Are interventions for carotid disease still needed?

W. Kent Williamson, M.D.
Medical director, Providence Noninvasive Vascular Labs
Chairman, Providence Vascular Quality Council-Oregon
Pacific Vascular Specialists

Published February 2013

New data from multiple clinical trials evaluating carotid endarterectomy versus carotid stent are raising new questions. Chief among them: Are interventions for patients with asymptomatic carotid disease irrelevant?

Earlier landmark clinical trials demonstrated the benefit of endarterectomy in certain patients with asymptomatic carotid disease, but these studies were done before vast improvements in medical management of atherosclerosis.

The questions are especially profound in the context of health care reform built around the “Triple Aim,” which seeks to provide higher-quality care at a lower cost while preserving a good patient experience.

Australian neurologist Anne L. Abbott, M.D., Ph.D., published a meta analysis of clinical trials, which indicates that contemporary medical management has led to a significant reduction in the incidence of stroke. Dr. Abbott suggests that newer combinations of antiplatelet agents, statin therapy and stricter blood pressure control are the primary reasons for this lower incidence.

Karen Woo, M.D., et al. also published a comparison study in the journal Stroke, which concluded that stroke rates in patients under contemporary best medical management for asymptomatic stenosis were similar in the long term to those who underwent carotid endarterectomy.

In review of those landmark earlier clinical trials, such as the Asymptomatic Carotid Atherosclerosis Study (ACAS), it is apparent that only a small proportion of study patients were on a statin. More recent clinical research has tended to support the theory that statin therapy is associated with a decreased incidence of stroke in patients with carotid disease.

While the debate continues, most clinicians now agree that updated clinical trials are needed to evaluate the effect of contemporary medical management against either carotid endarterectomy or carotid stent in patients with asymptomatic disease.

The SPACE2 trial in Germany is designed to address the efficacy of procedures versus best medical management, but enrollment has been slow. In the United States, it is anticipated that the CREST 2 trial will include a medical arm to evaluate the two options.

The evidence behind improved medical management on stroke prevention is so compelling that we cannot afford to ignore it. These efforts speak directly to the Triple Aim in health care in terms of providing higher quality of care at a lower cost.

Clinical articles by W. Kent Williamson, M.D.