Both surgical and nonsurgical options can prevent stroke.
The same process that causes obstructions in the heart’s arteries can block the carotid arteries in the neck, a disease known as carotid stenosis. If these interfere with blood flow, a stroke can occur.
Symptoms of pending stroke (see box) usually require treatment to reduce the risk. One option calls for opening the artery and removing the plaque—a surgical procedure known as endarterectomy. A less-invasive option, called carotid stenting, involves inserting a catheter into an artery in the groin, advancing it to the carotid artery, opening the blockage with a balloon, and leaving behind a wire cage (or stent) to hold the artery open.
Thanks to the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), we now know both procedures are safe and effective.
“The two-year follow-up of the CREST trial was encouraging for the safety and favorable outcomes of both procedures,” says Dr. Gad Marshall, a neurologist at Harvard-affiliated Brigham and Women’s Hospital and Massachusetts General Hospital.
In endarterectomy (left), the artery is opened and the plaque removed. In carotid stenting (right), the plaque is pushed aside and the artery held open with a stent.
Preventing stroke, restenosis
In the CREST study, the total stroke rate was higher in the stented group (4.1%) than in the surgery group (2.3%), yet less than 1% of participants in both groups suffered a major stroke.
As a surgical procedure, endarterectomy increases stress on the heart. So it was no surprise that the rate of heart attack was higher with endarterectomy than with stenting (2.3% vs. 1.1%). However, both rates are considered low.
Because neither endarterectomy nor stenting modifies the disease process, regrowth of plaque in the artery or stent (known as restenosis) is a concern. In CREST, the rate of restenosis in both groups was less than 6%—far less than could be expected without treatment.
Symptoms of pending stroke
Have someone call 911 immediately
In the hands of a skilled and experienced surgeon at a major medical center, carotid endarterectomy is usually safe and effective.
Carotid stenting is less invasive and often a better option for someone unable to tolerate major surgery.
“We recommend you consult with a specialist, preferably a stroke neurologist, to discuss which option might be right for you,” Dr. Marshall suggests.
There’s a third option, too: medical treatment of underlying risk factors, combined with lifestyle modifications.
“These might be as effective in preventing stroke and disability as either revascularization procedure,” says Dr. Marshall.