Preventing Strokes: Stents vs. Surgery

Study Shows Stents Are Effective in High-Risk Patients

By Salynn Boyles
WebMD Health News

Reviewed By Louise Chang, MD

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 artery narrowing.

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.

Follow-up Needed

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 WebMD.

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.

SOURCES: Gurm, H.S. New England Journal of Medicine, April 10, 2008; vol 358: pp 1572-1579. Hitinder S. Gurm, MD, interventional cardiologist, University of Michigan School of Medicine, Ann Arbor. Wesley Moore, MD, vascular surgeon, professor and chief emeritus, division of vascular surgery, UCLA Center for the Health Sciences, Los Angeles.

© 2008 WebMD Inc. All rights reserved.