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Friday, February 26, 2010

So far carotid endarterectomy looks better than carotid stenting

"So far" here means according to the results of the interim analysis of the International Carotid Stenting Study (ICSS) surgery looks better. This trial has enrolled 1713 with symptomatic carotid artery stenosis to either endarterectomy or stenting with the major outcome of interest to be the three year outcome of fatal or disabling stroke.

The interim analysis focused on the 3 month comparison of the rate of stroke,death and procedural myocardial infarction in the two groups.The endarterectomy group experienced 27 such events versus 34 in the stenting group or 8.5 % versus 5.2%.

The authors offered this closing sentence:

Completion of long-term follow-up is needed to establish the efficacy of carotid artery stenting compared with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients suitable for surgery.

A earlier trial ( see here) in France also demonstrated the apparent superiority of surgery over carotid stenting.This was the EVa-3s trial which was stopped early for reasons of futility and safety.

For what it is worth the latest Medical Knowledge Self-Assessment Program MKSAP 15 says this about symptomatic ,severe (greater than 70%), carotid artery stenosis:

"carotid endarterectomy is still considered the gold standard..". (One may wonder why a retired internist is still ordering and reading MKSAP)

If I had to decide today in regard to my own neck I would opt for surgery .Of course, I live in an area populated with a large number of excellent, well experienced vascular surgeons and hospitals in which a lot of vascular surgery is performed.

ADDENDUM: (2/26/2010 1:00pm CST)
On the other hand maybe things might be a bit different in North American.The CREST trial results were just reported and seemingly stenting fares better but still not better than endarterectomy overall. Are American stentists more adept? Is comparative effectiveness research (CER) easy or what?


Anonymous said...

Confused.I know lets have someone do a meta-analysis which as always will settle the issue.

Michael Kirsch, M.D. said...

This is an issue that is ripe for comparative effectivness research (CER). Of course, if CER were done, and one treatment was deemed superior, the other side would attack the research. CER will become entangled with politics and personal agendas. www.MDWhistleblower.blogspot.com