Treatment With Endarterectomy Is Safer Than Stenting for Severe Carotid Artery Stenosis
Carotid artery stenosis—a build-up of atherosclerotic plaque in the arteries that carry blood and oxygen to the brain—is a major risk factor for ]]>stroke]]> . Severe cases are treated with ]]>endarterectomy]]> , in which an incision is made in the neck, the carotid artery is opened, and the plaque is removed.
Endarterectomy requires ]]>general anesthesia]]> and carries a risk of nerve injury. Stenting may be a less risky treatment option. In this method, a catheter is inserted into the arterial system by being passed through the body up to the carotid artery. Once here, a balloon is inflated to push the plaque against the artery walls. Next, a mesh tube called a stent is placed to hold the artery open. Although stenting is less invasive, it may increase the risk of stroke compared to endarterectomy and its long-term usefulness is unknown.
To evaluate the benefits and risks of stenting and endarterectomy, French researchers compared these two procedures in patients with severe carotid artery stenosis. Their study was cut short when the incidence of stroke and death was significantly greater after stenting than after endarterectomy. These findings are described in the October 19, 2006 New England Journal of Medicine .
About the Study
Researchers from 30 French medical centers took part in The Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial. A total of 527 patients were randomly assigned to receive endarterectomy or stenting, and were evaluated 48 hours, 30 days, six months, and every six months after their procedures. The incidences of stroke or death within 30 days of treatment were compared between the two groups.
EVA-3S was stopped early due to excessive risks in the stenting group—the incidence of stroke or death within 30 days was 9.6% after stenting, compared with 3.9% after endarterecetomy. After six months, this risk rose to 11.7% for stenting, compared with 6.1% for endarterectomy. These percentages translate to one extra stroke or death for every 17 patients who underwent stenting rather than endarterectomy.
The researchers were unable to recruit the number of patients originally planned; a larger study group would have allowed for more detailed analyses of the risks and benefits of these procedures.
How Does This Affect You?
Is endarterectomy the treatment of choice for carotid artery stenosis? For arteries that are 70% clogged or more, especially in the presence of symptoms (eg, “mini-strokes”), this study and previous research say “yes.” The fact that the study was stopped early suggests that endarterectomy should remain the first option for patients with severe carotid artery stenosis who can tolerate this invasive procedure. However, stenting may still be appropriate in those who cannot.
If you have carotid artery disease, talk with your doctor about the severity of the plaque build-up and your treatment options. For less clogged arteries, medication and lifestyle changes may lower stroke risk.
To reduce the risk of stroke via carotid artery stenosis or other causes, follow these lifestyle habits:
- Don’t smoke and avoid secondhand smoke
- Lose excess weight
- Exercise regularly
- Eat less salt, saturated fat, and trans fat
- Have your blood pressure checked regularly and control high blood pressure through dietary changes, exercise, weight loss, relaxation, and medications, if recommended by your doctor
- Have your blood sugar tested and take steps to control it through diet or medications if necessary
- Drink alcohol in moderation (two drinks per day for men; one drink per day for women)
In addition, learn the warning signs of stroke and share this information with your family so you can get help immediately.
American Heart Association
National Heart, Lung, and Blood Institute
Mas J-L, Chatellier G, Beyssen B, et al., for the EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med . 2006;355:1660-1671.
What is carotid endarterectomy? American Heart Association website. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3009563 . Accessed December 7, 2006.
Last reviewed December 2006 by ]]>Richard Glickman-Simon, MD]]>
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