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Home > Press Center > Carotid Endarterectomy Better for Treating Carotid Artery Stenosis

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Emily Kalata
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Carotid artery stenosis, when a main artery in the neck narrows from plaque or a clot and blood flow to the brain is reduced, can lead to an ischemic (mini) stroke. Two methods that have been used to repair the artery, before or after a stroke: carotid endarterectomy (CEA), or carotid artery angioplasty and stenting (CAS).  

In a recent study published in the December 2007 issue of the Journal of Vascular Surgery, researchers from the division of vascular surgery at the University of Massachusetts Medical Center in Worcester, Mass., reviewed the discharge abstracts of 259,080 patients who had carotid artery stenosis revascularization to compare both procedures. Authors used the Nationwide Inpatient Sample (which has 100 percentage of abstracted discharge data from a national survey of 20 percent of all nonfederal acute-care hospitals in the United States) to obtain patient information for the calendar years 2003 and 2004. Comorbidities and postoperative complications were reviewed for each group.   

“Although CAS is an attractive option for some because it is minimally invasive, our results show that CAS was significantly and independently predictive of in-hospital mortality compared with CEA,” said Mohammad H. Eslami, MD, assistant professor of surgery in the division of vascular and endovascular surgery at the University of Massachusetts Medical School. “In patients who were preoperatively symptomatic and had CAS revascularization, there was a seven-fold increase in mortality and four-fold increase in postoperative stroke compared with those who had CEA surgery.” 

 Among the groups, patients who had no symptoms prior to repair had a similar mortality rate; however the postoperative stroke rate of 1.8 percent for those who had CAS was two-fold higher than the rate for those treated with CEA.      

Dr. Esalmi explained that CAS was recently introduced as an alternative to surgery. “It was initially offered to patients who had prior surgery or radiation (both of which may make surgery difficult and lead to complications) or to those where the location of the narrowed artery was surgically inaccessible. Recently, the Food and Drug Administration and Medicare allowed performance of CAS in patients older than 80 with neurological symptoms, who were deemed too “high risk” for surgery and as an alternative.”     

The authors maintain however, that stenting in clinical practice has increased in-hospital mortality. Researchers also noted that the CEA patients did better overall, even though they were older and, with the exception of renal failure, had similar or more severe comorbidities than those who had CAS. They added that because the database used is administrative and data collected can only be reviewed retrospectively, further randomized controlled studies with homogenous symptomatic and asymptomatic cohorts should be performed to determine what future role CAS will play in the treatment of carotid artery stenosis.

“This study was not performed to be an indictment of CAS and I still believe that carotid stenting has a rule in certain patients,” said Dr. Eslami. “I still use CAS albeit very selectively. However I believe that CEA clearly has significant advantageous over stenting in preventing postoperative complications or death, and should remain the first choice in patients who require carotid artery revascularization. Carotid stenting should be performed very cautiously.”  

Authors added that although the technology for CAS will undoubtedly improve and may replace CEA as the treatment of choice for some patients, any shift should be predicated on superior short- and long-term results of prospective randomized trials and not technical feasibility and potential benefits.