Treatment Of Carotid Artery Disease – Surgery Vs. Stents

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dr_alan_micklin_cardiology_phys_photo_am11_sqBy: Alan Micklin, M.D., F.A.C.C.

Carotid artery disease is the most common cause of stroke in the United States. Over one-half of all stroke cases can be attributed to these blockages of the arteries,
which provide blood flow to the brain.

Treatment of carotid artery disease, thus far, has been surgical with carotid endarterectomy performed in the vast majority of cases. Stent placement has typically been reserved only for those that are not candidates for surgical treatment. However, a recent study presented in February at the International Stroke Conference is causing reconsideration of our treatment strategies.

The CREST (Carotid Revascularization Endarterectomy vs. Stenting Trials) was designed to compare intermediate and long-term results of carotid stenting to carotid endarterectomy in patients with significant carotid stenosis.

This study is one of the largest and most rigorous randomized stroke prevention trials ever undertaken with over 2,500 patients enrolled at 118 centers in the United States and Canada over a nine-year period. This study consisted of patients who had suffered a TIA or non-disabling stroke in combination with a greater than 70% stenosis by carotid ultrasound or greater than 50% stenosis by CTA/MRA or angiography. Asymptomatic patients also were included if they had greater than 60% stenosis by angiography,  greater than 70% stenosis by carotid ultrasound or greater than 80% stenosis by carotid CTA or MRA. Patients were randomized to carotid artery stenting vs. endarterectomy and were also treated with anti-platelet agents. The primary outcome of this was combined mortality, stroke or MI at thirty days and ipsilateral stroke at thirty days.

Results of CREST reported in February indicate that the two treatment methods were overall similar in the combined endpoint of MI, stroke or death at thirty days. Researchers concluded that the safety and efficacy of carotid endarterectomy and carotid stenting were similar with equal benefits for men and women and for patients who had a previous stroke, as well as those that were asymptomatic. Closer inspection of the results did, however, reveal differences in the number of heart attacks and strokes suffered. This surgical group had a higher risk of heart attack (2.3% vs. 1.1%) while the stent group had a higher percentage of strokes (4.1% vs. 2.3%). This study also found in patients ages 69 or younger, stent results were slightly better. Conversely, over the ages of 70, surgical results were slightly better and with increasing age, the surgical results continued to improve compared to stents.

The results of the CREST study are causing the cardiovascular community to
re-examine our treatment recommendations for carotid artery disease.

However, this data must be weighed against previous studies (and a recent European study) suggesting superiority of carotid endarterectomy. In addition, experience of the vascular surgeon or interventionalist remains critically important. Encouragingly, it appears that both methods of treatment continue to technically improve, as does the outcome with both options. The rates of stroke and death in both the surgical and stent groups were the lowest ever reported in any randomized trial.

The CREST investigators ultimately concluded that while CEA has a proven record and long-term durability, both carotid artery stenting and endarterectomy are safe and useful tools in the right setting for stroke prevention.

In particular, in younger patients and in those who prefer a less invasive procedure, carotid artery stenting may offer a reasonable alternative to surgery.

The CREST study is ongoing and the discussion of their applications is just beginning.

However, while this debate continues, it has become evident that treatment results of carotid artery disease continues to improve with either approach. Specific recommendations regarding revascularization will likely continue to evolve for our patients with carotid artery disease.


Dr. Alan Micklin joined Cardiology Physicians, P.A. in July of 2006.  He began his studies as an undergraduate biology major at the University of Delaware and graduated in 1986.  He then went on to attend the Hahnemann University School of Medicine from 1986 to 1990.  Upon his graduation in 1990, he started his residency in Internal Medicine at Hahnemann University.  He began his fellowship in cardiovascular disease at Hahnemann in 1993 and was the chief cardiology fellow from 1994-1995.  Dr. Micklin is certified in internal medicine and cardiovascular disease, as well as interventional cardiology.  He has also been certified to perform nuclear cardiology procedures since 1996 and is certified to interpret vascular ultrasound studies.
Dr. Micklin specializes in both nuclear and interventional cardiology and had been practicing since 1996 in Charlotte, North Carolina before joining Cardiology Physicians.  At the University of Delaware he was a member of the Phi Beta Kappa and at Hahnemann University he was a member of Alpha Omega Alpha Honor Societies.  He also received a commendation for Superior Performance during his residency at Hahnemann.  Some of his clinical responsibilities include nuclear stress testing, echocardiography, and vascular ultrasound.  As an interventional cardiologist, Dr. Micklin also performs diagnostic cardiac catheterization including intravascular ultrasound as well as stent placement and angioplasty.  He has a strong commitment to inpatient and outpatient clinical patient care.
Dr. Mickin is married with three children.  Both he and his wife attended the University of Delaware and were members of the Class of 1986.  Hobbies include boating, skiing and golf.

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