SummaryBackgroundStents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but previous trials have not established equivalent safety and efficacy. We compared the safety of carotid artery stenting with that of carotid endarterectomy.MethodsThe International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call or fax to a central computerised service and was stratified by centre with minimisation for sex, age, contralateral occlusion, and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were followed up by independent clinicians not directly involved in delivering the randomised treatment. The primary outcome measure of the trial is the 3-year rate of fatal or disabling stroke in any territory, which has not been analysed yet. The main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.FindingsThe trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR] 1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group. There were also fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).InterpretationCompletion of long-term follow-up is needed to establish the efficacy of carotid artery stenting compared with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients suitable for surgery.FundingMedical Research Council, the Stroke Association, Sanofi-Synthélabo, European Union.

Statins appear to be associated with attenuation of AAA growth, irrespective of other known factors influencing aneurysm growth.

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To assess the age- and sex-specific prevalence and risk factors for aneurysms of the abdominal aorta, the authors performed a population-based study in 5,419 subjects (42% men, 58% women) aged 55 years and over. The proximal and distal diameter of the abdominal aorta were measured by ultrasound. An aneurysm was defined as a distal aortic diameter of 35 mm or more or a dilatation of the distal part of the the abdominal aorta of 50% or more. The mean distal and proximal aortic diameter increased 0.7 mm and 0.3 mm, respectively, with every 10 years of age. In 2.1% (95% confidence interval (CI) 1.7-2.5) of the study population, an aneurysm was present, or in 4.1% (95% CI 3.2-4.9) of the men and 0.7% (95% CI 0.4-1.0) of the women. Subjects with an abdominal aneurysm were more likely to be smokers and they had higher serum cholesterol levels and higher prevalence of cardiovascular disease compared with subjects without an aneurysm. The authors conclude that the ultrasound diameter of the abdominal aorta clearly increases with age in both men and women and that the prevalence of aneurysms of the abdominal aorta in older adults in relatively high, especially in men.

The feasibility of assessing arterial wall configuration with an intravascular 40 MHz ultrasound imaging device was investigated in an in vitro study of 11 autopsy specimens of human arteries. The system consists of a single element transducer, rotated with a motor mounted on an 8F catheter tip. Cross sections obtained with ultrasound were matched with the corresponding histologic sections. The arterial specimens were histologically classified as of the muscular or elastic type. Muscular arteries interrogated with ultrasound presented with a hypoechoic media, coinciding with the smooth muscle cells. In contrast, the media of an elastic artery densely packed with elastin fibers was as echogenic as the intima and the adventitia. On the basis of the cross-sectional image, it was possible to determine the nature of the atherosclerotic plaque. The location and thickness of the lesion measured from the histologic sections correlated well with the data derived from the corresponding ultrasound images. This study indicates that characterization of the type of artery and detection of arterial wall disease are possible with use of an intravascular ultrasound imaging technique.