The Risk of Carotid Artery Stenting Compared With Carotid Endarterectomy Is Greatest in Patients Treated Within 7 Days of Symptoms

May 17, 2013
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Authors:
Rantner B, Goebel G, Bonati LH, Ringleb PA, Mas JL, Fraedrich G; on behalf of the Carotid Stenting Trialists’ Collaboration.
Citation:
J Vasc Surg 2013;57:619-626.
Summary By:
Hitinder S. Gurm, MBBS, FACC

Study Questions:

Does the time from ischemic event influence the relative safety and efficacy of carotid stenting (CAS) versus carotid endarterectomy (CEA)?

Methods:

The authors performed a pooled analysis of data from individual patients randomized in the EVA-3S (Endarterectomy versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis) trial, the SPACE (Stent-Protected Angioplasty versus Carotid Endarterectomy) trial, and the ICSS (International Carotid Stenting Study) trial. The association of time between the qualifying ischemic event and treatment (0-7 days, 8-14 days, and >14 days) with the risk of stroke or death within 30 days after CAS or CEA was analyzed with a fixed-effect binomial regression model adjusted for source trial.

Results:

The study cohort was comprised of 2,839 patients on whom information on time of qualifying event was available. In the first 30 days after intervention, any stroke or death occurred significantly more often in the CAS group (7.7% vs. 3.8%; risk ratio [RR], 2.0; 95% confidence interval [CI], 1.5-2.7). Among patients undergoing treatment within 7 days of symptoms, the risks were 9.4% with CAS versus 2.8% with CEA (RR, 3.4; 95% CI, 1.01-11.8). Among those undergoing surgery within 8-14 days, the rate was 8.1% versus 3.4%, and for those undergoing surgery >14 days after the ischemic event, the rates were 7.3% with CAS and 4% with CEA.

Conclusions:

The authors concluded that among patients presenting early after transient ischemic attack or minor stroke, CEA is superior to CAS.

Perspective:

Among patients with symptomatic carotid disease, some observational studies suggest that early CAS is associated with an increased risk of major complications. This study suggests that the risk of CEA is not appreciably different among those undergoing early versus late intervention, and early CAS appears to carry high risk. Since the risk of recurrent events in symptomatic carotid disease is highest immediately after the index event, early CEA should be the preferred therapy in this population.

Keywords: Stroke, Ischemic Attack, Transient, Endarterectomy, Carotid, Extravehicular Activity, Carotid Arteries, Carotid Stenosis, Stents


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