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Carotid Stent or Surgery: Which is Best?

Kathleen Blanchard's picture

According to a new scientific review, questions remain about stenting for carotid artery disease versus surgery - both of which are used to open blocked carotid arteries to prevent stroke. In March 2010, University of Alabama researchers published findings from the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) that showed carotid stents are better than surgery for patients under age 69. Researchers say stenting for carotid artery disease is still controversial and questions remain about which procedure is best for stroke prevention.

Carotid artery stenting involves inserting a wire mesh tube through the groin into the carotid artery. The arteries are present on the left and right side of the neck and provide blood flow to the face and brain. The mesh tube is opened to press plaque from atherosclerosis against the artery wall to restore normal blood flow. The procedure is less invasive. Carotid artery surgery requires general anesthesia and involves removing the diseased portion of the artery. In a comparison of carotid stents versus surgery, Dr. Ethan Halm, chief of the William T. and Gay F. Solomon Division of General Internal Medicine at UT Southwestern reports the “jury is still out on the appropriate role for stenting and caution is merited for several reasons."

Dr. Halm says many patients don't get the right information from physicians about the risks of stents, surgery and medical treatment. Instead there is more focus on the risks of not performing a procedure, shown in studies. He adds that which procedure a patient receives might also be linked to demographics.

"Given the national policy interest in controlling rising health care costs, the fact that where you live may influence how much and what type of care you get as how sick you are has generated great interest," Dr. Halm said. "The rise in use of stenting is probably due to the fact that it can be done by a much larger group of specialists compared to surgery alone, and stenting is less invasive, so more people may want it." Carotid stenting has become increasingly more popular compared to surgery, but there are still wide geographic variations in the use of each procedure.

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Dr. Halm says even though studies show carotid artery stents are best for patients over age 70 there is still some controversy because no one knows the long-term effect compared to carotid surgery. Safety of the procedure is also a concern.

"Most people who have had a stroke or a 'temporary stroke' due to carotid disease in the past 12 months stand to benefit greatly from revascularization if they can tolerate the procedure. People who have silent or asymptomatic carotid disease have much more modest benefit from either surgery or stenting. They should make an informed decision with their doctors about the benefits and harms of all their treatment options, whether surgery, stenting or medication." Medication therapy for blocked carotid arteries includes cholesterol and blood pressure lowering medications and blood thinners.

Choosing the right procedure to treat carotid artery disease and prevent stroke that occurs when plaque breaks away from the artery should be an informed decision. Dr. Halm says it's best to speak with your doctor about individual circumstances when choosing carotid stenting or surgery or even medications for stroke prevention.

"Treatment of asymptomatic carotid disease is not an emergency, so you have time to get the facts about the pros and cons of all three options – surgery, stenting, medical therapy alone." However, if your artery is more than 50 percent narrowed or you've had a stroke in the past 12 months, either stenting or surgery is hugely beneficial. Dr. Halm is putting together an interactive computer program to help patients understand the pros and cons of carotid stenting, surgery and medical therapy. The question of which is best - carotid stent or surgery - should be an individual but informed patient decision.

Southwestern Medical Center