Efficacy of Carotid Endarterectomy for Asymptomatic Carotid Stenosis

Hobson, Robert W.; Weiss, David G.; Fields, William S.; Goldstone, Jerry; Moore, Wesley S.; Towne, Jonathan B.; Wright, Creighton B.

doi:10.1056/nejm199301283280401

Cited by 1,268 publications

(549 citation statements)

References 27 publications

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“…Randomized controlled trials have shown that surgical treatment of carotid artery stenosis is more efficient than medical therapy alone in terms of stroke prevention when treating carotid artery stenosis >70% in asymptomatic patients or >50% in symptomatic patients [7][8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

et al. 2008

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Carotid artery stenting (CAS) may be an alternative to surgical endoarterectomy not only in highrisk patients. We report results in the endovascular treatment of carotid artery disease with up to 8 years' follow-up. In this retrospective study, we analysed data from 853 consecutive patients (946 arteries) treated for carotid artery stenosis between April 1999 and March 2007; 491 (52%) arteries were symptomatic and 455 (48%) were asymptomatic. Preprocedural evaluation of the patients was performed with echo Doppler, magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) and a neurological examination. A cerebral protection device was used in 879 (92.9%) procedures. Anti-platelet therapy was administered before and after the procedure. All patients were included in a followup of up to 8 years. Technical success was achieved in 943 (99.6%) lesions. At 30 days, there was a 0.21% (n=2) death rate, a 0.42% major stroke rate, a 1.69% minor stroke/transient ischaemic attack (TIA) rate and a combined 2.32% TIA/stroke and death rate. During follow-up, echo Doppler evidenced restenosis in 39 (4.85%) cases; of these, only five, presenting restenosis >80%, were treated with an endovascular reintervention. At the long-term follow-up, two strokes (0.23%) were reported, which both occurred within the first 2 years. In our experience, carotid artery stenting seems to be a safe and effective treatment, providing satisfactory long-term clinical results.

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Section: Introductionmentioning

confidence: 99%

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

et al. 2008

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“…In the first, which compared 233 veterans (all men) in the medical group to 211 in the surgical group over about four years, found a significant difference in favor of surgery only when transient ischemia was included as an outcome event (when just stroke and death were considered only a trend favoring surgery was apparent). 11 In the larger Asymptomatic Carotid Atherosclerosis Study (ACAS) a total of 1662 patients were randomized to either CEA or medical treatment, and after following the patients for about 2 1 ⁄ 2 years it was calculated that CEA lowered the risk of stroke or death over five years from 11.0% to 5.1% (P=0.004) for stenoses between 60%-99%. 13 The benefit did not appear to apply to women, major strokes were not prevented, and a striking aspect of the trial was the very low (less than 2%) operative stroke or death rate in the surgical group.…”

Section: Discussionmentioning

confidence: 99%

“…For each patient, the appropriateness of surgery was classified on the basis of the results of randomized controlled trials studying CEA [9][10][11][12][13][14][15] and according to clinical practice guidelines established by the Canadian Neurosurgical Society 22 (Table 1). These criteria were used in conjunction with angiographic stenoses as recorded in the radiologists' reports as well as remeasurement values of carotid narrowing done as part of the first two audits.…”

Section: Methodsmentioning

confidence: 99%

“…Reported throughout the 1990s, these studies validated the use of CEAunder certain circumstances, [9][10][11][12][13][14][15] and led to a rapid and large resurgence in the use of CEA in A B S T R A C T: Background: Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials.…”

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confidence: 99%

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Auditing Carotid Endarterectomy: A Regional Experience

Findlay

Nykolyn²,

Lubkey³

et al. 2002

Can. j. neurol. sci.

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326Studies and commentaries from the 1980s expressing concern about the efficacy, appropriateness, and complications of carotid endarterectomy (CEA), 1 -8 were followed by a series of multicenter randomized controlled trials comparing CEA to medical treatment alone. Reported throughout the 1990s, these studies validated the use of CEAunder certain circumstances, [9][10][11][12][13][14][15] and led to a rapid and large resurgence in the use of CEA in A B S T R A C T: Background: Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials. Methods: We have completed four audits of CEAs performed in our region since 1994, each followed by feed-back of results to the participating surgeons. Operations for > 70% symptomatic stenosis were considered appropriate, those for 50%-69% symptomatic and > 60% asymptomatic stenosis were considered uncertain and all others, including those in medically or neurologically unstable patients, were designated inappropriate. In part 4, the referral source and nature of the patients was also determined. Results: Part 1 (April 1994 -September 1995 found that of 291 CEAs performed 33% were appropriate, 48% were uncertain and 18% were inappropriate, and 40% of patients who underwent CEA were asymptomatic. In part 2 (September 1996 -September 1997) appropriate indications significantly improved to 49% of 184 CEAs (P=0.005), uncertain indications remained nearly the same at 47%, inappropriate indications fell to 4% (P=0.00002), and asymptomatic patients remained at 40%. T h e results of part 3 (October 1997 -October 1998) remained nearly the same as part 2 (249 CEAs, 47% appropriate, 51% uncertain, 2% inappropriate, 45% asymptomatic). Part 4 (October 1999 -October 2000) results were significantly better than part 3, appropriate indications increasing from 47% to 58% of 222 CEAs (P=0.02), and an elimination of inappropriate operations (P=0.03). Stroke and death complications declined over the study period from an overall rate of 5.2% in part 1 to 2.3% in part 4. In part 4 the majority of patients (69%) were referred to surgeons directly from general practitioners, including 58 (73%) of the 80 asymptomatic patients who underwent CEA. Interpretation: Regular auditing and feedback of results and information to surgeons has resulted in significant and continued improvements in the surgical performance of CEAin our region. Since the majority of patients are referred directly to surgeons by general practitioners, it is important that this group of physicians be familiar with current CEA g u i d e l i n e s . RÉSUMÉ: Évaluation de l'endartérectomie carotidienne: une expérience régionale. Introduction: La preuve basée sur des études contrôlées randomisées que l'endartérectomie carotidienne (EAC) est efficace dans la prévention de l'accident vascul...

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“…Fortunately, for patients <80 years old, carotid endarterectomy (CEA) has been proven to decrease the incidence of stroke in patients with both symptomatic (European Carotid Surgery Trialists’ Collaborative Group, 1991) and asymptomatic (Hobson et al., 1993) carotid artery stenosis disease. In recent years, carotid artery stenting (CAS) has emerged as an alternative procedure for stroke reduction in patients who are considered too high risk to undergo CEA (Gurm et al., 2008).…”

Section: Introductionmentioning

confidence: 99%

Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

Duan

Dai

et al. 2017

Brain and Behavior

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BackgroundMultiple studies suggest that internal carotid artery stenting can be performed safely in octogenarians with low periprocedural complication rates. However, great concern still exists as to whether these patients will gain long‐term benefits from this procedure given their advanced age and uncertain life expectancy. We decided to conduct a retrospective study to determine short‐and long‐term clinical outcomes and to analyze survival duration in this population.Methods and ResultsSixty‐nine consecutive elderly patients with either symptomatic or asymptomatic stenosis ≥70% underwent 86 procedures. Immediate and late outcomes, as well as survival data, were analyzed retrospectively. Mean age was 83.1 ± 2.7 years. Mean survival was 49.3 ± 10.1 months. A complete neurological assessment was obtained at 1 and 2 years in 100% of patients, at 3 years in 90.7% of patients and at 5 years in 84.8% of patients. Two major and one minor ischemic strokes occurred during the periprocedural period. No death, myocardial infarction or intracranial hemorrhage was recorded. The mean follow‐up period was 55.4 ± 24.6 months. Four patients experienced a minimum of 1 year of follow‐up, and the longest is 8 years. Among the patients with the longest follow‐up time, 6 had ischemic strokes, of which 2 were fatal. In total, 17 deaths occurred. Four patients experienced dementia without stroke. Survival at 3 and 5 years was estimated to be 90% and 73%, respectively.ConclusionThis study demonstrated that stenting in octogenarians was safe and effective during the periprocedural period. Long‐term follow‐up showed a low rate of fatal and nonfatal stroke, and patients survived long enough to benefit from the procedure. However, it was associated with a relatively high rate of long‐term event. Though carotid artery stenting is a minimally invasive procedure, it should still be performed with great caution and only in carefully selected patients. The present study suggested that in this age population, carotid artery stenting might be considered as a revascularization option.

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Efficacy of Carotid Endarterectomy for Asymptomatic Carotid Stenosis

Cited by 1,268 publications

References 27 publications

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

Carotid artery stenting: a single-centre experience with up to 8 years’ follow-up

Auditing Carotid Endarterectomy: A Regional Experience

Immediate and late outcomes of stenting for severe extracranial internal carotid artery stenosis in octogenarian patients

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