Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease
To the Editor:
Three days before reading the article by Golledge et al,1 I recommended carotid stenting to a 74-year-old patient with critical asymptomatic left internal carotid artery stenosis. After reading the article, I was tempted to reconsider my recommendation, but a closer analysis reveals multiple flaws in the reasoning of Golledge et al.
The authors cite 14 endovascular studies published from 1992 through 1998 involving a total of 714 carotid arteries, of which 230 were treated with stenting. Three of the studies recruited fewer than 15 patients. The 20 studies on carotid endarterectomy (including the authors’ own article) were published from 1990 through 1999 and recruited 63 to 1997 patients. One cannot compare carotid endarterectomy, a technology that is several decades old, to carotid stenting, a technique that is only several years old. Carotid stenting has a very significant learning curve. To compare carotid endarterectomy in its infancy to carotid stenting in its infancy would be more valid.
I explained to my patient that he was being referred to a physician who had performed some 700 procedures (Dr Gary Roubin, personal communication, June 5, 2000). Vascular surgeons such as Dr Golledge may envision a “turf war” with the endovascular experts. I view stenting as a safer, less-invasive approach for my patients—provided that they are not part of the physician’s “learning curve.”
- Copyright © 2000 by American Heart Association
Golledge J, Mitchell A, Greenhalgh RM, Davies AH. Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease. Stroke.. 2000;31:1439–1443.
I read with interest the comments of Dr Jeret regarding our article published in Stroke this year. Dr Jeret correctly states that a number of the series of carotid angioplasty were small, while in general the carotid endarterectomy series were larger. Dr Jeret also points out correctly that carotid stenting is an evolving technique at present. It is also true to state that carotid endarterectomy has been demonstrated in enormous randomized controlled trials as the treatment of choice for patients with symptomatic severe carotid stenosis; unfortunately, such data is not available for carotid stenting. Dr Jeret states “I view stenting as a safer, less-invasive approach for my patients.” Where are the data for this? Surely, the only scientific way of proving the value of stenting is from randomized control trials. As stated in our article, only 1 published randomized trial presently exists.R1 This study was stopped after only recruiting around 15 patients because of the severe complications with the stenting group.
Ideally, we would have liked to perform a meta-analysis comparing randomized studies of stenting with carotid endarterectomy; owing to the paucity of randomized trials, such a comparison was not possible. Due to the increasing numbers of reported series of carotid stenting, we felt that some sort of comparison was badly needed so we could correctly advise patients of the most appropriate treatment at present. Hence the analysis we presented in our article, which shows that in the present state of the art, carotid stenting would not be advised for most patients with symptomatic carotid artery disease. Surely if we are to introduce a new technique for the treatment of symptomatic carotid artery disease we have to ensure that it is safe to do so, in both the short and long terms. The present data would suggest that carotid stenting is not a safe option in the majority of hands and therefore should be introduced only as part of carefully controlled studies. I would disagree with Dr Jeret’s opinion and feel that the flaws in the reasoning come from Dr Jeret’s idea that the evidence presently available demonstrates that stenting is a safer option.
Naylor AR, Bolia A, Abbott RJ, Pye IF, Smith J, Lennard N, Lloyd AJ, London NJ, Bell PR. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg.. 1998;28:326–334.