When Stroke Is Maximal After A TIA And When To Treat With CAS Or Carotid Endartecectomy

Main Category: Stroke
Also Included In: Cardiovascular / Cardiology
Article Date: 28 Nov 2008 - 2:00 PDT

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Talks on when stroke is maximal after a TIA and when a patient should be treated with CAS or carotid endarterectomy (CAE) were discussed in depth at this year's VEITHsymposium in New York. Frank J. Veith, MD said, "Vascular disease management is in the midst of the endo-revolution, and there are many and powerful motivations for both patients and health professionals to jump on the endovascular stent bandwagon."

Currently, large populations of patients in the United States who undergo carotid stenting (CAS) or carotid endarterectomy (CEA) are asymptomatic. Many experts are of the opinion that CAS or CEA is a good method to prevent stroke in asymptomatic patients. Frank J. Veith, MD, Professor of Surgery, Cleveland Clinic (Cleveland, OH, said, "This statement may be outdated for surgery and is currently unfounded for endovascular treatment."

All level I evidence that carotid endarterectomy (CEA) diminishes stroke risk is based on randomized comparisons with outdated best medical therapy, which does not include optimal use of statins and other pharmaceuticals agents. 1, 2, 3 We know that statins decrease stroke risk in atherosclerotic patients. 4, 5 Moreover, there is no Level I evidence comparing carotid stenting (CAS) with current medical treatment. Asymptomatic carotid disease is far more benign than symptomatic carotid stenoses. Although both CEA and CAS have low procedural risks in asymptomatic patients, older studies show that the long-term stroke risk for even outdated medical treatment is also low (2-3 % per year).2,3 With modern medical treatment it may be lower, even lower than that of CEA and CAS which carry late stroke risks around 1% per year in addition to their procedural risks. 2,3

Although there may be justification for carotid screening in some high risk patient groups, the presumption cannot be made that CEA or CAS for asymptomatic carotid stenoses will prevent more strokes than best current medical treatment. That presumption must be validated by level I evidence in which vintage 2008 medical therapy is compared with CEA and CAS for asymptomatic stenoses. Such a study, the TACIT trial has been designed but remains unfunded.

"Until the results of such a trial become known, it is more important to stress the value of good medical therapy rather than widespread carotid screening in asymptomatic patients at risk for arteriosclerosis," concluded Veith.

About VEITHsymposium™

Now in its fourth decade, VEITHsymposium™ provides vascular surgeons, interventional radiologists, interventional cardiologists and other vascular specialists with a unique and exciting format to learn the most current information about what is new and important in the treatment of vascular disease. The 5-day event features over 400 rapid-fire presentations from world-renowned vascular specialists with emphasis on the latest advances, changing concepts in diagnosis and management, pressing controversies and new techniques. Press registration details can be found at http://www.VEITHpress.org.

VEITHsymposium is sponsored by Cleveland Clinic (Cleveland, OH).

References

1. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high- grade carotid stenosis. N Eng J Med 1991; 325:445-453.

2. Hobson RW, Weiss DG, Fields WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Eng J Med 1993; 328:221-217.

3. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid entarterectomy in patients without neurological symptoms: randomized controlled trial. Lancet 2004:363:1491-1502.

4. Amarenco P, Labreuche J, Lavallee P,Touboul P-J. Statins in stroke prevention and carotid atherosclerosis: systematic review and meta-analysis. Stroke 2004;35:2902-2909.

5. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Eng J Med 2006; 355:549-559.

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