Carotid Endartectomy More Effective Than Angioplasty

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Two studies published online in the August 29 edition of The Lancet Neurology confirm that carotid endarterectomy surgery is more effective than balloon angioplasty in preventing strokes caused by blockage of the carotid artery in the neck.

Both reports involve data from the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), a large, randomized trial comparing endovascular treatment (angioplasty with or without stenting) with endarterectomy in patients with predominantly symptomatic, moderate, or severe carotid stenosis. CAVATAS involved patients from 22 medical centers in western Europe, Australia, and Canada between March 1992 and July 1997. The patients were followed for up to 10 years, with a median follow-up of five years.

The first paper focused on the recurrence of stenosis after treatment. Of the 413 CAVATAS participants who had a neck ultrasound every year to examine the carotid artery for restenosis, 31% of patients who received endovascular treatment experienced severe restenosis (narrowing of 70% or more of the artery,) compared to 10% in patients who underwent endarterectomy.

Implanting a stent -- a flexible tube that helps keep the artery open -- did reduce the incidence of blockage by about half in those who had angioplasty. But the overall superiority of surgery in reducing the risk of stroke was clear

Patients who developed severe restenosis within a year of treatment were more than twice as likely as those with no restenosis to suffer ipsilateral stroke or transient ischemic attack within five years.

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The second, related study found that within 30 days of treatment, patients suffered more minor strokes following endovascular therapy than with endarterectomy. The eight-year incidence of any stroke occurring after the 30-day post-treatment period was 21.1% for endovascular treatment versus 15.4% for endarterectomy. The number of people in the trial was small, so confirmation of the findings are needed from larger trials that are now in progress.

Endarterectomy remains the treatment of choice for carotid stenosis among patients who can tolerate it. Patients are increased risk from surgery include patients who have scarring in the neck from prior neck surgery or radiation therapy in the neck, and other medical problems such as heart or lung disease.

Past or current smoking increased the risk of >70% stenosis in both endovascular treatment and endarterectomy groups.

The American Heart Association describes carotid stenosis and its treatment.

Source reference:
Brown M, et al "Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): Long-term follow-up of a randomised trial" Lancet Neurol 2009; DOI:10.1016/S1474-4422(09)70228-5.

Brown M, et al "Long-term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): Long-term follow-up of a randomised trial" Lancet Neurol 2009; DOI:10.1016/S1474-4422(09)70227-3.

Rothwell, PM "Poor outcomes after endovascular treatment of symptomatic carotid stenosis: Time for a moratorium" Lancet Neurol 2009; DOI:10.1016/S1474-4422(09)70230-3.

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