European Journal of Vascular & Endovascular Surgery
Volume 36, Issue 3 , Pages 251-252, September 2008

Is Early Carotid Stenting Indicated in Patients with Recent Neurological Events?

Vascular and Endovascular Surgery, University of Siena, Viale Bracci 1, I-53100 Siena, Italy

published online 11 July 2008.

Article Outline

 

Although it is well recognized that surgical carotid revascularization is the treatment of choice in symptomatic carotid artery stenosis, the role of early intervention in patients with recent neurological events is still a controversial issue. Catastrophic outcomes reported in the first anedoctal cases of urgent carotid surgery in unselected patients presenting with stroke have influenced the “conventional teaching” that patients suffering stroke should wait 6-8 weeks for revascularization. However, recent data from population-based studies1 has revealed that the risk of recurrent stroke is up to 10% in the week after a transient ischaemic attack (TIA) or minor stroke. The prevention of recurrent strokes in the penumbra zone and the minimization of the incidence of reperfusion injury are the most important factors in the treatment of patients with acute stroke. The disapproval of early treatment after an acute stroke is inappropriate, as demonstrated by the analysis of pooled data from the randomized controlled trials of endarterectomy for symptomatic carotid stenosis.2 These data clearly showed that benefit from endarterectomy depends not only on the degree of carotid stenosis, but also on delay to surgery after the index event (ideally, the procedure should be performed within 2 weeks). An Italian multicenter study - The Surgical Treatment of Acute Cerebral Ischemia (STACI)3– has recently shown that patients whose neuroimaging studies in the early hours after stroke document a recent, limited cerebral infarction can safely undergo very early CEA (1.5 days after stroke) with similar risk to elective surgery.

There are now several guidelines in this direction: the National UK Stroke Strategy,4 the American Academy of Neurology (AAN)5 and the American Heart Association (AHA)6 recommend treatment within two weeks in patients presenting with a transient ischaemic attack (TIA) or a non-disabling stroke. The Italian SPREAD7 (Stroke Prevention and Educational Awareness Diffusion) guideline clearly states that carotid surgery is recommended as early as possible (within 2 weeks of the event) for patients with TIA, minor stroke or stabilized neurological deficit with normal CT scanning or minimal lesions (Grade A recommendation).

In the meantime carotid artery stenting (CAS) has emerged as a useful and potentially less invasive alternative to carotid endarterectomy (CEA) for the treatment of extracranial carotid stenosis in high risk patients. So far operators' experience has grown, techniques refined and indications extended. Although definitive scientific proof has still not been obtained from RCTs, after the publication of the EVA-3S8 and SPACE9 Trials, despite the vivid debate questioning the safety of CAS, there is an increasing number of reports by endovascular specialists that consider CAS equivalent to CEA.

However, principally in Europe, some surgeons/interventionists have based this feeling on treatment of a vast number of asymptomatic patients, while currently one of the most challenging questions is whether CAS could be offered to patients with acute neurologic symptoms. The major concerns regarding this possibility are two: first, cerebral revascularization in the acute stage remains challenging because of the possibility that hemorrhagic infarction or hyperperfusion syndrome will occur after revascularization; second, alarm about CAS in symptomatic patients is related to the general feeling that the remodeling of these vulnerable plaques by the stent might be at high risk of cerebral embolization.

The first point really still affects the median delay from the index event to surgery in real world practice. Most specialists involved in stroke care are reluctant to undertake carotid revascularization immediately after the onset of stroke for fear that hemorrhagic transformation of the cerebral infarct may increase the procedural risk, and offer surgery only after 2–4 weeks. Moreover, many emergency rooms are inadequately resourced to perform early treatment. According to Naylor10 a “delay” in the treatment “may reduce procedural risk, but at what price to the patient?”. Analysis of data from the Carotid Endarterectomy Trialists Collaboration database2 (more than 6000 symptomatic patients with carotid stenosis) clearly reveals that the price is paid by the cohort of patients operated on with a delay >2 weeks, in terms of less strokes prevented at 5 years.

There is insufficient evidence to predict which patients with severe carotid stenosis associated with recent stroke benefit most from early intervention. Information about the distal site of the vascular lesion and a number of exclusion criteria for early treatment should be taken into account; patient subgroups in which early surgery should be avoided include those with evidence: of ischaemic infarct >2.5cm in diameter, of intracranial haemorrhage, of recent carotid occlusion (lasted >6hrs), Rankin score >3, fluctuating level of consciousness and no neurological plateau. However, in correctly selected patients early treatment reduces the recurrent stroke rate, and is recommended as soon as possible from the index event.

The second main concern about CAS in patients with acute symptoms is related to the fact that while with CEA the plaque is completely removed, after stenting it is only remodelled and its stabilization is essential to avoid embolic events during the procedure and in the post-operative period.

For these reasons part of debate now revolves around the stent properties, in particular the important role of scaffolding of the emboligenic plaque by the struts of the stent.11, 12 This message has particularly been understood by many companies, which are now working on a next generation stent that prioritizes scaffolding improvement. Another part of the discussion concerns the importance of cerebral protection systems during CAS, with particular emphasis on evaluating the efficacy and safety of proximal occlusive devices in minimizing cerebral embolization from the vulnerable plaques during the procedure.

With regard to patient selection based on neurological status and instrumental findings, a recently published prospective multicenter registry - the “Submarine Study”13- indicated that early treatment with protected carotid stenting is both feasible and safe in selected patients with first episode or recurrent TIA or minor stroke. Although in a limited series of patients (n=57), this preliminary study revealed that endovascular treatment has a satisfactory outcome considering the very high risk profile of the patient population (at 30 days: death 1.7%, TIA/stroke 3.5%). Moreover the evaluation of some brain ischemia biomarkers (in particular PAPP-A, hs-CR, and IL-6) in this cohort of patients suggested an inflammatory role for them in the process of an unstable carotid plaque generating an acute cerebral event. These vulnerability markers could be useful attempts to noninvasively identify vulnerable plaques at early stages, and before the onset of an acute clinical event.

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References 

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PII: S1078-5884(08)00288-8

doi:10.1016/j.ejvs.2008.06.004

European Journal of Vascular & Endovascular Surgery
Volume 36, Issue 3 , Pages 251-252, September 2008

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