Carotid Stenting Rises in Asymptomatic Patients

STOCKHOLM -- More than half of patients who underwent carotid stenting at German hospitals last year were asymptomatic, up from 20% of all carotid stenting in 1996, according to a registry of almost 2,000 patients.

The asymptomatic patients also had somewhat better outcomes than those who had symptoms from carotid stenosis prior to stenting, but the differences were not statistically significant, Bernd Mark, M.D., said at the annual congress of the European Society of Cardiology.

The registry began in 1996 and includes all patients who undergo carotid artery stenting at 26 German hospitals. By August 2004, a total of 1,954 patients had been entered into the series.

Asymptomatic patients were eligible for carotid stenting if they had a greater than 70% stenosis, and if they met at least one of the following criteria: They were scheduled to undergo major surgery such as coronary bypass or valve surgery, there was evidence of stenosis progression, there was an occlusion of the contralateral carotid artery, or if they had asymptomatic cerebral ischemia documented by CT or MRI.

During the entire series, 910 patients were asymptomatic (47%) and 1,044 were symptomatic. By 2004, asymptomatic patients constituted 54% of all carotid stenting done during the year. The fraction of carotid stenting done in asymptomatic patients at each individual hospital varied widely, from a low of 17% of the procedures to a high of more than 80%. Distal protection devices became routinely used during the later part of the series and were used overall in about 55% of patients.

The incidence of in-hospital complications was 5.2% in asymptomatic patients and 7% in symptomatic patients, a difference that was not statistically significant, said Dr. Mark, a cardiologist at the Heart Center in Ludwigshafen, Germany. The incidence of death or stroke during hospitalization was 3% in the asymptomatic patients and 4.8% in symptomatic, a difference that was also not statistically significant.

But these complication rates may be inflated because they included many patients treated without distal protection devices. "I'd be cautious making conclusions about the complication rates," commented Antonio Columbo, M.D., director of the cardiac catheterization laboratory, EMO Centro Cuore Columbus in Milan. "During the last 3-4 years, use of distal protection devices has become routine. We penalize ourselves when we include procedures that are not done anymore."

Dr. Columbo also defended the value of carotid stenting in asymptomatic patients.

"Even with the best medical treatment, there is room for further improvement" in patients who have substantial carotid stenosis although they're asymptomatic, he said. "We should try to give asymptomatic patients a better prognosis" by offering them carotid stenting.