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Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre

  • Clinical Article - Vascular
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Abstract

Background

We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003–2007) and after that (2008–2012).

Method

During the years 2003–2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed.

Results

Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008–2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017).

Conclusions

CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.

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References

  1. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Stroke Association; American Association of Neuroscience Nurses; American Association of Neurological Surgeons; American College of Radiology; American Society of Neuroradiology; Congress of Neurological Surgeons; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery; American Academy of Neurology and Society of Cardiovascular Computed Tomography (2011) 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 42:e464–e540

    Article  PubMed  Google Scholar 

  2. Halm EA, Tuhrim S, Wang JJ, Rockman C, Riles TS, Chassin MR (2009) Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study. Stroke 40:221–229

    Article  PubMed Central  PubMed  Google Scholar 

  3. Barnett HJ, Eliasziw M, Meldrum HE, Taylor DW (1996) Do the facts and figures warrant a 10-fold increase in the performance of carotid endarterectomy on asymptomatic patients? Neurology 46:603–608

    Article  CAS  PubMed  Google Scholar 

  4. Pokras R, Dyken ML (1988) Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head. Stroke 19:1289–1290

    Article  CAS  PubMed  Google Scholar 

  5. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 339:1415–1425

    Article  CAS  PubMed  Google Scholar 

  6. NASCET (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 325:445–453

    Article  Google Scholar 

  7. NASCET (1991) North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 22:711–720

    Article  Google Scholar 

  8. NASCET (1991) Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. National Institute of Neurological Disorders and Stroke and Trauma Division. North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators. Stroke 22:816–817

    Article  Google Scholar 

  9. ECST (1991) MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99 %) or with mild (0–29 %) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet 337:1235–1243

    Article  Google Scholar 

  10. ECST (1996) Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet 347:1591–1593

    Article  Google Scholar 

  11. ECST (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387

    Article  Google Scholar 

  12. Warlow CP (1993) Symptomatic patients: the European carotid surgery trial (ECST). J Mal Vasc 18:198–201

    CAS  PubMed  Google Scholar 

  13. ACAS (1995) Endarterectomy for asymptomatic carotid artery stenosis. Executive committee for the asymptomatic carotid atherosclerosis study. JAMA J Am Med Assoc 273:1421–1428

    Article  Google Scholar 

  14. ACAS (1995) Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. National institute of neurological disorders and stroke. J Neurol Sci 129:76–77

    Article  Google Scholar 

  15. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502

    Article  CAS  PubMed  Google Scholar 

  16. Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, Pan H, Peto R, Potter J, Rahimi K, Rau A, Robertson S, Streifler J, Thomas D (2010) 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 376:1074–1084

    Article  PubMed Central  PubMed  Google Scholar 

  17. Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL (1999) AHA scientific statement. Supplement to the guidelines for the management of transient ischemic attacks: a statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 30:2502–2511

    Article  CAS  PubMed  Google Scholar 

  18. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L (1998) Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 97:501–509

    Article  CAS  PubMed  Google Scholar 

  19. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JV, Pearson TA (2011) Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 42:517–584

    Article  PubMed  Google Scholar 

  20. Moore WS, Mohr JP, Najafi H, Robertson JT, Stoney RJ, Toole JF (1992) Carotid endarterectomy: practice guidelines. Report of the Ad Hoc Committee to the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. J Vasc Surg 15:469–479

    Article  CAS  PubMed  Google Scholar 

  21. Moore WS, Barnett HJM, Beebe HG, Bernstein EF, Brener BJ, Brott T, Caplan LR, Day A, Goldstone J, Hobson RW, Kempczinski RF, Matchar DB, Mayberg MR, Nicolaides AN, Norris JW, Ricotta JJ, Robertson JT, Rutherford RB, Thomas D, Toole JF, Trout HH, Wiebers DO (1995) Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Stroke 26:188–201

    Article  CAS  PubMed  Google Scholar 

  22. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T (2006) Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 37:577–617

    Article  PubMed  Google Scholar 

  23. Bonati LH, Ederle J, McCabe DJ, Dobson J, Featherstone RL, Gaines PA, Beard JD, Venables GS, Markus HS, Clifton A, Sandercock P, Brown MM (2009) 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 8:908–917

    Article  PubMed Central  PubMed  Google Scholar 

  24. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L (2001) Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 38:1589–1595

    Article  CAS  PubMed  Google Scholar 

  25. Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L (2004) Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery 54:318–324, discussion 324–315

    Article  PubMed  Google Scholar 

  26. CAVATAS (2001) Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 357:1729–1737

    Article  Google Scholar 

  27. Coward LJ, McCabe DJ, Ederle J, Featherstone RL, Clifton A, Brown MM (2007) Long-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial. Stroke 38:1526–1530

    Article  CAS  PubMed  Google Scholar 

  28. Ederle J, Bonati LH, Dobson J, Featherstone RL, Gaines PA, Beard JD, Venables GS, Markus HS, Clifton A, Sandercock P, Brown MM (2009) 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 8:898–907

    Article  PubMed Central  PubMed  Google Scholar 

  29. Ringleb PA, Allenberg J, Bruckmann H, Eckstein HH, Fraedrich G, Hartmann M, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Stingele R, Zeumer H, Hacke W (2006) 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:1239–1247

    Article  CAS  PubMed  Google Scholar 

  30. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K (2004) Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:1493–1501

    Article  CAS  PubMed  Google Scholar 

  31. Bonati LH, Jongen LM, Haller S, Flach HZ, Dobson J, Nederkoorn PJ, Macdonald S, Gaines PA, Waaijer A, Stierli P, Jager HR, Lyrer PA, Kappelle LJ, Wetzel SG, van der Lugt A, Mali WP, Brown MM, van der Worp HB, Engelter ST (2010) New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 9:353–362

    Article  PubMed  Google Scholar 

  32. Howard VJ, Lutsep HL, Mackey A, Demaerschalk BM, Sam AD 2nd, Gonzales NR, Sheffet AJ, Voeks JH, Meschia JF, Brott TG (2011) Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol 10:530–537

    Article  PubMed Central  PubMed  Google Scholar 

  33. Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A, Bossavy JP, Denis B, Piquet P, Garnier P, Viader F, Touze E, Julia P, Giroud M, Krause D, Hosseini H, Becquemin JP, Hinzelin G, Houdart E, Henon H, Neau JP, Bracard S, Onnient Y, Padovani R, Chatellier G (2008) Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 7:885–892

    Article  PubMed  Google Scholar 

  34. Silver FL, Mackey A, Clark WM, Brooks W, Timaran CH, Chiu D, Goldstein LB, Meschia JF, Ferguson RD, Moore WS, Howard G, Brott TG (2011) Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 42:675–680

    Article  PubMed Central  PubMed  Google Scholar 

  35. Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lievre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viguier A, Piquet P, Garnier P, Viader F, Touze E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X (2006) Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 355:1660–1671

    Article  CAS  PubMed  Google Scholar 

  36. Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, Taylor DW, Haynes RB, Finan JW, Hachinski VC, Barnett HJ (1999) The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1,415 patients. Stroke 30:1751–1758

    Article  CAS  PubMed  Google Scholar 

  37. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK, Society for Vascular S (2011) Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 54:e1–e31

    Article  PubMed  Google Scholar 

  38. Wallaert JB, De Martino RR, Finlayson SR, Walsh DB, Corriere MA, Stone DH, Cronenwett JL, Goodney PP (2012) Carotid endarterectomy in asymptomatic patients with limited life expectancy. Stroke 43:1781–1787

    Article  PubMed Central  PubMed  Google Scholar 

  39. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11–23

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Chiam PT, Roubin GS, Panagopoulos G, Iyer SS, Green RM, Brennan C, Vitek JJ (2009) One-year clinical outcomes, midterm survival, and predictors of mortality after carotid stenting in elderly patients. Circulation 119:2343–2348

    Article  PubMed  Google Scholar 

  41. International Carotid Stenting Study i, Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, de Borst GJ, Lo TH, Gaines P, Dorman PJ, Macdonald S, Lyrer PA, Hendriks JM, McCollum C, Nederkoorn PJ, Brown MM (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 375:985–997

    Article  Google Scholar 

  42. Derubertis BG, Hynecek RL, Kent KC, Faries PL (2011) Carotid tortuosity in patients with prior cervical radiation: increased technical challenge during carotid stenting. Vasc Endovasc Surg 45:619–626

    Article  Google Scholar 

  43. Lian X, Liu W, Li M, Lin M, Zhu S, Sun W, Yin Q, Xu G, Zhang R, Liu X (2012) Risk factors and complications associated with difficult retrieval of embolic protection devices in carotid artery stenting. Cardiovasc Intervent Radiol 35:43–48

    Article  PubMed  Google Scholar 

  44. Wang Q, Liu C, Yan B, Fan X, Zhang M, Li Y, Zhu W, Chen M, Huang X, Zhang Z, Xu G, Liu X (2012) Correlation of extracranial internal carotid artery tortuosity index and intraprocedural complications during carotid artery stenting. Eur Neurol 68:65–72

    Article  PubMed  Google Scholar 

  45. Capoccia L, Speziale F, Gazzetti M, Mariani P, Rizzo A, Mansour W, Sbarigia E, Fiorani P (2010) Comparative study on carotid revascularization (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging. J Vasc Surg 51:584–591, 591 e581-e583; discussion 592

    Article  PubMed  Google Scholar 

  46. Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, de Borst GJ, Lo TH, Gaines P, Dorman PJ, Macdonald S, Lyrer PA, Hendriks JM, McCollum C, Nederkoorn PJ, Brown MM (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 375:985–997

    Article  PubMed  Google Scholar 

  47. Sternbergh WC 3rd, Crenshaw GD, Bazan HA, Smith TA (2012) Carotid endarterectomy is more cost-effective than carotid artery stenting. J Vasc Surg 55:1623–1628

    Article  PubMed  Google Scholar 

  48. Netuka D, Benes V, Mandys V, Hlasenska J, Burkert J, Benes V Jr (2006) Accuracy of angiography and Doppler ultrasonography in the detection of carotid stenosis: a histopathological study of 123 cases. Acta Neurochir (Wein) 148:511–520, discussion 520

    Article  CAS  Google Scholar 

  49. Netuka D, Ostry S, Belsan T, Rucka D, Mandys V, Charvat F, Bradac O, Benes V (2010) Magnetic resonance angiography, digital subtraction angiography and Doppler ultrasonography in detection of carotid artery stenosis: a comparison with findings from histological specimens. Acta Neurochir (Wein) 152:1215–1221

    Article  Google Scholar 

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Acknowledgments

Supported by IGA MZ NT 13627 and Institutional research support grant MO1012

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Authors and Affiliations

  1. Department of Neurosurgery, Military University Hospital and Charles University, First Medical Faculty, Prague, Czech Republic

    O. Bradac, M. Mohapl, F. Kramar, D. Netuka, S. Ostry, F. Charvat, J. Lacman & V. Benes

  2. Department of Neuroradiology, Military University Hospital, Prague, Czech Republic

    F. Charvat & J. Lacman

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  1. O. Bradac
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Correspondence to O. Bradac.

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Comment

This is an outstanding manuscript from a highly experienced, high-volume group, who are likewise dedicated to scholarship in cerebrovascular disease. It is a retrospective analysis of their outcome data over two time periods, essentially before and after the release of the EVA-3S results, which clearly favoured CEA over CAS. Their working hypothesis was that their results would mirror EVA-3S, and as far as I can see, the hypothesis is proved here.

In this large patient series, the CEA results are incrementally superior to the CAS results. In addition, after the release of EVA-3S, the overall results in all patients are improved, suggesting, as they speculate, that a tilt toward CEA, with its superior outcomes, has improved the health of this population as a whole.

I am not surprised by these results, as they reflect my own feelings and experience about CEA. I am pleased to see these data analyzed and reported so elegantly.

The authors now favour CEA, except in cases where significant surgical co-morbidities exist, such as radiation vasculopathy or recurrent stenosis, where they elect CAS. This is exactly what we do now at Loyola, and it shows the maturity of thought of experienced surgeons continually refining their judgment and techniques to yield the best patient outcomes.

Christopher Miranda Loftus

IL, USA

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Bradac, O., Mohapl, M., Kramar, F. et al. Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre. Acta Neurochir 156, 1705–1712 (2014). https://doi.org/10.1007/s00701-014-2166-x

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