Will Surgeons be eliminated from carotid stenting?

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Carotid stenting is clearly the hot topic at the moment but there is uncertainty whether vascular surgeons who are carrying out 180000 carotid endarterectomies a year in the United States will be widely practicing the procedure.While the total number of procedures may increase in the future, the “mix” of cases will change dramatically. It has been estimated that endovascular techniques may replace up to 50% of traditional vascular operations- though some reports indicate that endovascular repair appears to be augmenting treatment options rather than replacing open surgical repair. The fact is, however, that many vascular procedures of the 1980s are now in the hands of endovascular interventionalists rather than surgeons.

L Nelson Hopkins began his presentation by mentioning that carotid stenting is set to become the gold standard but omitted vascular surgeons from the various specialties that would be widely practicing the procedure. “It is only a matter of time before carotid stenting becomes the procedure of choice for patients with atherosclerotic carotid artery disease. High volume centers that have participated in many of the trials that have made carotid stenting a safe procedure already have a wealth of experience in overcoming technical difficulties and managing complications in what is sure to be a widely practiced procedure by cardiologists, interventional radiologists, and neurosurgeons.”

Ted Diethrich addressed the issue of whether vascular surgeons would be eliminated from carotid stenting in his talk at ISET in Miami. “As carotid artery stenting systems are approved by the Food and Drug Administration (FDA) and funding from the Centers for Medicare and Medicaid Services (CMS) is available, the vascular surgeon’s most economically important procedure, carotid endarterectomy, will be lost to cardiologists and radiologists unless the vascular surgeon has the training and credentials to perform a minimally invasive alternative. This is not a happy picture for the future of vascular surgery as we have known it in past years. To survive in the specialty today, one must be trained in vascular surgery techniques, advanced imaging, and endovascular intervention. In addition, knowledge of tissue engineering (cells and genes) will be important as well. This encompasses the definition of the vascular specialist of the future.”

Endovascular therapy has shown considerable promise and, while not every procedure or technique has shown equal success, the benefits we have come to expect- reductions in the use of general anesthesia, in procedural time, blood loss, length of stay, and overall recovery time as compared to open repair-continue to be important reasons this technology is replacing traditional vascular approaches at such a rapid pace. Only two options are open to the vascular surgeon of today; learn new techniques, or move over-the cardiologists are on a stampede and headed our way.”

One vascular surgeon who has got on with setting up a carotid stenting program is Keith Calligaro who spoke to Vascular News about his experience. According to Dr Calligaro vascular surgeons have no choice but to embrace carotid stenting. “It is patient driven.” In his experience the periprocedural stroke risk is only slightly higher than carotid endarterectomy (2-3% for carotid endarterectomy and 3-4% for carotid stenting).

When he spoke to Vascular News his center had conducted 50 cases with no strokes or TIAs in patients with a recurrent carotid stenosis of 80-90%. The patients selected were poor surgical candidates not accessible surgically because of radiated necks. In his center in Pennsylvania carotid stenting is carried out independently of other specialties. The plan is to do about 50 carotid stents and 100 carotid endarterectomies. The biggest problem has been getting into trials and they are performing carotid stents out of the trials. They have developed their own patient consent form.

Interestingly three prominent vascular surgeons have launched the Carotid Summit which will take place on 1 May 2005. Ouriel, Veith and Ascher.

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