Ederle, JR; (2012) Carotid artery disease: treatment and associated risks. Doctoral thesis , UCL (University College London).

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Abstract

Carotid artery stenosis is a major risk factor of stroke. Carotid endarterectomy is the established treatment of choice for severe carotid stenosis. Carotid stenting has gained widespread acceptance as alternative treatment, although trials of safety and efficacy have been inconclusive and contradictory. The history of our understanding of stroke and carotid atherosclerotic disease is sketched. Landmark trials of stroke prevention, including the carotid endarterectomy trials are discussed. The long-term results of one of the first trials of endovascular treatment, the Carotid And Vertebral Transluminal Angioplasty Study (CAVATAS) are presented and the results placed in context of other clinical trials of endovascular treatment for carotid stenosis. This Cochrane Review informed the largest completed trial of stenting and surgery in symptomatic carotid stenosis, the International Carotid Stenting Study (ICSS), whose short-term results up to 120 days after treatment are detailed. Age-related white matter changes are thought to be associated with an increased risk of per-procedural stroke and death. A study investigating the risk of stroke or death associated with age-related white matter changes is presented and discussed. CAVATAS has suggested that the risks and benefits of endovascular treatment for carotid stenosis may be similar to those of carotid endarterectomy. The Cochrane review revealed variable results of published randomised clinical trials. ICSS showed that carotid stenting was associated with a significantly higher short-term risk of stroke, myocardial infarction or death up to 120 days after treatment than carotid endarterectomy. Age-related white matter changes were shown to increase the risk of stroke or death in both treatment arms. Carotid endarterectomy should remain the treatment of choice for symptomatic carotid stenosis but stenting remains an option for certain patients, especially those less suitable for carotid endarterectomy. Scope for further research remains to improve patient selection and to compare invasive treatment to modern medical therapy.

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