Exploring Best Medical Treatments vs. an Intervention

The continuing debate among vascular specialists over the comparative benefits of different approaches to treating carotid artery disease takes center stage at the 39th Annual VEITHsymposium, November 14-18, with a number of presentations over the five-day event, and two dedicated afternoon sessions on Wednesday and Thursday afternoon to explore the controversies.

While there is universal acceptance of the fact that carotid atherosclerosis, (hardening of the arteries) is a high risk factor for stroke, vascular specialists continue to disagree on the optimal methods to treat it, especially in asymptomatic patients who have plaque deposits and narrowing of the arteries detectable via ultrasound but no prior history of a cardiovascular event.

One school of thought favors medical management over intervention, using prescription drugs (antiplatelet drugs, anti hypertensives, statins) to control cholesterol and prevent further build up of deposits on the vessel walls. They point to recent research indicating both lower costs and significant reduction in stroke for asymptomatic patients who receive only medicines and no interventions. Based on those positive outcomes, thirty-eight prominent vascular experts have written the F.D.A. urging the agency not to expand coverage for stents for asymptomatic patients, claiming that most of those patients will receive little benefit from the more aggressive and costly treatment. Medical management does present its own set of concerns, however, including potential side effects associated with the long-term use of statins.

Others continue to advocate for the more aggressive treatments to clear away the existing plaque, but here too experts disagree, with some espousing endovascular carotid-artery stenting (CAS) to expand and maintain the arterial opening and others wedded to carotid endarterectomy (CEA), conventional surgery that involves cutting directly into the arterial wall to remove the deposits.

The situation is further complicated by disputes over the value of several highly visible clinical trials that have sought to evaluate the effectiveness of the different treatments for the treatment of carotid atherosclerosis and prevention of stroke. The results of the CREST Trial (Carotid Revascularization Endarterectomy versus Stenting Trial) published in May 2010 in New England Journal of Medicine, purported to show that stenting was equally effective as CEA but critics have disputed those findings, calling into question some of the research methods and endpoints used in that trial. Adding further complication to the issue is the fact that new drug-eluting stents and balloons have been developed since the CREST Trial was convened, and these advanced treatment options must be considered in any comparative analysis.

In keeping with the VEITHsymposium format of rapid-fire presentations and structured debate, a wide-open and vigorous discussion can be expected, with speakers presenting from each of the competing treatment perspectives and a number of prominent critics of the clinical research trials.

Source: VEITHsymposium.