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Return to Stent or Surgery for Carotid Stenosis? Overview

More on Stent or Surgery for Carotid Stenosis?

Stent or Surgery for Carotid Stenosis?

NEW YORK (Jul 5, 2012)

William A. Gray M.D.
William A. Gray M.D.

Build up of fatty atherosclerotic plaque in the carotid arteries – the major vessels in the front of the neck which supply oxygen-rich blood to the brain – can cause a narrowing of these arteries called carotid stenosis. Over time, these cholesterol plaques can grow and break open, causing pieces of plaque and/or blood clots to travel to the brain and cause a stroke.

While some patients benefit from medical treatment for carotid artery disease (such as medications to lower cholesterol and blood pressure), others may require more aggressive methods to prevent stroke. Surgery to remove the plaque – a procedure called carotid endarterectomy – has been shown to be an effective way to improve blood flow through the carotid arteries and reduce the risk of stroke.

Wider Stent Usage Approved

Recently, the U.S. Food and Drug Administration approved carotid stenting devices to treat all patients with stenosis requiring carotid intervention; prior to that, these stents were only approved for patients in whom carotid surgery posed too great a risk. During stenting, a small tube-shaped wire mesh is inserted into the narrowed area of the affected carotid artery. The stent acts as a scaffold for the arterial walls, creating a larger opening through which blood can flow more freely and, more importantly, stabilizing the plaque so that it can't break open and cause a stroke.

The expanded approval was based on the long-awaited results of the CREST study (Carotid Revascularization Endarterectomy vs. Stenting Trial), conducted by the National Institutes of Health over the past decade. That study, published in 2010, found that patients with carotid stenosis (both those with and without symptoms) benefited equally from carotid stenting or endarterectomy; the combined risk of stroke, heart attack, and death did not differ between the two treatment groups.

"Carotid stenting over the past decade has come up to speed and is now as safe and effective as endarterectomy for treating patients with carotid stenosis," said William A. Gray, M.D., the Director of Endovascular Services at NewYork-Presbyterian/Columbia University Medical Center. Carotid stenting may, however, offer some advantages over endarterectomy, which include fewer side effects (such as neck wound complications, since the stent is inserted using a catheter placed in the femoral artery of the leg), no need for anesthesia (and its side effects), and a shorter hospitalization (typically an average of one night for stenting, versus two for surgery).

Surgery Still Favored By Some

There has been some debate over which procedure to use. Some doctors favor surgery, claiming that heart attack, which in the CREST study was slightly more common among surgery patients shortly after the procedure, was not an important endpoint. Other doctors still favor medical treatment over surgery or stenting. According to Dr. Gray, it is important to note that outcomes for both surgery and stenting are excellent in most patients, but are also highly dependent on the experience of the physician.

Concluded Dr. Gray, "We now have FDA-approved devices that have been shown in federally-funded studies to be safe and effective for stroke prevention, and which are associated with a lower risk of complications and a faster recovery. For some, stenting may offer the greatest benefit with the least risk. Patients do have a variety of options, and doctors can tailor therapy for each patient depending on individual circumstances."

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