Carotid stenting receives mixed marks

Carotid artery stenting (CAS) as an alternative to endarterectomy is still debated by many vascular surgeons. Researchers brought that debate to life in back-to-back presentations Sunday at the European Congress of Radiology, differing in their conclusions regarding CAS's efficacy.

Hungarian researchers, seeking to prove CAS's effectiveness, found that the procedure safely treated patients with primary atherosclerotic stenosis. Complications are minimal and in line with those after surgery.

Dr. Reka Ferdinandy-Szentgyörgyi and colleagues from the University of Szeged performed carotid artery stenting in 150 patients with primary atherosclerotic lesions.

All patients had stenosis greater than 70%. Atherosclerotic plaques were classified as smooth, irregular, or ulcerated. Subtotal occlusions were detected in 28% of the lesions.

Researchers followed patients with color-coded Doppler sonography at one, six, and 12 months. Additionally, 15 patients received pre- and postprocedural MR exams (FLAIR).

A majority of patients received monorail Wallstents and no patient underwent predilation. Protective devices were not used. Seven patients with ulcerated lesions confined to the internal carotid artery received stent-grafts.

Procedural success rate was 99%, while a favorable outcome was achieved in 97.3% (146/150). Complications included one major stroke, one death, one minor stroke, and one TIA, according to Ferdinandy-Szentgyörgyi.

Researchers found new ischemic lesions in two of the 15 asymptomatic patients who underwent MR. Two of those patients developed restenosis.

"There is some silent embolization that occurs in carotid artery stenting," Ferdinandy-Szentgyörgyi said.

All 150 patients were followed for one month, 97 for six months, and 50 for a year. The restenosis cases occurred in the group followed for a year.

Ferdinandy-Szentgyörgyi concluded that stenting is not only a safe alternative to surgery, but it is the first choice for this patient population. Few patients undergo endarterectomy at the University of Szeged, she told Diagnostic Imaging.

When questioned about not using protective filters, Ferdinandy-Szentgyörgyi said that the devices protect only during the procedure and debris that comes afterward is not protected. Furthermore, some believe the devices themselves cause complications such as TIA.

"If we use the most precise stents available on the market and quickly and very carefully do the procedure, we are better off than doing the procedure with a protective device," she said.

In another presentation, Dr. Johann Link and colleagues from Regensburg, Germany, reported that results from three-year follow-up indicate a higher restenosis rate in carotid stenting than in carotid surgery.

Of the 87 patients included in this trial, 43 were randomized for stenting, and 44 for surgery. Each patient underwent a neurological examination, duplex ultrasound, and MRI brain scan before and after the defined procedure.

In the stent group, primary technical success was achieved in 42 of the 43 patients. Complications included three TIAs and one reperfusion syndrome, which resolved completely. Five restenoses greater than 50% have been recorded thus far.

In the surgery group, primary technical success was achieved in 42 of the 44 patients. Recorded complications are one myocardial infarction, three TIAs, and five hematomas (four required surgical revision). No reported restenosis occurred.

The researchers concluded that further results of ongoing multicenter studies must be evaluated to define definite treatment strategies.