No equipoise, just better outcomes found in CEA over CAS

Atherosclerotic patients in a real-world setting did better when carotid endarterectomy (CEA) was used as opposed to carotid angioplasty and stenting (CAS). Contradictory to some earlier prospective studies, at no point did researchers find equipoise between the two procedures.

Significant carotid artery atherosclerosis puts patients at more risk for cerebral ischemic stroke. Interventions like CEA and CAS are intended to reduce those risks.

The study, published online Oct. 9 in Stroke, explored data from the Premier Perspective Database, which includes hospitalization information from over 600 hospitals across the U.S. Researchers matched CEA and CAS cases found in the database and determined hospitalization discharge outcomes to compare current practice with recent prospective controlled trials.

Lead author Robert J. McDonald, MD, PhD, of the Department of Radiology for the Mayo Clinic in Rochester, Minn., and colleagues found that whether a patient was symptomatic or not also played a role in outcomes. Symptomatic atherosclerosis patients were more likely than asymptomatic patients to have poor outcomes.

They found that in the practice setting, patients who underwent CAS procedures were more likely than CEA patients to have peri- or postoperative mortality, acute MI, or stroke (symptomatic odds ratio: 2.31, asymptomatic odds ratio: 1.4). This remained regardless of age or sex.

While these findings were comparable with several other smaller trials, McDonald et al found that the data did not support the results of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) trial. They failed to demonstrate a point where CAS and CEA reached an equipoise of adverse perioperative outcomes such as death, stroke or unfavorable hospital discharge. Also contrary to CREST, CEA outcomes in the McDonald et al analysis became increasingly favorable with patient age while they did not find an age range where CAS outcomes surpassed CEA.

The results were similar, however to other prospective studies. Meta-analysis of three other studies on CEA and CAS found that lower stenting volume centers related directly to significantly higher rates of unfavorable outcomes.

This finding, McDonald et al suggested, may offer the difference between the current study and CREST. The volume of data available through the database used by McDonald et al may have offset operator and medical center selection bias.

They wrote that the absolute risk to individual patients for adverse outcomes was low. However, as an aggregate, more unfavorable outcomes were seen in patients who underwent CAS as opposed to CEA. As poor outcomes are costly to patients physically and to the healthcare system as a whole, McDonald et al strongly suggested that if any factors may be clinically useful in bringing equipoise to a real-world setting, they be studied to make procedures safer for all patients.