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Carotid artery stenting: the 2011 NICE guidelines
  1. Simon K Neequaye1,
  2. Alison W Halliday1,2
  1. 1Department of Vascular Surgery, John Radcliffe Hospital, Oxford, UK
  2. 2Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK
  1. Correspondence to Professor Alison W Halliday, Nuffield Department of Surgical Sciences, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; alison.halliday{at}nds.ox.ac.uk

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Death and disability as a result of cerebrovascular disease are a significant and growing problem in our ageing society. Surgery for significant carotid artery stenosis (>50%) in the form of carotid endarterectomy (CEA) reduces the subsequent risk of ipsilateral stroke. This benefit is particularly evident in recently symptomatic patients with minor stroke or transient ischaemic attack.1 2 Asymptomatic subjects with significant carotid artery stenosis (>70%) also benefit from surgery (stroke risk at 10 years 10.8% vs 16.9% with medical treatment (gain of 6.1%, 95% CI 2.7% to 9.4%)).3

Carotid artery stenting (CAS) is a less invasive alternative to CEA avoiding the morbidity associated with a surgical incision. However, CAS is a technically demanding procedure and some early results were poor, with an unacceptably high peri-procedural stroke risk with CAS compared with CEA. Pooled outcome data for 3433 symptomatic patients randomised in EVA-3S, SPACE and ICSS trials demonstrated that risk of stroke and death in the first 120 days were significantly higher after CAS (8.9%) than after CEA (5.8%, RR=1.53, 95% CI 1.20 to 1.95; p=0.0006). Patients over 70 years of age were identified as a group in whom CAS has particularly poor results with double the risk of adverse outcome in CAS compared with CEA. In patients younger than 70 years there was no significant difference in risk estimate of stroke or death at 30 days.4 In the recent CREST study, there was no significant difference between stenting and surgery for the composite end point of any stroke, myocardial infarction or death within the perioperative period. Ipsilateral stroke risk at 4-years' follow-up was similar (2.0% and 2.4%, respectively; …

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