Carotid artery stenting versus endarterectomy for carotid stenosis
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The International Carotid Stenting Study (ICSS; March 20, p 985),1 which compared carotid artery stenting with carotid endarterectomy in patients with symptomatic carotid artery stenosis, showed a higher incidence of stroke and death with stenting than with endarterectomy. As the ICSS investigators mention, these results are consistent with those seen in previous randomised trials comparing stenting with endarterectomy in symptomatic patients (Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA-3S]2 and Stent-Protected Angioplasty versus Carotid Endarterectomy [SPACE]).3 As well as being associated with higher rates of stroke1,2 and recurrent carotid stenosis,3 carotid stenting is also substantially more costly than carotid endarterectomy.4 Thus, a reasonable question is: why should anyone attempt to establish carotid stenting as an alternative to carotid endarterectomy? Current data1–3 indicate that, with some exceptions (eg, distal lesions not accessible with carotid endarterectomy, previous irradiation therapy of the neck, and recurrent stenosis after previous endarterectomy), carotid endarterectomy should remain the gold standard for the treatment of carotid stenosis in symptomatic patients. Carotid stenting should be reserved for a minority of symptomatic patients for whom endarterectomy cannot be offered.5 I declare that I have no conflicts of interest.
Kosmas I Paraskevas
[email protected] Department of Vascular Surgery, Red Cross Hospital, Iraklio 14122, Athens, Greece 1
International Carotid Stenting Study Investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375: 985–97.
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Mas JL, Trinquart L, Leys D, et al; EVA-3S investigators. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008; 7: 885–92. Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol 2008; 7: 893–902. McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008; 48: 1442–50. Paraskevas KI, Mikhailidis DP, Veith FJ. Are symptomatic patients appropriate candidates for carotid artery stenting? No (at least not at present). Vascular (in press).
We would like to congratulate the International Carotid Stenting Study (ICSS) investigators1 for including myocardial infarction in the main outcome measure for the interim safety analysis at 120 days. Indeed, although the prevalence of coronary artery disease is known to be high in patients with carotid stenosis, cardiac complications have been frequently neglected in carotid revascularisation trials. However, neither in the current publication nor in the paper describing the trial protocol2 do the authors mention whether cardiac enzymes were obtained routinely after the procedure or only in the presence of clinical suspicion of myocardial ischaemia. On the basis of the exceedingly low incidence of myocardial infarction reported in the trial (
