The Rush to Stent: A Cause for Concern

BY FRANK J. VEITH, M.D.

We are in the midst of the Endo-Revolution in vascular disease management. Every day, vascular surgeons and other vascular interventionists from multiple disciplines are bombarded with reasons to perform exciting new endovascular treatments using ingenious devices or innovative improvements in guidewires, catheters, balloons, stents, and endografts. The motivations for all vascular specialists to jump on this endovascular treatment bandwagon are many and powerful. The treatments may help patients and are usually gratifying to perform and financially rewarding.

Patients and their referring physicians are pleased to have them undergo such high-tech, low-morbidity procedures. Hospital executives, health administrators, and the health care industry are supportive because their bottom lines are augmented.

Other incentives to treat with the glitzy endovascular devices are the need to accumulate case numbers for credentialing purposes, and the opportunity to expand the scope of one's practice to patients and lesions previously treated by other specialists.

And finally, there is the real fear of missing the boat with these endovascular treatments and being excluded from their usage, with dire consequences for one's professional survival.

For all these reasons, the utilization of endovascular treatments and devices has become a feeding frenzy for those involved in vascular disease management.

This frenzy is most striking with the use of intravascular stents, particularly those placed at the carotid bifurcation, a site of opportunity for vascular specialists from many disciplines.

This is the cause of my concern. Some of us who are vascular physicians may be losing sight of what our primary goal should be: namely, doing things that are good for patients.

Because of all the reasons and motivations to use endo devices other than the well-being of patients, are we forgetting to ask ourselves the question: "Is placement of this stent in this patient indicated and justified?"

If this question were asked and answered honestly, no one would ever place a carotid stent to treat a 30%-40% stenosis in an asymptomatic patient--something I have repeatedly observed being done at "live case" demonstrations around the world.

This trend to treat benign lesions is also reflected in the high percentage (70%-90%) of asymptomatic patients in most reports of carotid stent registries and trials. There is no good evidence that such procedures are beneficial to patients.

Moreover, because the likelihood of a poor outcome in patients with benign lesions is low, such needless treatment carries artifactually and misleadingly low adverse event rates. In this era of audits, this may be good for the treating physician.

It is interesting to note that it may also wrongly suggest the superiority of carotid stenting vis-à-vis endarterectomy.

However, this tendency to treat lesser lesions is of little or no value to patients, and it results in health care costs being raised unnecessarily.

Carried to the extreme, it will result in the stenting of near-normal carotid arteries with outstandingly low adverse event rates, but with little or no patient benefit.

What is to be done about this rush to stent, this cause of concern?

I really don't know. However, I believe that most physicians who treat vascular lesions are conscientious and well motivated to help their patients.

Perhaps, if we all see the problem, we will ask ourselves the right questions and be better able to resist the temptations and pressures to treat or place stents for the wrong reasons in patients who do not need them.