News Release

Angioplasty with stenting is an alternative to endarterectomy for treating carotid artery stenosis

Peer-Reviewed Publication

The Lancet_DELETED

Carotid angioplasty with stenting and endarterectomy show similar effectiveness for preventing ipsilateral* stroke at 2 years and 4 years after the procedure in patients with symptomatic stenosis of the carotid artery. These are the findings reported in two Articles authored by Hans-Henning Eckstein and Peter Ringleb, and John-Luis Mas, respectively, and published early Online and in the October issue of The Lancet Neurology.

Narrowing (stenosis) of the lumen† of the carotid artery due to atheroma‡ is a cause of transient ischaemic attacks and stoke. The standard treatment is to remove the obstruction surgically (endarterectomy). An alternative treatment, stenting, in which the lumen is widened and reinforced from within by a rigid mesh, is less invasive, the patient does not require general anaesthesia, and the length of stay in hospital is reduced. However, stenting does not remove the atheromatous plaque and also carries the risks of stroke, restenosis, and localised complications. The long-term efficacy of stenting has not been investigated.

The Stent-Protected Angioplasty Versus Carotid Endarterectomy (SPACE) investigators assessed the efficacy of stenting or endarterectomy in 1214 patients in Germany, Austria, and Switzerland by measuring the rates of ipsilateral ischaemic stroke and restenosis up to 2 years after stenting or endarterectomy in a prospective, randomised clinical trial. Reccurrence of the blockage to at least 70% of the vessel diameter, as assessed by ultrasound, was more common in the patients who had stenting (10·7%) than those who had surgery (4·6%); however, the patients who had stenting were no more likely to have ipsilateral ischaemic stroke than were those who had surgery (9·5 vs 8·8%).

In the long-term follow up to the Endarterectomy Versus Angioplasty in Patients with Severe Symptomatic Stenosis (EVA-3S) trial, Jean-Louis Mas and colleagues investigated 527 patients at 30 centres in France for a composite outcome of any stroke or death within 30 days of undergoing stenting (265 patients) or endarterectomy (262 patients) or any ipsilateral stroke up to 4 years after the procedures. Although, overall, the patients who underwent stenting were twice as likely to have this composite outcome, stroke mostly occurred soon after the procedure (within 30 days), and there was no difference in the risk of ipsilateral stroke among patients who did not have a stroke within this postoperative period; therefore, stenting seems to be as effective as endarterectomy in the medium term.

The results of both trials seem to recommend stenting as an alternative treatment to endarterectomy in the medium term, but the risks of stroke and death need to be reduced in the crucial 30-day period after surgery, possibly through defining better criteria to select patients.

In an accompanying Reflection and Reaction comment, A Ross Naylor of the Leicester Royal Infirmary sets out his recommendations for the future direction for research in the context of polarised attitudes, acrimonious history, and high stakes surrounding stenting as an alternative to endarterectomy.

"The mid-term to long-term results...published in this issue of The Lancet Neurology, add substantially to the body of data from randomised trials that compare CEA [carotid endarterectomy] with CAS [carotid angioplasty with stenting] for the management of patients with severe carotid disease who have recently developed symptoms.

"To this observer, the most important finding from the articles in this issue of The Lancet Neurology is recognition that the average annual risk of ipsilateral stroke is 1% or less, irrespective of whether the patient was treated by CEA [carotid endarterectomy] or CAS [carotid angioplasty with stenting]."

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Dr Peter Ringleb, University of Heidelberg, Germany. T) +496221567504 E) Peter_Ringleb@med.uni-heidelberg.de

Professor Jean-Louis Mas, Hôpital Sainte-Anne, Paris, France T) +33 1 45 65 82 84 E) jl.mas@ch-sainte-anne.fr

Reflection and Reaction Professor A Ross Naylor, Leicester Royal Infirmary, Leicester, UK. T) +116 252 3179 E) ross.naylor@uhl-tr.nhs.uk

Notes to Editors

*Ipsilateral means on the same side (ie, ipsilateral stroke is a stroke on the same side as the carotid artery that had the blockage).

†The lumen of an artery is the inside space through which blood flows.

‡Atheroma is the accumulation of cholesterol, macrophage cells, calcium, and fibrous tissue on the inside (lumen) of blood vessel leading to a reduction in width that impedes blood flow.

Full study: http://press.thelancet.com/TLNcarotidfinal.pdf


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