Despite the development of dedicated carotid artery stenting systems and years of experience, interventional treatment has not fared better than endarterectomy or best medical therapy in preventing stroke or death.
Despite the development of dedicated carotid artery stenting systems and years of experience, interventional treatment has not fared better than endarterectomy or best medical therapy in preventing stroke or death.
Only one study to date has shown that carotid artery stenting was superior to surgery in treating symptomatic patients. Others have reported no difference or poor outcomes following the procedure. As for treating asymptomatic patients, data do not support revascularization of any kind, said speakers at the 2007 meeting of the Cardiovascular and Interventional Radiology Society of Europe.
"Carotid artery stenting should not be offered as a routine standard of care to asymptomatic patients. The treatment of asymptomatic lesions should be reserved for randomized clinical trials," said Dr. Barry Katzen, founder and director of the Baptist Cardiac and Vascular Institute in Miami.
Admittedly, clinical trials of carotid artery stenting are plagued by small numbers of patients, and they tend to lump asymptomatic and symptomatic patients together.
"We are looking at fewer than 1000 patients in the trials in order to try and get some decision making on what we should do," said Dr. Trevor Cleveland of the Sheffield Vascular Institute in the U.K. "It is very difficult to tease out the symptomatic and the asymptomatic patients. Therefore, in terms of concluding what we can say from clinical trials, it's difficult."
Nevertheless, the risk of cardiovascular accident has been consistently higher after stenting than after endarterectomy in symptomatic patients. In the early Wallstent trial, the risk of death within 30 days was 12.1% for stenting and 3.6% for endarterectomy. Stenting was equivalent to endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS). Although only 25% of patients had stents and the stents were crude early devices, outcomes were similar between the endovascular and surgical patients, Cleveland said.
In the 2006 Endarterectomy vs. Stenting in patients with Symptomatic Severe Carotid Stenosis (EVA-3S) French trial, the risk of stroke or death and the risk of disabling stroke or death at 30 days had not improved even with more advanced stenting systems, Cleveland said. Carotid endarterectomy had a 3.9% risk of stroke or death and a 1.5% risk of disabling stroke or death within a month of surgery. Stenting had a 9.6% risk of stroke or death and a 3.45% risk of disability.
The European Stent Protection Angioplasty vs. Carotid Endarterectomy (SPACE) trial showed equality between stenting and endarterectomy, with a 30-day risk of a severe adverse event (stroke or death) of 6.34% for surgery and 6.84% for intervention. The trial has been stopped, however, because of lack of funding.
Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) appeared to offer cause for celebration among interventionalists, Cleveland said, because the risk of 30-day events was much lower (4.2%) for stenting than for endarterectomy (15.4%). But fewer than 100 symptomatic patients were included in the trial before it was stopped. In the end, meta-analyses show no difference in outcome between surgery and stenting.
The overall risk of stroke is declining, just as is the risk of acute myocardial infarction, because of the use of aggressive medical therapies. Best medical therapy alone, therefore, is clearly benefiting asymptomatic patients.
"The question with carotid angioplasty and stenting is, do they come close to best medical care in asymptomatic patients. And I would offer to you that at this point, I don't think we are close to it," Katzen said.
Emerging AI Algorithm Shows Promise for Abbreviated Breast MRI in Multicenter Study
April 25th 2025An artificial intelligence algorithm for dynamic contrast-enhanced breast MRI offered a 93.9 percent AUC for breast cancer detection, and a 92.3 percent sensitivity in BI-RADS 3 cases, according to new research presented at the Society for Breast Imaging (SBI) conference.
The Reading Room Podcast: Current Perspectives on the Updated Appropriate Use Criteria for Brain PET
March 18th 2025In a new podcast, Satoshi Minoshima, M.D., Ph.D., and James Williams, Ph.D., share their insights on the recently updated appropriate use criteria for amyloid PET and tau PET in patients with mild cognitive impairment.
Can Abbreviated Breast MRI Have an Impact in Assessing Post-Neoadjuvant Chemotherapy Response?
April 24th 2025New research presented at the Society for Breast Imaging (SBI) conference suggests that abbreviated MRI is comparable to full MRI in assessing pathologic complete response to neoadjuvant chemotherapy for breast cancer.
Clarius Mobile Health Unveils Anterior Knee Feature for Handheld Ultrasound
April 23rd 2025The T-Mode Anterior Knee feature reportedly offers a combination of automated segmentation and real-time conversion of grayscale ultrasound images into color-coded visuals that bolster understanding for novice ultrasound users.