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Reply to Letter to the Editor from Dr. Anne Abbott, Regarding: Pelz, DM, Lownie SP, Mayich MS, Pandey SK, Sharma M. Interventional Neuroradiology: A Review. Can J Neurol Sci 2020:1–17

Published online by Cambridge University Press:  25 November 2020

David M. Pelz
David M. Pelz*
Affiliation:
Department of Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, CanadaUniversity Hospital, London Health Sciences Centre, London, Ontario, Canada
*
Correspondence to: David M. Pelz, MD, FRCPC, Department of Medical Imaging, University Hospital, London Health Sciences Center, 339 Windermere Rd., London, Ontario, Canada N6A 5A5. Email: pelz@uwo.ca
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Information

Type
Letter to the Editor
Information
Canadian Journal of Neurological Sciences , Volume 48 , Issue 4 , July 2021, pp. 596
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press on behalf of The Canadian Journal of Neurological Sciences Inc.

I appreciate Dr. Abbott’s comments about carotid artery angioplasty and stenting (CAS) from our review article on Interventional Neuroradiology.

I agree with her opinion that only a small percentage of asymptomatic patients, likely less than 5%, may benefit from a carotid intervention. I agree that in the major randomized controlled trials (RCTs) of CAS versus carotid endarterectomy (CEA), stenting was associated with a higher risk of periprocedural stroke.Reference Ederle, Dobson and Featherstone1,Reference Brott, Hobson and Howard2 Finally, I agree that the high-risk features of carotid plaque in asymptomatic patients have not been adequately evaluated in the context of current optimal medical management (OMT).

I do, however, take issue with her statement that “there is no proven indication for any carotid artery procedure compared to current standards of medical intervention, only evidence of harm and cost”. Dr. Abbott does not reference this declaration, and the evidence for such a policy is suggestive at best.Reference Chaturvedi and Rothwell3 The most current Cochrane reviewReference Rerkasem, Orrapin, Howard and Rerkasem4 still regards CEA as highly beneficial for stroke reduction in symptomatic patients with 70%–99% stenosis, and of some benefit for those with 50%–69% stenosis. The efficacies of both CEA and CAS compared to current OMT in symptomatic and asymptomatic patients are being evaluated in the ECST-2 and ACST-2 trials,Reference Zhu and Yu5 with the ECST-2 results expected in 2022. Until definitive RCT data is available, carotid revascularization for severe, symptomatic stenosis remains the gold standard.

References

Ederle, J, Dobson, J, Featherstone, RL et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International carotid stenting study): an interim analysis of randomized controlled data. Lancet 2010;375:985–97.Google Scholar
Brott, TG, Hobson, RW, Howard, G et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363:11–23.10.1056/NEJMoa0912321CrossRefGoogle ScholarPubMed
Chaturvedi, S, Rothwell, PM. Stroke risk with symptomatic carotid stenosis: The future is not what it used to be. Neurology 2016;86:494–95.10.1212/WNL.0000000000002363CrossRefGoogle Scholar
Rerkasem, A, Orrapin, S, Howard, DPJ, Rerkasem, K. Cochrane Database Syst Rev 2020;9.Google Scholar
Zhu, Z, Yu, W. Update in the treatment of extracranial atherosclerosis disease for stroke prevention. Stroke Vascular Neurol 2020;5:65–70.Google ScholarPubMed