Kamal, Ayeesha Kamran

Shaikh,, Quratulain

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eCommons@AKUDepartment of Medicine Department of MedicineSeptember 2013My patient has carotid stenosis. should he getstenting or endarterectomy?Quratulain Shaikh,Aga Khan UniversityAyeesha Kamran KamalAgha Khan University, ayeesha.kamal@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Neurology CommonsRecommended CitationShaikh,, Q., Kamal, A. (2013). My patient has carotid stenosis. should he get stenting or endarterectomy?. JPMA. The Journal of thePakistan Medical Association, 63(9), 1201-1201.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/348Why is the study important?Extracranial atherosclorerotic disease is an important cause ofstroke. Guidelines for practice are still sparse as to whetherthese patients will benefit more from angioplasty orendarterectomy and trials have shown conflicting results. Theprimary aim of the Carotid Revascularization Endarterectomyvs. Stenting Trial (CREST) was to compare the outcomes ofcarotid-artery stenting with those of carotid endarterectomyamong patients with symptomatic or asymptomaticextracranial carotid stenosis.Who were the participants? What was theintervention?Patients were recruited from 108 centres in the United Statesand 9 in Canada. Centres assigned patients with symptomaticor asymptomatic carotid stenosis to undergo carotid-arterystenting or carotid endarterectomy. The primary compositeend point was stroke, myocardial infarction, or death from anycause during the periprocedural period or any ipsilateralstroke within 4 years after randomization. 2502 patients wereenrolled and followed up for a median of 2.5 years. 1271patients were in the carotid artery stenting arm and 1251 inthe carotid endarterectomy arm.What were the findings?There was no significant difference in the estimated 4-yearrates of the primary end point between carotid-artery stentingand carotid endarterectomy (7.2% and 6.8%, respectively;hazard ratio for stenting, 1.11; 95% confidence interval [CI],0.81 to 1.51; p <0.51) .Of the end-point events, 13 strokes werefatal (7 in the stenting group and 6 in the endarterectomygroup), and 1 myocardial infarction was fatal (in theendarterectomy group). An interaction between age andtreatment efficacy was detected (p<0.02) with a crossover atan age of approximately 70 years. Carotid-artery stentingtended to show greater efficacy at younger ages, and carotidendarterectomy at older ages. The incidence of ipsilateralstroke was similarly low with carotid-artery stenting and withcarotid endarterectomy (2.0% and 2.4%, respectively; p<0.85).What were the conclusions?CREST results indicate that carotid-artery stenting and carotidendarterectomy were associated with similar rates of theprimary composite outcome which is periprocedural stroke,myocardial infarction, or death and subsequent ipsilateralstroke among men and women with either symptomatic orasymptomatic carotid stenosis. However, the incidence ofperiprocedural stroke was lower in the endarterectomy groupthan in the stenting group, whereas the incidence ofperiprocedural myocardial infarction was lower in the stentinggroup. The selection of patients for either carotidarterystenting or carotid endarterectomy may require attention toage, with younger patients having a slightly better outcomewith carotid artery stenting and older patients having a betteroutcome with carotid endarterectomy.How can this study affect our clinical practice?Although carotid disease is not a frequent cause of stroke inPakistanis, it is important to appreciate that the interventionof angioplasty that appears relatively benign may beassociated with more periprocedural stroke than CEA in thebest of international centres. As we develop moresophisticated interventional centres in Pakistan, strict internalaudit of both our CEA and CAS will guide the rightintervention for our patients. At this point at least in Pakistan,CEA may be a better option due to local technical expertise. Acknowledgement and Disclosure StatementThe International Cerebrovascular Translational ClinicalResearch and Training Program (ICT_CRT) at the Aga KhanUniversity is supported by funds from the Award NumberD43TW008660 from the Fogarty International Center and theNational Institute of Neurologic Disorders and Stroke. Thecontent is solely the responsibility of the authors and does notnecessarily represent the official views of the FogartyInternational Center or the National Institutes of Health.Recommended Reading1. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W,et al. Stenting versus endarterectomy for treatment of carotid-arterystenosis. N Engl J Med 2010; 363: 11-23.2. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al.Stenting versus aggressive medical therapy for intracranial arterialstenosis. N Engl J Med 2011; 365: 993-1003.Vol. 63, No. 9, September 20131201EVIDENCE BASED MEDICINEMy patient has carotid stenosis. Should he get stenting or endarterectomy?Quratulain Shaikh, Ayeesha Kamran KamalStroke Service and Vascular Fellowship Program, International CerebrovascularTranslational Clinical Research Training Program (Fogarty International Centerand National Institute of Neurologic Disorders and Stroke), Aga KhanUniversity Hospital, Karachi, Pakistan.Correspondence: Ayeesha Kamran Kamal. Email: ayeesha.kamal@aku.edu

My patient has carotid stenosis. should he get stenting or endarterectomy?

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My patient has carotid stenosis. should he get stenting or endarterectomy?

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