Indication for Surgical Treatment of Carotid Arterial Stenosis in High-Risk Patients
The indication for carotid endarterectomy (CEA) or carotid artery stenting (CAS) has not been established, although the beneficial effects of these surgical treatments for severe cervical carotid stenosis have been confirmed by clinical trial studies. We
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Abstract The indication for carotid endarterectomy (CEA) or carotid artery stenting (CAS) has not been established, although the beneficial effects of these surgical treatments for severe cervical carotid stenosis have been confirmed by clinical trial studies. We report our clinical results of CAS and CEA and suggest an appropriate treatment strategy, especially for high-risk patients. From January 2001 to December 2009, we treated 171 carotid lesions by CEA and 251 lesions by CAS. Stenosis was symptomatic in 68%, and the average stenotic rate was 83% in the CEA group. In the CAS group, stenosis was symptomatic in 62%, and the average stenotic rate was 65%. Stenosis was relieved in all cases after CEA or CAS. Surgical mortality with CEA and CAS was 0.6% (1/171) and 0.4% (1/251), respectively. Surgical morbidity by ischemic stroke with CEA and CAS was 2.9% (5/171) and 1.2% (3/251), respectively. Surgical morbidity was not increased in patients with medical risk factors. The long-term outcome after CAS was not inferior to that after CEA. In conclusion, carotid stenosis can be treated with comparably low morbidity and mortality rates using CEA or CAS even in high-risk patients when the method is appropriately selected considering the characteristics of the carotid stenosis. Keywords Carotid endarterectomy (CEA) · Carotid artery stenting (CAS)
Introduction The benefit of surgical intervention for severe carotid stenosis has been confirmed by randomized clinical trials (RCT) [2, 4]. Two surgical therapeutic methods are available, carotid
T. Tsukahara (*), S. Fukuda, T. Nakakuki, M. Murakami, D. Arai, and S. Yamaguchi Department of Neurosurgery, National Hospital Organization, Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612–8555 Kyoto, Japan e-mail: [email protected]
endarterectomy (CEA) and carotid artery stenting (CAS), although no indication for CEA or CAS for cervical carotid stenosis has been established yet. A recent RCT reported that the stroke prevention effect was not statistically different between CEA and CAS for CEA high-risk patients [6]; however, to achieve a better outcome with surgical treatments, we have to select CEA or CAS considering not only the patient’s condition, but also the characteristics of carotid stenosis and plaque. In this study, we report our clinical therapeutic results of CAS and CEA and suggest an appropriate treatment strategy, especially for high-risks patient.
Materials and Methods From January 2001 to December 2009, we treated cervical carotid stenosis surgically in 171 lesions by CEA and 251 lesions by CAS. CEA was considered the first choice of the surgical treatment for severe carotid stenosis, especially with soft plaque, eccentric or tortuous lesions, and a narrow residual lumen with massive carotid plaque. CAS was chosen when CEA was considered to be high risk with: (1) a contralateral ICA lesion, (2) distal carotid lesion, (3) higher cervical lesion and (4) medical risk factors, such as untreated coronary heart disease. For bilateral caro
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