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Rapid access carotid intervention is key to prevent stroke
Monday, 06 Apr 2009 18:51
Postponing carotid endarterectomy is a risky strategy, say experts at the Maquet-sponsored satellite symposium on the third day of CX31.
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When it comes to intervention for asymptomatic carotid artery stenosis, "wait and see is not a good policy" according to the presenters at the Maquet Satellite Symposium which opened the third day of the CX Symposium. The symposium was entitled "It has all been said and done about carotid artery stenting, endarterectomy and best medical treatment - so why bother?"
Nick Cheshire, Imperial College London, UK, chairing the session, said that this was still an important issue, as "we all have different interpretations of the literature".However, Ross Naylor, University of Leicester, UK, and Hans-Henning Eckstein, Technical University of Munich, Germany, were in agreement.
"Because there’s this traditional belief that the early risk of recurrent stroke is relatively low after transient ischaemic attack, and there’s this belief that the procedural risks increase if you intervene early," said Naylor, "there’s actually been very little motivation or incentive for surgeons or systems to intervene early."
The traditional teaching, he said, is that the risk of stroke is 1% at two days, 2% at seven days, and 2-4% at 30 days. "Several recent meta-analyses suggest that this is not the case.
"Meta-analyses using passive ascertainment - that means looking at the case records on a computer - suggest that the risks are about three times higher." But more important, said Naylor, are the face-to-face follow-up meta-analyses, which present results almost seven times higher than the "traditional" figures.
"After four weeks," he said, "there’s actually very little evidence that we’re benefiting our patients.
"This is something that we cannot ignore. So I put it to you that surgery confers maximum benefit, provided it’s performed within two weeks. Patients attending surgeries deferred for more than 12 weeks actually gain very little benefit."
Naylor made the "uncomfortable observation" that analyses of the data suggest that the quick treatment is even more essential in female patients presenting with carotid stenoses. "Unless we treat women really, really quickly, we’re actually doing no benefit to them whatsoever."
"I put it to you," he said, "that, though early endarterectomy is associated with that slightly increased risk, this is offset by the much greater number of strokes preventable in the long term."
Also at the Maquet Symposium, Jean-Baptiste Ricco, University of Poitiers, France, spoke on carotid bypass as an alternative to endarterectomy, and Afshin Assadian, Wilhelminenspital Vienna and Medical University Vienna, Austria, made a presentation entitled "More guesswork than science - best medical treatment for primary and secondary stroke prevention in patients with carotid artery stenosis".
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