Correspondence
Extracranial Carotid Stenosis
N Engl J Med 2002; 346:1590-1591May 16, 2002
- Article
To the Editor:
In his review of extracranial carotid stenosis (Oct. 11 issue),1 Sacco recommends medical therapy alone for patients over the age of 79 years who have asymptomatic carotid disease of any severity. The problem is that most, if not all, of the original studies that were used as a foundation for these guidelines arbitrarily excluded patients who were older than 80 years of age. This fact should not be viewed as implying that surgery should never be considered in people over the age of 80 years merely because they are old.
1 ReferencesJeffrey L. Kaufman, M.D.
Vascular Services of Western New England, Springfield, MA 01107
kaufman@massmed.org 1
Sacco RL . Extracranial carotid stenosis. N Engl J Med 2001;345:1113-1118
Full Text | Web of Science | Medline
To the Editor:
I do not agree with Sacco's recommendation of carotid endarterectomy for the 64-year-old man with symptomatic carotid-artery stenosis. For every 15 patients who undergo surgery, a single stroke is prevented within five years after surgery. This means that 14 patients derive no benefit at all from surgery. The results of clinical trials cannot be applied wholesale to the real world. A recent observational study of carotid surgery reported a 30-day case fatality rate of 4.5 percent and a 30-day rate of stroke or death of 11.4 percent.1 These findings indicate that the risk–benefit ratio of surgery is more problematic than clinical trials suggest.
1 ReferencesW.A.J. Hoefnagels, M.D., Ph.D.
Ziekenhuis Zeeuws-Vlaanderen, 4500 AC Oostburg, the Netherlands
hoefnag@zeelandnet.nl 1
Chaturvedi S ,Aggarwal R ,Murugappan A . Results of carotid endarterectomy with prospective neurologist follow-up. Neurology 2000;55:769-772
Web of Science | Medline
To the Editor:
Dr. Sacco considers the role of carotid-artery stenting to be unclear. However, he does not address published data from multicenter registries that included more than 5000 patients1 and used devices to protect the brain from the microembolization of plaque during the procedure (neuroprotection systems).2,3 These case series reported low rates of immediate complications and favorable long-term outcomes,4 suggesting that carotid-artery stenting can be performed with rates of periprocedural complications that are similar to or lower than those associated with surgery. The Carotid and Vertebral Artery Transluminal Angioplasty Study,5 as noted by Dr. Sacco, reported lower rates of operative complications after stenting than after endarterectomy. Dr. Sacco advocates a surgical approach for symptomatic patients if the periprocedural risk is 6 percent or lower, as well as for asymptomatic patients if the risk is 3 percent or lower. If the risk of periprocedural complications from carotid-artery stenting meets these predefined standards, stenting should be considered an acceptable alternative to endarterectomy.
5 ReferencesGary S. Roubin, M.D., Ph.D.
Gishel New, M.D., Ph.D.
Lenox Hill Heart and Vascular Institute of New York, New York, NY 10021
gisheln@hotmail.com 1
Wholey MH ,Wholey M ,Mathias K , et al. Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv 2000;50:160-167
CrossRef | Web of Science | Medline2
Al-Mubarak N ,Colombo A ,Gaines PA , et al. Multicenter evaluation of carotid artery stenting with a filter protection system. J Am Coll Cardiol 2002;39:841-846
CrossRef | Web of Science | Medline3
Reimers B ,Corvaja N ,Moshiri S , et al. Cerebral protection with filter devices during carotid artery stenting. Circulation 2001;104:12-15
CrossRef | Web of Science | Medline4
Roubin GS ,New G ,Iyer SS , et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation 2001;103:532-537
Web of Science | Medline5
Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001;357:1729-1737
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Sacco replies:
To the Editor: The management of carotid stenosis continues to be a source of controversy. The age limit of 80 years is predicated on the findings of the Asymptomatic Carotid Atherosclerosis Study,1 from which evidence-based guidelines are derived. I agree that, despite their chronological age, some 80-year-olds may be good candidates for surgery, but the risk–benefit ratio may not be optimal for these patients. Trials provide data derived from populations and help us make clinical decisions involving individual patients, but they may not answer all the questions. Clinical judgment is still needed when evidence is lacking.
For patients with moderate symptomatic carotid stenosis of 60 to 79 percent, surgery will significantly reduce the absolute and relative risk of stroke, especially among those with a recent history of hemispheric transient ischemic attacks. The prevention of 1 stroke for every 15 patients treated is an acceptable achievement given our less than satisfactory results with certain medical approaches. Unfortunately, we cannot predict which patients will not benefit from surgery. The risk–benefit ratio may vary depending on the level of surgical expertise and the characteristics of the patients.
I agree that carotid angioplasty with stenting is a promising procedure. Despite the favorable rates of periprocedural complications, data from case series and registries can never replace the data on safety and efficacy from randomized trials. Selection biases and the lack of systematic identification of outcomes can threaten the validity of the results and conclusions of case series. I am sure Dr. Roubin, a member of the executive committee of the Carotid Revascularization with Endarterectomy or Stent Trial, would agree that a randomized trial of this approach is needed. The evidence derived from this trial will not only change guidelines, but also undoubtedly alter the way we practice.
1 ReferencesRalph L. Sacco, M.D.
Neurological Institute of New York, New York, NY 10032
rls1@columbia.edu 1
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study
CrossRef | Web of Science
