Variability in Carotid Endarterectomy Practice Patterns Within a Metropolitan Area

Kansara, Amit; Miller, Daniel J.; Damani, Rahul; Fuerst, Darren R.; Silver, Brian

doi:10.1161/strokeaha.112.669622

Cited by 5 publications

(2 citation statements)

References 9 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A recent study found significant heterogeneity in the treatment of "high surgical risk" patients, with a substantial proportion still receiving CEA. [58] There have been numerous single center case series and registry publications reporting results of CAS. In industry sponsored registries, the 30 day combined risk of stroke, death and MI has varied from 3.8% to 8.6%.…”

Section: The Risks Associated With Carotid Endarterectomymentioning

confidence: 99%

Stroke prevention-surgical and interventional approaches to carotid stenosis

Rajamani¹

2017

IJNS

Self Cite

View full text Add to dashboard Cite

surgery due to medical comorbidities (e.g., severe heart or lung disease) or surgical-anatomic factors (e.g., previous surgery or radiation to the neck) and are considered as "high-risk for CEA." In this group of subjects, carotid artery stenting (CAS) is an alternative to CEA for stroke prevention. In this chapter, we shall review the current data pertaining to CEA and CAS for stroke prevention. CARoTID ENDARTERECToMY FoR SYMPToMATIC CARoTID STENoSISBefore 1990, CEA had been used as a tool for stroke prevention for many decades without much certainty regarding its benefits. After 2 relatively unsuccessful attempts for a definitive answer to the clinical question of CEA's value, [1,2] two large-scale randomized studies -the North American Symptomatic Carotid Endarterectomy Trial (NASCET), [3] and the European Carotid Surgery Trial (ECST) [4] -were launched in the 1980s. A third randomized study, the Veterans Affairs Co-operative Study, [5] was stopped early for ethical reasons after the NASCET and the ECST reported a clear benefit in the surgically treated patients. High-grade symptomatic ICA stenosisThe NASCET and the ECST were pivotal studies that evaluated CEA in comparison with best, prevalent medical therapy for prevention of ischemic stroke in patients with symptomatic carotid stenosis. Patients with ICA stenosis determined by angiography, and previous TIA, non-disabling ischemic stroke in the INTRoDUCTIoNPatients with anterior circulation ischemic stroke or transient ischemic attack (TIA) should be screened for internal carotid artery (ICA) stenosis. Large vessel atherosclerotic disease accounts for about 20% of all ischemic stroke patients of which about half are due to extra cranial carotid artery stenosis. Patients with hemodynamically significant carotid stenosis should be considered for carotid revascularization, either the well-established surgical procedure of carotid endarterectomy (CEA) or carotid stenting.For patients who have experienced recent carotid territory symptoms, CEA can be very effective in decreasing the long-term stroke risk, if there is moderate to severe stenosis. Many patients without recent carotid territory symptoms (asymptomatic stenosis) also undergo CEA, although, the benefit is less certain for this group of patients. With advances in medical therapy, the benefits of carotid revascularization for asymptomatic carotid stenosis have come under further scrutiny. Some patients with carotid stenosis are not ideal candidates for A B s T R A C TExtra cranial carotid artery stenosis is an important cause of stroke, which often needs treatment with carotid revascularization. To prevent stroke recurrence, carotid endarterectomy (CEA) has been well-established for several decades for symptomatic high and moderate grade stenosis. Carotid stenting is a less invasive alternative to CEA and several recent trials have compared the efficacy of the 2 procedures in patients with carotid stenosis. Carotid artery stenting has emerged as a potential mode of therapy for high surgical risk pat...

show abstract

Section: The Risks Associated With Carotid Endarterectomymentioning

confidence: 99%

Stroke prevention-surgical and interventional approaches to carotid stenosis

Rajamani¹

2017

IJNS

Self Cite

View full text Add to dashboard Cite

show abstract

“…There is a great degree of variability of this procedure across the country and even among providers in the same center. 20,21 Traditional endarterectomy employs a longitudinal arteriotomy, while eversion endarterectomy employs a transverse arteriotomy with reimplantation of the carotid artery. 22 A Cochrane review of five randomized controlled trials showed no statistically significant difference in the rates of perioperative stroke or death when comparing eversion and conventional endarterectomy with either patch angioplasty or primary closure.…”

Section: Surgical Considerationsmentioning

confidence: 99%

Carotid Endarterectomy: Current Concepts and Practice Patterns

Saha

2015

Int J Angiol

View full text Add to dashboard Cite

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.

show abstract

Management of Asymptomatic Carotid Artery Stenosis

Bonaca

Beckman

2013

Curr Treat Options Cardio Med

View full text Add to dashboard Cite

Patients with atherosclerotic asymptomatic carotid artery disease are at a heightened risk of major adverse cardiovascular events including ischemic stroke. Intensive risk factor modification, including lifestyle interventions and the use of evidence based medical therapies, reduces the risk of adverse cardiovascular events in this population. Carefully selected patients with severe asymptomatic carotid stenosis may benefit from carotid endarterectomy or stenting. Patient and lesion characteristics may help to carefully select patients most likely to benefit from revascularization. Emerging therapies, including novel lipid lowering therapies, anti-platelet therapies, and anti-coagulant therapies, may further reduce the risk of adverse cardiovascular events in patients with stable atherosclerotic disease. The most important aspect of the management of asymptomatic carotid artery stenosis is reducing the overall cardiovascular risk of the patient.

show abstract

Variability in Carotid Endarterectomy Practice Patterns Within a Metropolitan Area

Cited by 5 publications

References 9 publications

Stroke prevention-surgical and interventional approaches to carotid stenosis

Stroke prevention-surgical and interventional approaches to carotid stenosis

Carotid Endarterectomy: Current Concepts and Practice Patterns

Management of Asymptomatic Carotid Artery Stenosis

Contact Info

Product

Resources

About