Northeast Florida Medicine
Vol. 66, No. 3 2015
41
Endovascular Neurosurgery
a chronic systemic vascular disease and after CAS or CEA,
patients should be evaluated by neurologists or primary
care physicians regularly to identify potentially treatable
problems and ensure adequate treatment compliance.
Long-Term Durability of CAS
The durability of CAS was a source of controversy in
the neurovascular community. The three-year follow-up
data of the SAPPHIRE trial revealed only a 4 percent rate
of recurrent stenosis,
25
which compares favorably with the
restenosis rate after CEA.
26
More recently, a secondary
analysis of the largest randomized clinical trial of CAS vs.
CEA to date (CREST trial) evaluated long-term results in
1086 patients after CAS and 1105 patients after CEA. At
two year follow-up, the investigators identified restenosis
(defined as a reduction in diameter of at least 70 percent or
peak systolic velocity of at least 3.0 m/s) in 58 patients who
underwent CAS (6 percent) and 62 who underwent CEA
(6.3 percent). Interestingly, female sex (hazard ratio 1.79),
diabetes (hazard ratio 2.31), and dyslipidemia (hazard ratio
2.07) was an independent predictor of vessel restenosis after
both procedures, whereas cigarette smoking increased the rate
of restenosis only after CEA (hazard ratio 2.26).
27
The rate of
restenosis following CAS also appears to be improving with
increased experience and expertise but, more importantly,
the durability of CAS should not influence the decision
between open surgery and endovascular treatment.
Conclusions
In the treatment of carotid stenosis, the most important
aspect is deciding which patients benefit fromCAS, CEA, or
observation. It is only when the morbidity and mortality of
the procedure are low that the benefits of CAS outweigh the
risks of natural history.Therefore the impetus to intervene on
any patient with carotid stenosis should always be tempered
by the Hippocratic precept of primum non nocere…first,
do no harm.
v
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