The carotid conundrum
It may look like a fielder’s choice between carotid artery stenting and endarterectomy for patients with carotid artery stenosis, with conclusions from one recent analysis and another randomized trial leaning in opposite directions.
Let’s start with the randomized trial, which was published Oct. 14 in The Lancet. Researchers in the International Carotid Stenting Study presented 10-year results of the multicenter randomized trial that compared endarterectomy and carotid artery stenting in 1,713 patients with symptomatic atherosclerotic carotid stenosis.
The cumulative five-year risk of a fatal or disabling stroke was 6.4 percent in the stenting group vs. 6.5 percent in the endarterectomy group. A larger proportion of the stenting group experienced any kind of stroke, at 15.2 percent vs. 9.4 percent for the endarterectomy cohort. The authors attributed most of the difference to nondisabling strokes.
Other outcomes showed parity between the two approaches. All-cause mortality, functional outcomes and long-term rates of restenosis were similar. Unpublished data suggested that age could be a factor in the 30-day risk of stroke, MI or death in patients treated with stenting.
“Overall we found that stenting and endarterectomy are durable procedures that are equally effective in preventing severe strokes that lead to disability or death,” they concluded. They recommended considering risks and individualizing treatment. They also recognized that in contemporary practice, procedures and technologies changed for the better since the trial wrapped up.
That is where the analysis may offer insights. The authors conducted a propensity score analysis using retrospective data up to 2011 from the Premier Perspective Database to assess adverse outcomes for carotid artery stenting and endarterectomy. The database included data from more than 600 hospitals in the U.S. Their goal was to clarify the safety of these therapies in a real-world setting.
They published their findings online Oct. 9 in Stroke. The good news was that the absolute risk to individual patients for adverse outcomes was low. But the risk of peri- or postoperative mortality, acute MI, or stroke was higher with stenting than with endarterectomy in their study.
They gave endarterectomy a clear victory over stenting. “Given these findings, the safety of carotid artery stenting should be more rigorously scrutinized, particularly among individuals who are symptomatic at the time of carotid revascularization,” they wrote.
We’ve explored the give-and-take between carotid artery stenting and endarterectomy, most recently in a magazine article, “Carotid Artery Stenting: Making Progress Amid Reimbursement Purgatory.” It looks like the issue remains unresolved, leaving physicians and patients to choose.
Candace Stuart
Editor, Cardiovascular Business