Stent While You Wait

Widening blocked arteries in the neck works well on an outpatient basis, study says

THURSDAY, Oct. 4, 2001 (HealthDayNews) -- Same-day service to prop open plaque-clogged carotid arteries works well and is safe, at least at experienced clinics, a new study says.

New York doctors who perform the procedure, called ambulatory carotid stenting, say patients can be treated in a matter of hours with only local painkiller, avoiding potential complications from anesthesia and saving the financial hurt of an overnight hospital stay.

"Patients like [the quickie operation] very much," says cardiologist Nadim Al-Mubarak, lead author of the study, which appears in this month's issue of the journal Stroke. "It's a very low-invasive procedure, with no cutting, no anesthesia." And as the new research shows, patients who undergo the outpatient procedure are at low risk of suffering strokes, infections and other potential complications after being sent home.

Stents are metal mesh cylinders that help keep narrowed vessels from choking off blood flow. Stenting arteries has become the standard of care for clogged vessels around the heart, and can greatly reduce the risk of heart attack in patients.

But stenting the neck's carotid artery, the main vessel that supplies the brain with blood, to reduce the risk of stroke is a relatively new technology whose benefits aren't yet certain. In the procedure, doctors thread a stent-tipped tube into the femoral artery in the groin, working it up to the carotid artery in the neck. Once there, they place the mesh tube in the vessel, expand it, and free up blood flow to the brain.

Medicare covers the procedure only for patients in clinical trials approved by the U.S. Food and Drug Administration.

Doctors who place carotid artery stents fret about two potential complications. The first, and foremost, is neurological trauma, such as stroke or mini-strokes -- also known as transient ischemic attacks (TIAs) -- caused by dislodged plaque that cuts off blood to the brain. These events can be debilitating or even deadly.

The second worry is infection or serious bruising in the groin, where the catheter tube is inserted.

As a result, doctors and hospitals like to observe stent patients overnight to make sure they're tolerating intervention well.

But Al-Mubarak says that in the 1,000 carotid stentings he and his colleagues have performed, almost all of the complications happen within about four or five hours of the operation and most occur while the procedure is underway.

In their study, Al-Mubarak and his colleagues at Lenox Hill Heart and Vascular Institute in New York City analyzed 92 patients who underwent 98 outpatient carotid artery stent procedures at their clinic. After six months, none of the 88 patients for whom follow-up was available had suffered neurological complications, there were no serious infections or bruising at the site of catheter entry, and none of the patients died, the researchers say.

Coronary stenting carries about a 20 percent to 25 percent risk that the vessel will close up again despite the stent, a process called restenosis. Al-Mubarak says the restenosis rate for carotid stenting is far lower, about 3 percent to 5 percent six months to a year after the procedure.

Patients who have undergone endarterectomy surgery to clear a carotid artery logjam or have neck scarring from radiation treatments are good candidates for stenting, Al-Mubarak says. So, too, are those whose blockages are close to the brain or in the lower neck.

But carotid stenting isn't for everyone, Al-Mubarak adds. People over 80 aren't good candidates for the treatment because they have a high risk of suffering a breakaway clot when the stent is placed. Nor are patients with a fully obstructed artery, whose blockages are rich in calcium, or whose artery is twisted and difficult to get to, he says.

The procedures carry small but significant risks of stroke and stroke-related death. However, new technologies to filter and catch stroke-threatening plaques dislodged during stent placement appear to cut those hazards, Al-Mubarak says.

Not every stroke expert is totally sold on stenting for blockages in the neck.

The WALLSTENT study of 221 patients, which was released last February, found that the procedure was about 3.5 times less effective than endarterectomy for preventing stroke or death. The difference was so marked that the researchers stopped the study early, in June 1999.

Dr. Mark Alberts, who led that trial while at Duke University, says the stenting procedure may prove to be useful for some patients. The key, though, is finding out who they are.

As for the latest findings on the procedure, Alberts, who now directs the stroke program at Northwestern University Medical School in Chicago, says the researchers looked at a select group of patients who were well enough to go home. Those who weren't were hospitalized.

"Typically, we talk about doing stenting in people who are too sick to be surgical candidates," Alberts says. "It doesn't seem wise to send them home so quickly."

On the other hand, he adds, "I'm sure that there's a population of patients who are relatively well" for whom outpatient stenting is appropriate. "Which is good to know," he says.

The National Institutes of Health is sponsoring a large study comparing carotid artery stenting with endarterectomy. Results from that trial won't be available for several years, Alberts says.

What To Do

Strokes are the nation's third-leading cause of death. They affect 600,000 people and claim almost 160,000 lives a year, according to the Centers for Disease Control and Prevention.

For more on carotid artery stenting and other heart-related therapies, visit the American Heart Association. You can also try the Internet Stroke Center or the Centers for Disease Control and Prevention for more about strokes.

If you'd like to know more about Alberts' study, here's an article from Duke University on it.

SOURCES: Interviews with Nadim Al-Mubarak, M.D., interventional cardiologist, Lenox Hill Heart and Vascular Institute, New York City; Mark Alberts, M.D., professor of neurology, director of the stroke program, Northwestern University Medical School, Chicago; October 2001 Stroke: Journal of the American Heart Association
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