CAROTID STENTING VERSUS CAROTID ENARTERECTOMY FOR CAROTID ARTERY STENOSIS IN STROKE PREVENTION. THE IMPORTANCE OF EXCELLENCE

This has been a highly contentious issue. Some studies are in support of carotid artery stenting and some are for endarterectomy, and some find them equivalent. the pendulum swings back and forth, and a definitive answer is not in sight. Every year, when I go to moderate at international interventional meetings, there will be some carotid artery stenting been demonstrated, and taught. ( we are interventionist after all ).
Part of the reason seemed to be that when clinical trials are being performed, the selected centers are centers who do them regularly ( good at them ), and so deliver good results, which are often not reproducible by centers ( or interventionist ), who do say 2 or 3 a year. It may therefore not be the procedure per sa, but the medical expertise in doing them. many of us ( myself included ), who have advocated a principle that these complex procedures should only be undertaken by centers, and individuals who do them regularly. In Malaysia, there is often a philosophy that after seeing one being done, doing one with some supervision, he is now an expert. Even worse, some travel around the region ( they are not acceptable except in the ASEAN region ), learning and teaching as he goes along. After travelling around for 1 year and learning as he goes along, he becomes an expert. It is not difficult to travel around the ASEAN region, where there is little quality standards control ( except perhaps in Singapore ). After device companies will gladly introduce you as an "expert" and bring you around to propagate their device. It is marketing wa... So the game goes on. There are some interventionist in Malaysia, who are experts in coronary stenting, carotid stenting, renal stenting, peripheral stenting, and I suppose eventually internal pudental ( penile ) artery stenting as well, as long as ther is money ( for some fame ) to be made.
Well, this blog is prompted somewhat by an article in the December issue of the Journal of Vascular Surgery, by Dr Kristina Giles. She and her research team from the Beth Israel Deaconess medical center, looked into the Database Agency for Healthcare Reasearch and Quality, for outcomes in carotid artery stenting and enarterectomy, to compare them. They collected ( with adequate outcomes documentation ) of 56,564 cases of carotid artery stenting versus 482, 394 cases of carotid enarterectomy, to compare their outcomes. They found that in virtually all subsets ( symptomatic versus assymptomatic, high risk versus low risk ), carotid enarterectomy carried a higher stroke rates and higher death rates. This database of course reflect the real world practice in the US community ( across the board, across all hospitals ). What this means is that, when you are not part of a clinical trial, and in everyday practice, in the average center, carotid enarterectomy does better. In selected centers, then perhaps both procedures are equivalent, and in some studies, stenting may actually have been shown to be superior.
Of course databases are not a very accurate way of comparing outcomes, but it does reflect real world and the large numbers ( although the numbers in both arm are not equivalent ), does moderate the good and the bad. We would like them to be matched, but with databases, that is sometimes impossible.
The last point that I wish to make is that the Ministry must begin to licence certain medical centers to focus ( become centers of excellence ) in certain procedures, so that we can excel. Every Tom, Dick and Harry doing everything, the Jack of all trades approach, is not good. How can they excel, when some centers are doing 1 angioplasty a week, or less then 100 a year. By the time the staff and interventionist have learn something, they would have forgotten, and the next case is a " start all over" to learn again. We need case loads in the hundreds, if not thousands to get good. When I visited Beijing to help them in 1993, they were doing a few angioplasties, a month. Now the same center is doing hundreds a month and thousands a year. China is doing about a quarter million coronary interventions a year, with two centers per province and, I thin, 37 province in China. They are probably much better then us now.
How to become a high income economy, if we do not have a plan also to develop centers of excellence for our people?