Asymptomatic Blocked Carotids Don't Need Surgery, Large Trial Shows

 

Why would you want to do stenting or endarterectomy at all if your doctor won't guarantee no problems?

I still don't understand why you would medically need to stent a carotid artery or do an endarterectomy at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery was closed for 10 years and I cognitively functioned quite well with no episodes of fainting.

Didn't your competent? doctor tell you of these possible complications of endarterectomy? NO? So, your doctor isn't competent?

Possible problems:

Cognitive Dysfunction and Mortality After Carotid Endarterectomy

Carotid Interventions for Women: The Hazards and Benefits

Female Gender Increases Risk of Stroke and Readmission after CEA(Carotid endarterectomy) and CAS(carotid artery stenting)

Ticagrelor Induced Angioedema Following Carotid Artery Stenting

Cognitive Dysfunction and Mortality After Carotid Endarterectomy

Here is why your doctor needs to GUARANTEE NO complications from stenting!

• stenting (22 posts to May 2011)

• carotid stenting (21 posts to May 2016)

• carotid artery stenting (7 posts to November 2021)

The latest here:

Asymptomatic Blocked Carotids Don't Need Surgery, Large Trial Shows

Stenting high-grade carotid stenosis did help prevent stroke or death, but experts question worth

Key Takeaways

• Most carotid-artery stenting or endarterectomy is done for asymptomatic cases.
• The large CREST-2 randomized trial now shows that endarterectomy holds no stroke and mortality benefit over intensive medical management alone.
• Stenting did provide a stroke or death prevention benefit over 4 years compared with medical treatment alone but the absolute difference in rates was small and experts suggested reserving this option for symptomatic patients.

For asymptomatic carotid stenosis, stenting helped prevent strokes compared with modern medical treatment whereas endarterectomy did not in the CREST-2 randomized trials.

The primary composite endpoint of any stroke or death at 44 days or ipsilateral ischemic stroke out to 4 years of follow-up occurred in 2.8% of patients randomly assigned to carotid stenting versus 6.0% in those on medical therapy alone (P=0.02), reported James F. Meschia, MD, of the Mayo Clinic in Jacksonville, Florida, and colleagues in the New England Journal of Medicine.

That rate was 3.7% with endarterectomy compared with 5.3% on medical therapy, a difference which didn't meet statistical significance (P=0.24).

"We can conclude that there is no longer a role for routine carotid endarterectomy in persons with asymptomatic stenosis," concluded an accompanying editorial by Martin M. Brown, FRCP, of University College London, and Leo H. Bonati, MD, of Basel University in Switzerland.

Some 75-80% of carotid-artery stenting or endarterectomy recipients in the U.S. are asymptomatic, although management has been controversial.

"Decades ago, surgery clearly helped prevent strokes in many patients," co-author Thomas Brott, MD, also of the Mayo Clinic in Jacksonville, noted in a statement. "But medical therapy has improved so much that we needed to reexamine the balance between benefit and risk for people who have no symptoms."

Along with the previous CREST trial that showed in 2010 that the two procedures had similar short- and longer-term outcomes in symptomatic and asymptomatic individuals at average surgical risk (albeit with more periprocedural strokes in the stenting group), the Second Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE-2) trial had similar results. The recent but smaller Second European Carotid Surgery Trial (ECST-2) also showed no advantage to revascularization over medical management alone.

But despite statistical significance favoring stenting in CREST-2, the editorialists cautioned against widespread adoption for asymptomatic but high-grade (≥70%) stenosis like that in the trial.

"The benefit from revascularization of asymptomatic carotid stenosis with regard to stroke prevention has become small with improved medical therapy," they wrote, calculating that the event rates meant 95 of every 100 patients would have had an unnecessary procedure over a 4-year period.

Also, the trial reflected a best-case scenario for the procedure, with careful selection of patients and skilled interventionists that would not be available in all vascular centers, Brown and Bonati noted. Medical therapy wasn't perfect either, with only 60-70% of the patients achieving a systolic blood pressure under 130 mm Hg, less than 80% getting LDL cholesterol within the 70 mg/dL target, and only about half of diabetes patients reaching HbA1c goals.

Since two-thirds of the events in patients treated with medical therapy alone were nondisabling strokes that would be expected to lead to good or fair recovery and put them in line for secondary prevention carotid revascularization, the editorialists suggested a pragmatic strategy: "We therefore consider it reasonable to advise patients with asymptomatic carotid stenosis to start intensive medical therapy immediately and to delay revascularization until such time as symptoms develop, which will occur in only a small proportion of patients. Exceptions would then be made for patients who prefer to take the risk of revascularization or who cannot take medical therapy -- in which case, stenting would be the choice for suitable patients at a center with skilled and experienced interventionists."

CREST-2 comprised two parallel trials in patients with at least 70% asymptomatic carotid stenosis seen at 155 centers in five countries. One trial randomly assigned 1,245 adults to receive either intensive medical management alone or with carotid-artery stenting. The other trial randomized 1,240 patients to intensive medical management alone or with endarterectomy.

Serious complications were uncommon with either procedure.

One limitation was the trials' single-blind design in which patients and treating physicians were aware of treatment group assignment; another was that the trial predated the new lower systolic blood pressure guidelines, the advent of PCSK9 inhibitors, and widespread dissemination of new, highly effective diabetes and obesity medication. Transcarotid-artery revascularization, while now in frequent use, wasn't incorporated in the trial.

Importantly, "the difference between stenting and medical management was based on a small number of events," the editorialists noted, such that the primary endpoint was fragile. Only three more events in the stenting group would have tipped the trial to a neutral finding.

Brott suggested that personalized decision making should play a key role, with stenting being more appealing particularly for patients with higher-grade stenosis or plaque that appears unstable or more likely to cause a blockage.

"What we need now are trials focusing on identification of the small proportion of patients with carotid stenosis in whom symptoms develop despite the use of medical therapy," the editorialists wrote, concurring with Meschia's group. "The most promising approach uses magnetic resonance imaging of carotid-artery plaque to identify intraplaque hemorrhage, a strong risk factor for stroke."