Carotid Stents vs Endarterectomy: Separate and Not Yet Equal
Medscape Published: February 23, 2011
No question that I take issue with the AHA guidelines that claim equivalency between carotid stenting and endarterectomy. View video here. You must be a registered user of Medscape to view the video. Medscape registration is free! Or if you prefer, read my comments below:
I'm Frank Veith, Professor of Vascular Surgery at New York University Medical Center and the Cleveland Clinic. This morning I'm going to talk a little bit about the recent guidelines from the American Heart Association, and a number of other important organizations, that have been recently published, and although it's a little premature to comment on them because they haven't been read and absorbed completely, I think it's worth making a comment.
The guidelines appeared to state that carotid stenting was equivalent to carotid endarterectomy, and even though prestigious organizations produced these guidelines, it is my opinion that this conclusion is a little bit premature and unjustified, in view of the data that have accumulated over the past 5 years. The 1 trial that suggested equivalence of carotid endarterectomy and carotid stenting, was the CREST [Carotid Revascularization Endarterectomy versus Stenting Trial], and even though the article in the New England Journal of Medicine stated as a conclusion, that equivalent results could be achieved by the 2 procedures, I believe that this conclusion is flawed, because the conclusion was only reached on the basis of a common composite endpoint, which included not only stroke and death, but also myocardial infarction.
The carotid stenting patients suffered more strokes and deaths, whereas the carotid endarterectomy patients suffered more myocardial infarctions, and when all those adverse events were added up, they were in fact, equivalent, but the flaw is, at least in my opinion, that it's not justified to equate a minor stroke with a minor myocardial infarction. A minor myocardial infarction, although it can have some serious adverse consequences, is not the equivalent of a minor stroke. In a minor stroke, even though the patient may recover measurable neurologic function completely, his brain is not the same. He has immeasurable defects in mood, intelligence, attitude, and so forth, so I believe that a minor stroke (strokes being what both procedures are designed to prevent) is not the equivalent of a minor myocardial infarction.
In addition, all the other trials and population-based studies demonstrate a significantly higher incidence of strokes following carotid stenting than following carotid endarterectomy. You can't ignore these trials and certainly can't ignore the population-based studies, which are other valid pieces of evidence. So I believe, as an enthusiast for carotid stenting, that carotid stenting will ultimately play a very major role in the treatment of carotid artery disease, but I don't think the data yet justify the conclusion that the 2 treatments are equivalent, or that carotid stenting should generally be an acceptable alternative to carotid endarterectomy.
At present, we really don't have that evidence in hand, although I believe it will come in the future. I might add in closing that, many of the points that I made were made by other speakers at our 2010 Veith symposium, held here in New York in November, and many additional points will be made at next year's meeting, which will be held in November of 2011.