The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.

What should we do with asymptomatic carotid stenosis

Background: Carotid endarterectomy (CEA) is still considered the “gold-standard” of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS. Methods: A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS. Results: Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects–such as evolving best medical treatment, timely intervention, interventionalists’ experience, and analysis of plaque composition–may have important influences on the future treatment of patients with carotid artery stenosis. Conclusions: CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA. © 2008 Excerpta Medica Inc. All rights reserved.

Endarterectomy or carotid artery stenting: the quest continues

Outcomes after carotid endarterectomy: is there a high-risk population? A National Surgical Quality Improvement Program report.

Abdominal aortic aneurysms (AAAs) are the result of a progressive degenerative process characterized by elastin depletion and inflammatory changes of the aortic wall. The process leads to gradual enlargement and a localized weakening of the aorta, with eventual rupture. Risk factors include age, sex, family history, and smoking.1 The normal aortic diameter varies with age, sex, and body size. An infrarenal abdominal aorta with a diameter >3 cm is considered aneurysmal. The risk of rupture increases directly with aneurysm size, and the death rate associated with rupture is very high (90%). Surgical repair has been the standard therapy for patients with AAAs but is associated with a risk of death and a high rate of complication. Thus, in considering open repair, the risk of the procedure is weighed against the risk of rupture.2 Patients with AAA, especially those with larger aneurysms at high risk of rupture, are usually elderly, and most have multiple comorbidities that increase the risk of surgical treatment. The treating physician, therefore, must balance the natural history of AAA, the operative risk of treatment, and the life expectancy of the patient.

Two prospective, randomized trials of good-risk patients with small AAAs (4.0 to 5.5 cm) found no difference in all-cause death rate between patients who were monitored with ultrasound surveillance and those who underwent early surgical repair3,4; however, despite close surveillance with ultrasound, ruptures occurred in 1% of the monitored aneurysm patients each year. Risk of rupture is higher in women, patients who smoke, and those with a family history of aortic aneurysm. Furthermore, most patients with small AAAs undergoing surveillance in these studies ultimately required surgical repair because of AAA enlargement, development of symptoms, or rupture. Therefore, intervention for AAAs <5.5 cm in diameter may be justified in selected patients, and the …

Atherosclerotic Peripheral Vascular Disease Symposium II Controversies in Abdominal Aortic Aneurysm Repair

Importance Uncertainty exists about the influence of advanced age on the outcomes of carotid revascularization. Objective To undertake a comprehensive review of the literature and conduct an analysis of the outcomes of carotid interventions in the elderly. Design and Setting A systematic literature review was conducted to identify articles comparing early outcomes of carotid endarterectomy (CEA) or carotid stenting (CAS) in elderly and young patients. Main Outcomes and Measures Combined overall effect sizes were calculated using fixed or random effects models. Meta-regression models were formed to explore potential heterogeneity as a result of changes in practice over time. Results Our analysis comprised 44 studies reporting data on 512 685 CEA and 75 201 CAS procedures. Carotid stenting was associated with increased incidence of stroke in elderly patients compared with their young counterparts (odds ratio [OR], 1.56; 95% CI, 1.40-1.75), whereas CEA had equivalent cerebrovascular outcomes in old and young age groups (OR, 0.94; 95% CI, 0.88-0.99). Carotid stenting had similar peri-interventional mortality risks in old and young patients (OR, 0.86; 95% CI, 0.72-1.03), whereas CEA was associated with heightened mortality in elderly patients (OR, 1.62; 95% CI, 1.47-1.77). The incidence of myocardial infarction was increased in patients of advanced age in both CEA and CAS (OR, 1.64; 95% CI, 1.57-1.72 and OR, 1.30; 95% CI, 1.16-1.45, respectively). Meta-regression analyses revealed a significant effect of publication date on peri-interventional stroke ( P  = .003) and mortality ( P Conclusions and Relevance Age should be considered when planning a carotid intervention. Carotid stenting has an increased risk of adverse cerebrovascular events in elderly patients but mortality equivalent to younger patients. Carotid endarterectomy is associated with similar neurologic outcomes in elderly and young patients, at the expense of increased mortality.

https://jamanetwork.com/journals/jamasurgery/articlepdf/1757343/soi130108.pdf

Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly

Carotid endarterectomy in octogenarians: Does increased age indicate “high risk?”

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Carotid endarterectomy in octogenarians: Does increased age indicate “high risk?”