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Carotid Stenting -- An Alternative to Endarterectomy

Carotid-artery stenting using an emboli-protection device clearly was not inferior to carotid endarterectomy.

Carotid-artery angioplasty with stenting is a less invasive alternative to carotid endarterectomy (CEA). One problem with stenting, however, is that it causes embolization of plaque debris to the brain. To mitigate this problem, emboli-protection devices have been developed.

In this U.S. trial, supported by a maker of stents and protection devices, 334 patients underwent either CEA or protected carotid-artery stenting. The protection device used in stented patients (and invented by the lead author) was a filter basket that was placed distal to the carotid stenosis via a guidewire. After the procedure, the filter and its captured embolic material were removed. The trial included both asymptomatic patients with at least 80% stenosis and symptomatic patients with at least 50% stenosis; all enrollees had at least one of seven specified high-risk characteristics.

The primary endpoint was death, stroke, or myocardial infarction at 30 days, plus ipsilateral stroke or neurologic death at 31 days to 1 year. This endpoint occurred in 12% of stented patients and 20% of CEA patients. Statistical analysis showed that stenting clearly was not inferior to CEA, and probably was superior to CEA (P=0.05).

Comment: According to the composite endpoint used in this study, protected carotid-artery stenting is at least as good as CEA. Longer follow-up and a comparison of CEA and protected stenting in lower-risk patients are additional research priorities.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 29, 2004

Citation(s):

Yadav JS et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004 Oct 7; 351:1493-501.

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