When given the option, patients with asymptomatic carotid stenosis are equally likely to choose medical therapy or a procedure (surgery or stenting), according to survey results published online April 11, 2011, ahead of print in the Journal of Vascular Surgery.

To assess patient preferences, lead author Alun H. Davies, MA, DM, and colleagues of Charing Cross Hospital (London, United Kingdom), analyzed questionnaires from 102 individuals eligible for carotid duplex screening based on the presence of peripheral arterial, coronary, or aneurysmal disease.

Investigators asked patients, who received information about available treatment options, to assume their imaging tests showed a unilateral 70% asymptomatic carotid stenosis and provided the following complication rates based on the literature:

• Optimal medical therapy: 5-year stroke or death risk of 11% (ACAS trial)
• Carotid endarterectomy (CEA): Perioperative stroke or death risk of 3% (ACAS, ACST, Veterans Affairs trials)
• Carotid artery stenting (CAS): Perioperative stroke or death risk of 3% to 5% (CREST lead-in phase, registries, and SAPPHIRE)

To minimize clinician bias, no physician interaction was allowed. The responses were almost evenly split between those who preferred optimal medical therapy (48%) and those who opted for CEA or CAS (52%). Of those who chose a procedure, 30% chose CEA (P = 0.006 vs. medical therapy) and 22% chose CAS (P < 0.001 vs. medical therapy). The difference between CEA and CAS did not reach statistical significance (P = 0.17).

The overall preference for medical therapy compared with either CEA or CAS was similar in subgroup analyses by gender, age, smoking status, prior stroke, and family history of cerebrovascular accident (table 1). Male smokers tended to choose intervention more often than other groups, and younger individuals preferred stenting. None of the differences were statistically significant except for mean age.

Table 1. Management Preferences by Subgroup

^a P = 0.053 vs. medical therapy.
^b P = 0.006 vs. medical therapy.

Abbreviations: TIA, transient ischemic attack; CVA, cerebrovascular accident.

Forty-three percent of patients who chose medical therapy said they did so because they wanted to avoid surgery, while 27% wanted to avoid periprocedural risk. Nearly all (97%) who selected CEA said it offered a lower periprocedural risk of stroke and death than CAS. Those who opted for CAS did so because of its minimally invasive nature (36%), a positive prior stenting experience (23%), or less cranial nerve injury than that associated with CEA (18%).

The researchers concluded that based on current Society for Vascular Surgery recommendations and patient preferences, no reason exists “for an increase in stenting asymptomatic patients.” Additionally, they noted that risk assessment tools and further study results may benefit patients and physicians in their decision-making process.

Patient Preference vs. the Physician’s Role

In an e-mail correspondence with TCTMD, Dr. Davies noted that for asymptomatic patients, “clinicians are undecided as to the best treatment option. Hence, patient preference becomes very important.”

A patient’s impression of available procedures depends on the information provided and on potential clinician bias, he added. Clinicians need to present data so that “patients are well informed and can make an informed choice as to the best option for them,” Dr. Davies said.

Survey Questioned

Mark H. Wholey, MD, of the University of Pittsburgh Medical Center, Shadyside (Pittsburgh, PA), noted that bias may exist in the United Kingdom because, if presented properly, a 70% theoretical lesion would lead most people to opt for best medical management and observation. “Quite frankly, 70% asymptomatic lesions are in fact managed medically, rarely needing either endarterectomy or stenting,” he said.

Another drawback is that the risks defined and presented for CAS do not accurately reflect contemporary stroke and death rates of less than 3% in asymptomatic patients under the age of 80, as the authors defined their population, wrote William A. Gray, MD, of Columbia University Medical Center (New York, NY) in an e-mail correspondence with TCTMD. Consequently, the survey study is flawed, he said.

Ideally, the study should have taken into account a 2.5% risk of stroke or death from CAS based on CREST main study data. Instead the authors cited 3.8% from CREST lead-in data, said Dr. Gray. Additionally, the 5% risk of stroke or death for CAS presented to patients in the study comes from SAPPHIRE, which was performed 10 years ago when stenting technique was still rudimentary, he said. Moreover, the population was also at high surgical risk.

Dr. Davies noted that final CREST study data were not available at the time the survey was developed. Additionally, “further evidence is now available that asymptomatic yearly risk of stroke with best medical therapy may be down to about 0.5%, favoring a nonintervention group further,” he said, citing recent data (Eur J Vasc Endovasc Surg. 2010;40:678-9).

Optimal Medical Therapy Not Well Established

However, Dr. Gray noted that data on medical therapy for established severe carotid stenosis “demonstrates that it is inferior to revascularization. Even its staunchest advocates will acknowledge that the targets for optimizing medical therapy are not established; that is, no one can say for carotid prevention what the optimal BP level or medication is, what the appropriate lipid level or medication is, and so on.” Additionally, compliance can be a challenge for patients, he said.

While optimal management for an 80% carotid stenosis is open for discussion, medication may still be a desirable alternative, said Dr. Wholey. More severe lesions, however, might best be managed with endarterectomy or stenting, he said.

Stenting and surgery have comparable outcomes, according to the CREST trial, added Dr. Wholey. “But, let’s face it, stenting with an experienced operator is a 25-minute procedure,” he said. “Patients can go home the same day.” With proper patient selection, the right lesion characteristics, and the right operator, stenting is “a satisfactory procedure,” he concluded.

2. Silver FL, Mackey A, Clark WM, et al; CREST Investigators. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2011(Mar);42:675-680.

3. Abbot AL. Current medical intervention alone is now the best solution for asymptomatic carotid stenosis. Eur J Vasc Endovasc Surg. 2010;40:678-679.

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