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Posted: 10:36 AM Nov 4, 2006
Stroke Prevention
Treatment option tested Most people have heard about fatty buildup causing problems in the heart but how about problems in the arteries that lead to your brain?
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Most people have heard about fatty buildup causing problems in the heart but how about problems in the arteries that lead to your brain?
Surgery is usually the way doctors treat these blockages but they’re now looking at whether stents can do the job.
Debbie Long doesn’t have time to be sick. She has got two kids and 13 pure-bred pups that need her.
“I said, 'I’ll do it right away on one condition, if you do it and I’m home by my birthday.' So, I went in on the 11th I think it was, and the 13th I was home. And my birthday was the 15th.”
What she had done was a procedure to fix a problem in her carotid artery before she had a stroke.
Dr. Brian Kluck says, "She’s a patient with a significant narrowing, but had no symptoms.”
Debbie’s doctor suggested she take part in a new “CREST” study, designed to compare the traditional fix, surgery called carotid endarterectomy, to the newer stenting. CREST stands for Carotid Revascularization Endarterectomy versus Stenting Trial.
Dr. Kluck says, "It’s really not fair to the operation or to the patient to say that it’s safer to do stenting than it is to do an operation, like carotid endarterectomy. And in order to identify whether that’s, whether that assumption is true or false, a clinical trial has to be performed.”
In carotid surgery, doctors make an incision in the neck to get to the blockage and scoop the plaque out. In stenting, doctors snake a flexible stent to the blocked artery and leave it in place to keep the artery open. Debbie was thrilled to get the stent.
“Anything’s better than getting cut open," she says. "And I was so happy when he told me I was getting a stent and they wouldn’t have to cut me open. They’d go up through my carotid, do it there and I went, alright.”
The CREST trial is going on at more than 100 sites around the country. In all, the study hopes to recruit 2,500 participants. For more information about the trial and the study sites, click here.
Fast Facts:
Carotid Artery Disease and Stroke
The carotid arteries are the main arteries in the neck that supply blood to the brain. Like the arteries in the heart, the carotid arteries can become narrowed or clogged by deposits of plaque that accumulate on the inside walls of the vessels (atherosclerosis). The affected portion of the carotid artery can become severely blocked, impeding the flow of the blood to the brain. In some cases, a small piece of plaque can break away, travel through the arteries to the brain and become lodged in a narrow cerebral artery. If the brain loses its supply of oxygenated blood, a stroke occurs and the affected portion of brain tissue dies.
According to the Society for Vascular Surgery, about one percent of adults 50 to 59 have significant narrowing in one or both carotid arteries. By 80 to 89, about 10 percent of adults have significant carotid artery disease. Researchers estimate 30 percent of strokes are caused by significant carotid artery narrowing.
Treating Narrowed Carotid Arteries
Doctors can determine the amount of carotid artery narrowing by performing one of two tests. Doppler ultrasound uses sound waves to measure the rate of blood flow through the carotid artery. In cerebral angiography, a special dye is injected into the arteries. X-rays are used to take images and follow the dye through the carotid arteries. By watching the dye, doctors can determine the amount of narrowing inside the artery.
For minor narrowing, doctors may recommend life-style modifications, medications and regular follow-up examinations. When the artery is significantly blocked, the gold standard of treatment is a carotid endarterectomy. In this procedure, an incision is made into the neck to access the carotid artery. The artery is cut open and the plaque is scraped away. The artery and the incision are then closed.
While carotid endarterectomy is considered the standard treatment for significant carotid artery disease, there are some risks associated with the procedure. Patients with serious medical conditions and those who have had a previous endarterectomy are at high risk of developing complications from the surgery.
An alternative treatment has emerged for those who are unable to undergo carotid endarterectomy. It’s called carotid artery stenting. A stent is a hollow, flexible metal tube that sits inside an artery. Similar devices have been used for years to treat blockages in the arteries of the heart. To place the stent, a tiny nick is made in the groin to access an artery. Using X-rays for guidance, a balloon-tipped catheter is fed through the circulatory system up to the point of blockage in the carotid artery. A special “umbrella-like” device is opened to catch debris and pieces of plaque that may break loose. Then the balloon is slowly inflated. As the balloon expands, it pushes against the plaque and compresses it against the wall of the artery. Once the artery is opened, the balloon is deflated and withdrawn. Then, the stent is fed into position. When the stent is released, it expands, or opens up. The stent acts like scaffolding to hold open the artery while blood flows freely through the center of the device.
The CREST Trial
Several studies have shown carotid artery stenting to be a safe and effective procedure for selected patients. However, doctors have wondered whether it is a better procedure over endarterectomy. A study, called CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial), aims to find out. CREST will compare the effectiveness of carotid endarterectomy vs. carotid stenting in preventing stroke, heart attack and death.
Doctors from around the country hope to enroll 2,500 patients with moderate to severe carotid artery disease (including those who have shown signs of stroke and those without symptoms). The participants will be randomly assigned to receive either carotid endarterectomy or carotid stenting and followed for up to four years. For information about the study, or a list of participating hospitals, log onto http://www.clinicaltrials.gov. When you reach the main page, type the trial number (NCT00004732) in the search box, then click on the link to the page.
Web Resources
For information about the crest study, click here.
For a list of trial sites, click here.
For information on carotid artery disease:
