Neck Surgery Less Risky Than Stents?
When it comes to opening blocked carotid arteries, surgery may be less risky than stents. That's according to a study by French doctors including Jean-Louis Mas, M.D., of the Hospitaux Sainte-Anne in Paris.
The carotid arteries run through the neck, taking blood to the brain. They can become narrowed from plaque buildup, making strokes more likely.
Mas' team found that patients who got surgery instead of stents to open the carotid arteries were less likely to die or have strokes in the first six months after their procedure.
But don't jump to conclusions.
While the French study "raises concern" about carotid artery stenting, it "cannot be considered the final word" on the topic, a journal editorialist cautions. The study and editorial appear in The New England Journal of Medicine.
Surgery to open a carotid artery is an older procedure than stenting.
With the surgery, surgeons first make a small cut in the neck to reach the carotid artery. They may temporarily reroute blood flow as they open the carotid artery and remove the plaque inside.
In the stenting procedure, doctors insert tiny metal mesh tubes, called stents, to open up the artery. The stent is put into place via a specially designed catheter. This catheter is introduced through a small puncture in a blood vessel in the groin and tracked up to the carotid artery in the neck.
Though stents are used in various blood vessels, this study covered only carotid artery stenting.
Mas' team studied 527 French patients who had a carotid artery at least 60% more narrow than normal. The patients had all experienced a non-disabling stroke, or "mini-stroke," because of the blockage. The researchers randomly assigned patients to get carotid artery surgery or stents.
Over the next six months, 6 percent of the surgery group died or had a stroke, compared with about 11 percent of the stent group.
"The rates of death and stroke at 1 and 6 months were lower with endarterectomy [carotid artery surgery] than with stenting," the researchers write. They stopped the experiment early due to those findings and called for larger, longer studies to check their results.
The journal also carries an editorial by Anthony Furlan, M.D., of The Cleveland Clinic. He says the FDA only allows carotid artery stents for people who meet all of these requirements:
The French study used a lower minimum standard of 60 percent narrowing, Furlan notes. He adds that the French doctors may have faced a "learning curve" in using new stents and other devices.
"For all these reasons, although the trial raises concerns about the safety of carotid stenting and bolsters the call for standardized training and credentialing requirements, it cannot be considered the final word on carotid stenting for patients with an average surgical risk," Furlan writes.
Furlan's bottom line: Given current evidence, the only widely accepted use of carotid artery stents is for high-risk symptomatic patients with at least a 70 percent narrowing of their carotid arteries.
"All other patients should be treated medically, undergoing carotid endarterectomy if indicated, or should be placed in a clinical trial," Furlan writes.
SOURCES: Mas, J. The New England Journal of Medicine, Oct. 19, 2006; Vol. 355: pp. 1660-1671. WebMD Medical Reference from Healthwise: "Carotid Endarterectomy for TIA and Stroke." WebMD Medical News: "FDA Approves Tiny Device to Prevent Stroke." Furlan, A. The New England Journal of Medicine, Oct. 19, 2006; Vol. 355: pp. 1726-1729.
By Miranda Hitti
Reviewed by Louise Chang, M.D