Carotid Artery Stenting Compared with Carotid Endarterectomy

Guidelines from the American Heart Association/American Stroke Association endorse carotid artery stenting (CAS) as a reasonable alternative to carotid endarterectomy (CEA) for the treatment of carotid artery occlusive disease. The guidelines endorse CAS when it is performed by operators with established periprocedural morbidity and mortality of 4% to 6% (class IIa). The safety and efficacy are controversial, according to researchers. Some recent trials found an increased risk of harm with CAS. CAS was associated with a significant increase in 30-day death or stroke; the increase was no longer significant in a random effects model. In another study, CEA was superior to CAS at the 30-day follow-up; there are limited data on the intermediate and long-term outcomes of the 2 strategies. In addition, results of the Carotid Revascularization Endarterectomy vs Stenting Trial demonstrated equivalent long-term risks of the procedures. Researchers recently conducted an analysis to evaluate the periprocedural (≤30 days) and intermediate to long-term outcomes of CAS compared with CEA in participants with carotid artery disease. Results were reported in Archives of Neurology [2011;68(2):172-184]. The researchers searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials using the terms carotid artery disease, endarterectomy, and carotid artery stenting until June 2010. To be eligible for the analysis, trials had to (1) be randomized clinical trials (RCTs) of participants with or without symptomatic carotid artery stenosis comparing CAS with CEA, with or without an embolic protection device and (2) report 30-day or longer-term outcomes. Periprocedural outcomes included death, myocardial infarction (MI), or stroke; death or stroke; any stroke; and MI. The intermediate to long-term outcomes were a composite of periprocedural death, MI, or stroke plus ipsilateral stroke or death thereafter; periprocedural death or stroke plus ipsilateral stroke thereafter; death or any stroke; and any stroke. After applying inclusion and exclusion criteria, the researchers identified 13 RCTs randomizing 7477 participants; 50% of the participants (n=3754) were randomized to CAS and 49.8% (n=3723) were randomized to CEA. Follow-up was a weighted mean of 2.7 years. CAS was associated with a 31% increase in the risk of periprocedural death, MI, or stroke compared with CEA (meta-analytic rate, 5.68%; 95% confidence interval [CI], 3.88%-7.48% vs 4.73%; 95% CI, 3.52%-5.94%), respectively. CAS compared with CEA was associated with a 65% increase in the risk of periprocedural death or stroke (metaanalytic rate, 5.50%; 95% CI, 3.69%-7.30% vs 3.81%; 95% CI, 2.63%-5.00%, respectively) and a 67% increase in the risk of any periprocedural stroke (meta-analytic rate, 4.97%; 95% CI, 3.31%-6.6% vs 3.19%; 95% CI, 2.13%-4.25%, respectively). CEA compared with CAS was associated with a 122% increase in the risk of periprocedural MI (meta-analytic rate, 1.16%; 95% CI, 0.45%-1.88% vs 0.27%; 95% CI, 0.10%-0.44%, respectively). There was no or low to modest heterogeneity in the analyses and no evidence for publication bias. CAS was associated with 19%, 38%, 24%, and 48% increases in the intermediate to long-term outcomes of SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy)-like outcome, periprocedural death or stroke, and ipsilateral stroke thereafter, death or any stroke, and any stroke, respectively. The trial sequential monitoring boundary was crossed by the cumulative z curve, suggesting firm evidence for at least a 20% relative risk increase of any stroke. In conclusion, the researchers summarized that “CAS was associated with an increased risk of both periprocedural and intermediate to long-term outcomes, but with a reduction in periprocedural MI and cranial nerve injury.” They added that “strategies are urgently needed to identify patients who are best served by CAS versus CEA.”