Surgery Better Than Stents at Stroke Prevention

French trial focused on patients with blocked arteries who showed symptoms

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By Ed Edelson
HealthDay Reporter

WEDNESDAY, Oct. 18, 2006 (HealthDay News) -- Surgery outperformed the use of stents in a French trial of patients who had warning symptoms of stroke because of blockage of the carotid arteries, the main blood vessels to the brain.

Indeed, the trial was cut short "for reasons of both safety and futility," said a report in the Oct. 19 issue of the New England Journal of Medicine. The incidence of stroke or death in the 30 days and six months after a procedure was about twice as high for patients given a stent, a tube-like device to keep an artery open, than for those who had the surgery called endarterectomy.

"The conclusion of the paper is that patients benefit from endarterectomy and not stenting if they have symptomatic stenosis [blockage]," said Dr. Jean-Louis Mas, professor of neurology at the Hospital Sainte-Anne in Paris, and lead author of the report.

But that conclusion doesn't necessarily apply to people with carotid blockage who show no symptoms and are at high risk of complications from surgery because of conditions such as severe heart disease, Mas added. "In our study, we did not include patients at high risk from carotid surgery," he noted.

The trial included 527 patients. The 30-day incidence of stroke or death was 3.9 percent for those who had surgery and 9.6 percent for those getting stents. The six-month incidence of stroke or death was 6.1 percent after surgery and 11.7 percent after stenting.

The results differed sharply from those of an American trial, SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy), which found a much higher incidence of stroke, heart attack or death in diabetic patients who got surgery rather than stents.

"SAPPHIRE was an entirely different kind of study," Mas said. "In our study, all the patients had symptoms, such as TIAs [transient ischemic attacks] or strokes."

The SAPPHIRE trial included many patients who had not experienced such symptoms, he said. "Patients who are symptomatic for stroke should be treated with surgery and not stented," Mas said.

Dr. Anthony J. Furlan, associate director of the cerebrovascular center at the Cleveland Clinic and author of an accompanying editorial in the journal, had his own view of the issue, which took into account the possible presence of other medical problems in a patient.

"Endarterectomy remains the gold standard, with one exception -- patients who have symptoms, 70 percent artery blockage and a high degree of surgical risk," Furlan said. "Stenting should be reserved for that group."

One of the most common reasons why surgery can be risky is the presence of heart disease, Furlan said. Surgery could trigger a heart attack in such a patient, for example.

Between 150,000 and 200,000 stroke-preventing procedures, most endarterectomies, are performed each year in the United States, Furlan estimated, and one-third to a half of the people who undergo the procedures have had symptoms of danger. The percentage of such patients who have no symptoms is beginning to increase because of screening programs, he added.

The decision about stenting or surgery is not always easy to make, Furlan said. The presence of other medical conditions, notably heart disease, must be taken into consideration. "If the patient has a bad heart, it's not clear whether anything should be done," he said. "If the patient has no symptoms and a good five-year life expectancy, stenting might be a little safer because of a lower risk of heart attack."

More information

Treatments for carotid artery blockage are described by the National Library of Medicine.

SOURCES: Jean-Louis Mas, professor, neurology, Hospital Sainte-Anne, Paris, France; Anthony J. Furlan, associate director, cerebrovascular center, Cleveland Clinic; Oct. 19, 2006, New England Journal of Medicine

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