NEJM April 2008 Sapphire 3 Year Data

Sarasota Vascular Specialists Article Summary and Comment:

This is an updated look at the long-term results of the original SAPPHIRE study that reported equipoise between carotid stenting (CAS) and carotid surgery (CEA). Although there was much criticism about the original manuscript, we as well as others instituted a program of CAS for highly selected patients who we thought would be poor risks for CEA. As of May 2008 we have performed 33 CAS without any untoward event.

However, three recent publications demonstrating higher stroke rates for CAS in comparison to CEA, as well as increased awareness of the pitfalls of stenting, have somewhat tempered our enthusiasm. Although a cursory read of this new SAPPHIRE data would seem reassuring, the same criticisms apply to the new data. Further, we now note that there were no surgeon authors and all of the authors had heavy financial investments in the reported stent technology. Of major import in the long-term data was the poor follow-up of the 334 patients (85.6% for CAS and 70.1% for CEA). Further only ipsilateral stroke was evaluated. This is appropriate for CEA where contralateral stroke is exceedingly rare, but not for CAS where contralateral stroke can happen more frequently due to manipulation in the aortic arch during catheter manipulation. The data may also be corrupted by the large number of redo procedures in the CAS group. These recurrent lesions are known to be less friable than de novo lesions and hence less likely to embolize during stent placement.

Despite these criticisms, it is apparent that CAS should have a role in our practice. When indicated in well selected patients, a good long-term outcome can be anticipated.

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