Implantácia stentu, Chirurgický zákrok, oboje ponechávajú otvorené karotické cievy

02.02.2012
Implantácia stentu, Chirurgický zákrok, oboje ponechávajú otvorené karotické cievy
Stents, Surgery Both Maintain Open Carotids

By Todd Neale, Senior Staff Writer, MedPage Today
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

Action Points
•        Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
•        Two-year follow-up of the CREST study found no significant differences in restenosis, occlusion, or revascularization rates between those undergoing carotid artery stenting or endarterectomy.
•        Note that those who had restenosis had a higher risk for an ipsilateral stroke, but the rates were low and equivalent in both groups.

NEW ORLEANS -- For patients with carotid stenosis, both stenting and endarterectomy provided durable revascularization through two years, an analysis of the CREST trial showed. Over that time period, the rate of restenosis or occlusion was 6% in the stent group and 6.3% in the endarterectomy group (HR 0.90, 95% CI 0.63 to 1.29), according to Brajesh Lal, MD, of the University of Maryland Medical School in Baltimore. Females, diabetics, and those with dyslipidemia were more likely to develop restenosis (HRs 1.83 to 2.22), he reported at the American Stroke Association's International Stroke Conference here.

Multiple factors go into choosing between stenting and surgery, and "what is reassuring based on this [study] is that once that decision has been made, the reblockage rates are equivalent for the two procedures," Lal said. Follow-up of trial participants will continue through 10 years. The primary results of the CREST trial -- which enrolled patients with asymptomatic and symptomatic carotid stenosis -- showed that the rate of stroke, MI, or death within the first 30 days was equivalent between the two approaches, although the rate of stroke was higher with stenting and the rate of MI was higher with surgery.

Because of the similar event rates, the durability of each approach became an important question. Previous studies looking at the issue had yielded conflicting results. Lal and his colleagues used two-year data from CREST to address the question. The analysis included 2,191 patients who had a carotid ultrasound reviewed at the core lab for the study. Through two years of follow-up, hemodynamically significant restenosis -- a 70% blockage or greater -- occurred in 5.8% of the patients in each group. Only eight patients developed an occlusion -- 0.3% in the stenting group and 0.5% in the endarterectomy group. Patients who developed a restenosis had about four times the risk of developing an ipsilateral stroke (HR 4.37, P=0.0007), Lal reported. Overall, 13 patients -- four in the stenting group and nine in the endarterectomy group -- had a stroke. The number of patients who underwent repeat revascularization also did not differ between the two groups through two years.

Lal noted that findings from CREST and other studies are starting to give clinicians an idea of which patients are best suited for either stenting or endarterectomy. Patients who have scar tissue in the neck from prior surgery or radiation therapy are better candidates for stenting, whereas patients with carotid arteries that are heavily calcified or extremely tortuous are better off getting surgery, he said.

Philip Gorelick, MD, MPH, medical director of the Hauenstein Neuroscience Center in Grand Rapids, Mich., and an American Heart Association spokesperson, highlighted some other circumstances that might favor one approach over the other. There is evidence that patients 70 and older might be better candidates for surgery, possibly because their arteries are more tortuous, he said. He said stenting might be a better option for patients with high carotid artery bifurcation, which makes the artery hard to access surgically without breaking the jaw bone.

But, Gorelick noted, no matter which approach is chosen, adhering to medical management and lifestyle modification is very important. There are even studies being proposed to examine whether revascularization is needed with the existence of such effective medications, he said.

CREST is funded by the National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions (formerly Guidant), which included donations of the Acculink and Accunet stent systems to most of the CREST centers.

Lal reported that he had no conflicts of interest. His co-authors reported relationships with Abbott Vascular, Cook, W.L. Gore, Cordis, and Boston Scientific.

From the American Heart Association:

•        Science News from International Stroke Conference 2012

Primary source: American Stroke Association's International Stroke Conference

Source reference:

Lal B, et al "Restenosis following carotid artery stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial" ASA 2012; Abstract 3.

Source: www.medpagetoday.com