Is it time to update the treatment result of extracranial internal carotid artery stenosis?
Editorial

Is it time to update the treatment result of extracranial internal carotid artery stenosis?

Sukwoo Hong^

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA

^ORCID: 0000-0002-3664-9245

Correspondence to: Sukwoo Hong, MD. Department of Neurological Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. Email: honsohkaisei6031@gmail.com.

Comment on: Cho JS, Song S, Huh U, et al. Comparing carotid endarterectomy and carotid artery stenting: retrospective single-center analysis. Ann Palliat Med 2022;11:3409-16.

Keywords: Carotid stenosis; revascularization; stent; endarterectomy

Submitted Nov 14, 2022. Accepted for publication Dec 16, 2022. Published online Dec 27 2022.

doi: 10.21037/apm-22-1292

Extracranial internal carotid artery stenosis is one of the major causes of ischemic strokes accounting for 8–20% (1,2). Its management includes the best medical treatment (BMT), carotid artery stenting (CAS), and carotid endarterectomy (CEA). The comparisons between these three methods have been studied extensively. To decide the treatment, we need to consider whether it is symptomatic. Symptomatic disease is characterized by one or more transient ischemic attacks of neurologic dysfunction, amaurosis fugax, or one or more ischemic strokes within the previous six months (3,4). If symptomatic with 50–99% stenosis of the internal carotid artery, CAS and CEA can be considered (5-8). On the other hand, if asymptomatic, CAS and CEA can be considered for 60–99% stenosis (6,8-10). We need to factor in patients’ specific factors including age, sex, comorbidities, and anatomical factors among others, to decide CAS or CEA. Patients 75 years old or younger had a better outcome after CAS compared to older patients (11,12). However, even for elderly patients, if there is no vascular tortuosity, calcification, or decreased cerebral reserve, CAS was shown to be safely performed (13).

Non-exhaustive past studies on the outcomes of CAS and CEA were summarized in Table 1 (5-10,14-19). In earlier studies, periprocedural strokes were more common in patients treated with CAS (5-7). However, in the later studies including the one performed by Cho et al., periprocedural strokes after CAS and CEA were comparable (8-10,16). One study even showed periprocedural stroke rate was higher in patients treated with CEA (18). In the study performed by Cho et al. (16), they performed a single-center retrospective study on the patients treated with CEA (107 patients) and CAS (128 patients) between 2012 and 2020. No statistically significant differences were observed in myocardial infarction (CAS group, 0.8%; CEA group, 0.9%), cerebral infarction (CAS group, 3.1%; CEA group 0.9%), or death (CAS group, 0.8%; CEA group 0%), within 30 days after surgery. In their study, they found no difference in outcome between CEA and CAS. This may reflect the advancement of the endovascular device including stroke protection filter and flow-reversal technique (20,21). We need to keep in mind that compared to the past now that various endovascular devices are developed, we need to update the result from past studies (22). The way of embolic protection during CAS is not necessarily the same as in past studies, which showed higher periprocedural stroke rates in patients treated with CAS (5-7). A nationwide study on patients treated either with CEA or CAS during 2010–2015 showed CEA patients had a higher periprocedural stroke rate than CAS patients after matching for characteristics and morbidity (18). This result is contradictory to that of the CREST study which studied patients treated during 2000–2008 (6). Since drugs, surgical armamentariums, and devices are constantly improving, we may need to update the outcomes of the three approaches. As for BMT, we need to keep in mind that it is one thing to recommend the BMT and it is another that the patients are complying with the BMT. It is sometimes hard to abide by diet restrictions and smoking cessation (23-25). We need to consider the medical cost as well. The mean hospital costs were lower for CEA compared with CAS (18).

Table 1

Summary of studies on carotid endarterectomy and carotid artery stenting

Author, year Study design† Study period Results 1 Results 2
Yadav et al., 2004 (SAPPHIRE) RCT; symptomatic with 50–99%; asymptomatic with 80–99%; high risk patients 2000–2002 CAS with an embolic-protection device is not inferior to CEA The 1-year incidence of major cardiovascular event: CEA group, 20%; CAS group 12%
Mas et al., 2006 (EVA-3S) RCT; symptomatic with 60–99% 2000–2005 The rate of stroke or death at 1 and 6 months more common in CAS 30-day incidence of any stroke or death: CEA group, 3.9%; CAS group, 9.6%
Brott et al., 2010 (CREST) RCT; symptomatic with 50–99% stenosis; asymptomatic with 60–99% stenosis 2000–2008 No difference in 4-year rates of the primary endpoint. The 4-year rate of stroke or death more common in CAS. Periprocedural stroke more common in CAS. Periprocedure MI more common in CEA Periprocedural‡ incidence: death (CEA group, 0.3%; CAS group, 0.7%), stroke (CEA, 2.3%; CAS, 4.1%), MI (CEA, 2.3%; CAS, 1.1%)
Bonati et al., 2015 (ICSS) RCT; symptomatic with 50–99% stenosis 2001–2008 Median follow-up of 4.2 (IQR, 3.0–5.2) years. Strokes more common in CAS. No difference in the number of fatal or disabling strokes –
Howard et al., 2016 Meta-analysis; symptomatic – Periprocedural stroke and death more common in CAS for patients aged 70–74 years old –
Rosenfield et al., 2016 (ACT-1) RCT; asymptomatic with 70–99% stenosis 2005–2013 CAS non-inferior to CEA with regard to the primary composite endpoint. No difference in stroke or death rates up to 5 years of follow-up –
Cole et al., 2020 Data base analysis with matching; symptomatic and asymptomatic 2010–2015 Periprocedural stroke more common in CEA for symptomatic patients. Inpatient mortality higher in CAS –
Halliday et al., 2021 (ACST-2) RCT; asymptomatic with 60–99% stenosis 2008–2020 No difference in stroke rate between CEA and CAS during a mean 5 years of follow-up 30-day incidence: any stroke (CEA, 2.4%; CAS, 3.6%), any MI (CEA, 0.7%; CAS, 0.3%)
Pasqui et al., 2021 Retrospective study; women; symptomatic with 50–99% stenosis; asymptomatic with 80–99% stenosis 2013–2019 No difference in periprocedural ischemic stroke. No difference in 6-year ipsilateral stroke/TIA/mortality. Restenosis rate during 6 years more common in CEA 30-day incidence: death (CEA, 0%; CAS, 0.8%), stroke 0%, MI 0%
Hasan et al., 2022 Systematic review – Symptomatic low-risk surgical patients: 120-day stroke and mortality favored CEA –
Cho et al., 2022 Retrospective study; CEA [107], CAS [128]; symptomatic with 50–99% stenosis [164]; asymptomatic with 70–99% stenosis [71]; CAS for certain conditions§ 2012–2020 No difference in 30-day MI and mortality. No difference in stroke during the follow-up of 34±29 months 30-day incidence: death (CEA, 0%; CAS, 0.8%), cerebral infarct (CEA, 0.9%; CAS, 3.1%), MI (CEA, 0.9%; CAS, 0.8%)
CREST-2 RCT; asymptomatic with 70–99% stenosis 2014–2026 Estimated completion in 2026 –

†, stenosis by NASCET criteria; ‡, when the procedure was performed within 30 days after randomization, the periprocedural period was defined as the period from randomization through 30 days after the procedure. When the procedure was not performed within 30 days after randomization, the periprocedural period was defined as the period from randomization through 36 days after randomization; §, Class III/IV congestive heart failure or angina, coronary artery occlusive disease involving more than two vessels or left main coronary artery, ejection fraction ≤30%, recent MI, and severe lung or renal disease. Prior neck surgery or radiation. Prior CEA. Lesion above the C2 vertebra. SAPPHIRE, stenting and angioplasty with protection in patients at high risk of endarterectomy; RCT, randomized controlled trial; CAS, carotid artery stenting; CEA, carotid endarterectomy; EVA-3S, endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis; CREST, carotid revascularization endarterectomy versus stenting trial; MI, myocardial infarction; ICSS, international carotid stenting study; IQR, interquartile range; ACT, asymptomatic carotid trial; ACST, asymptomatic carotid surgery trial; TIA, transient ischemic attack; NASCET, north American symptomatic carotid endarterectomy trial.

Since no distinctly superior method has been identified in the many high-quality studies, both CAS and CEA may be acceptable in the hands of well-trained surgeons if patients are appropriately selected. We need to consider the advancement of endovascular devices among advancements in other fields and update the treatment result periodically.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1292/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Hong S. Is it time to update the treatment result of extracranial internal carotid artery stenosis? Ann Palliat Med 2023;12(1):3-6. doi: 10.21037/apm-22-1292

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