Surgery vs. stents: Both effective for treating carotid artery stenosis

In the battle between endarterectomy and carotid artery stenting, the patient emerged as the ultimate victor in a study published online Oct. 14 in The Lancet. Both approaches proved to be equally effective at preventing severe stroke at 10 years, giving physicians a green light to choose the treatment that best fits the individual patient.

Leo H. Bonati, MD, of University College London in the U.K., and colleagues reported 10-year results of the International Carotid Stenting Study, a multicenter randomized trial that compared endarterectomy and carotid artery stenting in 1,713 patients with symptomatic atherosclerotic carotid stenosis. The primary outcome was fatal or disabling stroke.

They enrolled patients between 2001 and 2008, with a median follow-up of 4.2 years. At baseline, the patients has similar characteristics.   

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. More patients in the stenting group experienced any kind of stroke (15.2 percent vs. 9.4 percent), mostly due to nondisabling strokes.

All-cause mortality was similar for both approaches, at 17.4 percent with stenting and 17.2 percent with endarterectomy. Functional outcomes measured on the modified Rankin scale and long-term rates of restenosis were also similar.

“Carotid stenting was associated with a higher procedure-related and long-term risk of non-disabling stroke than endarterectomy, but functional ability did not differ overall,” Bonati et al wrote. “Both treatments seemed to be equally preventive against ipsilateral stroke and severe restenosis of the treated carotid artery.”

An unpublished analysis by the study group suggested that age could be a factor in the 30-day risk of stroke, MI or death in patients treated with stenting. They calculated a relative increase in the risk of 17 percent for every five-year increment of increasing age. “The choice between stenting and endarterectomy, therefore, should take into account the different procedure-related risks for the two approaches in individual patients.”

The results don’t fully reflect contemporary practice and technologies, they noted. Endarterectomy has become safer over time and physicians have become more experienced with stenting, which also has benefited from newer protection devices.