Correspondence
Stenting for Carotid Stenosis?
N Engl J Med 1997; 337:427-428August 7, 1997
- Article
To the Editor:
I was disappointed by “A Common Clinical Conundrum” (April 3 issue).1 This Clinical Problem-Solving article discussed a procedure — extracranial carotid-artery stenting — that is experimental, has not been validated by published multicenter trials, and is not widely available in community hospitals. In their discussion of success rates, complications, and long-term patency, the authors do not cite any article in a peer-reviewed journal to support their claims, only sketchy abstracts presented at a scientific meeting.2,3 They cite no study to prove cost effectiveness, referring only to their own unpublished “preliminary” work. The inclusion of carotid stenting in the Clinical Problem-Solving article has given the technique an imprimatur that it does not yet deserve.
3 ReferencesRobert L. Mittl, Jr., M.D.
Charlotte Radiology, Charlotte, NC 28236-69371
Gray WA ,DuBroff RJ ,White HJ . A common clinical conundrum. N Engl J Med 1997;336:1008-1011
Full Text | Web of Science | Medline2
Iyer SS ,Roubin GS ,Yadav JS , et al. Angioplasty and stenting for extracranial carotid stenosis: multicenter experience. Circulation 1996;94:Suppl I:I-58 abstract.3
Yadav JS ,Roubin GS ,Vitek J , et al. Late outcome after carotid angioplasty and stenting. Circulation 1996;94:Suppl I:I-58 abstract.
To the Editor:
In “A Common Clinical Conundrum” Gray and associates describe a patient with ischemic heart disease and asymptomatic carotid stenosis who underwent staged carotid-artery stenting and coronary bypass. We assert that the data they cite on morbidity after carotid stenting and endarterectomy are not representative. The data were obtained from a study by Iyer and colleagues, published as an abstract, in which the risk of stroke associated with carotid stenting was given as 3.3 percent.1 Other articles by the same group have reported stroke rates between 6 percent2 and 8 percent.3 At follow-up, which was limited to six months, 6 percent of patients required reintervention (endarterectomy or balloon angioplasty) for stent deformation or restenosis.3
The widely published estimates of the risk of neurologic events after carotid endarterectomy from the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) are 2.4 percent for asymptomatic patients4 and 5.5 percent for patients with symptoms (transient in two thirds of the latter).5
Furthermore, the arteriogram presented as proof of technical success after carotid stent placement demonstrated near-occlusion of the external carotid artery by the stent. This result would be unacceptable after endarterectomy because of the extensive cerebral collaterals dependent on this vessel should restenosis develop in the internal carotid artery.
In summary, the authors have described the use of carotid stenting in a high-risk patient with coronary artery disease. Undoubtedly, appropriate indications for this new technique will emerge for selected patients. However, at the present time, owing to the lack of long-term follow-up, increased risk of neurologic events, and uncertainties regarding its durability and long-term costs, carotid stenting is not yet appropriate for the routine management of carotid stenosis.
5 ReferencesJames M. Estes, M.D.
Magruder C. Donaldson, M.D.
Anthony D. Whittemore, M.D.
Brigham and Women's Hospital, Boston, MA 021151
Iyer SS ,Roubin GS ,Yadav JS , et al. Angioplasty and stenting for extracranial carotid stenosis: multicenter experience. Circulation 1996;94:Suppl I:I-58 abstract.2
Roubin GS ,Yadav S ,Iyer SS ,Vitek J . Carotid stent-supported angioplasty: a neurovascular intervention to prevent stroke. Am J Cardiol 1996;78:Suppl 3A:8-12
CrossRef | Web of Science | Medline3
Yadav JS ,Roubin GS ,Iyer S , et al. Elective stenting of the extracranial carotid arteries. Circulation 1997;95:376-381
Web of Science | Medline4
Hobson RW II ,Weiss DG ,Fields WS , et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med 1993;328:221-227
Full Text | Web of Science | Medline5
North American Symptomatic Carotid Endarterectomy Trial Collaborators
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We strongly agree with Dr. Mittl — at this time, carotid stenting should be performed only under a strict investigational protocol with appropriate multidisciplinary support and assessment. Its experimental nature should be clearly explained to potential patients, as should alternatives such as medical or surgical management. We disagree, however, that there are no peer-reviewed data supporting carotid stenting. At least one published article, by Yadav et al.,1 summarizes the experience with the procedure.
The representation by Estes et al. of the stroke rates in the Yadav article, which is the largest published series of its type, may be misleading. Of 126 stents implanted, there were seven strokes related to the procedure. One was a major stroke, and six were minor. A minor stroke was defined as modest deficits that resolved within a week. Because all these patients met NASCET exclusion criteria, they would not have been included in NASCET. Similar stroke rates were observed in NASCET, which involved a more highly selected patient population than that in the stent study.2 In addition, complications of surgery in NASCET, including cranial-nerve palsy (7.6 percent), wound hematoma (5.5 percent), and infection (3.4 percent), were not seen after carotid stenting. Although the rates of restenosis after carotid surgery range from 5 to 19 percent,3,4 only three patients received treatment for asymptomatic restenosis after carotid stenting in the study by Yadav et al.1
4 ReferencesWilliam A. Gray, M.D.
Robert J. DuBroff, M.D.
Harvey J. White, Jr., M.D.
Southwest Cardiology Associates, Albuquerque, NM 871021
Yadav JS ,Roubin GS ,Iyer S , et al. Elective stenting of the extracranial carotid arteries. Circulation 1997;95:376-381
Web of Science | Medline2
North American Symptomatic Carotid Endarterectomy Trial Collaborators
Full Text | Web of Science | Medline3
Zierler RE ,Bandyk DF ,Thiele BL ,Strandness E Jr . Carotid artery stenosis following endarterectomy. Arch Surg 1982;117:1408-1415
Web of Science | Medline4
Edwards WH Jr ,Edwards WH Sr ,Mulherin JL Jr ,Martin RS III . Recurrent carotid artery stenosis: resection with autogenous vein replacement. Ann Surg 1989;209:662-669
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Dong Ik Kim. (2004) Endovascular Treatment of Occlusive Cerebrovascular Diseases. Journal of the Korean Medical Association 47:7, 636
CrossRef2
Bradley B. Hill, Cornelius Olcott IV, Ronald L. Dalman, E.John Harris, Christopher K. Zarins. (1999) Reoperation for carotid stenosis is as safe as primary carotid endarterectomy. Journal of Vascular Surgery 30:1, 26-35
CrossRef
