To prevent ipsilateral stroke in patients with symptomatic stenosis of the cartoid artery, cartoid angioplasty with stenting shows a similar level of effectiveness as enarterectomy, according to two articles released on September 6, 2008 in The Lancet Neurology.
Stenosis of the lumen of the cartoid artery occurs when the space in the artery is abnormally narrow. When this is caused by atheroma, the accumulation of cholesterol and other biological components on the inside of the vessel, it can further cause transient ischaemic attacks, which can damage the heart, and stroke. The standard treatment for this condition is the physical removal of the obstruction, known as an endarterectomy. The alternative treatment widens and reinforces the vessel using a rigid mesh known as a stent. The latter can be less invasive, does not require general anesthesia, and has a reduced length of hospital recovery stay. However, since it does not imply removal of the plaque itself, it carries risk of stroke, restenosis, and other additional complications.
In order to investigate the long-term effects of stenting, the Stent-Protected Angioplasty Versus Carotid Endarterectomy (SPACE) investigators examined stenting or endarterectomy in 1,214 patients in Germany, Austria, and Switzerland in a randomized clinical trial. The rates of ipsilateral ischaemic stroke and restenosis were measured up to two years after the procedure. Blockage recurrence to at least 70% of the vessel diameter was evaluated by ultrasound.
In patients with stents, blockage recurrence was more common (10.7%) in comparison with patients who had the enarterectomy surgery (4.6%). But, there was no increased risk in this group for ipsilateral ischaemic stroke in comparison with the surgery patients (9.5% versus 8.8%).
A long-term follow up to this study, scientists examined 527 patients at 30 different centers in France to find the composite outcome of any stroke, or death within 30 days of undergoing stenting (265 patients) or endarterectomy (262 patients). Though stended patients had twice the risk of this outcome, stroke was usually soon after the procedure (within 30 days) and there was no difference in risk of ipsilateral stroke after a stroke occured in this group of people. After this initial period, in the medium term, therefore, stending seems as effective as the surgery.
Both of these trials recommend that stenting is an appropriate alternative treatment to endarterectomy in the medium term. However, the risks of stroke and death must still be reduced in the initial 30 day period after the procedure. This could be achieved through a better set of criteria to select patients.
A Ross Naylor of the Leicester Royal Infirmary contributed an accompanying comment in which he recommended future directions for research in the field of stenting. “The mid-term to long-term results.. published in this issue of The Lancet Neurology, add substantially to the body of data from randomised trials that compare CEA [carotid endarterectomy] with CAS [carotid angioplasty with stenting] for the management of patients with severe carotid disease who have recently developed symptoms.” He says.
“To this observer, the most important finding from the articles in this issue of The Lancet Neurology is recognition that the average annual risk of ipsilateral stroke is 1% or less, irrespective of whether the patient was treated by CEA [carotid endarterectomy] or CAS
[carotid angioplasty with stenting].”
Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial
Hans-Henning Eckstein, Peter Ringleb, Jens-Rainer Allenberg, Jurgen Berger, Gustav Fraedrich, Werner Hacke, Michael Hennerici,
Robert Stingele, Jens Fiehler, Hermann Zeumer, Olav Jansen
Lancet Neurology, September 6, 2008
DOI:10.1016/S1474-4422(08)70196-0
Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial
Jean-Louis Mas, Ludovic Trinquart, Didier Leys, Jean-François Albucher, Herve Rousseau, Alain Viguier, Jean-Pierre Bossavy, Beatrice Denis, Philippe Piquet, Pierre Garnier, Fausto Viader, Emmanuel Touze, Pierre Julia, Maurice Giroud, Denis Krause, Hassan Hosseini, Jean-Pierre Becquemin, Gregoire Hinzelin, Emmanuel Houdart, Hilde Hénon, Jean-Philippe Neau, Serge Bracard, Yannick Onnient, Raymond Padovani, Gilles Chatellier, for the EVA-3S investigator
Lancet Neurology, September 6, 2008
DOI:10.1016/S1474-4422(08)70195-9
Written by Anna Sophia McKenney