding author. Tel: +33 49180 69 05, fax: +33 49180 69 26. Email: pbergeron{at}hopital-saint-joseph.fr; endovasc{at}hopital-saint-joseph.fr
This editorial refers to ‘Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis’ by H.S. Gurm et al., on page 113
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. 
doi:10.1093/eurheartj/ehm362 An excellent meta-analysis from Gurm et al.1 updates the data concerning the treatment of symptomatic carotid stenosis by a surgical or endovascular approach.
The last two randomized trials, SPACE2 and EVA3S,3 did not, in fact, confirmed the equivalence of the two methods and there followed a general unfavourable feeling towards carotid stenting. The article by Gurm et al., 1 which eliminates some old randomized studies such as CAVATAS4 and the stopped Leicester trial,5 appears statistically sound.
We can learn that there is no significant difference between carotid stenting (CAS) and endarterectomy (CAE). Today, the data are heterogeneous and difficult to analyse; the authors have shown that we can approach the truth and keep the two options without bringing them into conflict.
Patients with symptomatic tight carotid stenosis have to be treated because the risk of a cerebrovascular accident is 
20% at 1 year. In the 1980s, surgical treatment was compared with medical treatment by lengthy randomized trials such as NACST6 and ECST,7 and has been recognized as the reference treatment. The contribution of antiplatelet agents and statins today offers much better patient care for atherosclerotic disease and raises questions about the validity of these outdated studies. CAS is still in evolution, with a varying number of different devices in use. Its application remains limited. This technique has unfortunately not been compared with medical treatment but has been introduced inappropriately as an alternative to surgery. This has led to passionate debates between surgeons and interventionists. This situation, which is confounded by ethical and economic factors, is the starting point of chaotic or, at least, disparate regulatory protocols which penalize both practitioners and patients.
Rather than confronting each other in order to maintain their prerogatives, both specialties should adopt the techniques without bringing them into conflict. Some surgeons who have not tried to acquire vascular catheterization skills have lost the clinical care of patients with subclavian or renal arterial stenosis. The techniques are improving, and most aortic aneurysm and arterial occlusions are now treated by the percutaneous approach. These advances will confer benefit to patients with carotid diseases.
Medical education regarding new techniques is mandatory. We now have the opportunity to assimilate CAS, and this represents a major breakthrough for surgeons. Training for carotid interventions is now easier thanks to workshops and simulators.8 Although it is clear that we can obtain similar immediate results with either technique, the long-term results are still unknown for carotid angioplasty and stenting.9 It is important now to move forward cautiously without exposing our patients to unnecessary risks. If it appears that the surgical risk is high, especially in terms of mortality, then stenting has to be considered. A multidisciplinary decision is the way to obtain consensus, taking into account anatomic factors, patients' co-morbidity, and other clinical issues.
Are the current trials relevant?
All the concerned trials have their drawbacks and are subject to criticism.
The SAPHIRE study,10 besides the inclusion of symptomatic and asymptomatic patients, has excluded an unacceptably high number of patients from randomization, excluding them from surgery and including them in a non-randomized stent registry. This has led to questionable results. This study showed an equivalent stroke and death rate.
The SPACE study2 (1200 randomized patients with from 50 to 99% stenosis) has used cerebral protection for only a quarter of the patients and had to be interrupted due to recruitment failure, without proving the non-inferiority of stenting. Nevertheless, no significant difference was demonstrated between 30-day stroke and death rates: 6.3% for CAE and 6.8% for CAS. Finally, the EVA3S study3 (527 randomized patients with from 50 to 90% stenosis and 73% with cerebral protection) reported a significant difference between CEA and CAS (P <0.05) for the 30-day stroke and death rate (3.8 vs. 9.5%). This study contained a lot of bias. A confounding factor was the lack of expertise of the interventionists performing CAS; this study was performed in France where very few centres had experience in this technique.
The interventionist's expertise is strongly linked to the anatomic state of the aortic arch and to carotid tortuosities, especially in elderly patients. That is why 80-year-old patients carry a high neurological complication risk—a group in which this should be a treatment of choice. A simplified vascular access avoiding intra-aortic difficult approaches should reverse this tendency. In the absence of strong proof from evidence-based medicine (EBM), risk factors can be difficult to detail, and this should be done with caution and proper analysis.
Is the plaque structure a determining factor?
Most hypoechogenic, ulcerated, and unstable plaques are symptomatic and most risky for CAS. If virtual angioscopy data12 are confirmed, some patient's lesions might be considered as contraindications for CAS.12 Recently the CREST study13 has pointed out the risk of placing multiple stents. Clinical common sense, logic, and strict enforcement of rules have to be used to choose indications: either surgery or angioplasty. The CaRESS registry14 showed that the complication rate of patients with a high surgical risk is very low and fairly similar for both techniques (2%).
CAS is the treatment of choice for post-surgical or post-radiation stenosis, and for lesions located in the upper internal carotid artery or at the origin of the supra-aortic trunks. It is a good alternative for patients with rigid neck or those who are obese, and in the case of tracheostomy or laryngeal palsy. It should be considered for tandem stenosis or contralateral occlusion. Finally, some co-existing cardiac and respiratory co-morbidity or even diabetes may be identifiable as good indications for CAS. Hopefully, the ICSS15 and TACIT16 trials, including a medical arm, will help to clarify the respective indications.
In our department, a multidisciplinary team decision is taken by vascular surgeons, anaesthesiologists, cardiologists, and radiologists. Low risk patients are treated by surgery; high risk patients are selected for CAS. The risks factors are studied by the group to enable better selection. Only after that are the technical aspects, based on the angiogram and the plaque morphology, considered. In the case of femoral access failure, our unit employs a cervical approach rather than a surgical conversion. This allows the indications for CAS or stenting to be respected.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
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Related articles in EHJ:
- Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis
- Hitinder S. Gurm, Brahmajee K. Nallamothu, and Jay Yadav
EHJ 2008 29: 113-119.[Abstract] [FREE Full Text]
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