Carotid stent has higher stroke risk than surgery

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Implanting a device called a stent in neck arteries is more likely to cause a stroke or death than surgically removing life-threatening blockages, U.S. researchers said on Monday.

But patients who get surgery known as carotid endarterectomy to clear blockages in their neck arteries are more likely to have nerve damage and heart attacks, they said.

The findings culled from an analysis of 13 clinical trials comparing the two approaches to preventing strokes add to the debate over which approach to stroke prevention is best.

Many trials have tried to answer the question. For many doctors, the answer is: It depends on the patient.

“Both therapeutic procedures are effective,” Dr. Louis Caplan of Beth Israel Deaconess Medical Center in Boston and Dr. Thomas Brott of Mayo Clinic in Florida, said in a commentary in the Archives of Neurology. “Both procedures showed a relatively low rate of serious complications. Surgery is superior concerning some outcomes; stenting seems to have advantages in others.”

For years, carotid endarterectomy - in which doctors cut open the neck, scrape away the fatty deposits in the artery and sew it back up - has been the preferred way to clear dangerous fatty deposits in neck arteries that can cause strokes.

Carotid artery stenting, a newer approach, involves threading a wire mesh coil called a stent in the neck artery to widen the blocked area and capture any dislodged plaque that could travel to the brain and cause a stroke.

Dr. Sripal Bangalore of New York University School of Medicine and Harvard Clinical Research Institute compared the results of clinical trials comparing the two treatments that involved more than 7,000 patients.

They found patients who got a carotid stent had a 19 percent higher risk of strokes or death compared with patients who had surgery.

But patients who had a stent had a 55 percent lower risk of heart attack and 85 percent reduction in the risk of injury to the cranial nerve compared with surgery.

“Strategies are urgently needed to identify patients who are best served by carotid artery stenting versus carotid endarterectomy,” the team wrote in the Archives of Neurology.

Dr. Chris White, president-elect of the Society for Cardiovascular Angiography and Interventions, a group for doctors that do stenting procedures, said in a telephone interview that for many doctors, the best approach is to make the choice based on what is best for the patient.

“Basically, the message that I’ve taken from the last year from all of the trials has been that overall ... there are patients who will do better with stenting and some who will better with carotid endarterectomy,” White said in a telephone interview.

“Who those patients are will be difficult to sort out,” he said.

Several medical device makers sell carotid stents, including Boston Scientific Corp, Abbott Laboratories, Johnson & Johnson, Ev3 Inc and C.R. Bard Inc.

SOURCE:  Archives of Neurology, online October 11, 2010.

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