Is it time to update the treatment result of extracranial internal carotid artery stenosis?

Sukwoo Hong
2022 Annals of Palliative Medicine  
Extracranial internal carotid artery stenosis is one of the major causes of ischemic strokes accounting for 8-20% (1,2). Its management includes the best medical treatment (BMT), carotid artery stenting (CAS), and carotid endarterectomy (CEA). The comparisons between these three methods have been studied extensively. To decide the treatment, we need to consider whether it is symptomatic. Symptomatic disease is characterized by one or more transient ischemic attacks of neurologic dysfunction,
more » ... urosis fugax, or one or more ischemic strokes within the previous six months (3, 4). If symptomatic with 50-99% stenosis of the internal carotid artery, CAS and CEA can be considered (5-8). On the other hand, if asymptomatic, CAS and CEA can be considered for 60-99% stenosis (6, (8) (9) (10) . We need to factor in patients' specific factors including age, sex, comorbidities, and anatomical factors among others, to decide CAS or CEA. Patients 75 years old or younger had a better outcome after CAS compared to older patients (11, 12). However, even for elderly patients, if there is no vascular tortuosity, calcification, or decreased cerebral reserve, CAS was shown to be safely performed (13). Non-exhaustive past studies on the outcomes of CAS and CEA were summarized in Table 1 (5-10,14-19). In earlier studies, periprocedural strokes were more common in patients treated with CAS (5-7). However, in the later studies including the one performed by Cho et al., periprocedural strokes after CAS and CEA were comparable (8-10,16). One study even showed periprocedural stroke rate was higher in patients treated with CEA (18). In the study performed by Cho et al. (16), they performed a single-center retrospective study on the patients treated with CEA (107 patients) and CAS (128 patients) between 2012 and 2020. No statistically significant differences were observed in myocardial infarction (CAS group, 0.8%; CEA group, 0.9%), cerebral infarction (CAS group, 3.1%; CEA group 0.9%), or death (CAS group, 0.8%; CEA group 0%), within 30 days after surgery. In their study, they found no difference in outcome between CEA and CAS. This may reflect the advancement of the endovascular device including stroke protection filter and flowreversal technique (20, 21) . We need to keep in mind that compared to the past now that various endovascular devices are developed, we need to update the result from past studies ( 22 ). The way of embolic protection during CAS is not necessarily the same as in past studies, which showed higher periprocedural stroke rates in patients treated with CAS (5-7). A nationwide study on patients treated either with CEA or CAS during 2010-2015 showed CEA patients had a higher periprocedural stroke rate than CAS patients after matching for characteristics and morbidity (18).
doi:10.21037/apm-22-1292 pmid:36627854 fatcat:rmpmjw6ljnfrtojvpbad2hf5ya