The First Consensus Document of ICCS-SPREAD Joint Committee on Carotid Artery Stenting Was Not Premature But Prophetic
To the Editor:
We read with great interest the recent Letter to Editor1 raising questions on the First Consensus Document of the ICSS-SPREAD Joint Committee on Carotid Artery Stenting,2 and we were very surprised by these comments.
Many of these concerns start from a totally different point of view, ie, the “simplicity” of CAS (as stated in line 8). First of all, we have never considered CAS an easy procedure and we have never focused on the procedure, but we have stressed our focus on the patient experiencing a carotid stenosis. This remarkably different point of view is what led us to consider a “team approach” essential. “Economic conflict of interest” could arise only when a single solution is offered to patients by a single endovascular specialist, with a mind-set addressed to only one procedure.
Even if “the evidence of high risk is not evidence-based and is not universally shared”, we have known since the Consensus of opinion leaders3 in 2001 and the SAPPHIRE4 trial that there are general and local conditions that describe patients at high risk for carotid endarterectomy.
Again, we do not think that “the selection of symptomatic patients remains a conundrum”. Grade 1 evidence has been provided in this sense, as reported in the Consensus.2
Regarding training, we strongly stress the importance of a long learning curve, which can be achieved and maintained only with the numbers stated in the Consensus. Although we may agree that interventional cardiologists, as well as other specialists, were involved in the development of the CAS procedure, we believe that the heart is rather different from the brain, and that expertise cannot easily be translated from coronary to carotid arteries.
Inappropriate indications may be a real emerging problem, but the problem is even more relevant if the procedure is performed by a physician who offers the patient only one solution, without accepting a team approach.
In conclusion, we don’t believe that the publication of the ICCS-SPREAD Committee document was premature. The importance of a “team approach” and a “correct learning curve” for CAS were the key points of our early consensus, published in September 2006. Our document seems simply to have prefigured some possible inadequate outcomes (EVA-3S,5 N Engl J Med Oct 2006; SPACE trial,6 Lancet Oct 2006) that can occur if, dealing with a patient experiencing a carotid stenosis, these 2 key points are not strongly complied with.
Belli G, Presbitero P. Questions on the first consensus document of the ICCS-SPREAD Joint Committee on Carotid Artery Stenting. Stroke. 2007; 38: e54.
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.
Veith FJ, Amor M, Ohki T, Beebe HG, Bell PR, Bolia A, Bergeron P, Connors JJ 3rd, Diethrich EB, Ferguson RD, Henry M, Hobson RW 2nd, Hopkins LN, Katzen BT, Matthias K, Roubin GS, Theron J, Wholey MH, Yadav SS. Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders. J Vasc Surg. 2001; 33 (2 Suppl): S111–S116.
Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004; 351: 1493–1501.
Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, Larrue V, Lievre M, Leys D, Bonneville JF, Watelet J, Pruvo JP, Albucher JF, Viquier A, Piquet P, Garnier P, Viader F, Touze E, Giroud M, Hosseini H, Pillet JC, Favrole P, Neau JP, Ducrocq X; EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006; 355: 1660–1671.
SPACE Collaborative Group, Ringleb PA, Allenberg J, Bruckmann H, Eckstein HH, Fraedrich G, Hartmann M, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Stingele R, Zeumer H, Hacke W. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. 2006; 368: 1239–1247.