Carotid Endarterectomy Remains the Standard of Care, Even in High-Risk Surgical Patients

Boules, Tamer N.; Proctor, Mary C.; Aref, Ahmad A.; Upchurch, Gilbert R.; Stanley, James C.; Henke, Peter K.

doi:10.1097/01.sla.0000150270.86267.29

Cited by 53 publications

(36 citation statements)

References 33 publications

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“…Although there continues to be debate in some circles regarding the actual definition of high surgical risk, 20,21 recent randomized data validate the concept given the increase in stroke and death outcomes in a predefined surgical population with both physiological and anatomic surgical risks. 7 However, in the 10 years since the publication of the AHA guidelines there has not been a similarly rigorous demonstration of fulfillment of the guidelines in the high-surgical-risk population undergoing CEA.…”

Section: Discussionmentioning

confidence: 99%

Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries

Gray

Chaturvedi

Verta

2009

Circ: Cardiovascular Interventions

124

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on behalf of the Investigators and the Executive CommitteesBackground-The American Heart Association has established guidelines for acceptable 30-day death and stroke rates for patients with severe carotid disease undergoing standard-risk carotid endarterectomy: Ͻ3% for asymptomatic lesions and Ͻ6% for symptomatic lesions. To date, carotid artery stenting has not demonstrated these outcomes in multicenter, prospective assessments of high-surgical-risk patients. Methods and Results-Data from 2 prospective, multicenter (280 US sites, 672 operators), postmarket surveillance studies in high-surgical-risk patients were analyzed: 2145 patients from the Emboshield and Xact Post Approval Carotid Stent Trial (EX) and 4175 patients from the Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (C2). Both studies had pre-and postprocedure neurological evaluation and independent adjudication of neurological events. The overall 30-day death and stroke rate was 4.1% (95% CI, 3.3% to 5.0%) for EX and 3.4% (95% CI, 2.9% to 4.0%) for C2. In the population comparable with American Heart Association guidelines (Ͻ80 years), the combined 30-day death and stroke rate was 5.3% (95% CI, 3.6% to 7.4%) for symptomatic patients and 2.9% (95% CI, 2.4% to 3.4%) for asymptomatic patients, independent of unfavorable risk factors (anatomic or physiologic); in patients Ն80 years, this rate was 10.5% (95% CI, 6.3% to 16.0%) and 4.4% (95% CI, 3.3% to 5.7%), respectively. In subjects with anatomic features unfavorable for surgery, the 30-day death and stroke rates were 1.7% (95% CI, 0.0% to 8.9%) and 2.7% (95% CI, 1.3% to 4.9%) for symptomatic and asymptomatic cohorts, respectively, independent of age. Conclusions-Outcomes

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Section: Discussionmentioning

confidence: 99%

Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries

Gray

Chaturvedi

Verta

2009

Circ: Cardiovascular Interventions

124

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“…Carotid angioplasty with stenting (CAS) has been used as an alternative treatment but its benefit has been deemed marginal or similar to CEA (Boules et al 2005;Coward, Featherstone, & Brown 2005). However, when used in conjunction with an emboli protection device, it proves to be an equally effective intervention (Yadav, Wholey, & Kuntz 2004).…”

Section: Treatment Of Carotid Diseasementioning

confidence: 99%

Carotid atherosclerotic plaque characterisation by measurement of ultrasound sound speed in vitro at high frequency, 20MHz

Brewin¹,

Srodon²,

Greenwald³

et al. 2014

Ultrasonics

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“…Endarterectomy is indicated in patients with TIA or minor stroke, ages lower than 80 years [7]. In asymptomatic patients, severe stenosis and those younger than 75 years should be considered.…”

Section: Endarterectomy: Still the Gold Standard?mentioning

confidence: 99%

“…The first one is precox, of myointimal location and the second is late and of atheromatous type. There is 10% increase in risk of restenosis following second endarterectomy [7,8,9]. …”

Section: Endarterectomy: Still the Gold Standard?mentioning

confidence: 99%

Carotid Endarterectomy: Is It Still a Gold Standard?

Rubio

Martínez-Yélamos²,

Cardona³

et al. 2005

Cerebrovasc Dis

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Extracranial internal carotid artery stenosis accounts for 15–20% of ischemic strokes. Carotid endarterectomy has high efficacy in stroke prevention in selected patients with symptomatic (age <80 years) and asymptomatic carotid stenosis (age <75 years). Randomized clinical trials demonstrated that carotid endarterectomy reduces the stroke risk, compared to medical therapy alone, for patients with 70–99% symptomatic stenosis with 16% absolute risk reduction at 5 years. The benefit for patients with 50–69% symptomatic stenosis is lower i.e. absolute risk reduction 4.6% at 5 years. Endarterectomy is not indicated for symptomatic patients with <50% stenosis. There is no need for time-delay for surgery in patients after transient ischemic attack or minor stroke. Patients with more extensive strokes or hemorrhage should undergo surgery after 4–6 weeks following initial symptoms. Carotid endarterectomy for asymptomatic stenosis reduces the risk of ipsilateral stroke, and any stroke, by approximately 30% over 3 years. However, the absolute risk reduction is small over the first few years and decision should be based on individual institutional experience. In all situations, the best medical therapy should accompany surgery. In the recent years, appearance of angioplasty, stenting, and distal protection procedures provides competitive alternatives to classical endarterectomy. However, long-term benefits of carotid angioplasty should be confirmed by bigger, randomized, comparative clinical trials.

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Carotid Endarterectomy Remains the Standard of Care, Even in High-Risk Surgical Patients

Cited by 53 publications

References 33 publications

Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries

Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries

Carotid atherosclerotic plaque characterisation by measurement of ultrasound sound speed in vitro at high frequency, 20MHz

Carotid Endarterectomy: Is It Still a Gold Standard?

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