Surgery News - January 2009 - (Page 14) 14 VASCULAR JANUARY 2009 • SURGERY NEWS CEA Considered Safer Than CAS for Elderly BY NANCY WALSH Long-Term EVAR Outcomes Still Under Investigation BY NANCY WALSH Else vier Global Medical Ne ws N E W Y O R K — Carotid endarterectomy is safer than carotid artery stenting for patients with severe, symptomatic carotid artery stenosis who are older than 68 years, according to a subanalysis of a prospective multicenter trial. The Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial tested the hypothesis that carotid artery stenting (CAS) was not inferior to carotid endarterectomy (CEA) in preventing ipsilateral ischemic stroke or death in the first 30 days post procedure. In the SPACE trial, 1,200 patients were randomly assigned within 180 days of a transient ischemic attack or moderate ischemic stroke to undergo carotid stenting (n=605) or carotid endarterectomy (n=595). To be eligible, patients had to have carotid stenosis, to correspond to more than 50% of North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, or more than 70% of the European Carotid Surgery Trial (ECST) criteria. The trial was carried out in 35 centers in Germany, Austria, and Switzerland, with neurologists, vascular surgeons, and interventionalists participating from each center. The trial failed to prove noninferiority of stenting, with event rates of 6.8% and 6.3% in the CAS and CEA groups, respectively (Lancet 2006;368:1239-47). “However, in a subgroup analysis there was one variable—age—that had a significant impact on the 30-day outcomes of ipsilateral stroke and death,” said Dr. Dittmar Boeckler of the department of vascular surgery, University of Heidelberg (Germany). The periprocedural risk of ipsilateral stroke or death increased significantly with age in the CAS group but not in the CEA group. Classification and regression tree analysis showed that an age of 68 years gave the greatest separation between high- and low-risk populations with CAS, with an event rate of 2.7% in patients aged 68 or younger and 10.8% in those who were older, Dr. Boeckler explained at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic. At 2 years post procedure, no differences have been seen in rates of ipsilateral stroke or death on intent-to-treat analysis, at 9.5% and 8.8% in the CAS and CEA groups, respectively. However, recurrent stenosis of 70% or more was seen in 10.7% of CAS patients, compared with 4.6% of CEA patients (Lancet Neurol. 2008;7:893-902). SPACE 2, which is being funded by the German Federal Ministry for Education and Research, will take place at 135 centers over an 8-year period. With enrollment beginning in December, investigators plan to recruit 3,640 patients, of which 1,550 would be randomized to each surgical group and 540 to the medical group. ■ Else vier Global Medical Ne ws N E W Y O R K — The early promise of endovascular repair of abdominal aortic aneurysms may not be borne out over the long term, according to ongoing follow-up of a randomized Dutch trial suggesting that mortality may be higher at 4 years after endovascular repair than after open surgery. Initial experience showed a survival advantage during the first month after endovascular repair (EVAR) of abdominal aortic aneurysms compared with open repair. In the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, which included 345 patients, the combined rate of operative mortality and severe complications was 10% in the open repair group and 5% in the EVAR group. In their first report the investigators wrote, “The findings of this randomized trial comparing open and endovascular aneurysm repair suggest that in patients who qualify for either procedure, endovascular repair is preferable to open repair over the first 30 days after the procedure” (N. Engl. J. Med. 2004;351:1607-18). However, that advantage was lost at 2 years, when the survival curves for the two groups converged, according to lead investigator Jan D. Blankensteijn, chief of vascular surgery, Radboud University Nijmegen (the Netherlands) Medical Centre. At that point the cumulative survival rate was 90% in both groups (N. Engl. J. Med. 2005;352:2398405). “Four years after discharge, with 62% of patients remaining alive and only 10% having been censored, overall survival shows a clear and highly significant difference between the groups, with a higher mortality rate as of discharge in the endovascular group,” Dr. Blankensteijn said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic. “The data are preliminary and incompletely analyzed, and in particular, the causes of death need further analysis before any interpretation can be given,” he explained in an interview. “For instance, were there more aneurysm ruptures in the EVAR group? Was there greater mortality associated with reinterventions? We don’t know.” All patients will continue to be followed for 5 years. “ We need to figure out if the apparent trend holds up in the long-term analysis of all randomized trials, why it is so, and whether this accounts for all patients or just particular subgroups,” he said. “This may be conceived as a disappointment to some, and in the long term it may jeopardize the perioperative survival advantage of EVAR,” he concluded. DREAM was supported by a grant from the Netherlands National Health Insurance Council. Dr. Blankensteijn declared no conflicts of interest. ■ CLASSIFIEDS A l s o a v a i l a b l e a t w w w. e l s e v i e r h e a l t h c a r e e r s . c o m PROFESSIONAL OPPORTUNITIES METRO SOUTH CAROLINA Hospital employed General/Bariatric Surgery position in desirable Blue Ridge Mountain metro area two hours from Atlanta associated with a growing 450 bed three hospital campus health system. 1-12 ER call. Excellent salary, bonus and benefits. 50/50 General and Bariatric surgery. 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Table of Contents Feed for the Digital Edition of Surgery News - January 2009 Surgery News - January 2009 Contents The 20/20 Vision Intent to Prevent News From the College: The Year Ahead Thoracic: Tracheal Triumph Practice Trends: Making the Grade Surgery News - January 2009 Surgery News - January 2009 - Contents (Page 1) Surgery News - January 2009 - Contents (Page 2) Surgery News - January 2009 - Contents (Page 3) Surgery News - January 2009 - Contents (Page 4) Surgery News - January 2009 - Contents (Page 5) Surgery News - January 2009 - The 20/20 Vision Intent to Prevent (Page 6) Surgery News - January 2009 - The 20/20 Vision Intent to Prevent (Page 7) Surgery News - January 2009 - News From the College: The Year Ahead (Page 8) Surgery News - January 2009 - News From the College: The Year Ahead (Page 9) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 10) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 11) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 12) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 13) Surgery News - January 2009 - Thoracic: Tracheal Triumph (Page 14) Surgery News - January 2009 - Practice Trends: Making the Grade (Page 15) Surgery News - January 2009 - Practice Trends: Making the Grade (Page 16)
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