Asymptomatic Carotid Surgery Trial - ACST-2

Contribution To Literature:

The ACST-2 trial showed that carotid artery stenting resulted in similar long-term outcomes compared to carotid endarterectomy.

Description:

The goal of the trial was to evaluate carotid artery stenting compared with carotid endarterectomy among patients with asymptomatic carotid artery stenosis.

Study Design

  • Randomization
  • Parallel

Participants with asymptomatic carotid stenosis were randomized to carotid artery stenting (n = 1,811) versus carotid endarterectomy (n = 1,814).

  • Total number of enrollees: 3,625
  • Duration of follow-up: mean 5 years
  • Percentage female: 30%

Inclusion criteria:

  • Unilateral or bilateral carotid artery stenosis ≥60% as assessed by ultrasound
  • Patients eligible by ultrasound then had computed tomography or magnetic resonance imaging to confirm that carotid artery stenting and carotid endarterectomy were both practical

Exclusion criteria:

  • Previous stroke or transient ischemic attack within the previous 6 months
  • Unsuitability for carotid stenting (for example, due to calcium or tortuosity) or carotid endarterectomy
  • High procedural risk (for example, due to recent acute myocardial infarction)
  • High risk of cardiac emboli
  • Major life-threatening condition

Principal Findings:

The primary outcomes:

  • Procedural death or disabling stroke at 30 days: 1.0% in the carotid stent group compared with 0.9% in the carotid endarterectomy group
  • Procedural death or disabling stroke at 5 years: 3.4% in the carotid stent group compared with 3.5% in the carotid endarterectomy group (p = 0.86)
  • Procedural death or any stroke at 5 years: 8.6% in the carotid stent group compared with 7.1% in the carotid endarterectomy group (p = 0.09)
  • Nonprocedural fatal or disabling stroke at 5 years: (relative risk [RR] 0.98, p = 0.91)
  • Nonprocedural stroke at 5 years: (RR = 1.16, p = 0.33)

Interpretation:

Among patients with asymptomatic carotid stenosis, carotid artery stenting was safe. Carotid artery stenting was associated with a low incidence of procedural death or disabling stroke within 30 days. The incidence of procedural death or disabling stroke within 30 days was similar to the incidence from carotid endarterectomy. Procedural death or disabling stroke within 5 years was also similar between treatment groups.

References:

Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomized comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021;Aug 29:[Epub ahead of print].

Editorial Comment: Tulamo R, Venermo M. Intervention for asymptomatic carotid artery stenosis. Lancet 2021;Aug 29:[Epub ahead of print].

Presented by Dr. Alison Halliday at the European Society of Cardiology Virtual Congress, August 29, 2021.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Magnetic Resonance Imaging

Keywords: ESC21, ESC Congress, Cardiac Surgical Procedures, Diagnostic Imaging, Endarterectomy, Carotid, Magnetic Resonance Imaging, Stents, Stroke, Tomography


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