Lesion Characteristics and Risk of Stroke With Carotid Stents
What are the lesion characteristics that predict risk of stroke in patients undergoing carotid artery stenting (CAS) versus carotid endarterectomy (CEA)?
The CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) investigators assessed the impact of patient and arterial characteristics on the relative risk of stroke in 2,502 patients treated in the CREST trials.
Risk of stroke was higher with CAS for those with longer lesion length (≥12.85 mm) (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for stroke or death was also higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). In contrast, for the 37% of patients with lesions that were both short and contiguous, the outcome was favorable in those treated with CAS (OR for stroke or death, 0.72; 95% CI, 0.21-2.46).
The higher risk of stroke observed with CAS (compared to CEA) appears to be limited to those with long or sequential stenosis.
This relative outcome of CEA and CAS continues to be debated, although more recent data suggest that outcomes are broadly similar in asymptomatic patients with either approach (ACT I trial, N Engl J Med 2016;374:1011-20). This study suggests that the anatomical characteristics of the lesion could help select lower-risk patients for CAS. The role for carotid revascularization for stable patients (in addition to contemporary medical therapy) remains unclear, and the ongoing CREST-2 trial will help clarify the role for CEA and CAS in this population.
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