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SURGERY OR ANGIOPLASTY FOR REDUCING STROKE FROM CAROTID STENOSIS? (pp 1722, 1729)

May 31, 2001

A non-surgical approach for preventing stroke for patients with partial blockage of the carotid artery might have similar long-term outcomes and fewer complications than standard surgical techniques, conclude authors of a study in this week's issue of THE LANCET.

Percutaneous transluminal angioplasty (balloon dilation) and stenting (insertion of a wire mesh), known as endovascular treatment, can be used to treat narrowing of the carotid artery (carotid stenosis); however, the risks and benefits associated with these techniques are uncertain. The CAVATAS study group led by Martin Brown from the National Hospital for Neurology and Neurosurgery, London, UK, compared endovascular treatment with conventional carotid surgery.

In a multicentre clinical trial (which included patients from Europe, Australia, and Canada), the investigators randomly assigned 504 patients with carotid stenosis to endovascular treatment (251 patients) or carotid artery surgery (253 patients). Stents were used in 55 (26%) and balloon angioplasty alone was used in 158 (74%) of treated endovascular patients.

The rates of major outcome events within a month of first treatment did not differ significantly between endovascular treatment and surgery (6.4% compared with 5.9%, respectively, for disabling stroke or death; 10.0% compared with 9.9% for any stroke lasting more than 7 days, or death). Cranial neuropathy was reported in 22 (8.7%) surgery patients, but not after endovascular treatment. Major groin or neck haematoma occurred less often after endovascular treatment than after surgery (1.2% compared with 6.7%). At 1 year after treatment, severe (70-99%) ipsilateral carotid stenosis was more usual after endovascular treatment (14% compared with 4%). However, no substantial difference in the rate of stroke occurred 3 years after the study.

In an accompanying Commentary (p 1729), David Spence and Michael Eliasziw from the Robarts Research Institute, London, Ontario, Canada, comment that CAVATAS would probably have been stopped early had the surgical outcomes been as expected. However, the outcomes were poor (the disabling stroke and death rate was 5.9% among the surgical patients and 6.4% among the angioplasty patients). David Spence comments: "Sadly, these results are probably representative of clinical practice, unlike those from the three large clinical trials of carotid endarterectomy, for which the average perioperative rate of disabling stroke or death was 2.3% and the rate of any stroke or death was 6.3%". He concludes: "At present, carotid angioplasty should clearly not be done routinely for patients with severe symptomatic stenosis, and it definitely should not be done for patients with moderate symptomatic or any degree of asymptomatic stenosis. It is conceivable that highly selected patients may benefit from angioplasty-for example, patients with a symptomatic severe stenosis that is not surgically accessible, or patients who are at high surgical risk because of severe cardiac disease".

Contact: Professor Martin M Brown, Section of Vascular Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; T) +44 (0)20 7829 8753; F) +44 (0)20 7833 8613; E) m.brown@ion.ucl.ac.uk

Professor J David Spence, Stroke Prevention & Atherosclerosis Research Center, Siebens-Drake/Robarts Research Institute, 1400 Western Road, London, Ontario, N6G 2V2, Canada; T) +1 519 663 3113 x33113; F) +1 519 663 3018; E) dspence@rri.on.ca


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