Stents as Good as Surgery at Preventing Stroke

Less Invasive Approach Works as Well as Gold Standard

By Charlene Laino
WebMD Health News

Reviewed By Louise Chang, MD

Feb. 26, 2010 (San Antonio) -- A less invasive approach for clearing clogged neck arteries proved just as effective and safe as surgical treatment for preventing strokes in high-risk patients, according to the largest comparison of the two procedures.

Stenting, in which flexible mesh tubes are used to prop open blocked blood vessels, is widely used to clear plaque-clogged coronary arteries, which cause heart attacks. More recently, it has been used to open blocked neck arteries that lead to strokes, but surgery called carotid endarterectomy remains the gold standard.

The new study shows that "we now have two good options for patients," says researcher Wayne Clark, MD, of Oregon Health & Science University.

The choice may come down to the individual patient's age, health, and preferences, he tells WebMD.

The study, presented at the American Stroke Association's (ASA) International Stroke Conference, showed that in the weeks after the procedure, patients who received stents suffered slightly more strokes, and patients who underwent surgery had slightly more heart attacks.

But an average of 2.5 years later, "there was no significant difference in the number of events between the two groups," Clark says.

About 2% of patients in both groups suffered a heart attack or stroke or died -- the lowest rates of adverse events ever seen in a stroke trial pitting stenting against surgery, he says.

Interestingly, patients under age 70 appeared to benefit slightly more from stents, while older patients benefited slightly more from surgery, says lead researcher Thomas Brott, MD, of the Mayo Clinic in Jacksonville.

"Most of us thought the less invasive procedure would be better suited for older patients, but based on our data we have to question that," he tells WebMD.

The study was funded by the National Institute of Neurological Disorders and Stroke with supplemental funding from stent maker Abbott Vascular.

Stenting vs. Surgery: European Trial Has Conflicting Results

The findings were announced just hours after European researchers reported that stenting is inferior to surgery when it comes to preventing stroke.

Those results, published online by the journal Lancet, showed that patients who received the stents had a much higher rate of stroke, heart attack, or death than patients who underwent surgery.

The University of Miami's Ralph Sacco, MD, president-elect of the American Heart Association, tells WebMD that patient selection might explain the disparate results.

The European study enrolled only patients whose neck blockages caused symptoms such as swishing in the ears or vision problems; the North American study included patients with and without symptoms. Those with symptoms are presumably sicker and would benefit more from surgery, Sacco says.

Also, the doctors who performed the stent procedures in the North American study were more experienced, Brott says.

There were also differences in the types of stents used, Clark says. In the European trial, doctors were allowed to use any approved stent, while the North American doctors all used Abbott's Acculink Carotid Stent System.

Stents Work as Well as Surgery

Each year, nearly 800,000 Americans suffer a stroke and nearly 140,000 die, making it the third leading cause of death in the United States.

The new study, called CREST, involved 2,502 patients at more than 100 U.S. and Canadian hospitals. About half underwent surgery and half received stents.

In the first 30 days after the procedure, 4.1% of stent patients had a stroke vs. 2.3% of surgery patients. But 2.3% of surgery patients had a heart attack, compared with 1.1 %of stent patients.

Patients who suffered a heart attack reported a better quality of life after recovery than patients who suffered a stroke, Brott says.

By 2.5 years later, 2.0% of patients who underwent stenting had died or suffered a heart attack or stroke vs. 2.4% of surgery patients, a difference so small it could have been due to chance.

In the European trial of 1,713 patients, 8.5% of stent patients had a stroke, death or heart attack in the first 30 days after surgery, compared with 5.2% of the surgery group.


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SOURCES: American Stroke Association's International Stroke Conference 2010, San Antonio, Feb. 24-26, 2010.

Wayne Clark, MD, of Oregon Health & Science University, Portland.

Thomas Brott, MD, Mayo Clinic, Jacksonville.

Ralph Sacco, MD, chief of neurology, University of Miami; president-elect, American Heart Association.

The Lancet, published online Feb. 25, 2010.

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