Dr. Jon S. Matsumura
Other experts see medical treatment alone as an excellent option for many carotid-stenosis patients.
"The majority of patients I see don’t get an intervention; we use medical treatment only," said Dr. Jon S. Matsumura in an interview. "I think that’s true for most vascular surgery practices, and in cardiology and neurology practices. A lot of these patients just need reassurance," said Dr. Matsumura, professor and chairman of vascular surgery at the University of Wisconsin in Madison.
"Most asymptomatic patients [with carotid stenosis] should be treated by best medical therapy, with very few – fewer than 5% – treated by CAS or CEA," said Dr. Frank J. Veith at the International Symposium on Endovascular Therapy (ISET 12) in January. He acknowledged that well-controlled trials done during the 1990s showed that CEA led to superior outcomes compared with medical therapy, but since the early 2000s, "best medical therapy to prevent strokes leapt forward," he said, especially with improved statin therapy. He cited findings from a 2010 prospective study that showed asymptomatic Canadian patients managed starting in 2003 with best medical therapy had an annual stroke rate of 0.7% (Arch. Neurol. 2010;67:180-6).
He singled out four small groups of asymptomatic patients who warrant revascularization: patients with CT or MRI evidence for a history of silent strokes, patients with very-high-grade carotid stenosis that leaves just 1% of the carotid lumen open, those with a contralateral occlusion, and patients who serially experience transient occlusions detected by transcranial Doppler ultrasound examination, said Dr. Veith, professor of surgery at New York University. Aside from this small fraction of patients with asymptomatic disease, performing interventions on anyone else will "cause more strokes than you’ll prevent," he warned in an interview.
What Will CMS Do?
Dr. Veith’s take on limiting CAS in asymptomatic patients received substantial support early this year in the days leading up to the Jan. 25 meeting of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) that heard evidence and opinions for and against widening of Medicare coverage for CAS. In early January, Dr. Veith joined with 40 other vascular surgeons and stroke specialists to urge CMS not to broaden CAS coverage (Eur. J. Vasc. Endovasc. Surg. 2012 Jan. 5 [doi:10.1016/j.ejvs.2011.12.006]). But, as MEDCAC heard during this meeting, experts differ on this issue.
Dr. William A. Gray
"CMS continues to restrict access to CAS to about 10% of patients" with significant carotid stenosis, said Dr. William A. Gray, director of endovascular services at Columbia University in New York, speaking at ISET 2012 in January. "Expanded CAS coverage would allow greater patient access and device development, and therefore create a safer option for patients." Dr. Gray presented his positive views on CAS to MEDCAC in January as well.
At press time, CMS had not announced whether or not the January MEDCAC hearing will result in a change to its CAS coverage policy. But the votes cast by MEDCAC’s membership in January suggested that the issues surrounding management of carotid stenosis remain too unresolved to trigger immediate changes.
Dr. Lal, Dr. Timaran, and Dr. Veith said that they had no disclosures. Dr. Howard said that he has received grant support from Abbott. Dr. Hopkins said that he has financial relationships with Bard, Boston Scientific, Cordis, Abbott Vascular, Toshiba, W.L. Gore, Medtronic, Micrus, St. Jude, Access Closure, Osteal, Vascular Dynamics, Square One, Valor Medical, Claret Medical, and Augmenix. Dr. Brott said that he has been a consultant to Edwards Lifesciences. Dr. Matsumura said that he has received research grants from Abbott, Cook, Covidien, Endologix, and W.L. Gore. Dr. Gray said that he has had financial relationships with Boston Scientific, Coherex, Contego, Cordis, Fiatlux 3D, Nexeon, Quantumcor, Abbott Vascular, and Biocardia.