Not Everyone Benefits from Stenting

Coronary artery stents in high risk Medicare patients tied to mortality risk

(RxWiki News) To stent or not to stent? Stenting works well to prevent strokes most of the time, but it may pose risks to some patients.

A recent study found that the very reason some patients underwent carotid artery stenting (CAS) may have affected the outcome of their procedure — that in this high-risk group, some patients had a stroke within two years. This study raised the question of whether CAS risks outweigh the benefits in high-risk patients.

“The decision to perform CAS should be based on overall survival as well as on the risk of complications and their effect on quality of life’” wrote the authors of this study, led by Jessica J. Jalbert, PhD, of the Duke Clinical Research Institute in Durham, NC.

Dr. Jalbert and colleagues looked at data on more than 22,000 Medicare patients who were 66 or older and had had a CAS procedure.

These were patients who had a CAS because they were too high-risk for a carotid endarterectomy (CEA). In a CEA, the carotid artery is cleared of plaque — a waxy material— that has accumulated in the artery and narrowed its opening.

CAS is recommended for some patients whose risk is too high for a carotid endarterectomy procedure — another type of surgery to open blocked arteries.

These patients were considered high-risk for CEA because they had a previous heart attack, radiation to the neck or some other heart problem.

Dr. Jalbert and team found that, within 30 days of the CAS, 3.3 percent of the patients had a small stroke, 2.5 percent had a heart attack and 1.7 percent of the patients died.

Patients who continued to have symptoms of blocked arteries (vision, balance, speaking, swallowing or thinking issues) and those who were older than 75 had a higher mortality rate than the other patients in this study.

Dr. Jalbert and team said that CEA — and probably CAS — reduces five-year stroke risk by about 16 percent for patients whose carotid artery was blocked at least 70 percent and decreases the stroke risk by about 5 percent in patients with a 50 to 69 percent blockage.

The benefits to high-risk patients are not likely to be as strong, these researchers said.

“These findings raise questions about whether performing CAS is justified if [risks during the time around the surgery] are too high or if patients do not live long enough to benefit from the main advantage of CAS, which is stroke prevention,” Dr. Jalbert and team wrote.

An editorial about this study, written by Mark J. Alberts, MD, of the University of Texas Southwestern Medical Center in Dallas, said the high death rate in this study could be due to age of the patients, their heart disease and the fact that the patients who entered the study were already sick. He said it was also possible that the stent procedure increased some other proteins in the blood that caused inflammation that contributed to the heart problems in these patients.

Dr. Alberts wrote that “treating an artery may not treat the patient — at least not enough to keep him or her alive for more than a few years."

The study and the editorial were published online Jan. 12 in JAMA Neurology.

The US Department of Health and Human Services funded this research. Study author Dr. Michael R. Jaff was an unpaid consultant for Cordis Corporation, Abbot Vascular, Boston Scientific, Covidien Vascular and Medtronic Vascular. These companies manufacture carotid stents.

Review Date: 
January 11, 2015