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Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease

2000; Lippincott Williams & Wilkins; Volume: 31; Issue: 12 Linguagem: Inglês

10.1161/01.str.31.12.3079

1524-4628

Nadim Al‐Mubarak, Gary S. Roubin, Jiri J. Vitek,

Intracranial Aneurysms: Treatment and Complications

HomeStrokeVol. 31, No. 12Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBSystematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease Nadim Al-Mubarak, Gary S. Roubin and Jiri J. Vitek Nadim Al-MubarakNadim Al-Mubarak The Lenox Hill Heart and Vascular Institute of New York, New York, NY , Gary S. RoubinGary S. Roubin The Lenox Hill Heart and Vascular Institute of New York, New York, NY and Jiri J. VitekJiri J. Vitek The Lenox Hill Heart and Vascular Institute of New York, New York, NY Originally published1 Dec 2000https://doi.org/10.1161/01.STR.31.12.3079Stroke. 2000;31:3079–3083To the Editor:In a recent article by Golledge et al,1 the authors attempted a meta-analysis of accumulated single-center reports to compare 30-day stroke and death risk of carotid intervention and carotid endarterectomy (CEA). The authors' conclusion that the risk of stroke is significantly higher with endovascular intervention compared to surgery was based on an incomplete collection of reports and a scientifically flawed analysis.For any meta-analysis to provide a reliable conclusion, it should meet the minimum standards expected from a carefully conducted randomized control trial, including the use of prospective protocols, comparable definitions of key outcomes, and the inclusion of all patients from all trials in the final analysis.2 The analysis reported by Golledge et al meets none of these requirements. First, the authors had the opportunity to include a more recent series of carotid stenting345678 (an important factor with a procedure in development) but failed to do so. Further, there is no mention of the large registry of multiple "single-center experience" in carotid stenting reported by Wholey et al, which demonstrated favorable outcomes from endovascular carotid therapy. This registry has recently been updated to include over 5000 carotid stent cases, with a technical success of 98.4% and 30-day event rates (all strokes/deaths) of 5.8% in symptomatic patients with extracranial carotid artery stenoses.9 Importantly, the authors conveniently excluded a group of 77 symptomatic patients from the Hertzer series10 that had an event rate of 19%. Similar groups are included in the endovascular series.The analysis was based on a comparison between a prospective endovascular series and a CEA series that was largely retrospective. Complications were adjudicated by a neurologist in the majority of the endovascular series, but in most of the surgical series they were judged by the surgeon. Medical literature documents well the bias of reported post-CEA complication rates when the analysis is reported solely by surgeons11The article provides no contribution to the scientific evaluation of carotid stenting, a potentially safer and less-invasive alternative to surgery. In fact, such a publication will hinder recruitment into future prospective randomized trials that will ultimately provide the medical community with an objective conclusion about the safety and efficacy of carotid stenting. References 1 Golledge J, Mitchell A, Greenhalgh RM, Davies AH. Systematic comparison of the outcome of angioplasty and endarterectomy for symptomatic carotid artery disease. Stroke..2000; 31:1439–1443.CrossrefMedlineGoogle Scholar2 Pogue J, Yusuf S. Overcoming the limitations of current meta-analysis of ramdomized controlled trialsLancet.1998; 351:47–52.CrossrefMedlineGoogle Scholar3 Waigand J, Gross CM, Uhlich F, Kraemer J, Tamaschke C, Vogel P, Luft FC, Dietz R. Elective stenting of carotid artery stenosis in patients with severe coronary artery disease. Eur Heart J..1998; 19:1365–1370.CrossrefMedlineGoogle Scholar4 Lanzino G, Mericle RA, Lopes DK, Ajay KW, Guterman LR, Hopkins N. Percutaneous transluminal angioplasty and stent placement for recurrent carotid artery J stenosis. J Neurosurg..1999; 90:688–694.CrossrefMedlineGoogle Scholar5 Deithrich EB, Mouhamadou Ndiaya, Reid DB. Stenting in the carotid artery: initial experience in 110 patients. J Endovasc Surg..1996; 3:42–162.CrossrefMedlineGoogle Scholar6 Theron JG, Payelle GG, Coskun O, Huet HF, Guimaraens L. Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. Neuroradiology.1996; 201:627–636.Google Scholar7 Shawl FA. Carotid stenting in patients with symptomatic coronary artery disease: a preferred approach. J Invasive Cardiol..1998; 10:432–441.MedlineGoogle Scholar8 Wholey MH, Wholey M, Bergeron P, Diethrich EB, Henry M, Laborde JC, Mathias K, Myla S, Roubin GS, Shawl F, Theron JG, Yadav J, Dorros G, Shawl F, Guimarains J, Higashida R, Kumar V, Leon MB, Lim M, Londero H, Mesa J, Ramee S, Rodriguez A, Rosenfield K, Teitelbaum G, Vozzi C. Cathet Cardiovasc Diagn..1998; 44:1–6.CrossrefMedlineGoogle Scholar9 Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, Baily S, Bergeron P, Dorros G, Eles G, Gains P, Gomez CR, Gray B, Guimarains J, Katzen B. Kambara A, Kumar V, Laborde JC, Leon MB, Myla S, Lim M, Londero H, Mesa J, Ramee S, Rodriguez A, Rosenfield K, Sakai N, Shawl F, Sievert H, Teitelbaum G, Theron JG, Vaclav V, Yadav J, Yoshimura SI. Gobal experience in cervical carotid artery stent placement. Cathet Cardiovasc Interv..2000; 50:150–157.Google Scholar10 Hertzer NR, O'Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven KG, Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995. J Vasc Surg..1997; 26:1–10.CrossrefMedlineGoogle Scholar11 Rothwell PM, Slattery J, Warlow CP. Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. BMJ..1997; 315:1571–1577.CrossrefMedlineGoogle ScholarstrokeahaStrokeStrokeStroke0039-24991524-4628Lippincott Williams & WilkinsResponseGolledge Jonathan, , MChir122000angioplastycarotid endarterectomycarotid stenosisI read the letter of Dr Al-Mubarak and colleagues with interest. Clearly, there is a concern that surgeons fear the loss of the treatment of carotid artery disease to interventional radiologists and therefore must protect their ground. In fact, the intention of our systematic analysis was to compare the present results published for carotid endarterectomy and endovascular treatment of carotid artery disease to see if we should take up this technique. Included among our authors was an experienced interventional radiologist. We wondered whether we should be learning this new technique to apply to our patients. Our analysis suggests that at the present state of the art, the use of carotid stenting should be limited to carefully controlled trials only.In answer to the issues raised by Al-Mubarak et al:1. As stated repeatedly in our articleR1 (in the introduction, for example), our study was not a meta-analysis: "To address the debate regarding the role of angioplasty in carotid artery disease, a systematic comparison of the reported results of angioplasty and endarterectomy has been performed. Because sufficient data are not yet available from randomized trials, the results from single-center reports from 1990 to 1999 have been used to carry out a meta-analysis."2.With respect to the additional studies that Al-Mubarak et al state should have been included, the inclusion criteria were clearly stated in the Methods section: "Studies were included if the following criteria were fulfilled: (1) number of strokes occurring within 30 days of carotid endarterectomy or endoluminal treatment were reported for patients with symptomatic carotid stenosis; (2) the report was a single-center study, since very few multicenter angioplasty series have been published; (3) the study was published between 1990 and 1999; and (4) only 1 series from any center was included unless there was clearly no overlap in cases." The additional studies mentioned by Al-Mubarak and colleagues were excluded because they contained mainly asymptomatic patients and results for symptomatic patients were not stated separately (References 4 through 7), and 1 series from that institute was already included (References 8 and 9).The article by Hertzer et al is included in our analysis (Reference 32), and all 750 patients with symptomatic carotid artery disease who undergo isolated carotid endarterectomy are included. We did exclude patients with asymptomatic disease and those undergoing combined coronary artery bypass, as was the case for all series. With respect to outcome assessment, while it is possible that some of the more subtle strokes may be difficult for surgeons to define, disabling strokes should be clearly evident to all. Our analysis demonstrated that disabling or fatal stroke was twice as common following endovascular treatment.In conclusion, we believe that endovascular therapy for carotid artery disease should be widely introduced only if it is clearly as safe as the current best treatment. The increasing number of series of cases being reported in the literature suggests that many patients are undergoing carotid stenting outside a randomized trial. At present, the evidence would not support such a practice. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Allison S, Gur I, Lee W and Katz S (2011) Carotid Stenting: A Surgeon's Perspective, Journal of the American College of Surgeons, 10.1016/j.jamcollsurg.2011.01.008, 213:1, (173-178), Online publication date: 1-Jul-2011. Mudra H (2008) Carotid artery stenting: what do recent trials and registries tell us?, Future Cardiology, 10.2217/14796678.4.5.449, 4:5, (449-453), Online publication date: 1-Sep-2008. Koenigsberg R, Bianco B, Faro S, Stickles S, Hershey B, Siegal T, Mohamed F, Dastur C and Tsai F (2007) Neuroimaging Textbook of Clinical Neurology, 10.1016/B978-141603618-0.10023-2, (437-476), . Narins C and Illig K (2006) Patient selection for carotid stenting versus endarterectomy: A systematic review, Journal of Vascular Surgery, 10.1016/j.jvs.2006.05.042, 44:3, (661-672), Online publication date: 1-Sep-2006. Kasirajan K (2004) Technique of Carotid Bifurcation Angioplasty and Stent Placement: How I Do It Carotid Interventions, 10.1201/b14184-11, (149-164) Becquemin J, Ben El Kadi H, Desgranges P and Kobeiter H (2003) Carotid Stenting Versus Carotid Surgery: A Prospective Cohort Study , Journal of Endovascular Therapy, 10.1583/1545-1550(2003)010 2.0.CO;2, 10:4, (687-694), Online publication date: 1-Aug-2003. Chan A, Roffi M, Mukherjee D, Bajzer C, Abou-Chebl A, Ciezki J, Bhatt D, Ghaffari S and Yadav J (2002) Carotid brachytherapy for in-stent restenosis, Catheterization and Cardiovascular Interventions, 10.1002/ccd.10397, 58:1, (86-92), Online publication date: 1-Jan-2003. Becquemin J, Kadi H, Desgranges P and Kobeiter H (2016) Carotid Stenting versus Carotid Surgery: A Prospective Cohort Study, Journal of Endovascular Therapy, 10.1177/152660280301000402, 10:4, (687-694), Online publication date: 1-Aug-2003. December 2000Vol 31, Issue 12 Advertisement Article InformationMetrics Copyright © 2000 by American Heart Associationhttps://doi.org/10.1161/01.STR.31.12.3079 Originally publishedDecember 1, 2000 PDF download Advertisement