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| EDITORIAL |
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| Year : 2022 | Volume
: 70
| Issue : 1 | Page : 3-4 |
Current Status of Carotid Stenosis and Revascularization
P Sarat Chandra
Department of Neurosurgery, AIIMS, New Delhi, India
| Date of Submission | 11-Feb-2022 |
| Date of Decision | 11-Feb-2022 |
| Date of Acceptance | 11-Feb-2022 |
| Date of Web Publication | 11-Feb-2022 |
Correspondence Address:
P Sarat Chandra
Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi – 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.338738
How to cite this article:
Chandra P S. Current Status of Carotid Stenosis and Revascularization. Neurol India 2022;70:3-4 |
The Neurology India, wishes all its reader a very happy new year! The 2021 has been a difficult with the corona pandemic being at peak. We all hope that the year 2022 will be kinder to us.
Stroke is increasingly recognized as a significant public health issue and is the second leading cause of mortality and considerable disability globally. The substantial disease burden comes from the low and middle-income countries (LMIC), with Asia alone accounting for more than 50% of the world's diseased population.[1] The stroke burden has seen a steady rise in the past decade, which might be a consequence of increased life expectancy due to better health care facilities. Higher incidence noted among the younger population owing to lifestyle changes, especially in the LMICs accounts for the changing dynamics. The estimated cumulative incidence of stroke in India ranges from 105 –152 per one lakh persons per year. Atherosclerosis of the carotid artery is a significant cause of stroke, accounting for 30% of all ischemic strokes. Approximately 15% of ischemic strokes are preceded by transient ischemic attacks (TIAs). In comparison, the annual risk of stroke in asymptomatic carotid stenosis of more than 50% stenosis ranges between 2-6%.[1],[2],[3],[4]
Extracranial carotid stenosis-related stroke has been the area of research interest due to its easy accessibility for evaluation and treatment. The society for vascular surgery recommends carotid revascularization with stenosis of more than 50% and 70-99% in symptomatic and asymptomatic individuals, respectively.[3] Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the two most recommended treatment modalities. At least four randomized controlled trials have focused on the extent of stenosis, type of intervention, and long-term outcomes.[3],[4],[5],[6],[7] These trials have helped formulate evidence-based guidelines in the management of carotid stenosis. The North American Symptomatic Carotid Endarterectectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) are the two large multicenter randomized controlled trial (RCTs) evaluating the role of surgery in symptomatic carotid stenosis of 50-99%, demonstrating beneficial effects of CEA. A meta-analysis involving individual data analysis of the NASCET and ECST patient population revealed that CEA offered no benefit in individuals with <50% stenosis and was rather harmful when performed in patients with <30% stenosis. The subgroup analysis revealed excellent results in at least three subgroups: male gender, age >75 years, and CEA performed within two weeks of the symptom onset.[3],[4],[5]
The ACST-1 was a multicenter RCT, studying the role of CEA in asymptomatic carotid stenosis of 70-99%. This trial found a significant reduction of 10-year stroke risk, with 50% of these being disabling and fatal strokes in patients aged less than 75 years. A Cochrane review involving twenty-two trials comparing the efficacy of CEA versus CAS showed:
- CAS was associated with a high risk of death within 30 days of treatment in symptomatic carotid stenosis patients aged 70 years or more compared to CEA
- The risk of moderate carotid artery restenosis was greater with CAS compared to CEA
However, beyond 30 days, there was no difference in mortality or incidence of new-onset strokes between both the procedures.[6]
ACST – 2 noted similar periprocedural mortality rates in the long run after competent CEA and CAS in the asymptomatic carotid stenosis group. Nondisabling procedure-related strokes were slightly higher in the CAS group.[7]
All the significant trials involved competent endovascular interventionists or neurosurgeons trained exclusively in performing CAS or CEA. Whether the complication rates are operator-dependent is another debate that stems primarily from CAS. To address this issue, multiple studies involving intervention radiologists, cardiac interventionists, cardiothoracic surgeons, neurosurgeons, intervention neurologists, and general surgeons, performing CAS and patient outcomes have been documented in the literature. The rates of complications might be subjected to inherent bias due to the small sample size, retrospective nature of the studies.[8],[9],[10],[11] Few studies show superior results favoring intervention radiologists over others, while the majority other studies noted similar outcomes and complication rates between the specialties.
The role of a dual trained neurosurgeon in this context might be crucial in times to come. Capable of performing both CEA and CAS, a hybrid neurosurgeon might offer an invaluable and unbiased management options. Timely management of post CAS neurosurgical complications like; intracranial hematomas, infarctions decisively is the other significant benefit. Literature comparing outcomes of both the revascularization techniques performed by hybrid neurosurgeons is non existent. Diyora et al, have attempted to address this lacuna by analysing their own experience of performing both CAS and CEA.[12] This article highlights the importance of a hybrid neurosurgeon capable of performing both CEA and CAS, especially in a community setting with limited resources. The rates of periprocedural stroke major adverse events were higher in CAS compared to CEA but did not reach statistical significance. The 30-day mortality rates were similar in both groups. A dual-trained neurosurgeon's clinical and statistical equilibrium between CEA and CAS offers comprehensive cerebrovascular care with one point solution. The necessity of hybrid neurosurgeons in community settings in developing nations like India is a welcome move. The future generation of neurosurgeons interested in cerebrovascular neurosurgery should receive training in endovascular procedures to provide skilled care for this patient population.
| » References | |  |
| 1. | Jones SP, Baqai K, Clegg A, Georgiou R, Harris C, Holland EJ, et al. Stroke in India: A systematic review of the incidence, prevalence, and case fatality. Int J Stroke 2022;17:132-40.  |
| 2. | Khurana S, Gourie-Devi M, Sharma S, Kushwaha S. Burden of Stroke in India During 1960 to 2018: A Systematic Review and Meta-Analysis of Community Based Surveys. Neurol India 2021;69:547-59. [ PUBMED] [Full text] |
| 3. | Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415e25. |
| 4. | Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379e87. |
| 5. | Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Carotid Endarterectomy Trialists' Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroupsand timing of surgery. Lancet 2004;363:915e24. |
| 6. | Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010;376:1074-84. |
| 7. | Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021;398:1065-73. |
| 8. | AbuRahma AF, Stone PA, Srivastava M, Hass SM, Mousa AY, Dean LS, et al. The effect of surgeon's specialty and volume on the perioperative outcome of carotid endarterectomy. J Vasc Surg 2013;58:666-72. |
| 9. | Ruby ST, Robinson D, Lynch JT, Mark H. Outcome analysis of carotid endarterectomy in connecticut: The impact of volume and specialty. Ann Vasc Surg 1996;10:22-6. |
| 10. | Sgroi MD, Darby GC, Kabutey NK, Barleben AR, Lane JS II, Fujitani RM. Experience matters more than specialty for carotid stenting outcomes. J Vasc Surg 2015;61:933-8. |
| 11. | Kempczinski RF, Brott TG, Labutta RJ. The influence of surgical specialty and caseload on the results of carotid endarterectomy. J Vasc Surg 1986;3:911-6. |
| 12. | Diyora B, Chheda RM, Dhall G, Gupta P, Dewani K, Mulla M, et al. Carotid Endarterectomy and Carotid Artery Stenting for Symptomatic Carotid Stenosis: An Experience of a Hybrid Neurosurgeon in a Developing Nation. Neurol India 2022;70:94-101. [Full text] |
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