Download PDF
Int J Angiol 2015; 24(03): 215-222
DOI: 10.1055/s-0035-1545073
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Comparative Review of the Treatment Methodologies of Carotid Stenosis

Coney Bae
1   Division of Vascular Surgery, Department of Surgery, Hofstra North Shore–Long Island Jewish School of Medicine, New York, New York
,
Mauricio Szuchmacher
1   Division of Vascular Surgery, Department of Surgery, Hofstra North Shore–Long Island Jewish School of Medicine, New York, New York
,
John B. Chang
1   Division of Vascular Surgery, Department of Surgery, Hofstra North Shore–Long Island Jewish School of Medicine, New York, New York
› Author Affiliations
Further Information

Publication History

Publication Date:
18 May 2015 (online)

    Permissions and Reprints

Abstract

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

Keywords

carotid artery stenosis - carotid endarterectomy - carotid angioplasty and stenting
 

  • References

  • 1 Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013; 61 (4) 1-117
    PubMedSearch in Google Scholar
  • 2 Lloyd-Jones D, Adams RJ, Brown TM , et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation 2010; 121 (7) 948-954
    CrossrefPubMedSearch in Google Scholar
  • 3 Williams O, DeSorbo A, Noble J, Gerin W. Child-mediated stroke communication: findings from hip hop stroke. Stroke 2012; 43 (1) 163-169
    CrossrefPubMedSearch in Google Scholar
  • 4 Koton S, Schneider AL, Rosamond WD, Gottesman RF, Coresh J. Abstract P214: Twenty-five Years Trends in Stroke Incidence in the Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2014; 129 (Suppl. 01) AP214
    PubMedSearch in Google Scholar
  • 5 Palm F, Dos Santos M, Urbanek C , et al. Stroke seasonality associations with subtype, etiology and laboratory results in the Ludwigshafen Stroke Study (LuSSt). Eur J Epidemiol 2013; 28 (5) 373-381
    CrossrefPubMedSearch in Google Scholar
  • 6 Bluth E, Carroll B, Rumack C, Wilson S, Charbonnet J, Levine D. The Extracranial Cerebral Vessels. Diagnostic Ultrasound, 4th ed. Philadelphia, PA: Elsevier; 2010
    Search in Google Scholar
  • 7 Constantinou J, Jayia P, Hamilton G. Best evidence for medical therapy for carotid artery stenosis. J Vasc Surg 2013; 58 (4) 1129-1139
    CrossrefPubMedSearch in Google Scholar
  • 8 Rothwell PM, Gutnikov SA, Warlow CP ; European Carotid Surgery Trialist's Collaboration. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 2003; 34 (2) 514-523
    CrossrefPubMedSearch in Google Scholar
  • 9 Rothwell PM, Eliasziw M, Gutnikov SA , et al; Carotid Endarterectomy Trialists' Collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361 (9352) 107-116
    CrossrefPubMedSearch in Google Scholar
  • 10 Rothwell PM, Gibson RJ, Slattery J, Sellar RJ, Warlow CP. Equivalence of measurements of carotid stenosis. A comparison of three methods on 1001 angiograms. European Carotid Surgery Trialists' Collaborative Group. Stroke 1994; 25 (12) 2435-2439
    CrossrefPubMedSearch in Google Scholar
  • 11 Mendelsohn FOYJ. Management of Atherosclerotic Carotid Disease: Medical, Surgical and Interventional Aspects. London: ReMedica Publishing; 2000
    Search in Google Scholar
  • 12 Brown M, Rogers J, Bland J. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357 (9270) 1729-1737
    CrossrefPubMedSearch in Google Scholar
  • 13 Gurm HS, Yadav JS, Fayad P , et al; SAPPHIRE Investigators. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008; 358 (15) 1572-1579
    CrossrefPubMedSearch in Google Scholar
  • 14 O'Brien M, Chandra A. Carotid revascularization: risks and benefits. Vasc Health Risk Manag 2014; 10: 403-416
    PubMedSearch in Google Scholar
  • 15 Silver FL, Mackey A, Clark WM , et al; CREST Investigators. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2011; 42 (3) 675-680
    CrossrefPubMedSearch in Google Scholar
  • 16 Howard VJ, Lutsep HL, Mackey A , et al; CREST investigators. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol 2011; 10 (6) 530-537
    CrossrefPubMedSearch in Google Scholar
  • 17 Voeks JH, Howard G, Roubin GS , et al; CREST Investigators. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. Stroke 2011; 42 (12) 3484-3490
    CrossrefPubMedSearch in Google Scholar
  • 18 Ringleb PA, Allenberg J, Brückmann H , et al; SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368 (9543) 1239-1247
    CrossrefPubMedSearch in Google Scholar
  • 19 Mas J-L, Trinquart L, Leys D , et al; EVA-3S investigators. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008; 7 (10) 885-892
    CrossrefPubMedSearch in Google Scholar
  • 20 Naggara O, Touzé E, Beyssen B , et al; EVA-3S Investigators. Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review. Stroke 2011; 42 (2) 380-388
    CrossrefPubMedSearch in Google Scholar
  • 21 Calvet D, Mas J-L, Algra A , et al; Carotid Stenting Trialists' Collaboration. Carotid stenting: is there an operator effect? A pooled analysis from the carotid stenting trialists' collaboration. Stroke 2014; 45 (2) 527-532
    CrossrefPubMedSearch in Google Scholar
  • 22 Bonati LH, Jongen LM, Haller S , et al; ICSS-MRI study group. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9 (4) 353-362
    CrossrefPubMedSearch in Google Scholar
  • 23 Malas M, Moore WS, Lal BK, Hughes SE, Voeks JH, Brott TG. Abstract 69: The Effect of Patching in Carotid Endarterectomy (CEA) on Reducing The Risk of Restenosis and Stroke in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2014; 45 (1) A69
    CrossrefPubMedSearch in Google Scholar
  • 24 Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2009; 4 (4) CD000160
    PubMedSearch in Google Scholar
  • 25 Eikelboom BC, Ackerstaff RG, Hoeneveld H , et al. Benefits of carotid patching: a randomized study. J Vasc Surg 1988; 7 (2) 240-247
    CrossrefPubMedSearch in Google Scholar
  • 26 Rosenthal D, Archie Jr JP, Garcia-Rinaldi R , et al. Carotid patch angioplasty: immediate and long-term results. J Vasc Surg 1990; 12 (3) 326-333
    CrossrefPubMedSearch in Google Scholar
  • 27 Katz D, Snyder SO, Gandhi RH , et al. Long-term follow-up for recurrent stenosis: a prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy. J Vasc Surg 1994; 19 (2) 198-203 , discussion 204–205
    CrossrefPubMedSearch in Google Scholar
  • 28 AbuRahma AF, Robinson PA, Saiedy S, Kahn JH, Boland JP. Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: long-term follow-up. J Vasc Surg 1998; 27 (2) 222-232 , discussion 233–234
    CrossrefPubMedSearch in Google Scholar
  • 29 Ren S, Li X, Wen J, Zhang W, Liu P. Systematic review of randomized controlled trials of different types of patch materials during carotid endarterectomy. PLoS ONE 2013; 8 (1) e55050
    CrossrefPubMedSearch in Google Scholar
  • 30 Stewart GW, Bandyk DF, Kaebnick HW, Storey JD, Towne JB. Influence of vein-patch angioplasty on carotid endarterectomy healing. Arch Surg 1987; 122 (3) 364-371
    CrossrefPubMedSearch in Google Scholar
  • 31 Bond R, Rerkasem K, Naylor R, Rothwell PM. Patches of different types for carotid patch angioplasty. Cochrane Database Syst Rev 2004; (2) CD000071
    PubMedSearch in Google Scholar
  • 32 Hans SS. Late follow-up of carotid endarterectomy with venous patch angioplasty. Am J Surg 1991; 162 (1) 50-54
    CrossrefPubMedSearch in Google Scholar
  • 33 Katz SG, Kohl RD. Does the choice of material influence early morbidity in patients undergoing carotid patch angioplasty?. Surgery 1996; 119 (3) 297-301
    CrossrefPubMedSearch in Google Scholar
  • 34 Stone PA, AbuRahma AF, Mousa AY , et al. Prospective randomized trial of ACUSEAL versus Vascu-Guard patching in carotid endarterectomy. Ann Vasc Surg 2014; 28 (6) 1530-1538
    CrossrefPubMedSearch in Google Scholar
  • 35 Katras T, Baltazar U, Rush DS, Sutterfield WC, Harvill LM, Stanton Jr PE. Durability of eversion carotid endarterectomy: comparison with primary closure and carotid patch angioplasty. J Vasc Surg 2001; 34 (3) 453-458
    CrossrefPubMedSearch in Google Scholar
  • 36 Ballotta E, Toniato A, Da Giau G, Lorenzetti R, Da Roit A, Baracchini C. Durability of eversion carotid endarterectomy. J Vasc Surg 2014; 59 (5) 1274-1281
    CrossrefPubMedSearch in Google Scholar
  • 37 Cao P, De Rango P, Zannetti S, Giordano G, Ricci S, Celani MG. Eversion versus conventional carotid endarterectomy for preventing stroke. Cochrane Database Syst Rev 2000; (1) 1921
    PubMedSearch in Google Scholar
  • 38 Mayberg MR, Wilson SE, Yatsu F , et al for the Veterans Affairs Cooperative Studies Program 309 Trialists Group. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 1991; 266 (23) 3289-3294
    CrossrefPubMedSearch in Google Scholar
  • 39 Bonati LH, Dobson J, Algra A , et al; Carotid Stenting Trialists' Collaboration. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet 2010; 376 (9746) 1062-1073
    CrossrefPubMedSearch in Google Scholar
  • 40 Laman DM, Wieneke GH, van Duijn H, van Huffelen AC. High embolic rate early after carotid endarterectomy is associated with early cerebrovascular complications, especially in women. J Vasc Surg 2002; 36 (2) 278-284
    CrossrefPubMedSearch in Google Scholar
  • 41 Stork JL, Levi CR, Chambers BR, Abbott AL, Donnan GA. Possible determinants of early microembolism after carotid endarterectomy. Stroke 2002; 33 (8) 2082-2085
    CrossrefPubMedSearch in Google Scholar
  • 42 Silvestrini M, Vernieri F, Pasqualetti P , et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 2000; 283 (16) 2122-2127
    CrossrefPubMedSearch in Google Scholar
  • 43 Matteis M, Troisi E, Monaldo BC, Caltagirone C, Silvestrini M. Age and sex differences in cerebral hemodynamics: a transcranial Doppler study. Stroke 1998; 29 (5) 963-967
    CrossrefPubMedSearch in Google Scholar
  • 44 van Everdingen KJ, Visser GH, Klijn CJ, Kappelle LJ, van der Grond J. Role of collateral flow on cerebral hemodynamics in patients with unilateral internal carotid artery occlusion. Ann Neurol 1998; 44 (2) 167-176
    CrossrefPubMedSearch in Google Scholar
  • 45 van Laar PJ, van der Grond J, Bremmer JP, Klijn CJ, Hendrikse J. Assessment of the contribution of the external carotid artery to brain perfusion in patients with internal carotid artery occlusion. Stroke 2008; 39 (11) 3003-3008
    CrossrefPubMedSearch in Google Scholar
  • 46 Brown KA, Itum DS, Reeves JG , et al. Carotid Artery Stenting Has Increased Risk of External Carotid Artery Occlusion Compared with Carotid Endarterectomy. J Vasc Surg 2013; 58 (6) 1730-1731
    PubMedSearch in Google Scholar
  • 47 Reichmann BL, Hellings WE, van der Worp HB , et al. Flow velocities in the external carotid artery following carotid revascularization. Eur J Vasc Endovasc Surg 2013; 46 (4) 411-417
    CrossrefPubMedSearch in Google Scholar
  • 48 de Borst GJ, Vos JA, Reichmann B , et al; Antonius Carotid Endarterectomy, Angioplasty, and Stenting Study Group. The fate of the external carotid artery after carotid artery stenting. A follow-up study with duplex ultrasonography. Eur J Vasc Endovasc Surg 2007; 33 (6) 657-663
    CrossrefPubMedSearch in Google Scholar
  • 49 Woo EY, Karmacharya J, Velazquez OC, Carpenter JP, Skelly CL, Fairman RM. Differential effects of carotid artery stenting versus carotid endarterectomy on external carotid artery patency. J Endovasc Ther 2007; 14 (2) 208-213
    CrossrefPubMedSearch in Google Scholar
  • 50 Zhou W, Lin PH, Bush RL , et al. Management of in-sent restenosis after carotid artery stenting in high-risk patients. J Vasc Surg 2006; 43 (2) 305-312
    CrossrefPubMedSearch in Google Scholar
  • 51 Setacci C, de Donato G, Setacci F , et al. In-stent restenosis after carotid angioplasty and stenting: a challenge for the vascular surgeon. Eur J Vasc Endovasc Surg 2005; 29 (6) 601-607
    CrossrefPubMedSearch in Google Scholar
  • 52 Silva M, Choi L, Cheng C. Peripheral Arterial Occlusive Disease. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19th ed. Philadelphia, PA: EEUU; 2012: 1725-1784
    Search in Google Scholar
  • 53 Yadav JS, Wholey MH, Kuntz RE , et al; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351 (15) 1493-1501
    CrossrefPubMedSearch in Google Scholar
  • 54 Raman G, Moorthy D, Hadar N , et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med 2013; 158 (9) 676-685
    CrossrefPubMedSearch in Google Scholar
  • 55 Norris JW, Zhu CZ, Bornstein NM, Chambers BR. Vascular risks of asymptomatic carotid stenosis. Stroke 1991; 22 (12) 1485-1490
    CrossrefPubMedSearch in Google Scholar
  • 56 Trial NASCE. Collaborative Group. The final results of the NASCET trial. N Engl J Med 1998; 339: 1415-1425
    CrossrefPubMedSearch in Google Scholar
  • 57 Barnett HJ, Taylor DW, Eliasziw M , et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339 (20) 1415-1425
    CrossrefPubMedSearch in Google Scholar
  • 58 Ferguson GG, Eliasziw M, Barr HW , et al. The North American symptomatic carotid endarterectomy trial surgical results in 1415 patients. Stroke 1999; 30 (9) 1751-1758
    CrossrefPubMedSearch in Google Scholar
  • 59 Njemanze P, Beck O, Gomez C , et al. North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22 (6) 711-720
    CrossrefPubMedSearch in Google Scholar
  • 60 Farrell B, Fraser A, Sandercock P, Slattery J, Warlow C. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351 (9113) 1379-1387
    CrossrefPubMedSearch in Google Scholar
  • 61 Walker MD, Marler JR, Goldstein M , et al. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273 (18) 1421-1428
    CrossrefPubMedSearch in Google Scholar
  • 62 Halliday A, Mansfield A, Marro J , et al; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363 (9420) 1491-1502
    CrossrefPubMedSearch in Google Scholar
  • 63 Sheffet AJ, Roubin G, Howard G , et al. Design of the carotid revascularization endarterectomy vs. stenting trial (CREST). Int J Stroke 2010; 5 (1) 40-46
    PubMedSearch in Google Scholar
  • 64 Brott TG, Hobson II RW, Howard G , et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (1) 11-23
    CrossrefPubMedSearch in Google Scholar
  • 65 Eckstein H-H, Ringleb P, Allenberg J-R , et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol 2008; 7 (10) 893-902
    CrossrefPubMedSearch in Google Scholar
  • 66 Mas J-L, Chatellier G, Beyssen B , et al; EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355 (16) 1660-1671
    CrossrefPubMedSearch in Google Scholar
  • 67 Ederle J, Dobson J, Featherstone RL , et al; International Carotid Stenting Study investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375 (9719) 985-997
    CrossrefPubMedSearch in Google Scholar