Carotid-Artery Endarterectomy or Stenting

First results of the EVA-3S trials were recently published in the NEJM. The conclusion is clear:

In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting.

OK, I am a surgeon and have the thinking of a surgeon. I always had a bad feeling regarding the carotid stents. The idea of an uncovered stent, pressed against the plaques on the carotid bifurcation, made me feel uncomfortable.

There are discussions between surgeons and radiologists in our hosputal about almost every single patient with a carotid stenosis. The non-invasive character of the stenting is the primary argument used against the operative treatment. The stents are not covered and can be placed in an elegant way over the femoral or the brachial artery. Our radiologists take care only for a stenosis of the external carotid artery because of the imaginable worsening of this situation when a stent is placed in the internal one, pressing the plaques against the surrounding structures, incl. the ECA. Long term results of this technique did not exist but many people believe primary that a non-operative method could a priori not harm more than an operation.
Well, I am not surprised that the operations outperformed the stenting in this situation. After the endarterectomy, the vessel looks great - with a smooth intima and a good, flexible wall. After placing a stent, I can only imagine a squeezed plaque, which breaks into the mash of the uncovered stent and shoots at least microemoli. In a long term a new plaque would build on the top of the overstented old one - there are perfect conditions for this to happen.

I think that covered stents could better the outcome of this patients for the following reasons. Placing a tube in a narrow way is a result of quite a mechanical thinking, not regarding the reasons for the building of the plaque in the vessel. The surgery also does not consider these reasons but we produce better results because we do not leave a row vessel wall ready to start building a plaque few minutes after the skin stitches. Using a covered stent would prevent the embolism originating in the stent mesh. Moreover, the "vessel wall" would be sleek and glossy, not allowing the thrombocytes or whatever else to just stop by. Covered stents are often coated in a short time with an intimal layer and I bet this is not the case with the uncovered ones. If I would have a carotid stenosis, I would choose the operation as treatment for me. Not because I am a surgeon, but because I believe that the stenting would not give me the best, the current medicine can do.

The EVA-3S-game was lost by the stents but stenting of vessels is a trend. Believing that the surgery would remain forever would be the wrong strategy. The main goal for the surgeons is to perform good operations with good results as long as this is not outperformed by an alternative way. New games are coming. :)