Newly published guidelines suggest expanded use for carotid artery stenting

Brott T. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2010.11.005.

Issue: March 2011

The 2011 Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease was recently published, highlighting the safety and efficacy of carotid artery stenting for patients requiring revascularization.

The guidelines, a joint collaboration between 14 organizations, including the American College of Cardiology Foundation, the American Heart Association and the Society for Cardiac Angiography and Interventions, were based upon a comprehensive review of literature relevant to carotid and vertebral artery interventions up until May 2010. They detail several indications for revascularization and make recommendations on the appropriate treatment regarding carotid artery stenting (CAS), carotid endarterectomy (CEA) and drug therapy, as well as appropriate diagnostic modalities.

Specifically, for selecting patients for carotid revascularization, the guidelines state that CAS may be considered in patients with asymptomatic carotid stenosis with a minimum of 60% detected by angiography or 70% detected by validated Doppler ultrasound. This recommendation follows less than a week after the FDA advisory panel vote that recommended expansion of the availability of CAS in patients at standard risk for surgical complications due to findings of the CREST trial.

The guidelines state that it is reasonable to perform CAS over CEA in patients with neck anatomy unfavorable for surgery and those with transient ischemic attack or stroke without contraindications to early revascularization, whereas CEA is advisable in older patients, as well as asymptomatic patients with more than 70% stenosis if the risk of stroke, MI and death is low.

However, members of the writing committee and task force said there are still many opportunities for future research because the CREST trial, although answering important questions, raised others.

“The most pressing question is how either technique of revascularization compares with intensive contemporary medical therapy, particularly among asymptomatic patients,” they said. “A direct comparative trial should include a sufficiently broad range of patients to permit meaningful analysis of subgroups based on age, sex, ethnicity and risk status.”

The executive summary, as well as the full text of the 2011 guidelines, can be accessed here.

This represents an acknowledgement that carotid stenting has and will have a major role going forward in treatment of carotid artery disease, both symptomatic and asymptomatic and both high-risk and conventional and standard surgical risk patients. That is a big step forward for patients because it now gives them choices.

One of the things the guideline underscores is the importance of optimal medical therapy with current medical therapy. For patients that have optimal medical therapy, some will be appropriate for revascularization on top of that, and these guidelines and the advisory panel meeting and the results of the CREST trial all support the concept that CAS as another equally effective modality to CEA.

I and others would urge the CMS and other payers to re-evaluate and consider covering this alterative so that patients can have options. Therapy for each patient will be individualized. My experience is that there are going to be 20% to 25% of patients that are better for one therapy or another and then a large group of patients, 50% or more, that could be treated with either modality equally effectively. And in those instances, it’s going to be an individualized choice between the patient and the physician, and that’s appropriate.

Finally, I would like to emphasize three things. First, this represents a paradigm shift. Second, as far as I’m concerned, outcomes for both stenting and surgery have not been tracked adequately. They need to be monitored by independent neurologic assessment. And, lastly, just like with any medical procedure, comprehensive and in-depth training makes a difference, and it’s really important with CAS, just like with CEA, to ensure that we have properly trained physicians doing this procedure, and that they’re carefully monitored. Preferably this would be in a national standardized database such as one offered by the National Cardiovascular Data Registry, called the CARE (carotid artery revascularization and endarterectomy) registry, which monitors the results of patients that undergo CAS or CEA. We would support all efforts in this regard.

– Ken Rosenfield, MD
Member, Society for Cardiac Angiography and Interventions
Head of Vascular Medicine, Massachusetts General Hospital, Boston

Disclosure: Dr. Rosenfield was involved in the creation of the CARE registry.