St Luke’s- Hospital
Carotid Intervention
Position Statement1


The faculty of the Division at St
Luke’s – Roosevelt endorse the
position recently taken by the
Society for Vascular Surgery in
regard to carotid artery surgery
being superior to carotid stenting
The full Society for Vascular Surgery
statement follows

The Society for Vascular Surgery® (SVS)
believes the recently reported results of the
Carotid Revascularization, Endarterectomy versus
Stenting Trial (CREST) and International Carotid
Stenting Study (ICSS) include several fine points
that must be appreciated and incorporated into
the practices of vascular surgeons. The differing
results of the studies make it most important that
physicians carefully and impartially balance their
recommendations for treatment based upon the
condition of each individual patient.

We are particularly excited about the improved
results with carotid stenting, a technology that
has been readily embraced by our specialty," said
Anton Sidawy, SVS president. "SVS is in the best
position to comment on this topic given the fact
that ours is the specialty involved in the
treatment of carotid disease using all three
modalities; 1) medical therapy, 2) carotid
endarterectomy (CEA), and 3) carotid stenting
(CAS). The long-term tradition in the
management of carotid disease and the ability of
Vascular surgeons to use all three treatment
modalities give them the advantage to provide
the most impartial advice to patients."

There are some important similarities and
differences between these two trials. Both trials,
CREST and ICSS, demonstrate a major
improvement in the results of CEA over
previously reported randomized trials. The stroke
and death rate for symptomatic patients
undergoing CEA in CREST is almost half of what
was reported in the previous NIH trial (North
American Symptomatic Carotid Endarterectomy
Trial, NASCET); and in ICSS is almost half of
what was reported in the previous European
Carotid Surgery Trial (ECST). This is consistent
with the excellent results of CEA reported from
many sources including administrative database
studies, regional and national registries such as
the National Surgical Quality Improvement
Program (NSQIP).

ICSS showed that endarterectomy had
fewer complications than stenting and was
therefore the preferred treatment; both
strokes and heart attacks occurred more
frequently after stenting. CREST showed
that these two procedures were equivalent
when all complications (stroke, heart
attack, and death) were measured
together. However, the primary and most
important aim of CEA or CAS is to prevent
a stroke, and strokes occurred more
frequently after stenting.

While heart attacks occurred more
frequently after endarterectomy, they
appeared to be minor, affecting quality of
life less than the strokes as determined by
SF-36 quality of life study in CREST.
Finally, since ICSS allowed the use of all
approved stent devices, SVS feels that its
results are going to be more reflective of
routine clinical practice. CREST allowed
the use of only one device, and its strict
credentialing process for interventionalists
served to produce a "best case scenario"
for CAS

We believe that both CAS and CEA are
useful tools for preventing stroke, but we
believe that the majority of patients
are still best served by CEA (surgery)
rather than CAS (stenting)" said Dr.
Sidawy. "We are reassured that vascular
surgeons have adopted the new
technology of CAS since low complication
rates can be achieved in a carefully
selected subgroup of patients."