2020.12.20 10:01
Scorned scientist now vindicated in her work on how to treat stroke
https://www.theguardian.com/society/2020/dec/19/scorned-scientist-now-vindicated-in-her-work-on-how-to-treat-stroke?CMP=Share_AndroidApp_Other
2020.12.20 10:02
2020.12.20 10:04
2020.12.20 10:05
2020.12.20 10:08
This is indeed a most amazing story in medicine.
A mere pure PhD neuroscientist in Australia finally succeeded in
convincing medical establishment that asymptotic carotid artery stenosis
is best managed medically no matter how severe rather than surgically
or by stenting.
She wound up putting the medical establishment of vascular surgery and,
carotid stent main stream MDs to shame. Sticking to medical science truth
over a decade in spite of continuing political pressures by the bureaucrats of
the establishment including denial of her research grants, she persevered
and finally got recognized internationally by receiving the prestigious award
along with Dr. Anthony Fauci.
By the way, as CV physiology being my lifetime backbone, I had known
what she's been fighting for for decades and have taken care of my patients
according to that principle and truth for many years.
We cardiologists always, I believe, have been more transparent in our scientific
research than other medical specialties, including neurology, so that we observed
the same thing in coronary artery disease that Dr. Abbott is talking about.
For example, an average MD would have a tough time being convinced when
someone says 95% unilateral asymptotic internal carotid artery stenosis
is better treated medically than by carotid artery endarterectomy or by stenting.
An average MD does not realize that for this particular patient, by the time 95%
stenosis has taken place without causing any symptoms, nature already provided
adequate collaterals so that even if it becomes 100% closed, the patient will have no stroke.
Indeed I had a fair number of such patients in my practice.
What causes a large stroke with hemiplegia or a large AMI is subtotal stenosis of the artery
anwhere from 20 to 80% stenosis before the collaterals fully develope become suddenly closed
with thrombus, not the 90-99% stenosis being completely closed with clot.
2020.12.20 21:32
Very interesting news, Dr. Lee, especially to me as a town-best (?) known carotid surgeon decades ago- I did more than 700 cases of carotid endarterectomy till I moved to Korea (where I introduced so called American style carotid endarterectomy to Koreans for the first time to get the best record out of it with two mortality among a total of 400 cases before we accommodated carotid stenting!)-. So I know what I am talking and wish to share my opinion as well if you would.
I don’t know to be sure whether such summary execution of ‘asymptotic carotid artery stenosis is best managed medically no matter how severe rather than surgically or by stenting’ is 100% acceptable or not. Believe me no one does surgical intervention to the ‘asymptomatic cases’ in these days unless there are specific indications. No Sirrrrreeee! No longer!!!! Olden days when we started this business was entirely different issue and we learned through trial and error and we no longer allow the abuse of carotid intervention without clear cut indications among asymptomatic cases.
Indeed, I brought up the carotid surgery to town, back in 1978, to Georgetown Univ program together with transplant surgery as one of the major tasks for the vascular surgery. Until we initiated ‘organized multidisciplinary team approach’ to the carotid surgery/endarterectomy with neurologists, the neurosurgeon at Georgetown U did all the carotid surgery cases infrequently with pretty poor outcome across the board according to the hospital peer review. Within three years, per recommendation by the hospital review board, the neurosurgery group voluntarily handed over the carotid program to us except the project of extracranial - intracranial bypass surgery which was also dropped eventually based on no merits.
Anyhow, in order NOT to keep myself spread too thin, and keep my main focus to transplant surgery, I chose this carotid surgery as my main subject together with distal bypass for the critical limb ischemia to establish my career as vascular surgeon. So I am quite confident to tell ‘such summary execution of asymptotic carotid artery stenosis is best managed medically no matter how severe’ regardless of the local plaque condition as well as intracranial combined lesion is NOT fair.
Almost all the cases I chose the endarterectomy for was the SYMPTOMATIC cases, of course, but I also committed to quite a large group of ‘asymptomatic’ stenosis ‘selectively’, based on clear cut indication like an ‘ulcerating plaque’ with/without evidence/suspicion of previous cerebral embolization, for example.
I also joined very early to my pal, Andrew Nicolaides of St. Mary Hospital/Imperial College, UK to imply ultrasonographic findings of the plague for the risk of rupture assessment - although I started Duplex US study earlier than he, I failed to secure the grant from NIH to organize the multicenter study - to the selection of candidates for the endarterectomy. So I actively joined/started to persuade the colleagues based on our experience against indiscriminating abuse of carotid endarterectomy especially to the ‘asymptomatic’ cases even before statin/medical treatment became available.
Indeed, we already learned slowly progressing stenosis would give a plenty of time to develop the collaterals till complete occlusion with no symptoms! 'Critical' stenosis is rather safe even on some cases with complete occlusion of contralateral carotid artery. But ‘wide opened’ carotid with minimal to moderate stenosis with ‘vulnerable’ plaques would not give such chance for natural compensation when the plaque is ruptured! It causes acute stroke especially when there is combined intracranial lesions- Koreans are, perhaps due to the smoking-.
When I chose to go back to Seoul in 1994, I handed over all the carotid projects including the ‘asymptomatic’ cases to Johns Hopkins to my mentor, Mel Williams to take over and merge to his project. And I started a new carotid project for such heavily smoking Koreans who have such notorious reputation of high stroke rates.
I further learned through Takayasu's arteritis (TA) - one of five vascular projects I brought to SamSung as a joint project with the Johns Hopkins was 'the Vascultis Clinic' to accommodate TA as well as Behcet's disease!- that such 'collaterals' to give a compensation are so critical for the decision on the surgical intervention. Indeed, through so many TA cases I dealt with Tashkent U of Uzbekistan team, I learned so much for the natural course of the occlusive lesions though the atherosclerosis is a different story.
Lastly, I have to tell you that with unlimited funds SamSung gave, I added a ‘cerebral angiogram’ to over 250 cases of carotid stenosis including quite a few ‘asymptomatic’ patients, as a part of assessment among the candidates for the endarterectomy; through this very unique study I did with SamSung team to coexisting intracranial carotid as well as intracerebral artery diseases, I learned a lot and rather shocked to find such high incidence of ‘combined’ intracranial lesions, which might be related to high incidence of smoking. I still see the colleagues, especially neurologists, quote many of our early works together with this unique finding as well in the literature!
Indeed, we found Koreans were much more vulnerable to subsequent embolization to cause ‘devastating’ stroke so that I studied the atheromatous plaque components with MRI to compare with the findings of Duplex US to assess the risk of rupture in order to choose right candidates among the asymptomatic case for ‘preemptive’ endarterectomy, till I retired to come back home to the U.S.
So, I still believe there are clear cut indication for the open surgical or endovascular surgery with stenting among the ‘asymptomatic’ cases and its selection should mandate ‘all things considered’ including the response to the statin-based medical care and the progress/change of the plaque and intracranial combined lesion/status.
One old retired carotid surgeon’s lament!!!!!
Happy Holidays!
BB Lee
2020.12.20 22:27
Thank you very much, Professor, for your invaluable comment on the subject.
I must say that as far as the abuse of the surgery or stenting is concerned,
it is an almost uncontrollable problem not so much at the academic institutions like yours
but in private clinical practice at community hospitals across the country or around the world.
It is no different from, say, cataract surgery being abused by some ophthalmologists.
This discussion, however, reminds me of decades long debate between cardiac surgeons and
cardiologists in regard to indications for cabg and coronary stenting.
Finally there are no serious disagreements between the surgeons and cardiologists as consensus
has evolved over the years.
Defining a true asymptomatic carotid or coronary artery stenosis is not always easy or simple.
We know unstable atherosclerotic plaque that brings on sudden onset thrombus is our enemy
that causes stroke and heart attack.
Efforts to identify unstable plaques over the years have been disappointing.
Ulcerating plaque, even with the help of radiologist, sometimes is hard to be convinced or
a matter of judgment call and can be used as indication for surgery or stenting by dishonest physician.
To complicate the matter for many years medical people like Dr. Abbott felt that we could stabilize
the unstable plaque with statins and other medical interventions such as stopping cigarettes.
What is notable here with Dr. Abbott, who is a PhD basic scientist, seems to have all the numbers,
statistics, in her favor if you tract her publications.
One thing for sure, she is a very stubborn lady who believes in what she has discovered and
has been fighting and preaching medical establishments although she is not an MD,
which is remarkable, indeed.
Happy Holidays!
hj
2020.12.21 07:51
Certainly remarkable story of Dr. Abbott, HJ! You are absolutely right.
Indeed, it took more than a decade to us to put the brake on rampant abuse in private sector but the damage was done enough to give such negative impact on even justfiable indications among the symptomatic cases.
Indeed, the Hopkins team led by Bruce Perler started the crusade to put the lid on with aggressive statin-based management on both symtomatic as well as asymptomaic cases more than two decades ago and still going on.
We all learn through such painful mistakes and try not to repeat same mistake!
Warm regards,
BB
2020.12.21 09:57
A/Prof Anne Abbott is a neurologist from the Central Clinical School at Monash University in Melbourne, Australia. She has been at the forefront of medical research regarding how to best prevent stroke, particularly associated with carotid arterial disease.
Her work is having a significant impact in updating international stroke guidelines, policy and practice for improved patient outcomes. She started a group of international experts, called FACTCATS to assist her (see FACTCATS.org).
A/Prof Anne Abbott’s next objective is to publish the world's first 'evidence-true' guideline on carotid arterial disease management and create ‘Brainy Medicine’, a way to integrate medical research with routine patient care.
Stroke Prevention, PhD, University of Melbourne
Award Date: 8 Apr 2004
Neurologist, Knox Private Hospital
https://scienceillustrated.com.au/blog/medicine/aussie-anne-abbott-wins-john-maddox-prize-for-standing-up-for-science/