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(Stroke. 2003;34:834.)
© 2003 American Heart Association, Inc.

Letters to the Editor

Carotid Angioplasty and Stenting in High-Risk Patients With Severe Symptomatic Carotid Stenosis

Section of Vascular Surgery, Department of Medical & Surgical Sciences, University of Padua, Padua, Italy

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

In a recent article, Fox et al¹ claim to have demonstrated the beneficial effect of a carotid angioplasty and stenting (CAS) procedure performed in a consecutive series of "poor surgical candidates" with severe symptomatic carotid stenosis by comparison with the outcome observed in medically-treated patients in the North American Symptomatic Carotid Endarterectomy Trial (NASCET).² In our opinion, the conclusions drawn by the authors are misleading for the following reasons.

First, the authors present a data analysis on a case series, for which the reader is simply informed of the fate of a relatively small sample of patients (n=42) (level V evidence).³ This type of retrospective study can hardly be used to dispute the results of a prospective, randomized trial, such as the NASCET,² designed to test a specific hypothesis (level I evidence): this defies logic.

Second, the authors acknowledge that most, if not all, of the patients in their series would have been excluded from NASCET for specific reasons - namely, medical risk factors (9.5%), angiographic risk factors (47.6%), restenosis after carotid endarterectomy (CEA) (40.4%), and stenosis after neck irradiation (9.5%)—and that "it would have been reasonable to assume that these patients would have had a similar natural history risk of stroke if left untreated as the NASCET medical treated patients". This assumption is a biased conjecture since the NASCET medically-treated patients form a carefully-selected group that met the same inclusion criteria as the surgically-treated patients. Indeed, the relatively strict inclusion/exclusion criteria in the most influential surgical . . . [Full Text of this Article]

Colin P. Derdeyn, MD; Douglas Fox, MD; Christopher J. Moran, MD; DeWitte T. Cross, III, MD Ralph G. Dacey, Jr, MD

Interventional Neuroradiology Services, Mallinckrodt Institute of Radiology and the Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri