St Luke’s- Hospital Carotid Intervention Position Statement1

The faculty of the Division at St Luke’s – Roosevelt endorse the position recently taken by the Society for Vascular Surgery in regard to carotid artery surgery being superior to carotid stenting The faculty of the Division at St Luke’s – Roosevelt endorse the position recently taken by the Society for Vascular Surgery in regard to carotid artery surgery being superior to carotid stenting The full Society for Vascular Surgery statement follows The full Society for Vascular Surgery statement follows

The Society for Vascular Surgery® (SVS) believes the recently reported results of the Carotid Revascularization, Endarterectomy versus Stenting Trial (CREST) and International Carotid Stenting Study (ICSS) include several fine points that must be appreciated and incorporated into the practices of vascular surgeons. The differing results of the studies make it most important that physicians carefully and impartially balance their recommendations for treatment based upon the condition of each individual patient. The Society for Vascular Surgery® (SVS) believes the recently reported results of the Carotid Revascularization, Endarterectomy versus Stenting Trial (CREST) and International Carotid Stenting Study (ICSS) include several fine points that must be appreciated and incorporated into the practices of vascular surgeons. The differing results of the studies make it most important that physicians carefully and impartially balance their recommendations for treatment based upon the condition of each individual patient.

We are particularly excited about the improved results with carotid stenting, a technology that has been readily embraced by our specialty," said Anton Sidawy, SVS president. "SVS is in the best position to comment on this topic given the fact that ours is the specialty involved in the treatment of carotid disease using all three modalities; 1) medical therapy, 2) carotid endarterectomy (CEA), and 3) carotid stenting (CAS). The long-term tradition in the management of carotid disease and the ability of Vascular surgeons to use all three treatment modalities give them the advantage to provide the most impartial advice to patients." We are particularly excited about the improved results with carotid stenting, a technology that has been readily embraced by our specialty," said Anton Sidawy, SVS president. "SVS is in the best position to comment on this topic given the fact that ours is the specialty involved in the treatment of carotid disease using all three modalities; 1) medical therapy, 2) carotid endarterectomy (CEA), and 3) carotid stenting (CAS). The long-term tradition in the management of carotid disease and the ability of Vascular surgeons to use all three treatment modalities give them the advantage to provide the most impartial advice to patients."

There are some important similarities and differences between these two trials. Both trials, CREST and ICSS, demonstrate a major improvement in the results of CEA over previously reported randomized trials. The stroke and death rate for symptomatic patients undergoing CEA in CREST is almost half of what was reported in the previous NIH trial (North American Symptomatic Carotid Endarterectomy Trial, NASCET); and in ICSS is almost half of what was reported in the previous European Carotid Surgery Trial (ECST). This is consistent with the excellent results of CEA reported from many sources including administrative database studies, regional and national registries such as the National Surgical Quality Improvement Program (NSQIP). There are some important similarities and differences between these two trials. Both trials, CREST and ICSS, demonstrate a major improvement in the results of CEA over previously reported randomized trials. The stroke and death rate for symptomatic patients undergoing CEA in CREST is almost half of what was reported in the previous NIH trial (North American Symptomatic Carotid Endarterectomy Trial, NASCET); and in ICSS is almost half of what was reported in the previous European Carotid Surgery Trial (ECST). This is consistent with the excellent results of CEA reported from many sources including administrative database studies, regional and national registries such as the National Surgical Quality Improvement Program (NSQIP).

ICSS showed that endarterectomy had fewer complications than stenting and was therefore the preferred treatment; both strokes and heart attacks occurred more frequently after stenting. CREST showed that these two procedures were equivalent when all complications (stroke, heart attack, and death) were measured together. However, the primary and most important aim of CEA or CAS is to prevent a stroke, and strokes occurred more frequently after stenting. ICSS showed that endarterectomy had fewer complications than stenting and was therefore the preferred treatment; both strokes and heart attacks occurred more frequently after stenting. CREST showed that these two procedures were equivalent when all complications (stroke, heart attack, and death) were measured together. However, the primary and most important aim of CEA or CAS is to prevent a stroke, and strokes occurred more frequently after stenting.

While heart attacks occurred more frequently after endarterectomy, they appeared to be minor, affecting quality of life less than the strokes as determined by SF-36 quality of life study in CREST. Finally, since ICSS allowed the use of all approved stent devices, SVS feels that its results are going to be more reflective of routine clinical practice. CREST allowed the use of only one device, and its strict credentialing process for interventionalists served to produce a "best case scenario" for CAS While heart attacks occurred more frequently after endarterectomy, they appeared to be minor, affecting quality of life less than the strokes as determined by SF-36 quality of life study in CREST. Finally, since ICSS allowed the use of all approved stent devices, SVS feels that its results are going to be more reflective of routine clinical practice. CREST allowed the use of only one device, and its strict credentialing process for interventionalists served to produce a "best case scenario" for CAS

We believe that both CAS and CEA are useful tools for preventing stroke, but we believe that the majority of patients are still best served by CEA (surgery) rather than CAS (stenting)" said Dr. Sidawy. "We are reassured that vascular surgeons have adopted the new technology of CAS since low complication rates can be achieved in a carefully selected subgroup of patients." We believe that both CAS and CEA are useful tools for preventing stroke, but we believe that the majority of patients are still best served by CEA (surgery) rather than CAS (stenting)" said Dr. Sidawy. "We are reassured that vascular surgeons have adopted the new technology of CAS since low complication rates can be achieved in a carefully selected subgroup of patients."