Response to the Letter by Froio and Biasi
We have read with interest the comments of Drs Froio and Biasi, who discussed their findings of a significant relation between plaque echolucency and the risk of stroke in carotid artery stenting (CAS).1 They concluded that the discrepancy between their findings and our results, indicating no significant effect of plaque morphology on the outcome after CAS, based on the high training level of our institution.1,2 The effect of learning in CAS has also been demonstrated by our group and is of course a major predictor of neurological outcome.3 Paying attention to the competency of the physicians performing CAS has additionally been pointed out by the Italian Consensus Carotid Stenting/SPREAD group, whose members also participated in the ICAROS trial.4
Therefore, we agree completely that the learning curve in CAS is fundamental. However, the authors’ conclusion that our results are not representative for the “real world” because of the high experience of our interventionists has to be challenged. One could argue that to identify an independent predictor of outcome of any intervention, it is important to rule out a “human” factor caused by untrained physicians, which might influence the final results.
Nevertheless, because of the missing literature dealing with this point, we cannot rule out an effect of plaque morphology on treatment performed by inexperienced interventionists or in elderly patients. Additionally, it would be interesting to perform a randomized trial analyzing a potential benefit of plaque evaluation for the selection of brain protection devices.
Biasi GM, Froio A, Diethrich EB, Deleo G, Galimberti S, Mingazzini P, Nicolaides AN, Griffin M, Raithel D, Reid DB, Valsecchi MG. Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation. 2004; 110: 756–762.
Reiter M, Bucek RA, Effenberger I, Boltuch J, Lang W, Ahmadi R, Minar E, Schillinger M. Plaque echolucency is not associated with the risk of stroke in carotid stenting. Stroke. 2006; 37: 2378–2380.
Cremonesi A, Setacci C, Bignamini A, Bolognese L, Briganti F, Di Sciascio G, Inzitari D, Lanza G, Lupattelli L, Mangiafico S, Pratesi C, Reimers B, Ricci S, de Donato G, Ugolotti U, Zaninelli A, Gensini GF. Carotid artery stenting: first consensus document of the ICCS-SPREAD Joint Committee. Stroke. 2006; 37: 2400–2409.