Selection of treatment for patients with carotid artery disease: medication, carotid endarterectomy, or carotid artery stenting

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.     

Safety and efficacy of carotid angioplasty and stenting in high-risk patients

Performance of carotid endarterectomy (CEA) may be associated with an increased risk in patients with significant comorbid medical conditions, neck irradiation, or previous CEA. This study compared the results of CEA with carotid angioplasty and stenting (CAS) in high-risk patients treated for carotid stenosis. Five hundred forty-five patients who underwent CEA and 148 patients who underwent CAS were evaluated. For patients undergoing CEA, general anesthesia was used in 91 per cent, electroencephalographic monitoring was used in 63 per cent, and shunting was performed in 19.8 per cent. Cerebral protection devices were used in 145/148 of CAS cases, and self-expanding stents were used in all cases. Evaluated end points included major cardiovascular events, and a composite of death, stroke, or myocardial infarction for the duration of the follow-up. Mean follow-up was 18 months for CAS and 23 months for CEA. Significant differences were present in patient age (CAS, 75 +/- 11.0 years vs CEA, 71 +/- 9 years, P = 0.012), however, there were no significant differences (P = NS) in gender or smoking history. The mean modified Goldman Score was significantly higher for CAS (21.1 +/- 14.8 [95% confidence interval = 18, 24]) than for CEA (6.3 +/- 6.8 [95% confidence interval = 5.7, 6.9]; P = 0.0001) patients. The incidence of periprocedural complications did not vary significantly between patients treated with CAS (CVA, 1.4%; myocardial infarction [MI], 1.4%; death, 0.7%; CVA/MI/death, 3.4%) compared with CEA (CVA, 1.8%; MI, 1.1%; death, 0.4%; CVA/MI/death, 4.0%). CAS is equivalent to CEA in safety and efficacy, even when performed in patients who may be at increased surgical risk.     

颈动脉内膜剥脱术和颈动脉支架的前瞻性随机对照研究

目的 评价颈动脉内膜剥脱术和颈动脉支架治疗颈动脉狭窄的近期和中期临床效果.方法 前瞻性单中心随机对照研究,自2004年5月至2006年12月,将同意入组的40例有症状(狭窄程度>50%)和无症状(狭窄程度>70%)颈动脉狭窄患者随机分为两组,即颈动脉内膜剥脱术组(CEA)和颈动脉支架组(CAS).一期观察终点是术后30 d内出现严重脑梗死或死亡;二期观察终点是各种手术并发症、急性脑缺血发作、偏瘫、急性心肌梗死和术后18个月内的脑卒中、死亡和再狭窄等,同时回顾性分析两组总的住院费用.结果 CEA和CAS两组患者术前一般资料、临床症状、伴随疾病等因素均无差异.CEA组20例23支颈动脉手术(3例分别行双侧CEA),术中应用转流管9条(39.1%),颈动脉补片12条(52.2%);CAS组20例23支颈动脉支架(3例行双侧CAS),应用脑保护装置21个(91.3%).CEA和CAS两组术后30 d内神经系统并发症(4.3%对8.7%,P=0.46)、急性心肌梗死(4.3%对0,P=0.31)和伤口血肿(8.7%对0,P=0.14)等差异均无统计学意义,至术后18个月无短暂性脑缺血发作和再狭窄病例.CEA和CAS两组平均住院费用分别为(16 450.95±6188.76)和(70 130.15±11 999.02)元人民币,差异有统计学意义(P<0.01).结论 CEA和CAS术后30 d和术后18个月的并发症、病死率和临床疗效无明显差异,但CAS的住院花费明显高于CEA.     

Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease

Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy.     

高危颈动脉狭窄患者内膜剥脱术和支架术的对比分析

目的对比颈动脉内膜剥脱术（carotid endarterectomy,CEA）与颈动脉支架置入术（carotid artery stenting,CAS）在治疗高危颈动脉粥样硬化性狭窄中的作用。方法对58例颈动脉粥样硬化性狭窄患者进行回顾性对照研究。其中32例为CEA组;26例为CAS组。术后30d、6个月、1年均进行颈部B超、CTA复查或DSA和神经系统检查。初级观察终点设定为术后30d内发生死亡、卒中事件、心血管不良事件,或随访6个月内的死亡或同侧卒中事件;次级观察终点为与CEA或CAS相关的并发症,或1年内的重度再狭窄。比较2组术后治疗的效果。结果CEA组有3例达到初级观察终点,发生率为9.4%;CAS组有4例达到初级观察点,累积发生率为15.4%（χ2=0.086,P=0.769）。CEA组有4例达到次级观察终点,发生率为12.5%;CAS组有4例达到次级观察终点,发生率为15.4%（χ2=0.000,P=1.000）。结论CAS在治疗高危颈动脉粥样硬化性狭窄时,在安全性和有效性方面与CEA是相同的。     

Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital

OBJECTIVE: Carotid endarterectomy (CEA) is effective in reducing the risk of stroke in individuals with more than 60% carotid stenosis. Carotid angioplasty and stenting (CAS) has been proffered as effective and used in treating individuals with asymptomatic carotid stenosis despite the absence of proven clinical equivalency. This randomized trial was designed to explore the hypothesis that CAS is equivalent to CEA for treating asymptomatic carotid stenosis. METHODS: A total of 85 individuals presenting with asymptomatic carotid stenosis of more than 80% were selected randomly for CAS or CEA and followed up for 48 months. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique, as determined by carotid ultrasonography. No major complications such as cerebral ischemia or death occurred. Procedural complications associated with CAS (n = 5) were hypotension and/or bradycardia; those concomitant with CEA (n = 3) were cervical nerve injury or complications related to general anesthesia (n = 4). Both procedures were well tolerated in the context of pain and discomfort. Hospital stay was similar in the two groups (mean, 1.1 versus 1.2 d). The occurrence of complications associated with CAS or CEA prolonged hospitalization by 3 days (mean, 4.0 versus 4.5 d). Return to full activity was achieved within 1 week by more than 85% of patients; all returned to their usual lifestyle by 2 weeks. Although hospital charges were slightly higher for CAS, costs were similar. CONCLUSION: CAS and CEA may be equally effective and safe in treating individuals with asymptomatic carotid stenosis.     

Carotid endarterectomy: still the standard of care for carotid bifurcation disease

Current treatment guidelines of symptomatic and asymptomatic carotid stenosis are based on studies performed over a decade ago. Since that time, significant advances have been made in medical management, namely high dose statin therapy and improved antiplatelet agents, and in carotid interventions, namely the advent of carotid artery stenting. Especially with carotid stenting, the technology has grown by leaps and bounds and continues to advance at a rapid pace. These advances have necessitated new studies to compare these treatments with the gold standard of carotid endarterectomy. In asymptomatic patients, the current data does not justify medical management alone for severe (>80%) carotid stenosis. Furthermore, in both asymptomatic and symptomatic patients current studies have failed to demonstrate equivalence of CAS to CEA for significant carotid stenosis. Clearly additional studies comparing CAS, CEA, and medical management are needed to further clarify this issue. In the future, advances in CAS technology and techniques may greatly expand the role of CAS beyond its current role in certain high-risk patient subsets. However, for the time being CEA still remains the gold standard for carotid intervention.     

Carotid endarterectomy in SAPPHIRE-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting

OBJECTIVES: Carotid angioplasty and stenting (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) in patients excluded from the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study and in those considered at high risk for CEA. In light of recently released CAS data in patients at high risk, we reviewed our experience with CEA. METHODS: The records for consecutive patients who underwent CEA between 1998 and 2002 were retrospectively reviewed, and risk was stratified according to inclusion and exclusion criteria from a "high-risk" or CAS-CEA trial, The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. RESULTS: Of 776 CEAs performed, 323 (42%) were considered high risk, on the basis of criteria including positive stress test (n = 109, 14%), age older than 80 years (n = 85, 11%), contralateral carotid occlusion (n = 66, 9%), pulmonary dysfunction (n = 56, 7%), high cervical lesion (n = 36, 5%), and repeat carotid operation (n = 27, 3%). Other high-risk criteria included recent myocardial infarction (MI), cardiac surgery, or class III or IV cardiac status; left ventricular ejection fraction less than 30%; contralateral laryngeal palsy; and previous neck irradiation (each <1.5%). Clinical presentation was similar in the high-risk and low-risk groups: asymptomatic (73% versus 73%), transient ischemic attack (23% vs 22%), and previous stroke (4% vs 5%). The overall postoperative stroke rate was 1.4% (symptomatic, 2.9%; asymptomatic, 0.9%). Comparison of high-risk and low-risk CEAs demonstrated no statistical difference in the stroke rate. Factors associated with significantly increased stroke risk included cervical radiation therapy, class III or IV angina, symptomatic presentation, and age 60 years or younger. Overall mortality was 0.3% (symptomatic, 0.5%; asymptomatic, 0.2%), not significantly different between the high-risk (0.6%) and low-risk groups (0.0%). Non-Q-wave MI was more frequent in the high-risk group (3.1 vs 0.9%; P <.05). A composite cluster of adverse clinical events (death, stroke, MI) was more frequent in the symptomatic high-risk group (9.3% vs 1.6%; P <.005), but not in the asymptomatic cohort. There was a trend for more major cranial nerve injuries in patients with local risk factors, such as high carotid bifurcation, repeat operation, and cervical radiation therapy (4.6% vs 1.7%; P <.13). In 121 patients excluded on the basis of synchronous or immediate subsequent operations, who also would have been excluded from SAPPHIRE, the overall rates for stroke (1.65%; P =.69), death (1.65%; P =.09), and MI (0.83%; P =.71) were not significantly different from those in the study population. CONCLUSIONS: CEA can be performed in patients at high risk, with stroke and death rates well within accepted standards. These data question the use of CAS as an alternative to CEA, even in patients at high risk.     

Carotid endarterectomy versus carotid stenting: an updated review of randomized trials and subgroup analyses

Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results. The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients. An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p < 0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41 ; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98). Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.     

Risk factors and angiographic technical considerations to guide carotid intervention

Carotid angioplasty and stenting (CAS) with embolic protection is currently accepted as treatment for patients considered to be at high risk for carotid endarterectomy (CEA). The purpose of this study was (1) to determine what proportion of patients treated with CEA would be categorized as "high" risk by currently accepted criteria, (2) to characterize preoperative angiographic findings in patients with carotid stenosis, and (3) to determine the potential technical challenges of CAS in these patients. Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, perioperative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied, and preoperative angiograms were examined for technical limitations to CAS. Two hundred and seventy-nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%), or stroke (8%) during the study period. Of these, 35.5% (n = 99) would have met one or more high-risk criteria. Overall risks of perioperative stroke, myocardial infarction, and death were 1.1%, 2.2%, and 0.4% (n = 279), respectively, with a combined major complication rate of 3.3%. No difference in major complication rates was observed between standard-risk and high-risk patients. Preoperative angiograms were available for review in 83.5% of CEAs (n = 233). The distribution of aortic arch configurations included types I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (n = 35) of angiograms. There were 77.7% (n = 181) with one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had relative angiographic contraindications to CAS. A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as high risk and considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which limit the ability to perform CAS, are common and should be anticipated when planning CAS.     

Thirty-day morbidity and mortality rates for carotid artery intervention by surgeons who perform both carotid endarterectomy and carotid artery angioplasty and stent placement

OBJECT: There is no known standard 30-day morbidity and mortality rate for high-risk patients undergoing carotid artery (CA) angioplasty and stent (CAS) placement. The high-risk registries and the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy, Carotid Revascularization using Endarterectomy or Stenting Systems, and European Long-term Carotid Artery Stenting trials report different rates of morbidity and mortality, and each high-risk cohort has a different risk profile. The applicability of carotid endarterectomy (CEA) results from North American Symptomatic Carotid Endarterectomy Trial/Asymptomatic Carotid Atherosclerosis Study (NASCET/ACAS) remains uncertain, as most clinical CAS placement series reported to date typically included patients who would not have qualified for those studies. At the University at Buffalo, the same neurosurgeons perform triage in patients with CA disease and perform both CEA and CAS insertion. The authors review morbidity and mortality rates in this practice model. METHODS: Diagnosis-related group codes were used to search the authors' practice database for patients who had undergone a completed CA intervention solely for the indication of atherosclerotic disease. One hundred twenty patients (129 vessels) treated with CAS surgery and 95 patients (100 vessels) treated with CEA met these criteria. In the CAS placement group, 78% of the patients would not have met NASCET/ACAS inclusion criteria. Demographic and clinical data for both groups were recorded on a spreadsheet for analysis. At 30 days, one patient in the CEA group and two in the CAS group had died. Stroke occurred in one patient in the CAS group and none in the CEA group. Myocardial infarction (MI) occurred in one patient who underwent CAS surgery compared with three undergoing CEA. Composite incidence of stroke/death/MI was 3.3% in the CAS group and 3.2% in the CEA group. CONCLUSIONS: In a practice in which surgeons perform both CEA and CAS surgery, the event rates for the CAS surgery equivalent to NASCET and ACAS rates for CEA can be achieved, even in high-risk NASCET/ACAS-ineligible patients in 78% of the CAS cases.     

Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs carotid endarterectomy

BACKGROUND: Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention for patients with symptomatic or asymptomatic carotid artery stenosis. Although several prospective randomized trials indicate that carotid artery stenting (CAS) is an alternative but not superior treatment modality, there is still a significant lack of long-term data comparing CAS with CEA. This study presents long-term results of a prospective, randomized, single-center trial. METHODS: Between August 1999 and April 2002, 87 patients with a symptomatic high-grade internal carotid artery stenosis (>70%) were randomized to CAS or CEA. After a median observation time of 66 +/- 14.2 months (CAS) and 64 +/- 12.1 months (CEA), 42 patients in each group were re-evaluated retrospectively by clinical examination and documentation of neurologic events. Duplex ultrasound imaging was performed in 61 patients (32 CAS, 29 CEA), and patients with restenosis >70% were re-evaluated by angiography. RESULTS: During the observation period, 23 patients (25.2%) died (10 CAS, 13 CEA), and three were lost to follow up. The incidence of strokes was higher after CAS, with four strokes in 42 CAS patients vs none in 42 CEA patients. One transient ischemic attack occurred in each group. A significantly higher rate of restenosis >70% (6 of 32 vs 0 of 29) occurred after CAS compared with CEA. Five of 32 CAS patients (15.6%) presented with high-grade (>70%) restenosis as an indication for secondary intervention or surgical stent removal, and three presented with neurologic symptoms. No CEA patients required reintervention (P < .05 vs CAS). A medium-grade (<70%) restenosis was detected in eight of 32 CAS patients (25%) and in one of 29 CEA patients (3.4%). In five of 32 CAS (15.6%) and three of 29 CEA patients (10.3%), a high-grade stenosis of the contralateral carotid artery was observed and treated during the observation period. CONCLUSION: The long-term results of this prospective, randomized, single-center study revealed a high incidence of relevant restenosis and neurologic symptoms after CAS. CEA seems to be superior to CAS concerning the development of restenosis and significant prevention of stroke. However, the long-term results of the ongoing multicenter trials have to be awaited for a final conclusion.     

Optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis

This commentary addresses the issue of optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis. Based on current data, carotid endarterectomy (CEA) should be performed in the majority of patients with symptomatic carotid artery stenosis. Carotid artery stenting (CAS) should be reserved for a minority of these symptomatic patients, in whom CEA is contraindicated. In asymptomatic patients, all should be placed on best medical treatment (BMT). With the use of one or more of the proposed stroke risk stratification models or some as yet undetermined method, the identification of those asymptomatic individuals may be possible in whom stroke risk is higher than usual with BMT. This asymptomatic subgroup, which may be small and is yet to be determined with certainty, could be offered an invasive carotid procedure (either CAS or CEA).     

Outcome of carotid stent-assisted angioplasty versus open surgical repair of recurrent carotid stenosis

PURPOSE: We compared outcome and durability of carotid stent-assisted angioplasty (CAS) with open surgical repair (ie, repeat carotid endarterectomy [CEA]) to treat recurrent carotid stenosis (RCS). METHODS: A retrospective review of anatomic and neurologic outcomes was carried out after 27 repeat CEA procedures (1993-2002) and 52 CAS procedures (1997-2002) performed to treat high-grade internal carotid artery (ICA) RCS after CEA. The incidence of intervention because of symptomatic RCS was similar (repeat CEA, 63%; CAS, 60%), but the interval from primary CEA to repeat intervention was greater (P <.05) in the repeat CEA group (83 +/- 15 months) compared with the CAS group (50 +/- 8 months). In the CAS group, 17 of 52 arteries (33%) were judged not to be surgical candidates because of surgically inaccessible high lesions (n = 8), medical comorbid conditions (n = 4), neck irradiation (n = 3), or previous surgery with cranial nerve deficit or stroke (n = 2). Three patients who underwent repeat CEA had lesions not appropriate for treatment with CAS. RESULTS: Overall 30-day morbidity was similar after CAS (12%; death due to ipsilateral intracranial hemorrhage, 1; nondisabling stroke, 1; reversible neurologic deficits or transient ischemic attack, 2; access site complication, 2). and repeat CEA (11%; no death; nondisabling stroke, 1; reversible cranial nerve injury, 1; cervical hematoma, 1). Combined stroke and death rate was 3.7% for repeat CEA and 5.7% for CAS (P >.1). All duplex ultrasound scans obtained within 3 months after CEA and CAS demonstrated patent ICA and velocity spectra of less than 50% stenosis. During follow-up, no repeat CEA (mean, 39 months) or CAS (mean, 26 months) repair demonstrated ICA occlusion, but two patients (8%) who underwent repeat CEA and 4 patients (8%) who underwent CAS required balloon or stent angioplasty because of 80% RCS. At last follow-up, no patient had ipsilateral stroke and all ICA remain patent. At duplex scanning, stenosis-free (<50% diameter reduction) ICA patency at 36 months was 75% after repeat CEA and 57% after CAS (P =.26, log-rank test). CONCLUSIONS: Carotid angioplasty for treatment of high-grade stenotic ICA after CEA resulted in similar anatomic and neurologic outcomes compared with open surgical repair. Most lesions are amenable to endovascular therapy, and CAS enabled treatment in patients judged not to be suitable surgical candidates. Duplex scanning surveillance after repeat CEA or CAS is recommended, because stenosis can recur after either secondary procedure.     

In-stent restenosis after carotid angioplasty-stenting: incidence and management

PURPOSE: Carotid angioplasty-stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in patients with restenotic lesions after prior CEA, primary stenoses with significant medical comorbidities, and radiation-induced stenoses. The incidence of restenosis after CAS and its management remains ill defined. We evaluated the incidence and management of in-stent restenosis after CAS. METHODS: Patients with asymptomatic (61%) and symptomatic (39%) carotid stenosis of > or = 80% underwent CAS between September 1996 and May 2000; there were 50 procedures and 46 patients (26 men and 20 women). All patients were followed up clinically and underwent duplex ultrasonography (DU) at 3- to 6-month intervals. In-stent restenoses > or = 80% detected with DU were further evaluated by means of angiography for confirmation of the severity of stenosis. RESULTS: No periprocedural or late strokes occurred in the 50 CAS procedures during the 30-day follow-up period. One death (2.2%) that resulted from myocardial infarction was observed 10 days after discharge following CAS. During a mean follow-up period of 18 +/- 10 months (range, 1-44 months), in-stent restenosis was observed after four (8%) of the 50 CAS procedures. Angiography confirmed these high-grade (> or = 80%) in-stent restenoses, which were successfully treated with balloon angioplasty (3) or angioplasty and restenting (1). No periprocedural complications occurred, and these patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 10 +/- 6 months. CONCLUSIONS: We recommend CAS for post-CEA restenosis, primary stenoses in patients with high-risk medical comorbidities, and radiation-induced stenoses. In-stent restenoses occurred after 8% of CAS procedures and were managed without complications with repeat angioplasty or repeat angioplasty and restenting.     

Cerebral tomographic findings in patients undergoing carotid endarterectomy for asymptomatic carotid stenosis: short-term and long-term implications

Purpose: Preoperative cerebral imaging has been considered not to be cost-effective in carotid endarterectomy (CEA) for asymptomatic carotid stenosis. Yet, silent brain infarction (SBI) has been associated with the embolization potential of a severe carotid stenosis. Thus the presence of SBI may represent an additional indication for CEA in asymptomatic patients. We examined the predictive value of preoperatively detected silent cerebral lesions on early and late outcomes in patients undergoing CEA for asymptomatic carotid stenosis. Methods: Preoperative cerebral tomographic (CT) scans performed on 301 asymptomatic patients undergoing 346 CEAs from 1986 to 1995 were reviewed by a single neuroradiologist blinded to patients' records. Mean follow-up was 67.3 months (range, 24-130 months). The degree of internal carotid lumen reduction was measured bilaterally in all patients (602 carotid arteries); carotid stenosis of 60% or more was found in 399 carotid arteries. Results: Of the 103 (34%) CT scans positive for cerebral lesions, 58% were lacunar. No significant association was observed between the side of the cerebral lesion on CT scan and the severity of the corresponding carotid stenosis; 38 silent lesions were detected in the 203 hemispheres ipsilateral to carotid stenoses that were less than 60% versus 95 SBIs in the 399 hemispheres ipsilateral to carotid stenoses that were 60% or more (19% vs 24%; P = .2). There were no significant differences in the perioperative stroke/death rate in patients with or without cerebral CT lesions (2% vs 1%; odds ratio, 1.94; P = .6). Mortality rate during follow-up was 22% in patients with preoperative SBI and 15% in patients without SBI (P = .1). However, actuarial survival at 10 years was shorter (P = .02) in patients with SBI. Late stroke occurred in 11% of patients with preoperative SBI and in 3% of patients without preoperative SBI (P = .006). Cox regression analysis showed that both preoperative lacunar and nonlacunar infarctions were independent predictors of late stroke (hazard ratio, 3.6; P = .04; and hazard ratio, 7.1; P = .001; respectively). Conclusion: In our experience, preoperative SBI did not occur more frequently in the hemisphere ipsilateral to asymptomatic severe carotid stenosis. Although our study lacks a medically treated control group, our data show that SBI is predictive of poor neurologic outcome in asymptomatic patients undergoing CEA. We conclude that CT before CEA, selectively applied, provides information on long-term neurologic prognosis and that a less aggressive attitude towards CEA in asymptomatic patients with SBI may be justified. (J Vasc Surg 1999;29:995-1005.)     

Current management of extracranial carotid artery disease

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.     

Carotid stent-assisted angioplasty: the newest addition to the surgeons' armamentarium in the management of carotid occlusive disease

Carotid artery angioplasty and stenting (CAS) has been accomplished in multiple centers with short-term and midterm results similar to carotid endarterectomy (CEA). Until completion of multicentered prospective evaluation of the benefit of CAS versus established therapy (CEA) clinical judgment must be used to determine whether an individual patient with unusual technical challenges and/or risks might be best suited for CEA or CAS. We report our experience with 41 CAS procedures in 39 patients treated from November 1996 through November 2001. Six patients had primary lesions (three symptomatic and three asymptomatic). Thirty-three patients had 35 procedures for recurrent carotid stenosis (11 symptomatic and 24 asymptomatic). Technical success was achieved in 40 of 41 procedures. No deaths occurred. The 30-day major stroke rate was one in 41 (2.4%), and the overall 30-day stroke/transient ischemic attack rate was three in 41 (7.3%). No recurrence or late neurologic events were seen in patients treated for primary carotid stenosis. A 23 per cent recurrence rate was observed in patients treated for recurrent carotid stenosis, after one or more CEAs, with mean follow-up of 18 +/- 14 months. Recurrence requiring operative correction with carotid resection and interposition grafts occurred in three patients treated with CAS in this group. Late deaths occurred in six patients; one of these was due to stroke. Overall freedom from late stroke and/or need for reintervention (by Kaplan-Meier analysis) was 64 +/- 13 per cent at 48 months in the group treated by CAS for post-CEA recurrence. CAS represents a technically simplistic means of providing carotid revascularization. However, its role remains undefined and benefits unproven. Surgical revascularization remains appropriate for patients with operable carotid lesions. However, surgical revascularization is not always an ideal option when we are faced with difficult carotid lesions and risks. For this reason we advocate that all surgeons who intend to remain specialists in the management of carotid disease should attain, master, and maintain the skills necessary for CAS.     

颈动脉狭窄血管内支架植入和内膜切除术治疗的临床选择

目的 探讨在不同条件下如何合理选择颈动脉狭窄的治疗方式.方法 回顾性分析经颈动脉血管内支架植入术(CAS)和颈动脉内膜切除术(CEA)治疗的133例颈动脉狭窄患者的临床资料.其中46例患者行CAS,87例行CEA.观察两组患者的住院天数和治疗前后的美国国立卫生研究院卒中评分量表(NIHSS)评分、前向血流,治疗前和治疗后1-24个月狭窄处收缩期血流速度峰值及狭窄程度,以及治疗后死亡、脑卒中或心肌梗死等终点事件的发生率.结果 两组住院天数和治疗后NIHSS评分>20层次时差异有统计学意义(P<0.05);两组治疗前后的前向血流评定差异无统计学意义(P>0.05);多普勒频谱测定两组治疗前后颈动脉狭窄程度有显著性差异(P<0.05);两组治疗后30 d内,终点事件的累计发生率差异有统计学意义(P<0.05);31 d～2年终点事件的累计发生率差异无统计学意义(P>0.05);6个月后再狭窄发生率CAS组高于CEA组.结论 CAS和CEA对颈动脉狭窄的效果无显著差异,狭窄的部位、原因及对侧病变是选择CAS和CEA的重要因素.     

Long-term results of 442 consecutive, standardized carotid endarterectomy procedures in standard-risk and high-risk patients

OBJECTIVES: The objectives of this study were to determine the results of a specific technique in the performance of carotid endarterectomy (CEA) and to compare results using this technique between standard-risk and high-risk patients eligible for Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) and between asymptomatic and symptomatic patients. METHODS: A total of 391 patients underwent 442 consecutive CEA procedures under general anesthesia with the intent to shunt, patch, and perform intraoperative completion duplex ultrasound imaging. Indications included 272 asymptomatic patients (61.5%) with carotid stenoses > or =60% and 170 symptomatic patients (38.5%) with carotid stenosis > or =50%. Data were analyzed to determine the early (< or =30 days) and long-term morbidity and mortality overall in standard-risk and high-risk procedures and in asymptomatic and symptomatic patients. The primary end points were the occurrence of all strokes or death or myocardial infarction (MI) in the first 30 postoperative days (100% follow-up) and the occurrence by life-table analysis of ipsilateral stroke or death or MI (SDMI) out to 93 months (mean, 31.4 months). RESULTS: A total of 441 (99.7%) procedures included shunting, 440 (99.5%) included patching, and 442 (100%) had completion duplex ultrasound imaging. Of these, 235 procedures were standard risk and 207 procedures were high risk. At the 30-day follow-up, there were two ipsilateral central neurologic deficits (1 major stroke, 1 minor stroke), no death, and one MI (0.45% for all strokes or death; 0.68% for all strokes or death or MI). After 30 days of follow-up, an additional 16 strokes (9 ipsilateral, 7 contralateral), eight MIs, and 38 deaths had occurred. No statistically significant difference was found between standard-risk and high-risk groups or between asymptomatic and symptomatic groups for stroke, death, MI, stroke or death, or stroke or death or MI at 30 days or during long-term follow-up at any interval up to 93 months. CONCLUSION: CEA performed with intent to treat using general anesthesia, shunting, patching, and completion duplex scanning results in extremely low 30-day and long-term morbidity and mortality in asymptomatic, symptomatic, standard-risk and high-risk patients. These results are substantially superior to those reported in carotid stenting trials for both carotid stenting and CEA and do not support the contention that there is a high-risk group for CEA.