Preventing Strokes: Stents vs. Surgery
Study Shows Stents Are Effective in High-Risk Patients
April 9, 2008 -- A less invasive alternative to surgery for clearing neck
arteries of plaque proved as effective as surgical treatment for preventing
strokes in high-risk patients in a three-year follow-up study.
Carotid artery stenting was compared to open-neck surgery in 260 patients
considered less than optimal surgical candidates at high risk for strokes.
Stenting is routinely used to open plaque-clogged coronary arteries, which
cause heart attacks. But it is still largely considered an experimental
treatment for opening the clogged neck arteries that lead to strokes.
The newly published findings are the first to show long-term outcomes for
neck stenting to be comparable to surgery in high-risk patients, University of
Michigan interventional cardiologist Hitinder S. Gurm, MD, tells WebMD.
The study appears in the April 10 issue of the New England Journal of Medicine.
The research was funded by Johnson & Johnson's Cordis, which makes the
stent used in the study.
"This is the first data
we have to suggest that these two procedures have similar long-term
benefits," Gurm says. "But the findings only apply to high-risk
patients. The trials examining lower-risk populations are going on now, and we
hope to know more over the next few years."
Stent vs. Surgery
The patients who took part in the study were treated at 29 hospitals around
the U.S. All were considered at increased risk for complications with surgery
because of advanced age (over 80), co-morbid conditions (heart
failure, advanced coronary artery disease, lung disease) or a history of
prior neck surgery or radiation. Most also had symptoms associated with carotid
Roughly half were treated with surgery, known as carotid endarterectomy,
which involves opening the blocked carotid artery surgically to manually clear
out accumulated plaque.
The other half got stents -- tiny wire mesh tubes threaded into the neck
artery from an incision in the arm or groin. A filter designed to capture
plaque and other debris freed from the arterial walls during the procedure was
also used during stent implantation.
Of the participants available for follow-up, 41 of 143 stent-treated
patients and 45 of the 117 patients treated with surgery had suffered a heart
attack, a stroke, or had died within three years.
Most of the deaths were from cardiac or other non-stroke-related causes.
Strokes accounted for about a third of the adverse events recorded, but most
were not serious enough to be life-threatening.
The findings suggest that outcomes with surgery and stenting are similar
among high-risk patients, but that doesn't mean that stenting will always be
the best choice for this group, Gurm says. Importantly, this trial did not
include a set of patients treated with medications alone.
"The first thing a patient who has a high surgical risk should discuss
with their doctor is whether they really need either procedure," he tells
If the answer is yes, the next consideration should be the doctor's prior
experience with surgery or stenting.
"There are those that do both, but most people working in this field are
either good at surgery or good at stenting," he says.
UCLA Medical Center vascular surgeon Wesley S. Moore, MD, tells WebMD that
three years of follow-up is not enough to prove that stenting and surgery are
equal for the treatment of high-risk patients with carotid artery blockage.
He adds that there is some evidence that neck arteries cleared using stents
become clogged again more quickly than those cleared by surgical means.
"This may not show up in three years, but we can't really say if this is
the case at four and even five years," he says.