Subject: Washington State Health Care Authority’s HTA of Carotid Artery
Stenting – Draft Key Questions
Dear Mr. Morse,
On behalf of the American Association of Neurological Surgeons (AANS) and the Congress of
Neurological Surgeons (CNS), we wish to thank you for the opportunity to comment on the Draft Key
Questions for the Health Technology Assessment (HTA) of Carotid Artery Stenting (CAS) conducted
by the Washington State Health Care Authority (HCA). As practitioners versed in both the surgical
and endovascular management of carotid disease, we believe the Key Questions (KQs) must
distinguish between primary and secondary stroke prevention. Moreover, the KQs must further
separate consideration of extracranial and intracranial atherosclerotic disease. Blurring carotid
disease, ICAD, and materially different catheter-based treatments will ultimately limit the HCA’s ability
to draw meaningful conclusions from this assessment.
Introduction
Based on the introductory language, the scope of the HTA appears designed to assess CAS for
secondary prevention of ischemic stroke in patients with symptomatic and asymptomatic cervical
internal carotid artery (ICA) stenosis. Cervical ICA stenosis is by definition extracranial and distinct
from intracranial atherosclerotic disease (ICAD). ICAD carries very different treatment alternatives,
natural history, and is not managed by CAS in the conventional sense. The following comments
therefore reflect our reading of the stated HTA’s objectives.
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