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(Stroke. 2005;36:912.)
© 2005 American Heart Association, Inc.

Emerging Therapies

Protected Carotid Artery Stenting Versus Endarterectomy in High-Risk Patients Reflections From SAPPHIRE

From the Neurology Department and Neurovascular Service, St Mary’s Hospital, London, UK.

Correspondence to D.J. Thomas, MD, Neurology Department and Neurovascular Service, St Mary’s Hospital, London, UK, W2 1NY. E-mail dayfdd.thomas@imperial.ac.uk

Section Editors: Marc Fisher MD Antoni Dávalos MD

Key Words: carotid stenosis • endarterectomy • randomized controlled trials • stents

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

	Introduction

 
The Stenting and Angioplasty with Protection in Patients at High Risk of Endarterectomy (SAPPHIRE) collaborators have attempted to perform a difficult trial.¹ It is of special interest because the majority of their randomized patients were asymptomatic. Their article in the New England Journal of Medicine¹ has already been much quoted and inevitably misquoted. The main result was that stenting with protection does not appear to be inferior to endarterectomy; particularly as far as peri-procedural risks are concerned. In asymptomatic carotid stenosis endarterectomy has been shown to halve stroke risk.² So some are assuming that stenting with protection should now be recommended in patients with asymptomatic carotid stenosis. This is a worry and may not be in the best interests of patients.

A number of criticisms of the SAPPHIRE trial need to be considered. Firstly, the authors have misinterpreted the previous carotid surgery trials by saying that carotid endarterectomy is more effective than medical management in stroke prevention; however these trials actually compared best medical treatment with best medical treatment plus carotid endarterectomy.^2,3,4,5 Best medical treatment has improved very considerably since the 2 major symptomatic^3,4 and 2 asymptomatic trials^2,5 were started, with better antiplatelet therapy, more efficient blood pressure control and the widespread use of statins. So the risks are now different, and historical controls may be misleading.

The patient characteristics in SAPPHIRE were not the same as in the carotid surgery trials. In particular there was a very high prevalence of significant coronary artery disease (approximately 85%), suggesting that their . . . [Full Text of this Article]

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