Stenting or endarterectomy: the debate continues
Date: December 26, 2011
At 79, Doris Harrison was faced with a carotid artery that was more than 90 percent blocked. Just one year earlier, she’d had an endarterectomy to remove plaque from the same vessel at her local hospital. Now the blockage was back and she felt “awfully tired”—an unusual symptom for an active woman who had enjoyed going line dancing twice a week. She knew the vessel had to be cleared to reduce her risk of stroke. The question was, should she undergo a second endarterectomy or have a stent procedure to open the vessel?
To help sort through the risks and benefits of her two treatment options, Harrison sought advice from Bruce Perler, Johns Hopkins’ director of vascular surgery.
Deciding which patients should have endarterectomy and which are better suited for stenting was supposed to have been made easier by the CREST trial, the largest prospective randomized trial comparing the two interventions. Final results were published in July 2010 in the New England Journal of Medicine. The study, however, produced what Perler describes as a composite clinical outcome.
“If you look at the results,” says Perler, who participated in the trial, “the incidence of stroke was a little over 4 percent with stenting as opposed to 2.3 percent with endarterectomy. On the other hand, the risk of heart attack was 2.3 percent for endarterectomy compared to 1 percent for stenting.”
The results varied depending on the age of the patients. Younger patients did better with stenting. Among those over 69, there were significantly fewer complications with endarterectomy.
“The older the patient,” says Perler, “the more atherosclerosis in the vessels leading to the carotids, and we believe this increases the risk of stroke with stenting.”
Although younger patients tend to have healthier vessels, Perler continues, “you also have to consider the durability of the procedure. A number of studies showed that the rate of restenosis after a stent procedure was much higher than after endarterectomy. So if you have patients in their 50s and 60s with a lot of years ahead of them, you may run into the problem of recurrent disease down the line that becomes very difficult to treat once the vessel has been stented.”
Another issue following carotid procedures is the risk of silent infarctions, when microscopic bits of plaque go to the brain. While they don’t manifest as a stroke, there is growing evidence that they may lead to vascular dementia. The multicenter International Carotid Surgery Study found evidence of cerebral microembolization among 50 percent of patients following stenting compared to 15 percent who had endarterectomy.
Perler followed Harrison for three months before recommending surgery and repeat Duplex testing demonstrated further worsening of her blockage. Although a repeat endarterectomy would be more challenging because of the possible risk of cranial nerve damage due to previous scar tissue, Perler believed the most pressing concern was to avoid a stroke. The data show, especially among older patients, that stenting would increase that risk.
“After the operation, I began to have more energy,” Harrison says, “and I’m still doing well.”
Perler, who has a lot of experience with repeat endarterectomy, kept Harrison on statin medication at the time of the procedure. Johns Hopkins vascular surgeons were the first to show, in a study published in 2005, that patients who take statins have a much lower rate of stroke, death and heart attack with the surgery.
Reflecting on CREST, Perler concludes that “while it was a very well-done study, it hasn’t really settled the issue of which is the optimum treatment across the board.”
However, he believes that overall, endarterectomy is a safer procedure than stenting, because of the lower stroke risk, “especially since the primary goal of opening a blocked carotid artery is to prevent a stroke in the first place.”