CAS vs. CEA for Stroke Prevention

Study Questions:

What is the relative safety and efficacy of contemporary carotid artery stenting (CAS) versus carotid artery endarterectomy (CEA)?

Methods:

The author performed a meta-analysis evaluating the efficacy and safety of CAS versus CEA and included randomized clinical trials with ≥50 patients that compared CAS and CEA. Random-effect models were used to calculate summary odds ratios (ORs) and 95% confidence intervals (CIs).

Results:

The meta-analysis included 6,526 patients from five trials with a mean follow-up of 5.3 years. There was no difference in the composite outcome of periprocedural death, stroke, myocardial infarction (MI), or non-periprocedural ipsilateral stroke (OR, 1.22; 95% CI, 0.94-1.59). The risk of any periprocedural stroke plus non-periprocedural ipsilateral stroke was higher with CAS (OR, 1.50; 95% CI, 1.22-1.84), and was due to increased periprocedural minor stroke (OR, 2.43; 95% CI, 1.71-3.46). CAS was associated with significantly lower risk of periprocedural MI (OR, 0.45; 95% CI, 0.27-0.75), and cranial nerve palsy (OR, 0.07; 95% CI, 0.04-0.14). The composite outcome of death, stroke, or MI during the periprocedural period and ipsilateral stroke during long-term follow-up was significantly higher with CAS among symptomatic patients (OR, 1.43; 95% CI, 1.15-1.79), but there was no difference among asymptomatic patients (OR, 0.92; 95% CI, 0.68-1.26).

Conclusions:

The authors concluded that CAS and CEA are associated with similar overall outcomes, but the risk of periprocedural stroke is higher with CAS.

Perspective:

The data on the comparative safety and efficacy of CEA and CAS have consistently demonstrated higher risk of periprocedural stroke with CAS and higher risk of periprocedural MI with CEA with no difference in long-term efficacy of the two procedures. A more important clinical question is whether there is any role for carotid revascularization in asymptomatic patients who are treated with contemporary medical therapy. The results of the ongoing CREST-2 trial are eagerly awaited to define the contemporary role for CAS and CEA in the treatment of asymptomatic patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias

Keywords: Cardiac Surgical Procedures, Carotid Arteries, Cranial Nerve Diseases, Endarterectomy, Carotid, Myocardial Infarction, Myocardial Revascularization, Perioperative Period, Primary Prevention, Risk Assessment, Stents, Stroke, Treatment Outcome, Vascular Diseases


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