Carotid Stenting: A Gordian Knot to be Unraveled (Part II of II)<br />

Conclusions. As this nascent period of endovascular carotid procedures draws to an end, what is clear, crystal clear to me, is that a significant conundrum exists. The Gordian knot to be unraveled is not whether stent-supported carotid angioplasty is the standard of care, but rather how will physicians adequately develop the cognition and skill to safely perform these procedures. The tools will define themselves. However, the image of an inexperienced interventionist (cardiologist, radiologist, or surgeon), having limited or minimal diagnostic angiographic imaging and catheter skills, let-alone, the necessary interventional cognitive and technical skill, performing carotid angioplasty with inadequate imaging systems is disconcerting. Scalpel experience does not miraculously transfer and impart to the surgeon the average interventionist’s skills and ability without dedication, education, study and work. The unbridled and cavalier use of stents or any devices within the extracranial carotid bifurcation, as standard care by such unskilled physicians is inappropriate, and should not be condoned. Without a resolution of this quagmire, trained physicians, from whatever specialty, will be precluded from best caring for patients. Presently, some segments of the medical community are not sufficiently perplexed as to the equivalency of carotid endarterectomy and stent-supported carotid angioplasty. Spokes-persons for each contingent vigorously and passionately detail their perspectives, often referencing their observational experiences as evidence of their unbiased, and logical conclusions. However, clinical equipoise, a genuine state of doubt regarding the equivalence of each procedure or the superiority of one procedure over another, does not exist. The point of perplexity has passed. While some members of the medical community may not share this view, their opposition and disagreement appears more likely to be lack of familiarity with the extant data, obstinacy, self-interest, and/or an inflexible need for a randomized trial to demonstrate the statistical merit of the therapy, rather than an assessment of the data. Disabling, debilitating, devastating and deadly complications can result from both surgery and angioplasty; testimonials and limited observational experiences or waiting 7 years for the results of an antiquated study with FDA imprimatur should not impede progress. Carotid angioplasty, subjects the patient to an immediate lower complication rate than carotid endarterectomy, with fewer traumas, and precludes subsequent ipsilateral neurologic deficit. While neurologic deficit can and will occur with both procedures, the incidence of such deficits appears significantly less likely to occur with carotid angioplasty, as such, all physicians should remember this when they make their therapeutic recommendations.

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