Talk:Carotid stenting

Untitled
I added a bit reflecting the evolving morbidity picture of CAS that has been reported in updates in the surgery literature from data from the CREST trialDroliver 19:18, 18 March 2007 (UTC)

Benefits section not neutral
This section reads like its was written by a proponent of CAS. This evidence is coming under question. Moreover, CREST is not a secondary source. This section should be re-written. BakerStMD 20:29, 1 May 2014 (UTC) — Preceding unsigned comment added by Bakerstmd (talk • contribs)

Needs rewrite to follow WP:Medmos
This article should be re-written to comply with WP:MEDMOS for procedures and operations. The following should be the order of sections:


 * Medical uses
 * Contra-indications
 * Technique (avoid step-by-step instructions)
 * Risks/Complications
 * Recovery or Rehabilitation
 * History (e.g., when it was invented)
 * Society and culture (includes legal issues, if any)
 * Special populations
 * Other animals

BakerStMD T&#124;C 21:35, 13 January 2015 (UTC)

Cochrane review of CAS
Per the conclusions from the Cochrane review: "Endovascular treatment is associated with an increased risk of peri-procedural stroke or death compared with endarterectomy. However, this excess risk appears to be limited to older patients. The longer term efficacy of endovascular treatment and the risk of restenosis are unclear and require further follow-up of existing trials. Further trials are needed to determine the optimal treatment for asymptomatic carotid stenosis."

This should be the main source for evidence for the article, per WP:MEDRS standards, NOT the conclusions from the CREST trial or any other primary source.

BakerStMD 15:56, 15 June 2015 (UTC)

Non-inline citations from body of article
The following were listed as "reference" but not cited in-line. I have not reviewed them for quality, but are listed as they were removed and may be useful:


 * Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A,Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF "CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23.
 * Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 357, 1729-37 (2001).
 * Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A, Bossavy JP,Denis B, Piquet P, Garnier P, Viader F, Touzé E, Julia P, Giroud M, Krause D, Hosseini H, Becquemin JP, Hinzelin G, Houdart E, Hénon H, Neau JP, Bracard S, Onnient Y, Padovani R, Chatellier G; EVA-3S investigators. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial:  results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008 Oct;7(10):885-92..
 * Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A,Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF "CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23.
 * Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 357, 1729-37 (2001).
 * Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A, Bossavy JP,Denis B, Piquet P, Garnier P, Viader F, Touzé E, Julia P, Giroud M, Krause D, Hosseini H, Becquemin JP, Hinzelin G, Houdart E, Hénon H, Neau JP, Bracard S, Onnient Y, Padovani R, Chatellier G; EVA-3S investigators. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial:  results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008 Oct;7(10):885-92..

Re-write done
I removed much of what I veiwed as POV promotion for trans-femoral carotid stents, with a lot of references to the CREST trial. I added a section for TCAR.

My personal POV is that TCAR is probably better than trans femoral, and may be as good as endarterectomy, but the jury is still out. See the SVS-VQI studies on the topic. BakerStMD 19:00, 24 January 2020 (UTC)

Primary material from carotid stenosis page
The largest clinical trial performed, randomized patients at risk for a stroke from carotid artery blockage to either open surgery (carotid endarterectomy) or carotid artery stenting. This trial followed patients for 4 years and found no overall difference in the primary end point of both treatment arms (myocardial infarctions, any perioperative strokes or ipsilateral strokes within 4 years, or death during procedure). Patients assigned to the surgical arm experienced more perioperative myocardial infarctions compared to the stenting group; however, the difference was not statistically significant (6.8% vs or 7.2% HR for stenting is 1.1 CI 0.81–1.51 P value 0.51) whereas patients assigned to the carotid stent arm experienced more periprocedural strokes compared to endarteretomy (6.4% vs 4.7% HR for stenting 1.5 P-0.03). There was no mortality difference and no difference for major (disabling) strokes between surgery and stenting. It was noted that there did seem to exist an age cutoff where below 75 years old endarterectomy and stenting showed equivalent results, while in patients over 75 endarterectomy offered a better risk profile. The CREST trial was not designed for subgroup analysis and thus not powered enough to draw any statistically significant conclusions. A later study published in 2013 evaluated how these perioperative complications affect long-term survival. This study showed that experiencing a stroke within the first year conferred a two-fold lower survival rate (Hazard Ratio(HR) 6.6 [CI 3.7–12]) than those who experienced a perioperative myocardial infarction at two years post intervention (HR 3.6 [CI 2–6.8]). This difference in mortality, however, converges and becomes negligible at 5 years (HR 2.7 [CI 1.7–4.3] vs HR 2.8 [CI 1.8–4.3]). A 2010 study found benefits (reduced strokes) from carotid endarterectomy in those without symptoms who are under 75.

Transcarotid artery revascularization
Transcarotid artery revascularization (TCAR) is a new procedure for carotid revascularization. It is currently approved in the U.S. for people with carotid artery disease who are at risk for open surgery, such as those who have undergone a previous CEA and the elderly. The procedure involves temporarily reversing blood flow, which prevents stroke-causing debris from reaching the brain, and implanting a stent into the carotid artery to stabilize the plaque and prevent a future stroke. An added advantage of TCAR is that is performed in less than half the time of CEA, limiting stress on the heart and significantly cutting the risk of stroke or heart attack during the procedure. As of May 2019, it has been reported that more than 10,000 TCAR procedures have been performed worldwide. TCAR has been studied in numerous clinical trials, including ROADSTER 1 and 2. In the ROADSTER 1 trial, the 30-day stroke rate was 1.4 percent – the lowest stroke rate at the time for any prospective trial of carotid stenting. In the real-world ROADSTER-2 trial, the stroke rate was 0.6% and the combined stroke and death rate was 0.8 percent for patients with 30-day follow-up. An additional study using data from the Society for Vascular Surgery’s TCAR Surveillance Project evaluated 5,716 patients receiving TCAR compared to 44,442 patients receiving CEA between 2015 and 2018, finding no statistical differences between TCAR and CEA for in-hospital stroke or in-hospital stroke and death. An additional analysis 5,160 patients in each group using propensity score matching based on comorbidities and demographics found patients treated with TCAR had significantly lower odds of composite in-hospital stroke, death, and myocardial infarction compared to CEA. BakerStMD 16:56, 21 May 2020 (UTC)