Thursday, October 19, 2006

Carotid Artery Angioplasty - A Technique looking for a role

When Greuntzig first started angioplasty in 1977 and later, when the stents came in, many thought that any endovascular lesion could be treated, and so they did. With great gusto, many "for bread" cardiologist quickly saw the obvious self benefit and went for short courses to master the technique of balloon angioplasty. Alas, without learning the art and science of decision making.

In the nineties, we see a great mushrooming of many vascular and cardiac interventionist, who have barely mastered the technique of manipulating a guide-wire and moving a balloon catheter, across arterial lesions of unsuspecting patients. With our country's strict law of non-advertising and the reluctance of local doctors to challenge fellow doctors who are abusing the technique, many "for business interventionist" have flourished. If the scene is bad in cardiac PCI, it is much much worse in peripheral vascular interventions.

Sometimes the same group of interventional cardiologist also double up as expert pericutaneous interventionist. After trying a few here and there, they become experts, enough (with a little device company sponsorship, who obviously are an interested group) to be invited to other ASEAN countries to showcase their skills. I have seen renal angioplasties being done, just because it is there. Carotid artery stenosis being dilated, just because it is there.

In fact, for a while in the late nineties and early twenties, there was a move by some quarters to do global angiograms. Meaning that if you have admitted a patient for a coronary angiogram, you also, by the way, do a screening carotid angiogram and also, by the way, a renal arteriogram. Of course if you happen to see a stenosis, you also dilate. Why? Just because it is there.

We have always been waiting for a comparative trial between carotid angioplasty versus carotid endarterectomy, to see the role of carotid angioplasty. Well, this posting is partly prompted by the publiction in Lancet october 7th, of the SPACE study, a non-inferiority comparison of carotid angioplasty against carotid endarterectomy. This study, carried out by the German group, showed that carotid angioplasty was inferior (they were not non-inferior, that is the technical jargon), to carotid endarterectomy. This was a population of people with symptomatic carotid artery disease. This proves what many of us have known for a long time.

Somehow, I don't think that this kind of evidence is not going to influence those "I dilate for food" interventionist. Interventionist are only human, and bread is important for living too, so who are we to judge. Evidence based medicine, nice idea.

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