Would a surgeon operate on such high-risk patients?

Dieter Raithel says "operate"

Professor Dieter Raithel (Clinic Nuremberg South, Germany)

Several international, prospective randomized studies have highlighted the value of carotid endarterectomy. These studies have reported that this procedure is the gold standard for the prevention of strokes.

In recent years, radiologists and especially cardiologists have recommended carotid artery stenting for patients with severe carotid stenosis.

So-called 'high-risk' patients have been cited as an argument for carotid stenting; patients have included those with severe coronary, pulmonary or renal disease, contralateral internal carotid artery occlusions, recurrent carotid stenoses or hostile neck, and of course an age over 80 years. These indications in so-called 'high-risk' patients are put forward to justify carotid artery stenting.

Based on our own patient population and the results reported in the literature, we can show, that these arguments do not apply, i.e. that conventional carotid endarterectomy is still the gold standard.

Subject and methods
During the period August 1984 to September 2003, 19,243 patients underwent carotid reconstruction (14.8% were over 80 years of age). 58% had a history of coronary heart disease with myocardial infarction.

In our clinic, the postoperative neurological deficit rate was only 2.4% (1.4% transient, 1.0% permanent), and mortality was 0.4%. In patients with a contralateral internal carotid artery occlusion we had a neurological deficit rate of 1.1% and a mortality of 0.9%.

In patients over 80 years of age, the neurological deficit rate was only 1.6%, mortality 0.2%. In those with hostile neck (neck dissection, radiation) we recorded a neurological deficit rate of 0.5% and a mortality of 0.6%.

The quality-management study of the German vascular society (DGG) incorporates 128 clinics which have carried out a total of 8,573 carotid operations during 2002; this includes our own clinic, with 1,113 operations in that year.

The stroke rate in this series (8,573 operations) was 2.4% and the mortality 0.8%. 1% suffered transient ischemic attacks. In our clinic (1,113 operations during 2002), the mortality was 0.4% and the stroke rate 0.5% (in 2002). Similar results were reported in the literature.

Even after carotid artery stenting with restenosis, re-do surgery can be performed with a low risk. In our own series of 117 interventions (carotid stenting), we had a restenosis rate of 34% after 6 months. In 7 patients, conversion was necessary, with stent removal. In this series, we had no instances of death, stroke, transient ischemic attack or cranial nerve lesions.

The pathological findings in these 7 conversions were maximal intimal hyperplasia (4 in-stent restenoses, 2 stenoses at the distal end, and 1 case with a proximal stenosis due to intimal hyperplasia).

Summary
Carotid endarterectomy is one of the most frequently and successfully performed vascular surgery procedures with a 45-year history of success.

Carotid endarterectomy has a high incidence of positive outcomes, based on well-documented and respected clinical studies (NASCET etc.).

Our results from the ICAROS study have shown relatively high morbidity and mortality rates after carotid stenting, especially a very high re-stenosis rate (34%) after 6 months.

The data from the literature have shown that so-called 'high-risk' patients are not a contraindication to carotid endarterectomy. Contralateral internal carotid artery occlusion, age over 80 years, severe pulmonary disease, etc. are not contrainidcations to carotid endarterectomy.

Carotid artery stenting should nowadays be seen only as an indication for patients with restenosis after CEA, or patients with hostile necks.

All other so-called 'high-risk' indications for carotid stenting apply in no way, since at least equally good results can be obtained by conventional carotid endarterectomy, at a considerably lower restenosis rate.