July 16, 2003

An Alternative To Carotid Artery Surgery

Genesis Introduces Carotid Stenting For High-Risk Patients

Davenport, IA - Thousands of patients with blocked carotid arteries in the neck are at high risk for surgical treatment. Now, Genesis Medical Center is the first hospital in the Quad Cities to offer them an alternative - a minimally-invasive procedure that cleans out the artery, keeps it open with a metal mesh tube or stent, and uses a tiny filter to trap any dislodged plaque that could cause a stroke.

The stenting procedure, performed this month by cardiologist Eric Dippel, M.D., along with a multi-disciplinary Genesis team of specialists in neurology and radiology, signals an emerging option for high-risk patients who are at unacceptable risk for surgery. It also illustrates how Genesis' well-developed medical specialties work together to screen patients and put safeguards in place to ensure the new procedure is done under the safest possible conditions, hospital officials say.

Carotid arteries pass up the neck and are the main blood vessels to the brain. They can develop a build-up of plaque caused by atherosclerosis, or "hardening of the arteries." Indeed, the American Heart Association estimates that 20-30 percent of strokes are caused by plaque that travels upstream into carotid arteries that supply the brain. Stroke is the third leading cause of death in this country, and the No. 1 cause of disability.

"Since the 1950s, surgeons have been making incisions in the arteries in the neck to remove plaque causing the blockage," says Dr. Dippel of Cardiovascular Medicine, P.C., who fulfilled a credentialing process to perform the procedure. "Recently, the technology has developed to the point where opening the blockage with angioplasty and supporting the newly widened artery with a stent has become a safer alternative for those patients who are at high risk for surgery."

At Genesis, the stent and filtering device was used successfully for the first time July 2 on heart patient Dennis McConnell, 66, of Clinton, Iowa, who had a tight narrowing of his carotid artery and was at high risk for traditional surgery, called a carotid endarterectomy. He needed the procedure to reduce his risk of stroke, so he can more safely undergo aortic valve surgery later this summer.

The Achilles heel of carotid stenting has always been the very real danger that plaque could become dislodged during angioplasty and float to the brain, causing stroke. "But the advent of the distal protection devices -- the umbrella-like filters that trap any plaque that may break off during the procedure and lead to a stroke - has been a huge breakthrough for enhancing the safety of carotid artery stenting," Dr. Dippel says.

Until November 2002, the potential advantages of carotid stenting over surgery were largely theoretical for patients like McConnell. That is when interim results of the SAPPHIRE trial, a randomized comparison of surgery versus stenting using the distal protection, showed the interventional procedure to be superior in high-risk patients.

"Stenting cut the 30-day rates of death, heart attack and stroke by more than 50 percent," Dr. Dippel says. "This was the first real convincing data that came out comparing the two different procedures head-to-head."

Only high risk patients are eligible for the procedure at Genesis Medical Center, including those who fit one or more of these criteria: those who have had prior surgery on the neck; a previous blockage in the same location; are age 80 and older; have severe coronary artery disease; or who have heart failure.

According to rigid criteria established through the Genesis Institutional Review Board, a neurologist must determine if a patient's medical condition warrants carotid artery stenting and then evaluates him or her after the procedure as well.

Neurologist Stephen Rasmus, M.D., of Neurology Consultants, P.C., evaluated McConnell and stresses that carotid artery stenting is currently limited to a carefully selected group of patients at high risk for surgery. Studies are still ongoing as to whether it will be an effective long-term treatment for stroke prevention.

"So far, it appears that carotid artery stenting may be effective to maintain open arteries, but it's still a new enough procedure that we don't know if it will be a durable treatment over the course of years," Dr. Rasmus says. "In a positive sense, though, it is very possible that carotid stenting is a viable alternative to carotid endarterectomy."

Radiologists, through the use of a cerebral angiogram, CT scanning and ultrasound, also play an integral role in evaluating the carotid artery blockages. Radiologist Robert Danielson, M.D., of Radiology Group, P.C., S.C., was present during the procedure. A vascular surgeon from Des Moines proctored on the first case, and will be present for the first 10 cases at Genesis.

That interdisciplinary cooperation of different disciplines was key to bringing the procedure to Genesis Medical Center, Dr. Dippel concludes. "We're a regional referral center, so we're in a position to be on the leading edge of medicine and adopt new procedures early."

Patients benefit when physicians bring together multiple areas of expertise, says Shauna Roberts, M.D., Medical Director of the Genesis Heart Institute. "It takes more effort, but the end result is much stronger than what one individual doctor can accomplish," Dr. Roberts says. "In planning for the initiation of carotid stenting procedures, we were collaborating cardiology, neurology, radiology, vascular surgery, the Heart Institute committee structure, hospital leadership, and the medical staff leadership all together. This effort is exceptional and speaks to the commitment we have to our community."

For more information about carotid stenting, contact Genesis On Call at 421-2000 or 1-800-383-2575.