To Stent, or Not to Stent for Carotid Stenosis?

Carotid stenosis (or narrowing) is due to the presence of increasing atherosclerosis in the carotid artery.  It may go unnoticed until the first major effect – a stroke or a transient ischemic attack (TIA, also called a ministroke) occurs, or it may be detected clinically by clinical examination or an ultrasound.  Treatment usually involves a combination of lifestyle changes, medications and, in some cases, surgery (endarterectomy, where the arterial plaques are removed) or a stenting procedure.  In the latter case, a small wire-mesh coil called a stent is inserted to keep the artery from narrowing.  Which type of procedure is the best?

Surgeons involved in 3 randomized trials, agreed to pool their results in a meta-analysis, which they published in the Lancet.  There were a total of 3,400 patients who had either endarterectomy or angioplasty (widening of the artery) with stent placement.  The end-points assessed were stroke or death; such evaluations were made at 30 days and 120 days after the procedure.  

At both time intervals, patients under the age of 70 showed no difference in risk for a combination of any stroke or death), regardless of their treatment.  However, in those 70 and older, stenting was associated with a doubling of the risk.  The surgeons conclude that their findings show that the harm of stenting compared with endarterectomy is lessened with younger age.  They state: “Stenting . . . should be avoided in older patients (age 70 or above), but might be as safe as endarterectomy in younger patients".  So the over-70s get a firm recommendation, but younger patients are still left a little uncertain.