Carotid Artery Stenosis: Winner Takes All?

Photo courtesy of Flickr user Charles Williams (CC)

Let’s admit it.  Those debate sessions at most medical meetings are pretty contrived.  Debating the BEST therapeutic option for carotid stenoses in asymptomatic patients–as three vascular experts did at the annual meeting of the Society for Vascular Surgery–is not only contrived but also potentially never ending as technique and technology continue to improve.

While I was sitting there, listening to this debate again–medical management vs. carotid endarterectomy (CEA) vs. carotid artery stenting (CAS)–I was very pleased to hear that there was someone else, who also thought that debating the best approach is, well, not the best approach to these patients.

“Why can there be only one winner?  In fact, why can’t there be more than one acceptable therapeutic approach,” asked Dr. Kim Hodgson, who is the chair of vascular surgery at Southern Illinois University, Springfield.  Dr. Hodgson had been tasked with making the case for CAS.

The debate illustrated that, for asymptomatic patients with carotid stenoses, there is good evidence for medical management and CEA, and even for CAS in certain patients.

Dr. Hodgson related that his plane to Boston had been late because of mechanical problems.  This got him thinking.  “As mechanics, there’s only one right way that they can repair this plane … I came to realize that there’s a difference between us and mechanics.  I think of us more as tailors.  I think we need to recognize that there could be more than one acceptable therapeutic approach.  We have to tailor this to our patients.”

In part, the controversy over CEA vs. CAS has been driven by competition between specialties–vascular surgeons and cardiac surgeons/cardiologists–and a “dysfunctional winner-takes-all mentality,” he said. In industry, this winner-takes-all mentality takes the form of a rush to be the first to market, which “leads to poorly designed and anemic scientific trials.”  In this scenario, the biggest losers may be patients, who are at the mercy of the currently blowing winds of trial data.

—Kerri Wachter, @knwachter on Twitter

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Filed under Cardiovascular Medicine, Drug And Device Safety, IMNG, Neurology and Neurological Surgery, Practice Trends, Surgery

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