Study: Stents as Good as Surgery at Keeping Neck Arteries Open

Feb. 1, 2012 -- A less invasive approach for clearing neck arteries of dangerous plaque works just as well as surgical treatment for most people at high risk of stroke, according to the largest comparison of the two procedures to date.

Ninety-four percent of patients' arteries remained open two years after undergoing either surgery or the less invasive procedure, which involved inserting a stent.

Stenting, in which flexible mesh tubes are used to prop open blocked blood vessels, is widely used to clear plaque-clogged heart arteries, which cause heart attacks. More recently, it began to be used to open blocked neck arteries that lead to strokes, but surgery in which the vessel is cut open and cleared out, called endarterectomy, remains the gold standard.

Previous findings from the study of more than 2,500 patients showed that about 7% of patients had a stroke, heart attack, or died over a four-year period whether they underwent surgery or stenting.

"Even after these results were published, many doctors were reluctant to perform stenting of the carotid artery [the blood vessel running up the neck to the brain] as they worried about reblockage of the arteries," says researcher Brajesh K. Lal, MD, associate professor of vascular surgery at the University of Maryland School of Medicine in Baltimore.

"Now we have evidence of virtually no difference in reblockage rate between surgery and stenting at two years," Lal tells WebMD.

Factors such as patient age and preference, and reimbursement, may influence the decision of whether to undergo stenting or surgery, he says.

The study, presented here at the American Heart Association/American Stroke Association’s International Stroke Conference 2012, was funded by the National Institute of Neurological Disorders and Stroke with supplemental funding from stent maker Abbott Vascular.

Neck Narrowing Causes 1 in 10 Strokes

Each year, more than 700,000 Americans suffer a stroke, and more than 140,000 die, making it the third leading cause of death in the United States.

In 2004 and 2005, about 320,000 surgeries and 20,000 stenting procedures were performed to open up plaque-laden neck arteries. Neck artery narrowing due to these blockages causes about 10% of strokes, according to Lal.

One of the unique aspects of the new study, called CREST, is that only about half of the patients had symptoms such as weakness on one side of the body or blurry vision. That’s important, Lal says, because about half of the procedures to unclog neck arteries are performed in people who have not yet developed symptoms.

In the study, 1,086 patients underwent stenting and 1,105 had surgery. By two years later:

• Six percent of patients in both groups had a 70% or greater blockage in the treated section of their artery.
• Complete blockage occurred in 0.3% of stenting patients and 0.5% of endarterectomy patients, a difference so small it could be due to chance.
• Twenty stent patients and 23 endarterectomy patients needed another procedure to open up a reblocked carotid artery.

Stenting or Surgery?

So how do you decide which procedure is best for you? Among the factors to consider:

• Age. The previously published findings showed that patients under age 70 with symptoms appeared to benefit slightly more from stents, while their older counterparts benefited more from surgery, the University of Miami's Ralph Sacco, MD, immediate past president of the American Heart Association/American Stroke Association, tells WebMD. He was not involved with the work.
• Reimbursement. Stenting is not routinely reimbursed unless a patient is at high risk of complications from surgery. A recent study places the costs of stenting and surgery at $12,782 and $8,916, respectively, says CREST researcher Larry B. Goldstein, MD, director of the Duke Stroke Center at Duke University Medical Center in Durham, N.C. 
• Extent of disease. "If a patient has a lot of plaque or it is close to the skull, for example, surgery becomes high risk. There's a risk of stroke or nerve damage," Lal says.
• Physician/institution. "If there's a great surgeon at your institution, you may choose endarterectomy. Similarly, if you have a terrific stenter, with low rates of complications,you may choose stenting," Sacco says.

How about drugs alone? Studies have shown that patients with symptoms gain a huge benefit from surgery over medication alone, Goldstein says.

But there is evidence that drugs may be sufficient for certain patients with narrowing in a neck artery who do not have symptoms, he tells WebMD. A clinical trial is planned to study the issue.

These findings were presented at a medical conference. They should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.